Moore, Eric J.

AbstractBackgroundPrevious wide local excision prior to sentinel lymph node biopsy (SLNB) may have the potential to disrupt lymphatic channels, thus incorrectly identifying the sentinel node. The purpose of this study was to investigate: (1) regional recurrence rates of prior wide local excision compared to other biopsy techniques and (2) survival outcomes in patients with melanoma of the head and neck.MethodsBetween the years 2000 and 2016, 391 cases were reviewed with a median follow‐up time of 30 months in a large tertiary care center. Biopsy practices included shave, punch, wide local excision, and narrow margin excisional/Mohs, and associations with time to local or regional relapse and death from melanoma were evaluated. Main outcomes included identification of sentinel lymph nodes, overall survival, and melanoma‐specific survival.ResultsOf the 391 patients, biopsy patterns were as follows: 77 (19%) unknown biopsy, 30 (8%) prior wide local excision (WLE), 105 (27%) narrow margin excisional biopsy, 69 (18%) punch biopsy, and 110 (28%) shave biopsy. SLNB was successfully identified in all 30 patients whom had a prior WLE. There were 50 regional recurrences in the neck and 27 local recurrences with the median (IQR) at 1.2 years and 1.0 years, respectively. Multivariable associations of type of prior biopsy, depth of invasion, and nodal status with time to regional recurrence, local recurrence, overall survival, and melanoma‐specific survival were not significantly different.ConclusionsSentinel lymph node biopsy for melanoma of the head and neck can be successfully performed in patients after previous wide local excision.

ObjectiveTo determine whether liposomal bupivacaine (Exparel) is safe and effective in the management of posttonsillectomy pain among adult patients.Study DesignA prospective single‐blind randomized controlled trial.SettingAn academic quaternary care center (Mayo Clinic, Rochester, Minnesota).Subjects and MethodsFrom May 2015 to December 2016, 39 patients were randomized to receive oral pain medication and 8 mL of injected liposomal bupivacaine or oral pain medication alone for treatment of their posttonsillectomy pain. Visual analog scale pain intensity scores, oral pain medication usage, liquid oral intake, and complications were recorded for 2 weeks after the procedure.ResultsThirty‐nine patients were randomized, with 17 patients in the liposomal bupivacaine group and 22 in the control group. Fifteen patients in the liposomal bupivacaine group and 18 patients in the control group completed the study. Pain intensity score on postoperative day 1 (P =. 043) proved to be the only statistically significant result, with no difference noted in pain scores on postoperative days 2 to 14. There was no difference in pain medication usage, liquid oral intake, postoperative hemorrhage, or adverse events between groups.ConclusionsThe injection of liposomal bupivacaine in the posttonsillectomy wound bed demonstrates improved pain intensity scores for the first 24 hours after surgery with no adverse complications noted in comparison with patients who did not receive the injection. Given the limited pain reduction and increased cost, use of liposomal bupivacaine in adult tonsillectomy patients appears to have minimal indication for use.

AbstractBackgroundTreatment options of Ewing sarcoma of the head and neck include surgery, radiotherapy (RT), and chemoradiotherapy. However, local control can be challenging.MethodsWe conducted a retrospective review of all patients with head and neck Ewing sarcoma treated from 1972 to 2015 at a single tertiary care hospital.ResultsSeventeen patients met criteria (median 21 years, range 5‐58 years; 5 women). Mean follow‐up was 10.4 years (range 2.2‐39 years). Tumors occurred commonly in the cervical spine (5/17), the skull (3/17), and the paranasal sinuses (3/17). A total of 14 of 17 patients underwent surgical resection, 9 with gross total resection. After multimodality therapy, the 5‐year overall survival (OS) and recurrence‐free survival (RFS) was 87% and 75%, respectively.ConclusionCombined multimodal treatment resulted in a 5‐year OS and RFS of 87% and 75%, respectively. Aggressive surgical resection with adjuvant chemoradiotherapy should be considered. Although negative margin surgery is the goal, subtotal resection may be acceptable in the setting of adjuvant treatment.

Importance The clinical and financial implications of the timing of dental rehabilitation after a fibula free tissue transfer (FFTT) for osteoradionecrosis (ORN) and osteonecrosis (ON) of the mandible have yet to be established. Objective To compare the outcomes of primary implantation vs secondary implantation after FFTT for ORN and ON of the mandible. Design, Setting, and Participants A retrospective review was conducted of 23 patients at a single tertiary academic referral center undergoing primary implantation or secondary implantation after FFTT for ORN and ON from January 1, 2006, to November 10, 2015. Interventions All patients underwent FFTT with primary implantation (n = 12) or secondary implantation (n = 11). Main Outcomes and Measures Outcomes of FFTT, dental implantation, implant use, diet, speech, and disease-free survival were reviewed. Fixed unit costs were estimated based on the mean cost analysis. Results Twenty-three patients (7 women and 16 men; mean [SD] age, 62.4 [8.2] years [range, 24-81 years]) met the inclusion criteria. Of these, 18 had ORN and 5 had ON. Dental implantation was performed at the time of FFTT for 12 patients and was performed secondarily for 11 patients. There were a mean of 5.2 implants per patient performed, for a total of 121 implants. There was 1 complete flap failure in the primary implantation group. Neither flap nor implant complications were affected by the timing of the implantation. Overall, the implant survival rate was 95% (55 of 58) in the primary implantation group and 98% (62 of 63) in the secondary implantation group. Time from FFTT to abutment placement (primary implantation, 19.6 weeks; secondary implantation, 61.0 weeks) was significantly shorter after primary implantation ( P < .001). There was no clinical difference in postoperative complications and implant outcomes for ORN vs ON. Improvement in speech and oral competence in the primary implantation group vs the secondary implantation group was not statistically significant, given an experiment-adjusted P = .001 set as significant (normal speech, 9 vs 3; P = .02; and normal oral competence, 9 vs 3; P = .02). Disease-free survival was 91% (20 of 22 patients) overall. Fixed unit (U) costs were 1.0 U for primary implantation and 1.24 U for secondary implantation. Conclusions and Relevance Patients undergoing primary implantation after FFTT for ORN and ON had a similar rate of complications compared with those undergoing secondary implantation. However, primary implantation allowed a faster return than secondary implantation to oral nutrition and prosthesis use. The fixed unit cost was reduced for those undergoing primary implantation. Although dental implantation was safe and effective in both groups, the decreased time to use and the decreased overall cost should prompt surgeons to consider primary implantation after FFTT for ORN and ON. Level of Evidence 3 .

Objectives Neck metastases in patients with esthesioneuroblastoma (ENB) constitute the most significant predictor of poor long-term survival. Recently, researchers discovered the existence of dural lymphatic channels that drain to the cervical lymph nodes. From this physiologic basis, we hypothesized that patients with ENB who develop dural invasion (DI) would exhibit a proclivity for neck metastases. Design Retrospective review. Setting Tertiary referral center. Participants All patients treated for ENB from January 1, 1994 to December 31, 2015. Main Outcome Measures Incidence, laterality, and recurrence rate of neck metastases by DI status. Results Sixty-one patients were identified (38% female; median age 49, range, 10–80), 34 (56%) of whom had DI and 27 (44%) did not. Of patients with DI, 50% presented with or developed neck disease following treatment compared with just 22% of those without DI (p = 0.026). Bilateral neck disease was more common in patients with DI (11/34, 32%) compared with those without (2/27, 7%) (p = 0.018). Five-year regional recurrence-free survival rates were 88% for those without and 64% for those with DI (p = 0.022). Kadish C patients with DI were more likely to develop regional recurrence when compared with Kadish C without DI and Kadish A/B (p = 0.083). Further, Kadish C patients with DI displayed worse overall survival than Kadish C without DI and Kadish A/B. Kadish D patients displayed the worst overall survival. The difference in overall survival among these four groups was significant (p < 0.001). Conclusion DI by ENB is associated with increased incidence of cervical nodal metastases, bilateral neck disease, worse regional recurrence-free survival, and poorer overall survival. These data support the division of Kadish C by DI status.

AbstractBackgroundOncologic 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.MethodsPatients with HPV‐related oropharyngeal SCC requiring resection of major muscular or neurovascular tissue during their neck dissections were retrospectively identified.ResultsSeventy‐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.ConclusionPatients 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.

AbstractBackgroundThis study presents oncologic outcomes after transoral robotic surgery (TORS) ± adjuvant therapy for oropharyngeal squamous cell carcinoma (SCC).MethodsThree hundred fourteen patients undergoing TORS ± adjuvant therapy for oropharyngeal SCC from May 1, 2007, to May 31, 2015, are analyzed.ResultsMedian 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).ConclusionThe need to take ≥2 margins to achieve resection portends an increased risk of locoregional recurrence and death due to disease in oropharyngeal SCC.

Objectives The objective of this study was to identify factors that may influence the rate and location of regional metastasis in sinonasal malignancies (SNMs). Design This is a retrospective review. Setting This study was set at the single-institution tertiary referral center. Participants A total of 299 patients were treated for SNMs from 1994 to 2014. Main Outcome Measures The main outcome measures were incidence and distribution of regional metastases. Results Several histologic subtypes were treated, with squamous cell carcinoma (28.4%), esthesioneuroblastoma (18.1%), and mucosal melanoma (12.4%) being the most common. Of the 299 patients, 59 (19.7%) developed a regional metastasis, either at presentation or during follow-up. Higher cumulative incidence of regional metastases was significantly associated with histologic type (p ≤0.001) and invasion of the dura (p = 0.005), infratemporal fossa (p = 0.036), orbit (p = 0.020), or palate (p = 0.016). Ipsilateral level II lymph nodes were the most commonly involved nodes. Contralateral regional metastases were associated with higher risk histologic types (p = 0.005) and dural invasion (p = 0.008). Parotid metastases were associated with invasion of the facial soft tissue (p = 0.028), and retropharyngeal metastases were associated with invasion of the pterygoid plates and musculature (p = 0.030). Conclusion Histologic type of SNM appears to be the most important factor in predicting the rate of regional metastases. Histologic type and invasion of certain neighboring structures may help define which lymphatic basins are at highest risk for metastasis.