-
OTO Open 2023We aimed to operationalize a head and neck microvascular free tissue transfer (MVFTT) program at a Veterans Affairs (VA) hospital with the emphasis on initiating...
OBJECTIVES
We aimed to operationalize a head and neck microvascular free tissue transfer (MVFTT) program at a Veterans Affairs (VA) hospital with the emphasis on initiating radiotherapy within 6 weeks of surgery for cancer patients and minimizing readmissions.
STUDY DESIGN
Case series.
SETTING
Tertiary care VA hospital.
METHODS
A retrospective analysis was performed on consecutive head and neck MVFTT patients from May 1, 2017 and April 30, 2022. Demographics, patient and disease characteristics, per-operative data and postoperative outcomes were recorded from the electronic medical record. We sought to compare our rate of 30-day readmissions with those published in the literature.
RESULTS
One hundred and forty-one procedures were performed in the queried timeframe. Eighty-four percent (119) were performed after oncologic resections and 16% (22) were for nononcologic procedures. The rate of total flap loss was <1% and the rate of partial flap loss was 3.5%. For mucosal defects, the fistula rate was 2.3%. The rate of return to the OR for any reason within 30 days was 7.8%. The 30-day readmission rate was 6.4% while the rates reported in the literature range from 13% to 20%. One hundred and four patients required postoperative radiotherapy (PORT) and 76% started PORT within 42 days of surgery.
CONCLUSION
Operationalizing a head and neck MVFTT program with a VA hospital is safe and allows for the successful delivery of multimodality treatment to cancer patients. These resources can be expanded for the care of head and neck cancer treatment sequelae, such as osteoradionecrosis, and other nononcologic patient needs.
PubMed: 37693829
DOI: 10.1002/oto2.80 -
Medicine and Pharmacy Reports Jan 2024The aim of this retrospective study was to identify the clinical, radiological, and histological characteristics of patients diagnosed with osteonecrosis of the jaw...
AIM
The aim of this retrospective study was to identify the clinical, radiological, and histological characteristics of patients diagnosed with osteonecrosis of the jaw (ONJ) and treated at the Oral and Maxillo-Facial Surgery Clinic of the Emergency Clinical County Hospital of Targu Mures between 2017 and 2022. The study aimed to analyze correlations between patient characteristics, particularly their history of bone modifying agent use or local radiotherapy during cancer treatment, in order to identify specific patient profiles that could aid in evaluating treatment response and guide individualized treatment strategies.
METHODS
Fifty-two patients diagnosed with ONJ were included in the study. The patients were divided into two groups based on their medical history: the bone modifying agent use group and the radiotherapy group. Clinical, radiological, and histological data were collected and analyzed. Statistical analysis, including p-values, was performed to compare patient characteristics between the two groups.
RESULTS
Patients in the radiotherapy group were significantly older than those in the bone modifying agent use group (66 years vs. 56.9 years, p=0.001). There was a higher proportion of males in the radiotherapy group compared to the bone modifying agent use group (90% vs. 22%, p<0.001). Jaw involvement was more prevalent in the radiotherapy group compared to the bone modifying agent use group (95% vs. 66%, p=0.018). Histological analysis showed a similar frequency of Actinomyces species in both groups (50% vs. 34%, p=0.264).
CONCLUSIONS
The findings of this study suggest the existence of two distinct patient profiles based on their treatment history (bone modifying agent use vs. radiotherapy) in ONJ. Patients in the radiotherapy group were older, predominantly male, and exhibited a higher prevalence of jaw involvement. Histological analysis revealed no significant differences in Actinomyces species frequency between the two groups. These distinct patient profiles may indicate different responses to treatment, emphasizing the need for individualized treatment strategies tailored to specific patient characteristics. Further research is warranted to validate these findings and develop personalized approaches for managing ONJ.
PubMed: 38344330
DOI: 10.15386/mpr-2610 -
Advances in Radiation Oncology Apr 2024For patients with head and neck squamous cell carcinoma (HNSCC), locoregional failure and second primary tumors are common indications for adjuvant reirradiation...
PURPOSE
For patients with head and neck squamous cell carcinoma (HNSCC), locoregional failure and second primary tumors are common indications for adjuvant reirradiation (re-RT). Given an absence of clear consensus on the role of adjuvant re-RT, we sought to assess histopathologic risk factors of patients with HNSCC and their resulting outcomes after adjuvant re-RT with proton therapy.
METHODS AND MATERIALS
We conducted a retrospective analysis of patients with HNSCC who underwent salvage surgery at our institution followed by adjuvant re-RT with proton therapy over 1.5 years. All included patients received prior radiation therapy. The Kaplan-Meier method was used to evaluate locoregional recurrence-free survival and overall survival.
RESULTS
The cohort included 22 patients, with disease subsites, including oropharynx, oral cavity, hypopharynx, larynx, and nasopharynx. Depending on adverse pathologic features, adjuvant re-RT to 66 Gy (32% of cohort) or 60 Gy (68%), with (59%) or without (41%) concurrent systemic therapy was administered. The majority (86%) completed re-RT with no reported treatment delay; 3 patients experienced grade ≥3 acute Common Terminology Criteria for Adverse Events toxicity and no patient required enteral feeding tube placement during re-RT. Median follow-up was 21.0 months (IQR, 11.7-25.2 months). Five patients had biopsy-proven disease recurrences a median of 5.9 months (IQR, 3.8-9.7 months) after re-RT. Locoregional recurrence-free survival was 95.2%, 70.2%, 64.8% at 6, 12, and 24 months, respectively. OS was 100%, 79.2%, and 79.2% at 6, 12, and 24 months, respectively. Four patients had osteoradionecrosis on imaging a median of 13.2 months (IQR, 8.7-17.4 months) after re-RT, with 2 requiring surgical intervention.
CONCLUSIONS
Adjuvant re-RT for patients with HNSCC was well-tolerated and offered reasonable local control in this high-risk cohort but appears to be associated with a risk of osteoradionecrosis. Additional study and longer follow-up could help define optimal patient management in this patient population.
PubMed: 38778826
DOI: 10.1016/j.adro.2023.101418 -
Radiology. Imaging Cancer Jan 2024Interpretation of posttreatment imaging findings in patients with head and neck cancer can pose a substantial challenge. Malignancies in this region are often managed... (Review)
Review
Interpretation of posttreatment imaging findings in patients with head and neck cancer can pose a substantial challenge. Malignancies in this region are often managed through surgery, radiation therapy, chemotherapy, and newer approaches like immunotherapy. After treatment, patients may experience various expected changes, including mucositis, soft-tissue inflammation, laryngeal edema, and salivary gland inflammation. Imaging techniques such as CT, MRI, and PET scans help differentiate these changes from tumor recurrence. Complications such as osteoradionecrosis, chondroradionecrosis, and radiation-induced vasculopathy can arise because of radiation effects. Radiation-induced malignancies may occur in the delayed setting. This review article emphasizes the importance of posttreatment surveillance imaging to ensure proper care of patients with head and neck cancer and highlights the complexities in distinguishing between expected treatment effects and potential complications. CT, MR Imaging, Radiation Therapy, Ear/Nose/Throat, Head/Neck, Nervous-Peripheral, Bone Marrow, Calvarium, Carotid Arteries, Jaw, Face, Larynx © RSNA, 2024.
Topics: Humans; Neoplasm Recurrence, Local; Head and Neck Neoplasms; Osteoradionecrosis; Radiation Injuries; Positron-Emission Tomography
PubMed: 38276904
DOI: 10.1148/rycan.230155 -
JAMA Otolaryngology-- Head & Neck... Jul 2023Mandibular osteoradionecrosis (ORN) is a progressive disease that can be difficult to treat. Conservative measures often fail, while conventional definitive management...
IMPORTANCE
Mandibular osteoradionecrosis (ORN) is a progressive disease that can be difficult to treat. Conservative measures often fail, while conventional definitive management requires a morbid segmental resection with osteocutaneous reconstruction. Evidence of the anterolateral thigh fascia lata (ALTFL) rescue flap technique's safety, effectiveness, and long-term outcomes is needed.
OBJECTIVE
To determine the long-term outcomes of the ALTFL rescue flap procedure for treating patients with mandibular ORN.
DESIGN, SETTINGS, AND PARTICIPANTS
This was a retrospective medical record review performed at a single tertiary-level academic health care institution with patients who were appropriate candidates for the ALTFL procedure to treat mandibular ORN from March 3, 2011, to December 31, 2022. Data analyses were performed from January 1 to March 26, 2023.
MAIN OUTCOMES AND MEASURES
Patient characteristics, preoperative radiographic Notani staging, intraoperative defect size, length of stay, complication rates, and clinical and radiographic findings of progression-free intervals.
RESULTS
The study population of 43 patients (mean [SD] age, 66.1 [47-80] years; 24 [55.8%] male individuals) included 52 cases of mandibular ORN. The preoperative Notani staging of the study population was known for 46 of the 52 total cases: 11 cases (23.9%) were stage I; 21 (45.7%), stage II; and 14 (30.4%), stage III. The mean defect area was 20.9 cm2. Successful arrest of ORN disease progression was noted in the clinical and radiographic findings of 50 of the 52 (96.2%) cases, with only 2 (3.8%) cases subsequently requiring fibular free flap reconstruction. The major complication rate was 1.9% (1 case). Clinical and radiographic progression-free intervals were assessed, and no statistically significant differences were noted between Notani staging groups (log-rank P = .43 and P = .43, respectively); ie, patients with stage III disease had no significant difference in risk of clinical (HR, 0.866; 95% CI, 0.054-13.853) or radiographic (HR, 0.959; 95% CI, 0.059-15.474) progression vs those with stage I disease. Weibull profiling revealed 96.9%, 94.6%, and 93.1% successful mandibular ORN arrest at 1, 3, and 5 years, respectively. The major complication rate was 1.9%. Mean (SD) length of stay was 2.7 (0.0-7.0) days. Mean (SD) radiographic follow-up was 29.3 (30.7) months.
CONCLUSIONS AND RELEVANCE
The findings of this large retrospective patient case series support the continued success of the ALTFL rescue flap technique, a safe and highly effective long-term treatment for mandibular ORN in carefully selected patients.
Topics: Humans; Male; Aged; Female; Retrospective Studies; Thigh; Fascia Lata; Osteoradionecrosis; Treatment Outcome; Mandibular Diseases; Free Tissue Flaps
PubMed: 37261824
DOI: 10.1001/jamaoto.2023.1089 -
MedRxiv : the Preprint Server For... Sep 2023Osteoradionecrosis of the jaw (ORN) can manifest in varying severity. The aim of this study is to identify ORN risk factors and develop a novel classification to depict...
PURPOSE
Osteoradionecrosis of the jaw (ORN) can manifest in varying severity. The aim of this study is to identify ORN risk factors and develop a novel classification to depict the severity of ORN.
METHODS
Consecutive head-and-neck cancer (HNC) patients treated with curative-intent IMRT (≥ 45Gy) in 2011-2018 were included. Occurrence of ORN was identified from in-house prospective dental and clinical databases and charts. Multivariable logistic regression model was used to identify risk factors and stratify patients into high-risk and low-risk groups. A novel ORN classification system was developed to depict ORN severity by modifying existing systems and incorporating expert opinion. The performance of the novel system was compared to fifteen existing systems for their ability to identify and predict serious ORN event (jaw fracture or requiring jaw resection).
RESULTS
ORN was identified in 219 out of 2732 (8%) consecutive HNC patients. Factors associated with high-risk of ORN were: oral-cavity or oropharyngeal primaries, received IMRT dose ≥60Gy, current/ex-smokers, and/or stage III-IV periodontal disease. The ORN rate for high-risk vs low-risk patients was 12.7% vs 3.1% (p<0.001) with an area-under-the-receiver-operating-curve (AUC) of 0.71. Existing ORN systems overclassified serious ORN events and failed to recognize maxillary ORN. A novel ORN classification system, RadORN, was proposed based on vertical extent of bone necrosis and presence/absence of exposed bone/fistula. This system detected serious ORN events in 5.7% of patients and statistically outperformed existing systems.
CONCLUSION
We identified risk factors for ORN, and proposed a novel ORN classification system based on vertical extent of bone necrosis and presence/absence of exposed bone/fistula. It outperformed existing systems in depicting the seriousness of ORN, and may facilitate clinical care and clinical trials.
PubMed: 37745576
DOI: 10.1101/2023.09.12.23295454