Is open surgery for head and neck cancers truly declining?

In the past two decades, major modifications in the way we treat head and neck cancers, due to advances in technology and medical oncology, have led to a decline in the use of open surgery as first-line treatment of cancers arising from several primary tumor sites. The incidence of tobacco- and alcohol-related squamous cell carcinoma of the pharynx and larynx has been steadily decreasing, with a rise in the incidence of human papillomavirus-related oropharyngeal tumors and the use of minimally invasive endoscopic surgery and non-surgical treatment modalities has increased in the treatment of all of these tumors. However, open surgery remains the initial definitive treatment modality for other tumors, including tumors of the skin, oral cavity, sinonasal cavities and skull base, salivary glands, thyroid and sarcomas. Selected group of nasal, paranasal, base of the skull and thyroid tumors are also candidates for minimally invasive procedures. For some indications, the rate of open surgery has actually increased in the past decade, with an increase in the incidence of oral cavity, thyroid and skin cancer, an increase in the number of neck dissections performed, and an increase in salvage surgery and free flap reconstruction. The use of minimally invasive, technology-based surgery—with the use of lasers, operating microscopes, endoscopes, robots and image guidance—has increased. Technology, epidemiology and advances in other domains such as tissue engineering and allotransplantations may further change the domains of competencies for future head and neck surgeons.     

Erythropoietin in patients with head and neck carcinomas?

BACKGROUND: Various studies have demonstrated the prognostic significance of the pretherapeutic blood hemoglobin concentration for patients with head and neck cancer following surgery or primary definitive or adjuvant radio- or radiochemotherapy. It was the aim of this study to evaluate whether the prognosis of these patients might be improved when correcting decreased pretherapeutic hemoglobin values by administering erythropoietin. METHOD: In a prospective placebo-controlled double-blind study (Cochrane "evidence-based medicine" level Ib) the effect of erythropoietin was analyzed in patients with locally advanced head or neck tumours with low blood hemoglobin values (women: < 12 g/dL; men: < 13 dL) and a Karnofski value of > 60 following primary definite or adjuvant radiotherapy (up to 70 Gy). The time to local tumour progression and survival was evaluated. Kaplan-Maier estimates were applied and, the relative risk of well-known prognostic factors tested for with a Cox Proportional Hazards model. RESULTS: 157 patients of the Freiburg University ENT-clinic were recruited from 1997 to 2001. Study conduct was performed according to the GCP guidelines. A rapid increase of the blood hemoglobin value happened during the first five weeks of treatment under epoetin beta. Placebo patients experienced only minor changes of the hemoglobin value. Following adjuvant radiotherapy local tumour control probability at two years was 68 % +/- 7 % and 72 +/- 7 % for placebo and epoetin beta patients, respectively (p = 0.64). Patients who had undergone primary definite radiation experienced a local control probability of 36 % +/- 11 % in the placebo arm after two years, compared to epoetin beta with 23 % +/- 11 % (p = 0.05). CONCLUSION: Epoetin beta resulted in prompt and stable correction of blood hemoglobin values in anemic patients with advanced head or neck tumours, but tumour control and survival was impaired particularly in patients with a high tumour burden.     

Castleman’s disease of the head and neck

Castlemans disease is an uncommon benign disease that causes progressive lymph node enlargement. We report 12 cases of Castlemans disease in the head and neck region in a retrospective review of the medical records of all patients with the pathological diagnosis of Castlemans disease during the period of 1993 through 2002. In the 12 patients, the neck was the most commonly involved site with 9 (75%) cases. Level III was the most common subsite (five cases). The most common sign in our study was an asymptomatic neck mass. No patient had any past histories that required medical attention. Preoperative work up such as fine-needle aspiration and radiographic study was not helpful for diagnostic confirmation. The histopathologic evaluation was the only way to make a definitive diagnosis. The histopathologic subtype of our study was hyaline-vascular type. Excision was curative for all cases. There was no evidence of recurrence with a minimum follow-up duration of 24 months.     

Is elective neck dissection indicated during salvage surgery for head and neck squamous cell carcinoma?

Among patients with head and neck squamous cell carcinoma with a negative neck who are initially treated with (chemo)radiotherapy, a number of cases will recur locally without obvious neck recurrence. There is little information available as to the most efficacious management of the neck in these cases. We have reviewed the literature to see what conclusions can be drawn from previous reports. We conducted a bibliography search on MEDLINE and EMBASE databases. Studies published in the English language and those on squamous cell carcinoma of the oral cavity, nasopharynx, oropharynx, larynx and hypopharynx were included. Data related to neck management were extracted from the articles. Twelve studies satisfied the inclusion criteria. Five studies reported only one treatment plan (either neck dissection or observation), while the others compared neck dissection to observation. The rate of occult metastases ranged from 3.4 to 12 %. The studies included a variable distribution of primary sites and stages of the recurrent primary tumors. The risk of occult neck node metastasis in a clinically rN0 patient correlated with tumor site and T stage. Observation of the neck can be suggested for patients with T1-2 glottic tumors, who recurred with less advanced tumors (rT1-2). For patients with more advanced laryngeal recurrences or recurrence at other high-risk sites, neck dissection could be considered for the rN0 patient, particularly if the neck was not included in the previous radiation fields.     

Ex-vivo-chemoresponse testing of head and neck cancer: an old hat?

Reliable prediction of the chance of a successful treatment of head and neck squamous cell carcinoma by cytostatics and targeting therapies would be very valuable, since HNSCC due to their heterogenic biology mostly respond non-uniformly and moreover with low response rates. To raise the prospect of chemotherapy by using multimodal therapies usually goes hand in hand with a higher incidence of severe adverse events and acute toxicity but also chemo-associated increased cancer risk following successful treatment. In addition, the increasing numbers of treatment options without availability of reliable prognostic biomarkers for a probably successful outcome make the decision for one or the other medication to something rather like gambling. Therefore, quite early a pre-therapeutic predictive exvivo chemoresponse testing of bioptic specimens was intended. However, the results gained mostly were disillusioning and allowed not for reliable prediction of chance of successful outcome of treatment with tolerable doses of the pharmaceuticals and in particular their combinations. Predictive testing, hence, was belittled as improper for the clinical context. Based on advanced methods, some working groups reassume this subject. This review describes recent advances in ex-vivo chemoresponse testing, discusses pre-requisites which have to be fulfilled before their inclusion into decision-making, and outlines why ex-vivo chemoresponse testing probably is not an old hat.     

Managing regional metastasis in patients with cutaneous head and neck melanoma – is selective neck dissection appropriate?

Background

Neck dissection is recommended for patients with head and neck cutaneous melanoma and nodal metastasis. However, there appears to be no clear evidence to guide the extent of nodal resection.

Methods

Loco-regional recurrence (LR), overall survival (OS) and progression free survival (PFS) was retrospectively compared between patients who had Comprehensive neck dissection (CND) and Selective neck dissection (SND).

Results

There was no difference in LR, OS and PFS between CND (n = 18) and SND groups (n = 79). Extra capsular extension (ECE), frontal disease and increasing number of involved nodes resulted in worse OS and PFS but had no impact on LR.

Conclusion

Patients with disease limited to one node without ECE can be effectively treated by SND alone. In patients who have these unfavourable pathological features more extensive nodal resection does not improve outcome if they receive radiotherapy. Extent of neck dissection or adjuvant radiotherapy has no impact on overall survival.     

Conformal radiotherapy in head and neck tumors: increased tumor control and decreased morbidity?

Conformal radiotherapy in head and neck tumors is only at its premise. Its offers attractive prospect to decrease late morbidity and increase loco-regional control probability not only in patients with primary treatment but also in patients with recurrent disease previously fully irradiated. Such modality however, requires complex infrastructure and qualified staff. Comprehensive evaluation are thus needed to determine the patient population that will benefit the most from this new promising technique before its use can be generalized.     

Complications associated with Dermabond® during head and neck surgery: MAUDE and literature review

IntroductionDermabond® is a liquid surgical sealant containing 2-octyl-cyanoacrylate that has been widely used during head and neck surgeries. This study aims to provide a summary of adverse events related to Dermabond® in head and neck procedures as reported in the MAUDE database, and to report a complete overview of all documented adverse events related to Dermabond® use in current literature.MethodsThe US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database was queried for reports of adverse events related to Dermabond® use from January 1, 2010, to February 1, 2020. Data were extracted from reports pertaining to head and neck procedures. In addition, literature review was performed from January 1970 to January 2021. Various adverse events related to Dermabond® were included in the study.ResultsWe identified 32 adverse events, from which 29 (90.6%) were patient-related events and 3 (9.4%) were operator-related events. Of the patient-related events, contact dermatitis (CD) (20 [69.0%]) was the most common, followed by wound dehiscence (4 [13.8%]). All of the operator-related events were from inadvertent cut injury (3 [100%]). Following the literature review, adverse events of Dermabond® were categorized into CD, wound dehiscence, infection, and cut injury.ConclusionDermabond® demonstrated utility in various surgical procedures including head and neck surgeries but are associated with risks. This study identified adverse events associated with Dermabond®. Further studies are needed to establish the causation of contact dermatitis in certain populations.     

Risk-adjusted comparative audit. Is Possum applicable to head and neck surgery?

Possum (the physiological and operative severity score for the enumeration of mortality) is used in many surgical specialities for comparative audit. We investigated its validity in relation to head and neck surgery by retrospectively scoring 301 operative interventions. We also applied the P-Possum (Portsmouth Possum) equation for mortality. We compared our observed with the predicted outcomes. We introduced two new variables, radiotherapy and previous surgery to the operative site, to test their association with outcome. We found that Possum is valid for morbidity but predicts more accurately for high-risk than for low-risk groups. Neither Possum or P-Possum accurately predicts mortality. Radiotherapy and previous surgery were both significant for the development of postoperative complications (P = 0.002, P = 0.007 respectively) and are worthy of inclusion in a Possum score for head and neck surgery.     

Can we get rid of hospital infections in head and neck surgery?

Infection rate registered on the basis of clinical symptoms and of microbiological forms in patients treated in Surgery Division, Head & Neck Cancer Department during 2001-2003, was analyzed. Total number of patients treated was 2343. In 664 preoperative microbiological cultures have been obtained from suspected areas and in 52.8% of these a pathogen has been found. Patients undergoing major surgery received a prophylactic antibiotic selected by an infection control team and Microbiology Department. If preoperative cultures showed resistance to standard prophylactic antibiotic, another was selected on the antibiogram basis. Particular attention was paid to all the elements of prophylactic against infection in the ward, examination and dressing rooms, operating theatre. In 48% of patients, mainly those after extensive, prolonged surgery, antibiotics (usually 3rd generation cephalosporins) were used for 5-7 days. During 2001, 2002 and 2003 correspondingly 148, 97 and 58 infections were registered with positive culture and infection with clinical symptoms occurred in 30, 21 and 20 patients (4%, 2,8% i 2,3%). Comparisons of hospital infection rates between different institutions are very difficult, but relatively low rate in our material and decreasing number of infections registered during consecutive years show that persistent and multifaceted prophylactic interventions can result in significant reduction of hospital infections also in patients wits contaminated surgical field.     

Safety of the “incidental” neck dissection or exploration during free tissue transfer after head and neck irradiation

ImportancePatients with either local recurrence of head and neck cancer or osteoradionecrosis after prior radiation treatment often require free tissue transfer for optimal reconstruction. In this setting, neck exploration for vessels is necessary, and an “incidental” neck dissection is often accomplished despite clinically negative cervical lymph nodes. While neck surgery in the post-radiated setting is technically challenging, the safety of post-radiated elective neck dissection or neck exploration for vessels is not well-studied, especially for patients undergoing non-laryngectomy salvage resections.ObjectiveTo define intraoperative and postoperative surgical complications for patients undergoing elective neck dissection or exploration with free tissue transfer reconstruction in the post-radiated setting, with attention to complications from neck surgery.DesignRetrospective cohort study. Patient charts from May 2005 to April 2020 were reviewed.SettingTertiary care referral center.ParticipantsPatients underwent free tissue transfer after prior head and neck irradiation for non-laryngeal local cancer recurrence or second primary, osteoradionecrosis, or for sole reconstructive purposes. Patients with clinically positive neck disease were excluded.Main outcomes and measuresIntraoperative and postoperative complications including unplanned vessel or nerve injury, hematoma, chyle leak, wound dehiscence, wound infection, fistula formation, flap failure, and perioperative medical complications. Neck exploration and neck dissection patient outcomes were compared by Fisher exact test.ResultsSeventy-two patients (56 men and 16 women) of average age sixty-one (range 34–89) were identified with average follow-up 25.7 months. Most patients (78%) underwent salvage neck dissection, and the rest underwent neck exploration for vessels only. There were five intraoperative neck complications: three vessel injuries and two nerve injuries. There were twenty-six postoperative surgical complications among eighteen patients. There was no difference in surgical complications whether patients underwent neck dissection or exploration only. Two partial and two complete flap failures occurred. There were nine perioperative medical complications among six patients.Conclusions and relevanceElective neck dissection or exploration among patients undergoing free tissue transfer in the post-radiated setting carries a risk of both intraoperative and postoperative surgical complications. The present study defines risk of complications and helps to inform patient discussions for risk of complications in the post-radiated setting.