Pirgousis, Phillip

Objectives: Despite advantages of titanium mesh, hardware exposure affects up to 25% of cases reported in the literature. We aim to identify risk factors associated with titanium mesh exposure following cranioplasty and characterize early wound changes that may signal impending hardware exposure. Methods: A review of 34 patients who underwent titanium mesh cranioplasty between 2015 and 2025 was performed. Seventeen patients with hardware exposure were matched 1:1 with 17 controls. Data on demographics, comorbidities, operative details, and postoperative complications were collected. Statistical analysis included Fisher exact test and t tests, with significance set at P <0.05. Results: Significant risk factors for titanium hardware exposure included a history of metal allergy and reconstruction with advancement flaps. Significant protective factors included patients undergoing postoperative radiation therapy and reconstruction with rotational flaps. Conclusions: Titanium mesh exposure risk increases with metal allergy history, postoperative radiotherapy, and use of advancement flaps for reconstruction. Recognition of early wound changes is crucial for timely intervention. These findings support individualized surgical planning and highlight the need for close postoperative monitoring to reduce complications and improve reconstructive outcomes.

Localized cutaneous squamous cell carcinoma (cSCC) has a favorable prognosis, unlike advanced disease, especially with clinical perineural invasion (PNI), which poses substantial management challenges due to aggressivity and higher recurrence, metastasis, and mortality risks. PNI, a high-risk staging feature, has worse outcomes, particularly when clinically evident rather than incidental. Clinical PNI (cPNI) is evident by clinical symptoms (such as pain, paresthesia, or motor deficits) or radiologic findings, whereas incidental PNI (iPNI) is identified only histologically without associated symptoms or radiologic evidence. PNI remains a novel area with varying practice patterns across institutions. Improving risk stratification and tailoring multidisciplinary approaches are critical for optimizing outcomes. Our review outlines clinical practice patterns at our institution, providing insights into managing cSCC with PNI, focusing on diagnosis, imaging, staging, and emerging immunotherapies. A structured search was conducted using the terms “perineural invasion,” “cutaneous squamous cell carcinoma,” and “immunotherapy.” cPNI has a poor prognosis and requires nuanced clinical decision-making. Surgery and radiation remain central to management. Adjuvant therapy offers substantial survival benefit in cSCC with PNI, with improved disease-free and overall survival compared with surgery alone, supporting its use in appropriately selected high-risk patients. Traditional systemic therapies, including cisplatin and cetuximab, remain foundational but have shown only moderate response rates and limited durability in advanced or neurotropic cSCC. In contrast, immunotherapy—now preferred for advanced or unresectable cases—has transformed management, with programmed cell death protein-1 (PD-1) inhibitors showing promising results (up to 69% response rate) and disease stabilization. Neoadjuvant immunotherapy may enable tumor downstaging, improve radiation planning, and reduce surgical morbidity. Imaging for squamous cell carcinoma (SCC) with PNI aids staging and surveillance, but symptoms remain key for detecting recurrence. Our multidisciplinary approach emphasizes personalized care. Larger trials are needed to define the optimal role and sequencing of immunotherapy in this high-risk patient population.

ABSTRACT Background As head and neck cancer survival rates improve, there is growing demand for quality survivorship care and tools to predict patient adherence; this study aims to evaluate an advanced practice provider ( APP )‐led survivorship clinic and assess these key metrics. Methods We performed a retrospective review of 213 head and neck cancer patients treated with curative radiation therapy between 2016 and 2023, to assess follow‐up adherence in an advanced practice provider–led survivorship clinic. Results With a median follow‐up of 2.4 years, follow‐up care metrics identified high completion percentages (> 90%) for lung cancer screening, smoking cessation, thyroid screening, dental evaluation, xerostomia, dysphagia, and dysgeusia. The HOUsing ‐based SocioEconomic Status ( HOUSES ) index at diagnosis showed a significant adherence difference (median percentile, 78% vs. 55%, adherent vs. nonadherent; p = 0.03). Conclusions High adherence rates with guideline‐defined care metrics are achievable in an advanced practice provider‐led head and neck cancer survivorship clinic. The HOUSES index may assist in predicting nonadherence; however, further studies are needed.

Abstract Synchronous squamous cell carcinoma (SCC) and chronic lymphocytic leukemia (CLL) in the parotid gland is rare, with limited evidence on personalized treatment. We report a 75-year-old male with prior cutaneous SCC who presented with a hypermetabolic parotid mass and cervical lymphadenopathy; fine needle aspiration confirmed SCC. Surgery revealed poorly differentiated SCC and CLL in multiple lymph nodes. He underwent radiotherapy but developed regional SCC relapse without systemic CLL symptoms. Recurrence in the ear required extensive surgical resection and reconstruction. Genetic profiling showed high tumor mutational burden (&gt;50 mutations/Mb) and mutations in ARID1B, CDKN2A, MSH2, PMS2, and TP53. He received six cycles of cemiplimab followed by cetuximab-based targeted therapy, based on rising circulating DNA levels. This case emphasizes the value of genetic profiling and tools like TMB, FISH, and immunohistochemistry for risk stratification and personalized treatment in managing advanced or complex parotid malignancies, including synchronous SCC and CLL, to optimize patient outcomes.

ABSTRACTObjectivesThyroglossal duct cyst (TGDC) associated carcinoma is rare, accounting for less than 2% of TGDC cases. The majority of cases are classified as papillary thyroid carcinoma (PTC). Standard treatment for TGDC‐PTC involves a Sistrunk procedure and prophylactic total thyroidectomy (TT). However, the necessity of these extensive surgical interventions remains debated. This report aims to explore whether individualized surgical approaches may reduce morbidity while maintaining favorable oncological outcomes.MethodsRetrospective case series of three patients with TGDC‐PTC.ResultsThe age range at presentation for our patients with TGDC‐PTC was 26 to 50. Case 1 involved a 38‐year‐old patient with a cystic mass near the hyoid bone and submental lymphadenopathy who underwent cyst excision with level Ia lymph node clearance. Case 2 is of a 50‐year‐old patient with a history of TGDC‐PTC who presented with a recurrent neck mass 9 years after the initial surgery and underwent a revision Sistrunk procedure. Case 3 presents a 26‐year‐old patient with a large TGDC and a benign thyroid nodule who underwent a Sistrunk procedure. All three patients had PTC confirmed by final pathology. All had no evidence of recurrent disease at follow‐up evaluations ranging from 1 to 12 years.ConclusionThis case series demonstrates the feasibility and safety of individualized surgical management for TGDC‐PTC. Risk stratification allowed for tailored interventions and avoided overly aggressive approaches. Further studies are needed to establish definitive guidelines for managing TGDC‐PTC, particularly in low‐risk patients.Level of Evidence4.

ABSTRACTBackgroundDespite the general perception of minimal donor‐site morbidity associated with scapular free flaps, the surgical harvest of scapular bone and subsequent reattachment of parascapular muscle have the potential to compromise postoperative shoulder function. A comprehensive assessment of functional impairment remains undocumented in the literature. Therefore, this systematic review was conducted to thoroughly explore both subjective and objective donor‐site morbidity following free flap surgery.MethodsSearches were conducted on PubMed, Embase, and CENTRAL to locate articles addressing functional donor‐site morbidity after the transfer of scapular bone. Qualifying articles reported scapular free flaps which utilized bone, including lateral border, medial border, and scapular tip. Each measured donor‐site morbidity using at least one of these measures: Constant‐Murley score (CM), Disabilities of Arm, Shoulder, and Hand questionnaire (DASH), shoulder range of motion (ROM), and shoulder strength.ResultsThe search culminated in 16 eligible studies, incorporating data from 316 cases. The CM was employed in five studies, yielding mean values from 60.6 to 95, while the DASH was utilized in nine studies, with means ranging from 10.44 to 46.7. Compared to normative values, these CM and DASH scores reflected negligible to mild impairment in shoulder function. Additional evaluations of shoulder ROM, conducted in four studies, revealed modest yet statistically significant reductions in flexion, abduction, and external rotation. Three studies measuring shoulder strength reported associated mild weakening of these motions.ConclusionsThis systematic review enables healthcare providers to characterize the probable scope of shoulder dysfunction following scapular bone harvest. Patient‐reported outcomes imply a high tolerance for the procedure, while objective measures denote the potential for substantial restoration of shoulder function approaching preoperative levels. To augment the understanding of functional recovery, future research should incorporate a comparative analysis of preoperative and postoperative functional metrics for each subject.

IntroductionPatients who become severely ill from coronavirus disease 2019 (COVID‐19) have a high likelihood of needing prolonged intubation, making tracheostomy a likely consideration. The infectious nature of COVID‐19 poses an additional risk of transmission to healthcare workers that should be taken into consideration.MethodsWe explore current literature and recommendations for tracheostomy in patients with COVID‐19 and look back at previous data from severe acute respiratory syndrome coronavirus 1 (SARS‐CoV‐1), the virus responsible for the SARS outbreak of 2003.ResultsGiven the severity and clinical uncertainty of patients with COVID‐19 and the increased risk of transmission to clinicians, careful consideration should be taken prior to performing tracheostomy. If tracheostomy is performed, we recommend a bedside approach to limit exposure time and number of exposed personnel. Bronchoscopy use with a percutaneous approach should be limited in order to decrease viral exposure.ConclusionThorough preprocedural planning, use of experienced personnel, enhanced personal protective equipment where available, and a thoughtful anesthesia approach are instrumental in maximizing positive patient outcomes while successfully protecting the safety of healthcare personnel. Laryngoscope, 130:2546–2549, 2020

AbstractBackgroundVenous invasion (VI) is not frequently evaluated on routine histologic examination of head and neck squamous cell carcinoma (HNSCC), and the prognostic significance is largely unknown. Studies have shown that extramural venous invasion is an adverse prognostic factor in colorectal carcinoma. To our knowledge, this is the first study evaluating the prognostic significance of venous invasion in node‐negative (without clinical or pathologic evidence of lymph node involvement) HNSCC, utilizing the elastic stain.MethodsA total of 105 consecutive lymph node‐negative (N0) HNSCC were evaluated for the presence of venous channel invasion by tumor utilizing the elastin stain. Clinical, demographic, and follow‐up data were recorded.ResultsOf 37 patients with venous invasion, 19% had loco‐regional recurrence, as opposed to 12% of those without. Univariate analysis revealed statistically significant decreased recurrence‐free survival in the presence of venous invasion (log‐rank [Mantel‐Cox] test P‐value .025).ConclusionIdentification of VI is greatly aided by elastic stain. In patients with node‐negative HNSCC, presence of VI resulted in decreased recurrence‐free survival on univariate analysis. The impact of VI as a prognostic marker should be further evaluated.