Moore, Eric J.

AbstractBackgroundAggressive dose de‐escalated adjuvant radiation therapy (RT) in patients with human papillomavirus–associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC).MethodsPatients with HPV(+)OPSCC on a phase II clinical trial of primary surgery and neck dissection followed by dose de‐escalated RT (N = 79) were compared with a cohort of patients who received standard adjuvant therapy (N = 115). Local recurrence‐free, regional recurrence‐free, distant metastases‐free survival, and progression‐free survival (PFS) were assessed.ResultsOf 194 patients, 23 experienced progression at a median of 1.1 years following surgery (interquartile range [IQR] 0.7‐2.0; range 0.3‐5.4); 10 patients in the de‐escalated cohort and 13 patients in the standard cohort. The 3‐year PFS rate for the de‐escalated cohort was 87%, and in the standard cohort was 90% (hazard ratio [HR] 1.18, 95% confidence interval (CI) [0.50‐2.75]).ConclusionPatients with HPV(+)OPSCC who undergo surgical resection and neck dissection and meet criteria for adjuvant therapy can undergo aggressive dose de‐escalation of RT without increasing risk of progression locally, regionally or at distant sites.

We sought to determine the incidence and location of human papillomavirus (HPV)–associated anogenital disease in women with HPV‐positive oropharyngeal squamous cell carcinoma (OPSCC) via a retrospective cohort study with prospective contact to update history at Mayo Clinic in Rochester, Minnesota. Females undergoing treatment for nonmetastatic HPV‐positive OPSCC from 2011 to 2019 were identified. Clinical history and outcomes were abstracted from medical records. Patients without documented anogenital history were contacted, consented, and administered a survey, and external records were requested and reviewed. Seventeen of 46 patients (37.0%) had a history of anogenital HPV‐associated disease, and 16 of 17 (94.1%) required procedures to diagnose or treat HPV lesions. The cervix was the most common site (16/17, 94.1%). Procedures included colposcopy (n = 6), cervical excision (n = 3), cryotherapy (n = 4), and hysterectomy (n = 3). One case of fatal cervical carcinoma was noted, diagnosed 1 year following OPSCC. Three of 17 (17.6%) had HPV‐related vulvovaginal disease, and 1 of 17 had anal disease. Patients with a history of HPV‐positive OPSCC may be at elevated risk for HPV‐associated anogenital disease.

Objectives/HypothesisUse validated eye‐tracking technology to objectively measure 1) the attentional distraction of facial contour defects after superficial and total parotidectomy and 2) changes in attentional distraction with abdominal dermal fat graft reconstruction.MethodsStandardized frontal and oblique facial images of 16 patients who had undergone superficial or total parotidectomy with or without fat graft reconstruction; four normal controls were obtained. One hundred casual observers were recruited to view these images, and gaze data were collected using a Tobii Pro eye‐tracking system. Gaze durations for predefined facial areas of interest were analyzed using mixed‐effects linear regression to test study hypotheses.ResultsFor frontal images, total parotidectomy increased gaze to the operated parotid area compared to the contralateral nonoperated parotid area (92 milliseconds, 95% confidence interval [CI]: 48‐138 milliseconds, P < .001). Fat grafting normalized the attentional distraction, with no difference in gaze time on the operated parotid region compared to normal control faces (P = .414). For oblique images, total parotidectomy increased gaze to the operated parotid area compared to the contralateral nonoperated parotid area (658 milliseconds, 95% CI: 463‐854 milliseconds, P < .001). Fat grafting normalized this attentional distraction, with no difference in gaze time on the operated parotid region compared to normal control faces (P = .504). In both views, superficial parotidectomy demonstrated no significant attentional distractions, with or without fat grafting.ConclusionsThis eye‐tracking study objectively demonstrates that total parotidectomy results in a facial contour deformity that is distracting to observers, whereas superficial parotidectomy does not. For total parotidectomy, this attentional distraction can be normalized with dermal fat graft reconstruction.Level of Evidence3b Laryngoscope, 131:E124–E131, 2021

ObjectivesTo describe pain experience and opioid use after major head and neck reconstructive surgery.Study DesignRetrospective cohort study.MethodsPatients undergoing major head and neck surgery with microvascular free tissue transfer (free flaps) at a tertiary academic center were included. Pain scores (0–10) and demographic and clinical data were ascertained from medical records. Discharge opioid prescriptions and refills obtained within 30 days were recorded. Patient characteristics were compared with pain scores using nonparametric rank‐sum tests and with likelihood of refill using logistic regression models to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs).ResultsThe study population comprised 445 patients. Median age was 60 years (interquartile range 50–68). Most patients had cancer (N = 350, 78%). The majority of free flaps were fibula (N = 153, 34%) or radial forearm (N = 159, 36%). Older patients reported significantly lower pain scores, whereas patients with opioid tolerance, anxiety, current smokers, and those undergoing larger volume resections or boney free flaps reported significantly higher pain scores. One‐quarter (N = 115, 26%) of patients obtained opioid refills. Patients aged ≥ 60 years had one‐half the odds of obtaining a refill compared with patients aged < 60 years (adjusted odds ratio [aOR] = 0.52, 95% confidence interval [CI] = 0.33–0.84), whereas surgical defect volume ≥ 100 cm3 (aOR = 1.92, 95% CI = 1.21–3.07) and higher pain score (aOR = 1.19, 95% CI = 1.07–1.32 per 1 point increase) increased the odds of refill.ConclusionContinued opioid use after discharge is common among patients undergoing major head and neck reconstruction, particularly for younger patients and after more extensive surgery. Older patients reported lower pain intensity and were less likely to obtain opioid refills, highlighting the wisdom of judicious opioid use for this vulnerable population.Level of EvidenceIV Laryngoscope, 130: E469–E478, 2020

ObjectivesClinical variables affecting anesthetic recovery following transoral robotic surgery (TORS) to resect oropharyngeal squamous cell carcinoma have not been described. We aimed to explore risk factors associated with prolonged postanesthesia recovery following TORS.Study DesignRetrospective case‐control study.SettingTertiary referral center, January 2010 to November 2016.Subjects and MethodsPatients included adults undergoing primary TORS ± neck dissection for oropharyngeal squamous cell carcinoma. Patients were categorized by phase I recovery time into the “goal” recovery group (75th percentile [lower 3 quartiles], n = 272) and the “prolonged” recovery group (n = 91). Univariate and multivariate logistic regression analyses were performed to assess the associations between clinical characteristics and prolonged phase I recovery.ResultsA total of 363 patients were included. Median (interquartile range) duration of postanesthesia recovery was 1.5 hours (1.0‐2.0). Prolonged recovery was associated with isoflurane (odds ratio, 2.83 [95% CI, 1.56‐5.14], P <. 001), midazolam (2.77 [1.50‐5.12], P =. 001), and larger opioid doses (1.26 [1.01‐1.58] per 10‐mg intravenous morphine equivalents, P =. 040) and inversely associated with multimodal antiemetic therapy (0.34 [0.15‐0.78], P =. 011). Prolonged cases had higher rates of postoperative nausea and vomiting (n = 43 [47.2%] vs 86 [31.6%], P =. 008), respiratory depression (28 [30.8%] vs 12 [4.4%], P <. 001), sedation (Richmond Agitation‐Sedation Scale < –2; 26 [28.6%] vs 35 [12.9%], P =. 001), severe pain (numeric rating score ≥7; 31 [34.4%] vs 45 [17.2%], P =. 001), and longer hospital stays (4 vs 3 days, P <. 001).ConclusionsSeveral anesthetic factors are associated with anesthesia recovery duration, which may be shortened by efforts to reduce postoperative sedation, severe pain, and nausea/vomiting. Shortened anesthesia recovery time may reduce hospital stay.

Abstract Background Consensus in timing of radiotherapy is yet to be established in esthesioneuroblastoma (ENB). Objective This study was aimed to investigate if planned adjuvant radiotherapy improves tumor control after complete margin negative resection of low Hyams' grade (1 or 2) ENB. Methods A retrospective review of patients with pathologically confirmed negative margin resection of Kadish's stage B or C and Hyams' grade 1 and 2 ENBs was conducted. Seventeen patients meeting the criteria were divided into the following two groups for cohort study: (1) those who underwent planned immediate postoperative adjuvant radiotherapy (IR group) and (2) those who did not (delayed radiotherapy [DR] group). Results The IR group included nine patients (Kadish's stage B in one and stage C in eight; Hyams' grade 1 in two and grade 2 in seven). Mean follow-up was 140.8 months. Seven patients (78%) had disease progression (DP) at a median of 88 months (four with cervical lymph node metastasis [CLNM], one with distant metastasis, and two with both local recurrence and CLNM). One patient experienced frontal lobe abscess. The DR group included eight patients (Kadish's stage B in six and stage C in two; all Hyams' grade 2). Mean follow-up was 123.3 months. Four (50%) patients who developed DP (all local recurrence) were salvaged with surgery and adjuvant radiotherapy at a median of 37.5 months. There was no statistically significant difference in DP rate (p = 0.23), time to DP (p = 0.26), or the local tumor control rate (p = 0.23). Conclusion In our limited cohort, immediate postoperative radiotherapy did not demonstrate superiority in tumor control, although risk of radiotherapy toxicity appears low.

Abstract Background The da Vinci single‐port (SP) robot is a new instrument for transoral robotic surgery (TORS) in oropharyngeal cancers (OPSCCs). We describe one‐year SP surgical outcomes and compare them to da Vinci Si outcomes. Methods Retrospective cohort study at a high‐volume TORS center. Consecutive patients undergoing TORS SP procedures from 10/2018 to 09/2019 were included. SP OPSCC outcomes were compared to a historical cohort of Si OPSCC patients. t tests were used to compare continuous variables; χ 2 or Wilcoxon rank‐sum tests were used to compare nonparametric categorical variables. Results Seventy‐eight patients underwent SP TORS. The bleed rate was 5.1%, mortality rate was 2.6%, and conversion rate was 0%. Compared to the Si cohort, OPSCC patients undergoing TORS SP procedures saw no significant differences in operative time or post‐TORS bleeds ( P > .05). Conclusions The SP is a comparably safe surgical instrument. Overall learning curve for the SP was rapid among experienced TORS surgeons.

6095 Background: Prognosis for patients (pts) with locally-advanced, HPV-positive oropharynx squamous cell carcinoma (HPV+OPSCC) is significantly better than for pts with HPV-negative head and neck squamous cell carcinoma (HNSCC). Historic survival of pts with metastatic HNSCC is 6-9 months with palliative therapy. However, the prognosis and survival of pts with HPV+OPSCC with distant metastases is not known. Methods: Pts with HPV+OPSCC with distant metastatic disease were identified from databases from the departments of surgery, radiation, and medical oncology. Demographic and clinical data was abstracted from the medical record. All pts had confirmed HPV/p16+ disease. Results: Fifteen pts with metastatic HPV+ OPSCC were identified. The median age was 57 years (range 42-78, 15 male). The median pack-year smoking was 0 (range 0-120). Primary site included 10 tonsil and 5 tongue base. At diagnosis, one pt had stage III and 14 had stage IV disease (IVA: 9, IVB: 2, IVC: 3). T- and N-stage included T1 (1), T2 (10), T3 (3), T4 (1) and N1 (1), N2a (1), N2b (9), N2c (3), N3 (1). Extracapsular extension was seen in 8 pts, absent in 2, and unknown in 5. Seven pts had lymph node (LN) involvement at level IV/V. Initial therapy for locally-advanced disease included surgery followed by adjuvant radiation (RT) in 1 pt and chemoRT in 8, and definitive chemoRT in 3 pts. Three pts were metastatic at initial diagnosis. Of 6 pts with an isolated metastatic site, 3 pts are alive > 2 years from diagnosis of metastasis (median 1.97 years, range 0.49-2.29). Palliative therapy included surgery (3), RT (9), platinum chemo +/- cetuximab (8), cetuximab alone (2) or with a taxane (2). The most common sites of metastasis included bone (6), lung (5), and LNs (5). The 1-year survival rate after diagnosis of metastatic disease was 92%. The median time to diagnosis of metastatic disease after definitive therapy was 0.47 years (95% CI 0.19-1.29); 75% of pts who developed metastatic disease did so within 1 year of definitive therapy. Of note, 2 of the 15 pts developed a secondary immune-mediated malignancy (melanoma and non-HIV associated Kaposi’s sarcoma). Conclusions: The survival of pts with metastatic HPV+OPSCC is significantly better than that of historic controls.

AbstractObjective The objective of this study is to describe the clinical presentation, tumor characteristics, natural history, and treatment patterns of sinonasal osteosarcoma.Methods Fourteen patients who had been treated for osteosarcoma of the nasal cavity and paranasal sinuses at a tertiary care center were reviewed. In addition, a systematic review of the literature for osteosarcoma of the sinonasal cavity was performed.Results In a systematic review, including 14 patients from the authors' institution, 53 total studies including 88 patients were assessed. Median follow-up was 18 months (interquartile range: 8–39 months). The most common presenting symptoms were facial mass or swelling (34%), and nasal obstruction (30%). The most common paranasal sinus involved by tumor was the maxillary sinus (64%), followed by the ethmoid sinuses (52%). The orbit (33%), dura (13%) and infratemporal fossa (10%) were the most common sites of local invasion. The majority of patients underwent surgery followed by adjuvant therapy (52.4%). Increasing age was associated with decreased overall survival rate (unit risk ratio [95% confidence interval (CI)] = 1.02 [1.003–1.043]; p = 0.0216) and T4 disease was associated with decreased disease-specific survival rate (hazard ratio [HR] = 2.87; p = 0.0495). The 2- and 5-year overall survival rates were 68 and 40%, respectively, while 2- and 5-year disease-specific survival rates were 71% and 44%, respectively.Conclusion Sinonasal osteosarcomas are uncommon tumors and can pose a significant therapeutic challenge. Increasing age and T4 disease are associated with worse prognosis. This disease usually warrants consultation by a multidisciplinary team and consideration of multimodality therapy.