Oncologic outcomes of extended neck dissections in human papillomavirus-related oropharyngeal squamous cell carcinoma.

BACKGROUND: Oncologic outcomes of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (SCC) requiring resection of major muscular or neurovascular tissue during neck dissection for invasive nodal disease remain uncertain. METHODS: Patients with HPV-related oropharyngeal SCC requiring resection of major muscular or neurovascular tissue during their neck dissections were retrospectively identified. RESULTS: Seventy-two patients were included. Regional and distant recurrences occurred in 6% and 17% of patients. Advanced T classification, pathological node number of 5 or more, and omission of adjuvant therapy were associated with decreased disease-free survival (DFS). The addition of adjuvant chemotherapy was not associated with improved survival. CONCLUSION: Patients with invasive nodal disease from HPV-related oropharyngeal SCC can be managed with up-front surgery and adjuvant therapy, as indicated with good regional control. Although distant recurrence was the primary site of failure, adjuvant chemotherapy was not associated with improved outcomes. The T classification, node number, and adjuvant radiotherapy are independent prognostic factors in this patient population.

Transoral robotic surgery for oropharyngeal carcinoma: Surgical margins and oncologic outcomes.

BACKGROUND: This study presents oncologic outcomes after transoral robotic surgery (TORS) ± adjuvant therapy for oropharyngeal squamous cell carcinoma (SCC). METHODS: Three hundred fourteen patients undergoing TORS ± adjuvant therapy for oropharyngeal SCC from May 1, 2007, to May 31, 2015, are analyzed. RESULTS: Median follow-up was 3.3 years (interquartile range [IQR] 1.8-5.3 years; range 1 day to 9.3 years). Estimated locoregional recurrence-free survival, distant metastasis-free survival (DMFS), overall survival (OS), and cancer-specific survival (CSS) rates (95% confidence interval [CI] number still at risk) at 5 years after surgery were 92% (88-95; 92), 90% (86-94; 92), 86% (82-92; 98), and 94% (91-97; 98), respectively. Negative margins were achieved in 98% of cases. The adult comorbidity evaluation (ACE)-27 comorbidity index, human papillomavirus (HPV) status, pathologic N classification, and number of attempts to clear margins were associated with death due to cancer (P = .003, P = .002, P = .030, and P = .002, respectively). CONCLUSION: The need to take ≥2 margins to achieve resection portends an increased risk of locoregional recurrence and death due to disease in oropharyngeal SCC.

Management of Recurrent and Metastatic HPV-Positive Oropharyngeal Squamous Cell Carcinoma after Transoral Robotic Surgery.

Objective To describe management and oncologic outcomes for patients who develop locoregional recurrence (LRR) or distant metastasis (DM) following transoral robotic surgery for human papilloma virus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC). Study Design Case series with chart review. Setting Tertiary care referral center. Subjects and Methods A total of 286 patients with HPV-positive OPSCC who underwent transoral robotic surgery-based treatment from May 2007 to May 2015. Results Of 286 patients (12.2%), 35 met inclusion criteria. Of these, 19 experienced an LRR and 16 developed a DM; 2 patients with LRR subsequently developed DM. In those patients with an LRR, 79% had T1/T2 tumors, and 47% had N0/N1 nodal disease, compared with 75% and 6% in the DM group, respectively. The median time to LRR or DM was 0.6 years (interquartile range [IQR], 0.4-1.0) and 1.8 years (IQR, 1.0-2.1), respectively. Salvage treatment with intent to cure was attempted in 23 patients (16 LRR, 7 DM). The median time from LRR or DM to last follow-up for the 18 patients who were still alive after salvage was 1.9 years (IQR, 0.4-3.8; range, 7 days-6.2 years). Estimated cancer-specific survival rates at 3 years following intent-to-cure treatment were 63% (95% CI, 39-100; number still at risk, 5) in the LRR group and 100% (95% CI, 100-100; number still at risk, 2) in the DM group. Conclusion Overall, LRR and DM for HPV-positive OPSCC following transoral robotic surgery-based therapy are infrequent. In our subset of patients who underwent intent-to-cure treatment, cancer-specific survival rates were favorable. Therefore, aggressive salvage treatment for LRR and DM for HPV-positive OPSCC should be recommended for appropriate candidates.

Outcomes of surgically treated human papillomavirus-related oropharyngeal squamous cell carcinoma with N3 disease.

OBJECTIVES/HYPOTHESIS: To evaluate outcomes for patients with pathological N3 (pN3) neck disease from human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) and determine variables predictive of survival. STUDY DESIGN: Retrospective case series with chart review. METHODS: This study was conducted between 1998 and 2013 and included patients with HPV-related OPSCC treated with surgery with or without adjuvant therapy and who had pN3 nodal disease. The primary outcome was disease-specific survival (DSS). Secondary outcomes included overall survival (OS), disease-free survival (DFS), adverse events, and gastrostomy tube rates. RESULTS: Thirty-nine patients were included, of whom 36 (90%) underwent adjuvant therapy. Median follow-up was 39 months (range, 2-147 months). Mean age was 56 years, and 87% were male. Seventeen patients (44%) underwent selective neck dissection, whereas six (15%) underwent radical (n = 2) or extended radical (n = 4) neck dissection. Ninety-two percent had extracapsular extension. Five-year Kaplan-Meier estimated DSS, OS, and DFS were 89% (95% confidence interval [CI]: 79%-99%), 87% (95% CI: 75%-99%), and 84% (95% CI: 72%-96%), respectively. The disease recurrence rate was 10% (5% regional, 5% distant metastasis). Patients with less than 5 pathologically positive lymph nodes (P = .041) had improved DFS. CONCLUSIONS: Patients with HPV-related OPSCC and pN3 nodal disease treated with surgery and adjuvant therapy have very favorable long-term survival and regional control. Patients with five or more pathologically positive lymph nodes may be at higher risk for recurrence. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2033-2037, 2017.

Oncologic outcomes of selective neck dissection in HPV-related oropharyngeal squamous cell carcinoma.

OBJECTIVES: To examine outcomes of selective neck dissection (SND) in patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) who present with clinical neck disease. STUDY DESIGN: Multi-institutional retrospective review. METHODS: Two institutional databases of patients with HPV-related OPSCC were reviewed to identify patients with clinical (c) N1-N3 neck disease who underwent SND ± adjuvant therapy. RESULTS: Three hundred and twenty-four patients were identified with a median follow-up of 49 months (range 3-199 months). All patients underwent transoral resection of the primary tumor and SND, including levels II-IV and ± levels I or V, with resection of additional nonlymphatic tissue (extended SND) as indicated by extent of disease, including the spinal accessory nerve (7%), the internal jugular vein (13%), and the sternocleidomastoid muscle (8%). Two hundred and seventy (83%) patients underwent adjuvant radiation. There were 13 (4%) regional recurrences and 19 (6%) distant recurrences. Regional control following salvage was 98%. On univariable analysis, absence of radiation was associated with regional recurrence (odds ratio [OR] 9.2, 95% confidence interval [CI] 2.9-29.4). On multivariable analysis, adjuvant radiation was associated with improved disease-free survival (DFS) (OR 0.27, 95% CI 0.14-0.53) but lost significance for overall (OS) and disease-specific survival (DSS) (P > 0.05). Five-year Kaplan-Meier estimates for OS, DSS, and DFS were 88% (95% CI 84%-92%), 93% (95% CI 89%-96%), and 83% (95% CI 78%-87%), respectively. CONCLUSION: In HPV-related OPSCC presenting with clinical neck disease, a SND ± additional tissue resection and adjuvant therapy, when indicated, provides excellent long-term regional control. Omission of radiotherapy increases the risk of regional recurrence, although it may not significantly impact OS or DSS. It appears unnecessary to routinely perform a comprehensive neck dissection. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:623-630, 2017.

Hemifacial Spasm Secondary to Parotid Pleomorphic Adenoma With Stylomastoid Foramen Extension.

OBJECTIVE: To report hemifacial spasm (HFS) as a rare presenting symptom of a benign parotid neoplasm involving the stylomastoid foramen. METHODS: Case report with literature review. RESULTS: An 18-year-old woman presented with a 1-year history of a progressively enlarging right infra-auricular mass with new onset ipsilateral severe HFS. Clinical vetting unveiled a palpable 2 cm, firm, minimally mobile mass medial to the angle of the mandible. Imaging revealed a heterogeneous intraparotid mass with tumor extension into the stylomastoid foramen. Diagnostic consideration was given to neurogenic tumors and neoplasms of parotid origin.The patient ultimately underwent superficial parotidectomy and the tumor was found superficial and extrinsic to the proximal facial nerve trunk but extended into the stylomastoid foramen. The tumor was removed after performing mastoidectomy with mastoid segment facial nerve decompression. Frozen section pathology was consistent with pleomorphic adenoma. Postoperatively the patient had normal facial nerve function with immediate and complete resolution of HFS. To date there are only three other published reports of benign parotid tumors presenting with HFS and this is the first illustrating intratemporal tumor extension. CONCLUSIONS: HFS is a rare presenting symptom associated with benign parotid neoplasms with scarce documentation in the literature. In this index case, tumor extirpation with mastoid segment facial nerve decompression provided immediate and durable resolution of symptoms.

Prefabricated auricular cartilage radial forearm free flap reconstruction for cricoid chondrosarcoma.

This case describes a subtotal cricoid cartilage defect reconstructed with a prefabricated composite free flap. A 61-year-old man with a chondrosarcoma of the cricoid cartilage required a subtotal cricoidectomy. The resulting defect was successfully reconstructed with a two-stage prefabricated radial forearm free flap utilizing auricular cartilage. Our case further adds to the evidence that prefabricated flaps are reliable in airway reconstruction. Additionally, this provides another option for laryngeal preservation in patients with laryngeal chondrosarcoma.

Ultrasonic shears in free-tissue transfer: increased efficiency and cost savings.

OBJECTIVE: The harvest of some microvascular free flaps for head and neck reconstruction entails tedious and time-consuming dissection of multiple perforating vessels and/or muscular attachments. The objective of this study is to investigate the use of ultrasonic shears as a means to decrease operative time and increase surgical efficiency in the harvest of microvascular free flaps. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary referral center. SUBJECTS AND METHODS: A prospective study of all people undergoing fibula (FFF) or anterolateral thigh (ALT) free flap reconstruction of head and neck defects was conducted from October 1, 2005, through December 30, 2009. RESULTS: There were 69 FFF and 39 ALT free flaps performed by a single surgeon during the study period. Ultrasonic shears were used in 53 (76.8%) FFF and 26 (80.6%) ALT free flaps, whereas traditional dissection techniques were used in 16 (23.2%) FFF and 13 (19.4%) ALT free flaps. The use of ultrasonic shears significantly decreased the harvest time of FFF and ALT free flaps an average of 14.5 and 16.3 minutes, respectively. The average cost savings associated with the use of ultrasonic shears was $492 for FFF and $543 for ALT free flaps compared to traditional dissections techniques. Similar rates of complications were observed when ultrasonic shears were used compared to traditional techniques. CONCLUSIONS: The use of ultrasonic shears in the harvest of microvascular free flaps decreases operative time, leading to significantly decreased costs without an increased risk of complications compared to traditional dissection techniques.

Concurrent neck dissection and transoral robotic surgery.

OBJECTIVES: 1) Determine the incidence of pharyngocutaneous fistula associated with transoral robotic oropharyngectomy with concurrent neck dissection. 2) Discuss prevention and treatment of pharyngocutaneous fistulization as a consequence of transoral oropharyngeal surgery with concurrent neck dissection. METHODS: Retrospective, single-institution chart review of 148 consecutive patients who underwent transoral robotic surgery with synchronous neck dissection for oropharyngeal neoplasia April 2007 to February 2010. RESULTS: Forty-two of 148 (29%) patients were identified as having an orocervical communication intraoperatively. All were managed with some combination of primary closure, local tissue advancement, fibrin glue application, and cervical drain placement. Of these, six (4%) developed a subcutaneous pharyngeal fluid accumulation requiring postoperative management via controlled incision and drainage with daily packing placement. All the patients had aesthetic and functional results comparable to those patients who did not have/develop an orocervical communication. No patients experienced a delay from their operative treatment that prevented them from initiating recommended adjuvant therapy on schedule. CONCLUSIONS: Transoral robotic surgery is emerging as a primary treatment modality for oropharyngeal malignancies. Neck dissection is a required portion of operative therapy in many of these patients, and many surgeons delay neck dissection to prevent pharyngocutaneous fistula. Pharyngeal communication with the neck is a common occurrence during transoral surgery when it is combined concurrently with neck dissection, but persistent fistula formation is an uncommon, preventable, but potentially problematic, complication resulting from this operative technique. Prompt recognition and intervention are of paramount importance in preventing acute, long-term functional impairment.