Readmission after surgery for oropharyngeal cancer: An analysis of rates, causes, and risk factors.

OBJECTIVES/HYPOTHESIS: Determine the rate, diagnoses, and risk factors associated with 30-day nonelective readmissions for patients undergoing surgery for oropharyngeal cancer. STUDY DESIGN: Retrospective cohort study. METHODS: We analyzed the Nationwide Readmissions Database for patients who underwent oropharyngeal cancer surgery between 2010 and 2014. Rates and causes of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission. RESULTS: Among 16,902 identified cases, the 30-day, nonelective readmission rate was 10.2%, with an average cost per readmission of $14,170. The most common readmission diagnoses were postoperative bleeding (14.1%) and wound complications (12.6%) (surgical site infection [8.6%], dehiscence [2.3%], and fistula [1.7%]). On multivariate regression, significant risk factors for readmission were major ablative surgery (which included total glossectomy, pharyngectomy, and mandibulectomy) (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.06-1.60), advanced Charlson/Deyo comorbidity (OR: 2.00, 95% CI: 1.43-2.79), history of radiation (OR: 1.58, 95% CI: 1.15-2.17), Medicare (OR: 1.34, 95% CI: 1.06-1.69) or Medicaid (OR: 1.82, 95% CI: 1.32-2.50) payer status, index admission from the emergency department (OR: 1.19, 95% CI: 1.02-1.40), and length of stay ≥6 days (OR: 1.57, 95% CI: 1.19-2.08). CONCLUSIONS: In this large database analysis, we found that approximately one in 10 patients undergoing surgery for oropharyngeal cancer is readmitted within 30 days. Procedural complexity, insurance status, and advanced comorbidity are independent risk factors, whereas postoperative bleeding and wound complications are the most common reasons for readmission. LEVEL OF EVIDENCE: 4. Laryngoscope, 129:910-918, 2019.

A case of squamous cell carcinoma of the nasal cavity in a patient with granulomatosis with polyangiitis (Wegener granulomatosis).

We report a rare case of squamous cell carcinoma (SCC) of the nasal cavity arising in a patient with granulomatosis with polyangiitis (GPA). The patient was a 35-year-old man who had been diagnosed 15 years earlier with GPA and treated medically for sinonasal, pulmonary, and renal involvement. He presented to us with left-sided orbital and cheek pain and nasal obstruction. Endoscopy detected a friable, exophytic mass that involved the left lateral nasal wall and septum. Biopsy analysis identified the mass as an SCC. A definitive endoscopic resection was performed, followed by chemoradiation, but the patient exhibited progression of disease 2 months after the cessation of therapy. He then underwent an open craniofacial resection and a second round of chemoradiation. At 7 months of follow-up, he remained disease-free. Sinonasal symptoms in GPA are consistent with those in chronic rhinosinusitis, but the presence of unilateral symptoms may suggest a neoplastic process. Immunosuppressants are implicated in the pathophysiology of this malignancy, but equally plausible is the oncogenic role of chronic inflammation.

Intratumor cisplatin nephrotoxicity in combined laser-induced thermal therapy for cancer treatment.

INTRODUCTION: Thermal ablation of tumors by Nd:YAG laser has been growing as a multidisciplinary subspecialty defined as laser-induced thermal therapy (LITT), and has been increasingly accepted as a minimally invasive method for palliation of advanced or recurrent cancer. Previous studies have shown that adjuvant chemotherapy can potentiate laser thermal ablation of tumors leading to improved palliation in advanced cancer patients. OBJECTIVE: Evaluate nephrotoxicity by early markers of renal function in treating head and neck cancer using intra-tumor injections of cisplatin combined with laser-induced thermal therapy (CDDP-LITT). METHODS: Nine patients with recurrent head and neck tumors were treated by CDDP-LITT in order to determine nephrotoxicity related to this synergistic association. Among the tests requested to detect early were creatinine, magnesium, creatinine clearance, serum urea-BUN, type I urine, and proteinuria at 24 hours. RESULTS: Twelve recurrent tumors in nine patients were treated by CDDP-LITT. Pain was the major complaint (four patients), while other symptoms included dysphagia, dyspnea, bleeding, and difficulties in chewing. Fifteen laser procedures were performed and maximal CDDP dose was 50 mg. None of the markers for nephrotoxicity showed changes at these levels of CDDP intra-tumor injections. CONCLUSION: This initial experience with (CDDP-LITT) indicates both safety and therapeutic potential for palliation of advanced head and neck cancer. However, safety and feasibility must be confirmed by longer follow-up and further escalation of CDDP doses in a Phase I study to determine maximum tolerated dose (MTD) and demonstrate tangible benefits for patients. Lasers Surg. Med. 49:756-762, 2017. © 2017 Wiley Periodicals, Inc.

Infarction of papillary thyroid carcinoma after fine-needle aspiration: case series and review of literature.

IMPORTANCE: Although infarction after fine-needle aspiration (FNA) is a rare occurrence, it is a known phenomenon that may lead to difficulties in interpretation for pathologists and in decision-making for head and neck surgeons. OBJECTIVE: To characterize our experience with infarction in papillary thyroid carcinomas (PTCs) after FNA and review existing cases of infarcted PTCs in the literature to better understand this phenomenon. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective case series and review of literature at a tertiary medical center (University of California, Los Angeles [UCLA], Medical Center). All patients who had a surgical pathologic diagnosis of infarcted PTC and who underwent FNA prior to surgery at UCLA from June 2006 to June 2012 were identified. There were 620 cases of PTC and 12 cases of infarcted PTC. MAIN OUTCOMES AND MEASURE: Demographic data, FNA cytologic findings, and surgical pathologic data were gathered for each patient. A comprehensive literature search for infarcted PTC was performed. RESULTS: Twelve cases of infarcted PTC were found in a total of 620 cases of PTC (1.9%). The mean (SD) time interval between the last FNA and surgery was 52 (35) days (range, 13-133 days). All patients received a diagnosis of infarcted PTC after thyroidectomy was performed. Focal infarction was found in 4 patients (33%), and near-total infarction was found in 8 patients (67%). Five patients (47%) had the follicular variant of PTC, making it the most common subtype in our series. A thorough literature search yielded 11 articles reporting a total of 26 cases of infarcted PTC after FNA. To our knowledge, our case series on infarcted PTC is the largest reported series in the literature. CONCLUSIONS AND RELEVANCE: Although infarction of PTC after FNA occurs infrequently, it may lead to difficulties in histologic diagnosis. Awareness of this phenomenon and its histologic associations, along with careful reevaluation of the FNA and surgical specimens, is important for appropriate diagnosis and subsequent treatment. At this point, infarction in PTC should not alarm a head and neck surgeon to change management, but future prospective studies with a large population of patients with infarcted PTCs are needed to establish the impact of infarction on differences in treatment outcomes for therapies that may be used in PTCs.

Update on laser photochemotherapy: an alternative for cancer treatment.

Although major progress has been made in surgery, radiation, and chemotherapy for the treatment of malignancy during the last 20 years, there has been little improvement in the survival of patients with recurrent or advanced head and neck cancer. Because of the ease and accessibility for surgery and their loco-regional biological behavior, head and neck cancers serve as an ideal model to test combined laser energy delivered via interstitial fiberoptics and chemotherapeutic agents activated by photo-thermal energy as an alternative, less invasive treatment for cancer. A number of investigators have shown that anthracyclines and cisplatin are likely candidates for light or heat activation in cancer cells. Maximum tolerated dose followed by photochemical and thermal activation via laser fiberoptics can improve treatment by sensitizing tumor response. The higher intratumor drug levels compared to systemic drug administration along with laser activation should also reduce systemic toxicity. In this article the authors analyze the concept of combining anti-cancer drugs and laser therapy and review the clinical application. In summary, the literature available suggests photochemotherapy with currently approved drugs and lasers may soon become an attractive alternative for cancer treatment.

Neck mass due to pedicle ossification after oromandibular reconstruction.

OBJECTIVES/HYPOTHESIS: To determine the radiographic incidence of heterotopic ossification and the clinical incidence of neck masses secondary to heterotopic ossification in a series of patients who underwent fibula free flap oromandibular reconstruction. STUDY DESIGN: Retrospective review at a university medical center. METHODS: Patient database of 520 consecutive fibula free flaps from 1995 to 2010 was reviewed to identify patients who had postoperative computed tomography (CT) scans of the neck to further investigate the radiologic presence of heterotopic ossification. Patient chart review was also performed to identify patients who had clinical evidence of neck masses consistent with heterotopic ossification. RESULTS: Of the 66 patients who had postoperative CT scans available for radiologic assessment, 43 (65%) showed heterotopic ossification of the fibula periosteum. Clinically, 14 of 520 patients (2.6%) presented with firm, level I or II neck masses that proved to be secondary to heterotopic ossification. CONCLUSIONS: Development of a firm neck mass after treatment of head and neck cancer often indicates recurrent tumor. Heterotopic ossification has not been previously reported as a potential etiology of neck masses after fibula free flap oromandibular reconstruction in the head and neck surgery literature. The radiographic incidence of this phenomenon is high, and the clinical incidence of neck masses secondary to heterotopic ossification is low. Heterotopic ossification can be distinguished from recurrent tumor on the basis of physical examination, radiographic assessment, and/or fine-needle aspiration biopsy. Awareness of heterotopic ossification should be included in the differential diagnosis of patients with a neck mass who have undergone fibula free flap reconstructions.

Disease relapse after segmental resection and free flap reconstruction for mandibular osteoradionecrosis.

OBJECTIVE: The objective of this study was to assess the outcomes, complications, and incidence of disease recurrence of mandibular osteoradionecrosis (ORN) after resection and microvascular free flap reconstruction. STUDY DESIGN: Case series with chart review. SETTING: Academic medical center. SUBJECTS AND METHODS: Retrospective patient data review of 40 patients with mandibular ORN who were treated by segmental mandibulectomy and microvascular reconstruction between 1995 and 2009. All patients received radiation therapy for previous head and neck cancer, and 12 of 40 patients received concurrent chemotherapy. All patients failed to respond to conservative management. There were 26 males and 14 females, with a median age of 62 years. Median follow-up was 17.4 months. RESULTS: There were no free flap failures. The incidence of wound-related complications was 55 percent. Median time to complication was 10.6 months. Ten (25%) patients developed symptoms of residual or recurrent ORN, with 70 percent of the recurrences arising in unresected condyles that were adjacent to the segmental mandibulectomy. Statistical analysis revealed that current smokers were at reduced risk to develop residual or recurrent ORN. CONCLUSION: This present study confirms that microvascular free flaps are reliable for treatment of advanced mandibular ORN. Nevertheless, there remains a 55 percent incidence of wound-healing complications. The lack of objective clinical criteria to judge the appropriate amount of mandible resection in patients with ORN remains an unresolved issue that resulted in the development of recurrent ORN in 25 percent of patients. Further investigations are needed to better understand the pathophysiology of ORN to prevent postoperative wound complications and disease recurrence.

Outcomes of laser thermal therapy for recurrent head and neck cancer.

OBJECTIVE: To review the outcomes of a phase II study using laser-induced thermal therapy (LITT) as a palliative treatment for 106 patients with recurrent head and neck tumors. STUDY DESIGN: Retrospective study. SETTING: Tertiary hospital in the United States. SUBJECTS AND METHODS: The primary endpoints were tumor response and survival. Prognostic values were assessed by the Kaplan-Meier method. RESULTS: The best results were seen in oral cavity tumors, in which mean survival was 29.1 months, as compared to neck tumors (mean 14.4 +/- 6.9 months; range 7.5-20.7 months; with a 95% confidence interval). Further analysis showed that clinical factors such as gender, smoking, and alcohol use were not indicators of poor prognosis, whereas neck disease and tumor stage at first treatment were relevant factors. CONCLUSION: In this study, 40 out of 106 patients treated by LITT remained alive at the end of our follow-up, and a complete response was seen in 24 (22.6%) patients. The highest response rate was seen in oral cavity tumors, which suggests that tumor location at this site may be a predictor of favorable outcome with LITT.

Laser-induced thermal therapy and cisplatin for recurrent head and neck cancer: a case characterized by an unusually long disease-free survival.

Recurrent squamous cell carcinoma after major surgery and microvascular reconstruction with a free-flap transfer is difficult to handle via conventional treatment methods. Based on our experience with laser-induced thermal therapy for recurrent head and neck tumors, we explored an aggressive treatment protocol using laser thermal ablation with concurrent cisplatin chemotherapy as a minimally invasive option for the treatment of a patient with recurrent squamous cell carcinoma of the neck who had previously undergone a reconstructive free-flap transfer. Because of the very favorable outcome we observed in this patient with this combined treatment modality, we report this case, and we review some aspects of the treatment proposed. The remarkable survival of this patient suggests that the combination of laser-induced thermal therapy and chemotherapy warrants further investigation as an alternate treatment for patients with recurrent head and neck cancer.

The use of ultrasonic shears for the harvest of perforator free flaps.

A retrospective chart review was performed at a university medical center to evaluate the use of ultrasonic shears for the harvest of perforator free flaps over an 18-month period. The anterolateral thigh (ALT) was the perforator free flap site selected for the study. The site of origin and the number of musculocutaneous perforator vessels that were dissected using ultrasonic shears were recorded, and ALT flap viability and wound-healing complications were evaluated to assess safety. Seventeen patients underwent harvest of ALT perforator free flaps. Successful dissection of musculocutaneous perforators was achieved in 96% (27 of 28) of the descending branch perforators and in 100% (9 of 9) of the transverse branch perforators. Flap viability was 100% (17 of 17). We found that ultrasonic shears were effective and safe to use for harvesting perforator free flaps. According to these preliminary findings, the use of ultrasonic shears appears promising, yet further prospective analysis is needed.

Retention of intratumor injections of cisplatinum in murine tumors and the impact on laser thermal therapy for cancer treatment.

Recent studies using murine models of human squamous cell carcinoma (SCCA) have revealed a significant improvement in survival and cure rate of animals transplanted with human SCCA when treated with a combination of intratumor injections of chemotherapy and laser induced thermal therapy (LITT). These preliminary results suggest that this novel combination therapy may lead to improved clinical response compared to either treatment modality alone. Using a murine model of human SCCA we investigated two different modes of intratumor injection of cisplatin: a sustained-release cisplatin gel implant (CDDP/gel) versus cisplatin in solution (CDDP) at varying doses (range 1-3 mg/ml). In addition, we tested CDDP/gel combined with LITT. Results showed optimal drug concentration (30-300 nM) at tumor margins up to 4 h after injection of CDDP/gel implant compared to 3 nM at 5 min after injection with CDDP solution. Combined CDDP/gel and laser therapy significantly decreased tumor volume (P<0.05), with recurrence in only 25% of animals tested, compared to 78% tumor regrowth after LITT alone. These results suggest that laser chemotherapy may be an effective treatment for head and neck SCCA.

Reirradiation after salvage surgery and microvascular free flap reconstruction for recurrent head and neck carcinoma.

OBJECTIVE: To evaluate the outcome and complications of reirradiation of recurrent head and neck cancer after salvage surgery and microvascular reconstruction. STUDY DESIGN: Retrospective. SUBJECTS AND METHODS: Twelve patients underwent salvage surgery with microvascular reconstruction for recurrent or second primary head and neck cancer in a previously irradiated field. Median prior radiation therapy dose was 63.0 Gy. Patients then underwent postoperative reirradiation, and received a median total cumulative radiation dose of 115.0 Gy. RESULTS: Three (25%) patients experienced acute complications (<3 months) during reirradiation. Four (33%) patients developed grade 3 or 4 late reirradiation complications (>3 months). There were no incidences of free flap failure, brain necrosis, spinal cord injury, or carotid rupture. The incidence of soft tissue necrosis and osteoradionecrosis was 8%. Six (50%) patients are alive without evidence of recurrent disease a median of 40 months after reirradiation. CONCLUSION: Microvascular free flaps allow for maximal resection and reliable reconstruction of previously irradiated cancers before high dose reirradiation and may reduce the incidence of severe late complications and treatment related mortality.

Cystic parathyroid presenting as an apparent thyroid goiter.

Parathyroid cysts are rare lesions that can present clinically as low neck masses. The clinical diagnosis of parathyroid cyst can be challenging and requires a high level of suspicion as it often mimics a thyroid nodule. The cyst occasionally can cause compressive symptoms such as dysphagia or dyspnea. When it occurs in the mediastinum, it can cause recurrent laryngeal nerve paralysis. In this report, we present a patient with a hyperfunctional parathyroid cyst in association with a papillary thyroid carcinoma. In addition, we briefly discuss the current literature on parathyroid cyst. This case is unusual in its clinical presentation in that the parathyroid cyst mimicked a thyroid goiter.

Evaluation of hardware-related complications in vascularized bone grafts with locking mandibular reconstruction plate fixation.

OBJECTIVE: To identify the incidence of hardware and bone-healing complications in patients who underwent locking mandibular reconstruction plate (LMRP) fixation of vascularized bone grafts for reconstruction of segmental mandibular defects. DESIGN: Case series. SETTING: Academic tertiary care medical center. PATIENTS: One hundred one patients who had undergone LMRP fixation of vascularized bone grafts for reconstruction of segmental mandibular defects with a minimum follow-up of 6 months. MAIN OUTCOME MEASURES: Association of patient- and defect-related characteristics with the incidence of loose screws, osteosynthesis nonunion, and complications necessitating hardware removal. RESULTS: The incidence of loose screws was 0.8% in 984 locking screws implanted. The incidence of nonunion was 0.7% in 290 osteosyntheses. Overall, 15 of 101 LMRPs (14.8%) were removed because of hardware-related complications, with plate extrusion (n = 10) the most common complication necessitating hardware removal. Pathologic diagnosis (P = .002), previous treatment with hyperbaric oxygen (P < .001), radiation therapy (P < .001), and cancer recurrence (P = .03) were statistically significant predictors of LMRP-related complications at univariate analysis. At multivariate analysis, previous treatment with hyperbaric oxygen (P < .046) remained a statistically significant predictor of LMRP-related complications. CONCLUSIONS: In patients undergoing mandibular reconstruction, LMRPs are highly effective for fixation of vascularized bone grafts, with a high incidence of bone-graft healing and a low incidence of complications related to loose screws. Nevertheless, there remains a 15% incidence of hardware-related complications, most related to hardware extrusion. Previous treatment with hyperbaric oxygen is a statistically significant predictor of LMRP-related complications.

Salivary duct carcinoma: a clinical and histologic review with implications for trastuzumab therapy.

BACKGROUND: Salivary duct carcinoma (SDC) is an aggressive tumor of the head and neck with a poor prognosis. The objective was to study SDC and recommend the use of trastuzumab as adjuvant therapy. METHODS: A retrospective chart review of patients seen between 1993 and 2006 was performed. Tumor specimens were examined for HER-2 protein overexpression via immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) methods. RESULTS: Of the 7 patients with SDC, 57% had tumors arising in the parotid gland, the majority having facial nerve paralysis, 71% with nodal disease, and 43% having recurrence. All samples were HER-2 positive on IHC. Three patients had FISH-positive tumors, recurrent disease, and received trastuzumab therapy; 1 of the 3 died after 20 months and a second has shown disappearance of metastatic disease. CONCLUSIONS: Trastuzumab is effective in treating HER-2-positive breast cancer. Given immunohistochemical similarities between SDC and ductal carcinoma of the breast, patients with FISH-positive HER-2/neu SDC should be considered for trastuzumab therapy.

Salvage surgery with free flap reconstruction: factors affecting outcome after treatment of recurrent head and neck squamous carcinoma.

OBJECTIVE: To determine factors predicting the outcome after salvage surgery with microvascular flap reconstruction for recurrent squamous cell cancer (SCC) of the head and neck. STUDY DESIGN: This is a retrospective analysis of patients treated at an academic medical center. METHODS: One hundred six patients underwent salvage surgery and microvascular flap reconstruction after prior unsuccessful cancer treatment using surgery, radiation, or chemotherapy. All patients had a follow-up interval after salvage surgery of at least 24 months unless cancer rerecurrence occurred within 24 months after salvage surgery. Factors including age, sex, comorbidity level, tobacco use, alcohol use, disease-free interval since prior therapy, prior radiation, prior chemotherapy, prior surgery, recurrent tumor T class, recurrent tumor N class, recurrent cancer stage, and tumor location were examined to determine their association with cancer rerecurrence after salvage surgery. Successful treatment was defined as patients who remained free from cancer rerecurrence for a minimum 2 year period after salvage surgery. RESULTS: Advanced recurrent T class (P = .02) was significantly associated with cancer recurrence. Recurrent cancer stage and patient smoking status approached statistical significance (P = .06). CONCLUSION: Patients with recurrent T1 and T2 class are the best candidates for salvage surgery and microvascular flap reconstruction for treatment of recurrent SCC of the head and neck. Patients with T3 and T4 class recurrent cancers and patients who continue to smoke after initial diagnosis and treatment of head and neck SCC are poor candidates to undergo salvage surgery.

Positron emission tomography: poor sensitivity for occult tonsillar cancer.

PURPOSE: The aim of the study was to determine the sensitivity of preoperative positron emission tomography (PET) scans in the detection of primary tumors of the tonsils. MATERIALS AND METHODS: We conducted a retrospective review of 46 patients treated at a university medical center for occult tonsillar cancer during the years 2002 to 2004. We identified patients who underwent a preoperative PET scan to locate an unknown primary tumor. Fusion computed tomography with PET (PET/CT) was used to further delineate anatomic localization to the tonsil area. A positive PET/CT scan was defined as asymmetric increased tracer uptake in the tonsil and/or tonsillar fossa ipsilateral to the tonsillar cancer site when compared with the contralateral site. A negative PET/CT scan was defined as equivocal symmetric tracer uptake bilaterally. RESULTS: Of the 46 patients, 6 (13.0%) had pretreatment PET scans. Of these 6 patients, 16.7% (n = 1) had positive PET, 66.7% (n = 4) had negative PET, and 16.7% (n = 1) demonstrated increased tracer uptake in tonsils bilaterally greater on the side contralateral to the cancer. In this group, PET scans had a sensitivity of 0.167 and false-negative ratio of 0.667 for tonsillar cancer detection. CONCLUSIONS: Although the patient population in this study is small (n = 6), the findings suggest that PET/ CT scans may offer a low sensitivity in detection of primary tonsillar cancers. However, PET/CT scans still have a significant role in the detection of other unknown primary head and neck tumors. Technical reasons for this finding are discussed.