A novel surgeon credentialing and quality assurance process using transoral surgery for oropharyngeal cancer in ECOG-ACRIN Cancer Research Group Trial E3311.

PURPOSE: Understanding the role of transoral surgery in oropharyngeal cancer (OPC) requires prospective, randomized multi-institutional data. Meticulous evaluation of surgeon expertise and surgical quality assurance (QA) will be critical to the validity of such trials. We describe a novel surgeon credentialing and QA process developed to support the ECOG-ACRIN Cancer Research Group E3311 (E3311) and report outcomes related to QA. PATIENTS AND METHODS: E3311 was a phase II randomized clinical trial of transoral surgery followed by low- or standard-dose, risk-adjusted post-operative therapy with stage III-IVa (AJCC 7th edition) HPV-associated OPC. In order to be credentialed to accrue to this trial, surgeons were required to demonstrate active hospital credentials and technique-specific surgical expertise with ≥20 cases of transoral resection for OPC. In addition, 10 paired operative and surgical pathology reports from the preceding 24 months were reviewed by an expert panel. Ongoing QA required <10% rate of positive margins, low oropharyngeal bleeding rates, and accrual of at least one patient per 12 months. Otherwise surgeons were placed on hold and not permitted to accrue until re-credentialed using a new series of transoral resections. RESULTS: 120 surgeons trained in transoral minimally invasive surgery applied for credentialing for E3311 and after peer-review, 87 (73%) were approved from 59 centers. During QA on E3311, positive final pathologic margins were reported in 19 (3.8%) patients. Grade III/IV and grade V oropharyngeal bleeding was reported in 29 (5.9%) and 1 (0.2%) of patients. CONCLUSIONS: We provide proof of concept that a comprehensive credentialing process can support multicenter transoral head and neck surgical oncology trials, with low incidence of positive margins and *grade III/V oropharyngeal bleeding.

Clinical and functional outcomes after total laryngectomy and laryngopharyngectomy: Analysis by tumor subsite, salvage status, and extent of resection.

BACKGROUND: Outcomes following surgical intervention for laryngeal and hypopharyngeal tumors are dependent on several factors. In the present study, we sought to determine whether tumor subsite, salvage status, and extent of resection influenced postoperative outcomes. METHODS: Retrospective review of 107 patients at a single institution who underwent total laryngectomy or partial/total laryngopharyngectomy. RESULTS: Hypopharyngeal subsite and total laryngopharyngectomy subgroups had inferior speech and swallow outcomes compared to their respective cohorts (P < .05). Salvage patients had inferior 3-year overall survival (P < .05) and swallow outcomes (P < .001). Previously radiated patients had increased fistula rates (29.9% vs 10%, P = .02), and the use of tissue coverage in salvage total laryngectomy had a protective effect on fistula formation (10% vs 37%, P = .04). CONCLUSIONS: By stratifying patients across multiple subgroups, we provide a detailed narrative in surgical outcomes that can be incorporated into treatment planning. Further prospective studies are needed to compare surgical outcomes to those of organ preservation therapy.

Vascular interventions in head and neck cancer patients as a marker of poor survival.

OBJECTIVE: Head and neck cancer can involve the surrounding vasculature and require technically challenging vascular interventions. These interventions can be complicated by tumor invasion, history of prior surgery, and history of radiation therapy. Our aim was to examine patients with vascular interventions in association with head and neck cancer to determine outcomes and best practice. METHODS: We performed a retrospective review of cancer patients treated by head and neck surgery and vascular surgery between 2007 and 2014. Data concerning previous cancer treatment, operative details of head and neck surgery and vascular surgery, perioperative outcomes, and survival data were collected. Statistical analyses were performed using the χ2 test, Student t-test, and binomial regression. Patency and survival data were determined by Kaplan-Meier analysis. RESULTS: A total of 57 patients with head and neck cancer requiring vascular interventions were identified. Of these, 44 patients had squamous cell carcinoma, 4 had thyroid cancer, 3 had sarcoma, 2 had Merkel and basal cell carcinoma, and 1 each had a parotid tumor, paraganglioma, extrarenal rhomboid tumor, and malignant spindle cell neoplasm. The majority of the interventions (n = 36 [63%]) were performed on patients with recurrent or persistent malignancy despite prior treatment. The most common previous treatment was radiation therapy (n = 44 [77%]). Tumor resection and vascular intervention were performed concurrently in 26 patients (46%). The mean time between cancer treatment and vascular intervention was 37 months (range, 18 days-18 years). The most common indication for vascular intervention was bleeding (n = 21 [37%]), which included vessel rupture (n = 14), tumor bleeding (n = 5), and intraoperative bleeding (n = 2). The remaining indications for intervention included invasion/encasement of major vasculature (n = 25), stenosis/occlusion (n = 12), and aneurysm (n = 1). The most common intervention was stenting (n = 22 [41%]), followed by resection (n = 20 [35%]), exposure/dissection (n = 12 [22%]), bypass (n = 8 [15%]), and embolization (n = 3 [6%]). Of the 22 patients who were stented, 12 (55%) were placed electively (11 for stenosis and 1 for aneurysm) and 10 (45%) were placed emergently (6 for blowout and 4 for tumor bleeding). A total of six patients (11%) required reintervention after their index vascular procedure. There were no intraoperative mortalities. The 30-day mortality was 9% (n = 5). The 30-day stroke rate was 7% (n = 4; one s/p common carotid artery-internal carotid artery bypass and three with emergent intervention for vessel rupture). Primary patency at 1 year was 66% for stents and 71% for bypass (P = .604). Survival in those patients operated on emergently for bleeding at 1 year was 38%, with a trend toward worse survival compared with the 77% survival at 1 year for all other indications (P = .109). The overall survival in the cohort at 1 and 2 years was 62% and 44%, respectively. CONCLUSIONS: Vascular involvement in head and neck cancer is a marker for poor survival. Any intervention performed in light of mass resection, persistent disease, and previous radiation complicates management. Minimally invasive techniques can be used with emergent bleeding but the survival benefits are marginal. Vascular interventions, including reconstruction, are feasible but should be approached with adequate expectations and multidisciplinary support.

Percutaneous endoscopic gastrostomy tube dependence following chemoradiation in head and neck cancer patients.

OBJECTIVES/HYPOTHESIS: Compare long-term percutaneous endoscopic gastrostomy (PEG) tube dependence, stricture rate, and weight loss in patients receiving a prophylactic gastrostomy tube with those who initially rely on oral intake during chemoradiation for head and neck cancer. Also, to determine what other patient and treatment characteristics influence development of long-term severe dysphagia. STUDY DESIGN: Retrospective review. METHODS: Seventy-nine patients received a PEG tube and 25 did not. The prophylactic and initial oral intake groups were then analyzed to assess the primary outcomes of PEG dependence at last follow-up >1 year. RESULTS: On univariate and multivariate analysis, Zubrod score >1, prophylactic PEG placement, and higher T classification were predicted for PEG tube dependence at last follow-up at least 1 year after treatment. CONCLUSIONS: Prophylactic PEG tube, high Zubrod score, and high T stage were independent predictors for PEG tube dependence at least 1 year after treatment in patients with head and neck cancer receiving definitive chemoradiation. LEVEL OF EVIDENCE: 4.

Primary carcinoid tumor of the frontal sinus: A case report.

Carcinoid tumors are rare, indolent, neuroendocrine tumors that are most commonly found in the gastrointestinal tract and lungs. They occasionally develop in the head and neck, either as a primary tumor or, more commonly, as a metastasis. The most common sites of head and neck carcinoids are the larynx and middle ear. Only a few cases of carcinoid in the nasal cavity and paranasal sinuses have been reported. We describe a case of primary typical carcinoid of the frontal sinus in a 61-year-old man, and we review the clinical, imaging, surgical, and histochemical findings in this case. The patient was treated with endoscopic resection. A subsequent workup for metastatic and occult primary disease was negative, confirming that the frontal sinus was the primary source. At follow-up 12 months postoperatively, the patient remained without disease. To the best of our knowledge, this is the first report of a primary typical carcinoid tumor originating in the frontal sinus.

Effectiveness of surgeon interpretation of technetium tc 99m sestamibi scans in localizing parathyroid adenomas.

OBJECTIVES: To evaluate the ability of surgeons to predict the laterality of parathyroid adenomas from technetium Tc 99m sestamibi scans and compare their results with the radiologic interpretations. DESIGN: Retrospective medical record review with single- blinded review of sestamibi scans. SETTING: Tertiary care academic medical center PATIENTS: The study population included 110 consecutive parathyroidectomy cases from January 2001 to June 2004. Inclusion criteria were biochemically proven primary hyperparathyroidism, with documented serum hypercalcemia and elevated parathyroid hormone levels. Only cases due to a single adenoma that were cured with a single surgical procedure were included. INTERVENTION: All patients underwent resection of a parathyroid adenoma following a preoperative sestamibi localization study and serum calcium and parathyroid hormone level analysis. MAIN OUTCOME MEASURE: Adenoma location was determined from a review of operative and pathological reports. Two head and neck surgeons performed a blinded review of all scans, and their findings were compared with the radiology reports. RESULTS: Of 82 adenomas, 51 (62%) were correctly lateralized in the radiology report, while the other 31 were interpreted as normal scans. The sensitivity and specificity of the radiologic interpretations for parathyroid adenomas in all patients with primary hyperparathyroidism were 62% and 83%, respectively. The scan interpretation of the 2 surgeons produced accurate lateralization of 91% and 91% of these single adenomas. Of the 31 single adenoma scans read as normal by the radiologist, the surgeons correctly lateralized 22 of 29 (76%) and 21 of 28 (75%) of the adenomas. CONCLUSION: The review of sestamibi scans by surgeons allows accurate localization of parathyroid adenomas that may not be identified by standard radiologic interpretations.

Analysis of transnasal endoscopic versus transseptal microscopic approach for excision of pituitary tumors.

BACKGROUND: The traditional method of pituitary tumor excision is transseptal microscopic excision; however, the transnasal transsphenoidal endoscopic approach has shown comparable results with the transseptal microscopic approach at some institutions. The objective of this study is to compare the two types of sellar and parasellar mass resection: transnasal transsphenoidal endoscopic excision versus transseptal microscopic excision. METHODS: A retrospective cohort analysis was performed on subjects who were referred to a tertiary hospital for surgical management of sellar or parasellar masses. The two groups of patients either underwent a transnasal endoscopic approach with endoscopic excision or transseptal microscopic excision. Demographics, tumor characteristics, operative details, length of hospital stay, intraoperative and postoperative complications, level of postoperative pain, recurrence rate, use of computed tomography (CT) image guidance, and length of follow-up were gathered. The data between the two groups were then compared. RESULTS: The analysis included 19 subjects who underwent endoscopic excision and 29 subjects who underwent transseptal microscopic excision. Null macroadenoma was the most common sellar mass followed by prolactinoma. There were no statistical differences in rates of perioperative complications and suprasellar or cavernous sinus invasion. Patients who underwent an endoscopic approach had shorter operative times, lower estimated blood loss, less lumbar drain use, less pain, and a shorter postoperative hospital stay (p < 0.05). CONCLUSION: The two approaches show similar intraoperative characteristics and immediate complication rates. Transnasal transsphenoidal endoscopic excision is a reasonable alternative to the traditional method of sellar mass excision.

Stridor and dysphagia in diffuse idiopathic skeletal hyperostosis (DISH).

As otolaryngologists, we are the first consulted for stridor and dysphagia. One must consider both extrinsic and intrinsic etiologies in the differential diagnosis of these symptoms. We report a series of patients with diffuse idiopathic skeletal hyperostosis (DISH) who presented with stridor or dysphagia. We describe the initial presenting symptoms, physical examination/radiographic findings, and discuss the management options. Traditional teaching is that surgery is rarely indicated for DISH of the cervical spine. Recommendations regarding the role of surgery as well as a review of our surgical experience are discussed.

Quality of life with well-differentiated thyroid cancer: treatment toxicities and their reduction.

INTRODUCTION: Patients with well-differentiated thyroid cancer have a good prognosis but a significant chance for local recurrence. In the past, limited surgery with postoperative 131I only for extremely high-risk cases or recurrence was not uncommon. As more aggressive surgical and postoperative treatments appear to gain wider acceptance, toxicity and long-term morbidity become more important issues. Our goal is to present the experience of a single institution with emphasis on oral side effects related to 131I as well as acute and chronic symptoms related to this diagnosis and their impact on quality of life. METHODS: Fifty-seven patients were followed for a median time of 19.3 months. All patients received therapeutic 131I (mean dose, 154.7 mCi) between January 1, 1996 and August 30, 2002. RESULTS: Fifty-four patients (94.7%) were alive at the time of analysis. Sixteen (28.1%) required a second treatment: any sign of persistence resulted in retreatment. Complaints with 131I treatment included altered taste, 26.3%; acute xerostomia, 21.1%; and acute sialoadenitis, 15.8%. Chronic xerostomia occurred in 6 (35.3%) of all patients who received multiple treatments. The incidence of chronic xerostomia was reduced to 1 of 11 (9.1%) with amifostine pretreatment. Other chronic side effects associated with this disease included fatigue 54.4%, weight gain of more than 6 months duration 24.6%, with 12 (27.9%) of those under 60 experiencing an average gain of 2.3 kg from initial diagnosis. CONCLUSION: Review of treatment-related symptoms prompted policies to reduce toxicity including amifostine pretreatment for 131I therapy and thyrotropin (synthetic TSH) use in place of iatrogenic hypothyroidism for thyroglobulin testing and scanning.

Solitary schwannoma of the olfactory groove: case report and review of the literature.

Schwannomas of the olfactory groove are rare tumors. Only 10 have been reported in the past century. The case of a 59-year-old woman with an isolated olfactory schwannoma with cribriform plate erosion is presented.