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Importance: The assessment and management of surgical margins in stage I and II oral cavity squamous cell carcinoma is one of the most important perioperative aspects of oncologic care, with profound implications for patient outcomes and adjuvant therapy. Understanding and critically reviewing the existing data surrounding margins in this context is necessary to rigorously care for this challenging group of patients and minimize patient morbidity and mortality. Observations: This review discusses the data related to the definitions related to surgical margins, methods for assessment, specimen vs tumor bed margin evaluation, and re-resection of positive margins. The observations presented emphasize notable controversy within the field about margin assessment, with early data coalescing around several key aspects of management, although studies are limited by their design. Conclusions and Relevance: Stage I and II oral cavity cancer requires surgical resection with negative margins to obtain optimal oncologic outcomes, but controversy persists over margin assessment. Future studies with improved, well-controlled study designs are required to more definitively guide margin assessment and management.
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Carcinoma de Células Escamosas , Neoplasias de Cabeza y Cuello , Neoplasias de la Boca , Humanos , Estados Unidos , Carcinoma de Células Escamosas de Cabeza y Cuello , Márgenes de Escisión , Neoplasias de la Boca/patología , Carcinoma de Células Escamosas/patología , Neoplasias de Cabeza y Cuello/cirugía , Estudios RetrospectivosRESUMEN
Abstract Introduction Head and neck lymphedema is an omnipresent morbidity related to head and neck cancer therapies. Studies on therapy for these patients in the acute postsurgical population have not been published to date. Objective To assess changes in the measurements of lymphedema in surgical head and neck cancer patients during the hospital stay with implementation of modified decongestive therapy (MDT). Methods Patients aged > 18 years undergoing neck dissection with or without primary-site resection or laryngectomy between 2016 and 2019 were included. Facial measurements were obtained prior to beginning MDT and again prior to discharge. A total facial composite measurement was calculated and used to assess change over time. Rates ≥ 2% of change were considered significant. Results A total of 38 patients were included (subsites: larynx = 27; thyroid =4; oral cavity = 3; and neck = 4). The mean number of days between surgery and the start of lymphedema therapy was 3.0 days. The mean number of days between measurements was 5.2 days. Reduction in the total composite score was observed in 37 (97%) patients, and 35 (92%) patients had a total composite reduction score > 2%. Tumor subsite and surgery type did not portend toward greater percent change, except for those patients treated with total laryngectomy, regional flap reconstruction, and neck dissection (p = 0.02). Conclusion Acute postsurgical inpatient MDT was associated with reduced total composite measurements in patients after head and neck surgery. As the first published study on lymphedema therapy in this acute postsurgical period, further prospective case-control studies are warranted to explore further benefits of acute therapy.
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Introduction Head and neck lymphedema is an omnipresent morbidity related to head and neck cancer therapies. Studies on therapy for these patients in the acute postsurgical population have not been published to date. Objective To assess changes in the measurements of lymphedema in surgical head and neck cancer patients during the hospital stay with implementation of modified decongestive therapy (MDT). Methods Patients aged > 18 years undergoing neck dissection with or without primary-site resection or laryngectomy between 2016 and 2019 were included. Facial measurements were obtained prior to beginning MDT and again prior to discharge. A total facial composite measurement was calculated and used to assess change over time. Rates ≥ 2% of change were considered significant. Results A total of 38 patients were included (subsites: larynx = 27; thyroid = 4; oral cavity = 3; and neck = 4). The mean number of days between surgery and the start of lymphedema therapy was 3.0 days. The mean number of days between measurements was 5.2 days. Reduction in the total composite score was observed in 37 (97%) patients, and 35 (92%) patients had a total composite reduction score > 2%. Tumor subsite and surgery type did not portend toward greater percent change, except for those patients treated with total laryngectomy, regional flap reconstruction, and neck dissection ( p = 0.02). Conclusion Acute postsurgical inpatient MDT was associated with reduced total composite measurements in patients after head and neck surgery. As the first published study on lymphedema therapy in this acute postsurgical period, further prospective case-control studies are warranted to explore further benefits of acute therapy.
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BACKGROUND: The effectiveness of community-based walking programs for patients with peripheral artery disease (PAD) can be limited by calf claudication during exercise. Recent evidence finds adding carbon fiber ankle foot orthoses (AFO) to a walking program can result in improvements in patient mobility and delay claudication onset when walking. RESEARCH QUESTION: How may carbon fiber AFO alter ankle walking mechanics and corresponding triceps surae muscle recruitment in a manner that could improve patient mobility? METHODS: In this repeated measures cohort study, fifteen patients with PAD were fit with bilateral AFO before completing self-paced gait analysis including electromyography. Patients were then given standard advice to walk at home using the devices for 12 weeks. Twelve patients completed follow-up testing. RESULTS: There were no significant interactions between main effects for any variable of interest (p ≥ 0.189). Further, there were no within-subjects main effects for testing time for self-selected gait speed or any of the kinetic or kinematic variables (p ≥ 0.435). There were significant main effects for AFO use with reductions in dorsi flexion (p < 0.001), plantar flexion at toe off (p < 0.001), ankle plantar flexor moment (p = 0.037), and ankle plantar flexor power (p < 0.001). Triceps surae recruitment did not change between AFO conditions (p > 0.05). SIGNIFICANCE: Adding carbon fiber AFO limits peak ankle motion and joint power during self-paced walking for people with PAD while maintaining their walking speed. These gait adaptions were maintained over our 12 weeks of walking practice time. A resulting decrease in plantar flexor power while maintaining gait speed may provide the mechanism by which AFO can delay claudication onset which are major barrier to PAD walking programs. Calf muscle recruitment was maintained when adding the AFO which suggests sufficient muscle exertion could exist to maintain muscle integrity with sustained AFO use.
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Ortesis del Pié , Enfermedad Arterial Periférica , Humanos , Tobillo , Fibra de Carbono , Estudios de Cohortes , Limitación de la Movilidad , Caminata/fisiología , Marcha/fisiología , Articulación del Tobillo/fisiología , Enfermedad Arterial Periférica/complicaciones , Claudicación Intermitente/terapia , Fenómenos BiomecánicosRESUMEN
Abstract Introduction Patients with head and neck cancer (HNC) experience unique physical and psychosocial challenges that impact their health and quality of life. Early implementation of palliative care has been shown to improve various health care outcomes. Objective The aim of the present study was to evaluate the patterns of referral of patients with HNC to outpatient palliative care as they relate to utilization of resources and end-of-life discussions. Methods We performed a retrospective review of 245 patients with HNC referred to outpatient palliative care services at two Louisiana tertiary care centers from June 1, 2014, to October 1, 2019. The control group consisted of those that were referred but did not follow-up. Reasons for referral were obtained, and outcome measures such as emergency department (ED) visits, hospital readmissions, and advance care planning (ACP) documentation were assessed according to predictive variables. Results There were 177 patients in the treatment group and 68 in the control group. Patients were more likely to follow up to outpatient palliative care services if referred for pain management. Hospital system, prior inpatient palliative care, and number of outpatient visits were associated with an increased likelihood for ED visits and hospital readmissions. Those in the palliative care treatment group were also more likely to have ACP discussions. Conclusion Early implementation of outpatient palliative care among patients with HNC can initiate ACP discussions. However, there are discrepancies in referral reasons to palliative care and continued existing barriers to its effective utilization.
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Introduction Patients with head and neck cancer (HNC) experience unique physical and psychosocial challenges that impact their health and quality of life. Early implementation of palliative care has been shown to improve various health care outcomes. Objective The aim of the present study was to evaluate the patterns of referral of patients with HNC to outpatient palliative care as they relate to utilization of resources and end-of-life discussions. Methods We performed a retrospective review of 245 patients with HNC referred to outpatient palliative care services at two Louisiana tertiary care centers from June 1, 2014, to October 1, 2019. The control group consisted of those that were referred but did not follow-up. Reasons for referral were obtained, and outcome measures such as emergency department (ED) visits, hospital readmissions, and advance care planning (ACP) documentation were assessed according to predictive variables. Results There were 177 patients in the treatment group and 68 in the control group. Patients were more likely to follow up to outpatient palliative care services if referred for pain management. Hospital system, prior inpatient palliative care, and number of outpatient visits were associated with an increased likelihood for ED visits and hospital readmissions. Those in the palliative care treatment group were also more likely to have ACP discussions. Conclusion Early implementation of outpatient palliative care among patients with HNC can initiate ACP discussions. However, there are discrepancies in referral reasons to palliative care and continued existing barriers to its effective utilization.
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COVID-19 , SARS-CoV-2 , COVID-19/diagnóstico , Señales (Psicología) , Pruebas Diagnósticas de Rutina , Humanos , NarizRESUMEN
The Delta SARS-CoV-2 variant is very infectious, and it is spreading quickly during this pandemic. In the study, we compared viral loads estimated by means of the Ct values emerging from RT-PCR swab tests in surging cases infected with the SARS-CoV-2 Delta variant in the fourth wave of COVID-19 with the three prior waves. The data comprised viral loads from positive cases detected within the UPMC health care system in Allegheny County, Pennsylvania. A total of 2059 upper airway samples were collected and tested for SARS-CoV-2 positive by RT-PCR during March 2020 to September 2021. We did not observe significant difference in viral load difference between the third (December 2020 to January 2021) and fourth (June 2021 to September 2021) waves; however, they had the higher viral load than the first (March 2020 to June 2020) and second waves (June 2020 to August 2020). We did find an age-related effect with the elderly presenting with lower viral loads, which was also seen in the earlier waves. However, the level of the viral loads in the fourth wave in the respect of the previous ones was not sufficiently increased to change our testing strategies by means of increased use of rapid antigen tests (RAT).
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Accurate and rapid laboratory tests are essential for the prompt diagnosis of COVID-19, which is important to patients and infection control. The Xpert Xpress SARS-CoV-2 test is a real-time RT-PCR intended for the qualitative detection of nucleic acid from SARS-CoV-2 in upper respiratory specimens. In this study, we assessed the analytical performance characteristics of this rapid test for SARS-CoV-2 in 60 bronchoalveolar lavage (BAL) specimens. BAL is a specimen type that is not authorized under EUA for the Xpert Xpress SARS-CoV-2 test. The limit of detection of the Xpert Xpress SARS-CoV-2 test was 500 copies/ml. The overall agreement of the Xpert Xpress SARS-CoV-2 test was 100%. The Xpert Xpress SARS-CoV-2 test is sensitive and specific to aid in diagnosis of COVID-19 using bronchoalveolar lavage.
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BACKGROUND: Total laryngectomy (TL) with thyroidectomy can pose significant risks to parathyroid function, and variance in rates of post-operative hypocalcemia (POH) based on extent of thyroidectomy have not been previously reported. Our objective is to identify the rates of hypocalcemia and hypoparathyroidism in TL+/-thyroidectomy and compare this to matched thyroidectomy alone cohorts. METHODS: Multi-institutional retrospective chart review of patients treated surgically for laryngeal cancer with TL or benign/malignant thyroid disease with thyroidectomy at regional tertiary care centers in New Orleans and Baton Rouge, Louisiana from 2016 to 2019. Cases were evaluated for post-operative and post-discharge calcium and parathyroid hormone levels, post-operative and long-term calcium supplementation, and intraoperative parathyroid identification and management. RESULTS: 101 TL and 319 thyroidectomy patients' charts were reviewed. Regression analysis revealed increased odds of hypocalcemia and hypoparathyroidism in TL + TT versus TT alone (OR 10.7, OR 16.5, p < 0.001, respectively). TL + HT versus HT alone had increased odds of hypoparathyroidism (OR 1.6, p < 0.001). TL with any thyroidectomy compared to TL alone demonstrated both increased odds of hypocalcemia and hypoparathyroidism (OR 4.4 p = 0.009, and OR 4.5 p = 0.05). Odds of requiring long-term calcium supplementation were significantly increased with the addition of thyroidectomy across all groups. TL + TT was 8 times as likely (p = 0.002) and TL + HT was 5.3 times as likely (p = 0.001) to require long-term calcium supplementation compared to TL alone. CONCLUSIONS: Thyroidectomy combined with TL demonstrates marked increased risk of parathyroid dysfunction and resultant POH. Despite improved visualization of soft tissue anatomy with TL, risk of parathyroid injury in these settings requires special attention to extent of parathyroid dissection and potential devascularization to reduce long-term sequelae of hyperparathyroidism. Therefore, post-operative calcium monitoring after TL is necessary and should resemble the long-standing stringent protocols that already exist for monitoring in thyroidectomy populations.
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Hipocalcemia , Cuidados Posteriores , Calcio , Humanos , Hipocalcemia/epidemiología , Hipocalcemia/etiología , Laringectomía/efectos adversos , Hormona Paratiroidea , Alta del Paciente , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Tiroidectomía/efectos adversos , Tiroidectomía/métodosRESUMEN
BACKGROUND: Immunotherapy agents are used to treat advanced head and neck lesions. We aim to elucidate relationship between immunotherapy and surgical wound complications. METHODS: Retrospective multi-institutional case series evaluating patients undergoing ablative and flap reconstructive surgery and immunotherapy treatment. MAIN OUTCOME: wound complications. RESULTS: Eight-two (62%) patients received preoperative therapy, 89 (67%) postoperative, and 33 (25%) in both settings. Forty-one (31%) patients had recipient site complications, 12 (9%) had donor site. Nineteen (14%) had major recipient site complications, 22 (17%) had minor. There was no statistically significant difference in complications based on patient or tumor-specific variables. Preoperative therapy alone demonstrated increased major complications (odds ratio [OR] 3.7, p = 0.04), and trend to more donor site complications (OR 7.4, p = 0.06), however treatment in both preoperative and postoperative therapy was not. CONCLUSIONS: Preoperative immunotherapy may be associated with increased wound complications. Controlled studies are necessary to delineate this association and potential risks of therapy.
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Colgajos Tisulares Libres , Neoplasias de Cabeza y Cuello , Procedimientos de Cirugía Plástica , Neoplasias de Cabeza y Cuello/cirugía , Humanos , Inmunoterapia/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: When gastric pull-up is unsuccessful or unsuitable for total esophageal reconstruction, a supercharged pedicled jejunum can be used to reestablish gastrointestinal continuity. The authors reviewed their technique and outcomes of the supercharged pedicled jejunum for total esophageal reconstruction. METHODS: A retrospective review of a prospectively maintained database was performed of 100 patients who underwent supercharged pedicled jejunum for total esophageal reconstruction between 2000 and 2017 at the Texas Medical Center. Patient characteristics, technical details, and outcomes were analyzed. RESULTS: Mean patient age was 59.5 ± 11.4 years. Forty-two patients (42 percent) had surgical complications (18 percent at the recipient site, 13 percent at the donor site, and 11 percent at both). Medical complications occurred in 28 patients (28 percent). A major surgical complication occurred in 20 patients (20 percent). The average length of stay was 15 days (range, 6 to 152 days). At last follow-up, 20 patients (20 percent) had metastatic disease and six (6 percent) had local recurrence. Fifty-four patients (54 percent) died during the follow-up period. Of 79 patients with follow-up longer than 6 months, 68 (86 percent) tolerated a solid or soft oral diet, with a 16 percent tube feed-dependence rate. Overall survival at 1, 3, and 5 years was 78.8, 53.7, and 33.1 percent, respectively. The median survival time was 38.7 months. CONCLUSIONS: The authors present their experience with 100 supercharged pedicled jejunums for total esophageal reconstruction. Functional outcomes are comparable to, or better than, other salvage modalities. With careful multidisciplinary planning and meticulous, well-orchestrated surgical technique, swallowing function can be restored to provide quality of life in patients with few remaining surgical options.
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Neoplasias Esofágicas/mortalidad , Esofagectomía/métodos , Yeyuno/cirugía , Procedimientos de Cirugía Plástica/métodos , Colgajos Quirúrgicos , Anciano , Bases de Datos Factuales , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Femenino , Rechazo de Injerto , Supervivencia de Injerto , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Procedimientos de Cirugía Plástica/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
Calf claudication is a significant cause of walking limitation for patients with peripheral artery disease (PAD). Ankle-foot orthoses (AFO) are leg devices that can reduce the physical demands on the calf muscles during ambulation. The purpose of this study was to determine the efficacy of AFO on walking ability in patients with PAD. This was an open-label, interventional trial including 15 patients with calf claudication who were fit with AFO. Patients completed graded treadmill testing, followed by 12 weeks of unstructured community-based walking using the AFO ad libitum. Comparison of peak walking time (PWT) at baseline versus 12 weeks was the primary outcome. A secondary outcome was claudication onset time (COT) assessed during graded treadmill tests. Change in walking ability of AFO group patients was also compared to outcomes from a historical PAD control group (n = 10) who received upfront advice to walk at home. Patients in the AFO group significantly improved their walking ability from baseline to 12 weeks (mean ± SD) (PWT: 7.8 ± 5.1 to 9.3 ± 5.4 min, p = 0.049; COT: 3.0 ± 2.3 to 4.8 ± 2.7 min, p = 0.01). Change in PWT for AFO group patients when tested without using the devices was not significantly greater compared to historical controls (+1.4 ± 2.4 vs +0.1 ± 2.6 min, p = 0.16) but it was for COT (+1.8 ± 2.5 vs -0.6 ± 2.2 min, p = 0.02). This study found that AFO used during community-based walking improved the primary outcome of PWT in patients with PAD. Further, using AFO delayed claudication onset, indicating patients may be able to increase their walking activity. Large-scale, randomized controlled trials are needed to further explore the use of AFO for PAD. ClinicalTrials.gov identifier: NCT02280200.
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Terapia por Ejercicio/instrumentación , Tolerancia al Ejercicio , Ortesis del Pié , Claudicación Intermitente/terapia , Limitación de la Movilidad , Enfermedad Arterial Periférica/terapia , Caminata , Anciano , Diseño de Equipo , Femenino , Humanos , Claudicación Intermitente/diagnóstico , Claudicación Intermitente/fisiopatología , Masculino , Persona de Mediana Edad , Minnesota , Medición de Resultados Informados por el Paciente , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/fisiopatología , Recuperación de la Función , Factores de Tiempo , Resultado del Tratamiento , Prueba de PasoRESUMEN
Isolated lingual and lower face Raynaud phenomenon without primary Raynaud of the digits is a very rare condition associated with chemoradiation therapy (RT) in previous reports. The condition, which more commonly presents in patients with a history of Raynaud disease, is often self-limiting, but vasodilating agents and steroids have been suggested as possible treatment options. Spasmodic torticollis is a different, more common entity, also associated with history of RT or previous head and neck surgery. We present a rare case of a patient who developed Raynaud phenomenon of the lower face and tongue in the presence of spasmodic torticollis after mandibulectomy and free fibula reconstruction followed by RT to the oral cavity and neck. Possible causes, pathophysiologic mechanisms and treatment options are discussed. This is the first report of botulinum toxin treatment of isolated secondary Raynaud phenomenon of the lower face and tongue.
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Toxinas Botulínicas/administración & dosificación , Neoplasias Mandibulares/cirugía , Osteotomía Mandibular/efectos adversos , Procedimientos de Cirugía Plástica/efectos adversos , Enfermedad de Raynaud/tratamiento farmacológico , Tortícolis/tratamiento farmacológico , Trasplante Óseo/efectos adversos , Trasplante Óseo/métodos , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/radioterapia , Carcinoma de Células Escamosas/cirugía , Peroné/cirugía , Estudios de Seguimiento , Humanos , Masculino , Neoplasias Mandibulares/patología , Neoplasias Mandibulares/radioterapia , Osteotomía Mandibular/métodos , Persona de Mediana Edad , Disección del Cuello/efectos adversos , Disección del Cuello/métodos , Radioterapia Adyuvante/efectos adversos , Radioterapia Adyuvante/métodos , Enfermedad de Raynaud/etiología , Enfermedad de Raynaud/fisiopatología , Procedimientos de Cirugía Plástica/métodos , Medición de Riesgo , Tortícolis/etiología , Resultado del TratamientoRESUMEN
BACKGROUND: Optimal treatment and prognostic factors affecting long-term survival in patients with sinonasal adenoid cystic carcinoma (ACC) have yet to be clearly defined. METHODS: We conducted a retrospective review of patients treated with curative intent from 1980-2015 at MD Anderson Cancer Center. RESULTS: One hundred sixty patients met inclusion criteria, including 8 who were treated with radiotherapy alone. Median follow-up time was 55 months. The 5-year overall survival (OS) and disease-free survival (DFS) rates were 67.0% and 49.0%, respectively. The 10-year OS and DFS rates were 44.8% and 25.4%, respectively. Factors that portended for poor survival on multivariate analysis were recurrent disease, any solid type histology, epicenter in the sinus cavity, the presence of facial symptoms, or the original disease not treated with surgery. There was no association between surgical margin status or nodal status and survival. CONCLUSION: In this large cohort of patients with sinonasal ACC with extended follow-up, long-term survival is better than reported in prior literature. Future research should target patients with adverse risk factors.
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Carcinoma Adenoide Quístico/mortalidad , Neoplasias de los Senos Paranasales/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma Adenoide Quístico/patología , Carcinoma Adenoide Quístico/radioterapia , Carcinoma Adenoide Quístico/cirugía , Terapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Masculino , Márgenes de Escisión , Persona de Mediana Edad , Análisis Multivariante , Estadificación de Neoplasias , Neoplasias de los Senos Paranasales/patología , Neoplasias de los Senos Paranasales/cirugía , Neoplasias de los Senos Paranasales/terapia , Pronóstico , Estudios Retrospectivos , Análisis de SupervivenciaRESUMEN
OBJECTIVE: Compare outcomes of patients with olfactory neuroblastoma (ONB) without skull base involvement treated with and without resection of the dura and olfactory bulb. METHODS: Retrospective review of ONB patients treated from 1992 to 2013 at the MD Anderson Cancer Center (The University of Texas, Houston, Texas, U.S.A.). Primary outcomes were overall and disease-free survival. RESULTS: Thirty-five patients were identified. Most patients had Kadish A/B. tumors (97%), Hyams grade 2 (70%), with unilateral involvement (91%), and arising from the nasal cavity (68%). Tumor involved the mucosa abutting the skull base in 42% of patients. Twenty-five patients (71%) received surgery and radiation, whereas the remainder had surgery alone. Five patients (14%) had bony skull base resection, and eight patients (23%) had resection of bony skull base, dura, and olfactory bulb. Surgical margins were grossly positive in one patient (3%) and microscopically positive in four patients (12%). The 5- and 10-year overall survival were 93% and 81%, respectively. The 5- and 10-year disease-free survival (DFS) were 89% and 78%, respectively. Bony cribriform plate resection was associated with better DFS (P = 0.05), but dura and olfactory bulb resection was not (P = 0.11). There was a trend toward improved DFS in patients with negative resection margins (P = 0.19). Surgical modality (open vs. endoscopic) and postoperative radiotherapy did not impact DFS. CONCLUSION: Most Kadish A/B ONB tumors have low Hyams grade, unilateral involvement, and favorable survival outcomes. Resection of the dura and olfactory bulb is not oncologically advantageous in patients without skull base involvement who are surgically treated with negative resection margins and cribriform resection. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1274-1280, 2018.
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Duramadre/cirugía , Estesioneuroblastoma Olfatorio/cirugía , Cavidad Nasal/cirugía , Neoplasias Nasales/cirugía , Bulbo Olfatorio/cirugía , Adolescente , Adulto , Anciano , Estesioneuroblastoma Olfatorio/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias Nasales/mortalidad , Estudios Retrospectivos , Base del Cráneo , Análisis de Supervivencia , Adulto JovenRESUMEN
BACKGROUND: Heterotopic ossification along free flap pedicles has been reported. Reports suggest that subperiosteal dissection of the pedicle from the bone during the harvest of the fibula free flap may predispose the pedicle to heterotopic ossification. METHODS: A 56-year-old man with history of a T2N1M0 squamous cell cancer of the left tonsil who was treated with chemoradiation developed osteoradionecrosis of the mandible requiring fibula free flap reconstruction. The patient presented with a firm submandibular mass 1 year after reconstruction. RESULTS: Imaging revealed bone along the mandible projecting to the floor of the mouth. Surgery revealed heterotopic bone along the submandibular triangle and vascular pedicle. The bone was removed and the periosteum fulgurated to prevent further proliferation. CONCLUSION: Our practice includes a high-volume head and neck extirpative and reconstruction practice. To the best of our knowledge, this represents the first documented case of heterotopic ossification along a free flap pedicle despite routine subperiosteal elevation to free the peroneal artery from the proximal fibula.
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Peroné/trasplante , Colgajos Tisulares Libres/efectos adversos , Mandíbula/cirugía , Osificación Heterotópica/etiología , Procedimientos de Cirugía Plástica/efectos adversos , Trasplante Óseo/efectos adversos , Peroné/patología , Humanos , Masculino , Mandíbula/patología , Persona de Mediana Edad , Osificación Heterotópica/cirugía , Osteorradionecrosis/cirugía , Complicaciones Posoperatorias , Carcinoma de Células Escamosas de Cabeza y Cuello/cirugía , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: The purpose of this study was to examine the cost differences between preoperative and postoperative placement of gastrostomy tubes (G-tubes) in patients with head and neck cancer. METHODS: We conducted a retrospective chart review of patients with aerodigestive tract cancers from 2010 to 2015. Data included inpatient and postdischarge costs, demographics, tumor characteristics, surgical treatment, length of stay (LOS), time spent in the intensive care unit (ICU), and readmissions. RESULTS: Five hundred ninety patients were included in this study. There was a $7624 inpatient cost savings (P = .002) for those G-tubes placed preoperatively ($26 060) versus postoperatively ($33 754). Postdischarge costs did not differ significantly between groups (P = .60). There was a $9248 total costs savings (P = .009) for those patients with G-tubes placed preoperatively ($39 751) versus postoperatively ($48 999), despite patients with preoperative G-tubes having lower body mass index (BMI; P = .009), higher Association of Anesthesiologist (ASA) class (P = .02), more preoperative radiation (P < .001), and more free tissue transfer reconstruction (P = .007). CONCLUSION: There is potential for savings by placing G-tubes preoperatively, possibly driven by decreased LOS, despite data suggesting that patients with G-tubes placed preoperatively are higher risk.
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Ahorro de Costo , Nutrición Enteral/economía , Gastrostomía/economía , Neoplasias de Cabeza y Cuello/cirugía , Costos de la Atención en Salud , Anciano , Estudios de Cohortes , Análisis Costo-Beneficio , Nutrición Enteral/métodos , Gastrostomía/métodos , Neoplasias de Cabeza y Cuello/economía , Neoplasias de Cabeza y Cuello/patología , Humanos , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Readmisión del Paciente/economía , Cuidados Posoperatorios/métodos , Cuidados Preoperatorios/métodos , Estudios RetrospectivosRESUMEN
BACKGROUND/AIM: Perineural invasion and distant metastasis lead to a poor prognosis of adenoid cystic carcinoma and there is no effective therapy available. MicroRNAs (miRNAs) are small non-coding RNAs that regulate target gene expression, which can be biomarkers or therapeutic targets for certain cancer types. We aimed to identify miRNAs and their target genes possibly involved in metastasis of salivary gland adenoid cystic carcinoma (SACC). MATERIALS AND METHODS: Using Nanostring nCounter analysis, we examined miRNA expression in two SACC cell lines: SACC-83 and SACC-LM, with low and high lung metastasis rates, respectively. We then verified the differentially expressed miRNAs with real-time polymerase chain reaction in the cell lines and in tumor samples from patients with SACC. miRNA target-gene expression was also analyzed. RESULTS: SACC-83 showed higher gene expression of miR-130a, miR-342, and miR-205; SACC-LM showed higher gene expression of miR-99a and miR-155. In human tissue, miR-205 was highly expressed in the primary SACC, while miR-155 and miR-342 were highly expressed in recurrent SACC. Six predicted target genes of miRNA-155 and miR-99a linked to tumorigenesis were further analyzed and RNA expression of ubiquitin-like modifier activating enzyme 2 (UBA2) was higher in SACC than normal salivary gland tissue, and higher in primary compared to recurrent SACC (p<0.05). RNA expression of retinoic acid receptors (RARS) was higher in tissue from primary than recurrent SACC and normal salivary gland (p<0.05), but that in recurrent SACC was not significantly higher than normal salivary gland tissue. RNA expression of minichromosome maintenance 8 homologous recombination repair factor (MCM8) and 24-dehydrocholesterol reductase (DHCR24) was higher in primary SACC than normal salivary gland tissue (p<0.05). CONCLUSION: miR-99a, miR-155, miR-130a, miR-342, and miR-205 may play a role in metastasis of SACC. MiR-155 may be involved in SACC metastasis through UBA2 pathways, and UBA2 may function as a biomarker/mediator of SACC metastasis.