BACKGROUND:Intraoperative 18F-fluorodeoxyglucose (18F-FDG) micro-positron emission tomography/computed tomography (micro-PET/CT) is an emerging modality for margin assessment. Prior to clinical use, micro-PET/CT margin distances must be correlated with gold-standard histopathology. METHODS:Micro-PET/CT uptake was co-registered to 3D specimen models annotated with margin sampling sites using principal component analysis and iterative closest point surface registration. Margin distances were measured on the fused models using Gaussian Mixed Modeling and compared with histopathology. RESULTS:Fused micro-PET/CT and 3D specimen models were successfully generated for five patients with head and neck cancer. Among the 16 measured margins, the margin distance on the fused models was within 1 mm of histopathology in 15/16 cases. The Bland-Altman plot demonstrated excellent agreement (±1.25 mm). CONCLUSION:We report a novel technique to register micro-PET/CT data to annotated 3D specimen models. Margin distance measured on the micro-PET/CT scans correlated closely with histopathology. Intraoperative micro-PET/CT warrants further investigation in head and neck margin assessment.
BACKGROUND:Postoperative radiotherapy is the standard treatment for locally advanced oral squamous cell carcinoma (OSCC); however, the indication for neck irradiation (NI) in pN0 patients remains debatable. We evaluated whether the omission of NI compromises outcomes in pT3-T4 pN0 patients treated with adequate neck dissection (ND). METHODS:This retrospective single-institution study included patients with pT3-T4pN0 OSCC who underwent primary surgery, exhaustive ND (≥ 18 lymph nodes), and postoperative radiotherapy limited to the tumor bed. Overall survival (OS), disease-free survival (DFS), and regional control were also analyzed. RESULTS:Seventy-seven patients were included in the study. After a median follow-up of 51 months, only three nodal recurrences occurred, all associated with local tumor relapse. No isolated neck failures were observed. The regional control rate was 96% and the 5-year OS and DFS rates were 77.6% and 79.2%, respectively. CONCLUSION:In selected pT3-T4 pN0 OSCC patients undergoing high-quality ND, omission of postoperative NI does not compromise oncologic outcomes. This strategy allows for a meaningful reduction in irradiation volumes and potentially treatment-related morbidity, supporting de-escalation of treatment.
BACKGROUND:Dysphagia is a common side-effect after radiotherapy in head and neck cancer patients. This randomized study aimed to evaluate the effect of the shaker head-lift exercise (HLE) after 12 months with flexible endoscopic evaluation of swallowing (FEES). METHODS:Patients were randomly assigned to the intervention (n = 30) or the control (n = 31) group. The primary outcome was change according to the Penetration Aspiration Scale (PAS) at 12 months. Secondary outcomes included change according to the dynamic imaging grade of swallowing toxicity for flexible endoscopic evaluation of swallowing (DIGEST-FEES) at 8 weeks and 12 months. RESULTS:The intention-to-treat analysis revealed no significant difference between the intervention and control groups regarding the change in the PAS score from baseline to 12 months. Swallowing safety improved significantly in the control group at the 8-week follow-up. CONCLUSIONS:The HLE does not seem to improve swallowing function in individuals with radiation-induced dysphagia.
BACKGROUND:Near-infrared (NIR) fluorescence-guided surgery using EGFR-targeted tracers (e.g., panitumumab-IRDye800CW) can provide real-time visualization of tumors and margins in Head and Neck Squamous Cell Carcinoma. Prior studies have demonstrated its safety and potential to improve intraoperative decision-making and margin assessment. METHODS:A patient with biopsy-proven oral cavity squamous cell carcinoma (SCC) was enrolled in an imaging-based clinical trial and received intravenous panitumumab and panitumumab-IRDye800CW prior to surgical resection. Intraoperative wide-field NIR fluorescence imaging was performed during marginal mandibulectomy to assess tumor extent, and regions of increased fluorescence signal prompted targeted frozen section biopsy. RESULTS:Intraoperative fluorescence imaging revealed focal signal within the left mandible and along the inferior alveolar canal that was not grossly apparent. Targeted biopsy of these regions confirmed invasive SCC with mandibular bone invasion and perineural invasion of the inferior alveolar nerve. Fluorescence findings correlated with frozen section analysis, specimen-level imaging, histopathology, and final surgical staging, ultimately prompting a recommendation for definitive re-resection. CONCLUSIONS:This case demonstrates that EGFR-targeted NIR fluorescence can detect subclinical bony and perineural tumor extension beyond mucosal surfaces, guiding targeted frozen section sampling and intraoperative management. Fluorescence-guided surgery may serve as a valuable adjunct for evaluating deep and anatomically complex margins in head and neck oncologic surgery. TRIAL REGISTRATION:NCT06819228.
BACKGROUND:Treatment of laryngeal squamous cell carcinoma (SCC) requires specialized expertise. While high-volume facilities demonstrate superior outcomes, the relationship between facility volume and travel distance on survival remains poorly understood. METHODS:Retrospective cohort study using the National Cancer Database (2004-2022) of adults with laryngeal SCC receiving definitive treatment. Risk-adjusted restricted cubic splines characterized non-linear survival relationships, guiding development of multivariable Cox-proportional hazards regression models. RESULTS:Among 106 700 patients, an inflection point was identified at 10 cases/year. Below this threshold, volume had no effect (HR 1.00 [95% CI: 0.97-1.03]); above it, each doubling was associated with an 11% mortality reduction (HR 0.89 [0.84-0.94]). Travel distance showed a paradoxical protective effect (HR 0.97 [0.96-0.99]), but only in advanced-stage disease (HR 0.96 [0.94-0.97]), with no effect in early-stage disease. CONCLUSIONS:A 10-case/year threshold exists for laryngeal SCC care. Early-stage disease can be treated at facilities meeting this, while advanced-stage disease may warrant referral to higher-volume centers.
BACKGROUND:Large cell neuroendocrine carcinoma (LCNEC) of the palatine tonsil is an extremely rare malignancy characterized by an aggressive clinical course and poor prognosis. Its nonspecific presentation often delays diagnosis. METHODS:We present the case of a 76-year-old female patient admitted to the Emergency Department with throat bleeding as her sole symptom. A computed tomography (CT) scan revealed an infiltrate in the right palatine tonsil. RESULTS:Following a tonsillectomy, histopathological examination confirmed LCNEC. PET-CT showed no distant metastases or local recurrence, and multidisciplinary consultation excluded adjuvant therapy due to age and comorbidities, opting for ongoing outpatient surveillance. CONCLUSIONS:This case highlights the importance of oncological vigilance in the differential diagnosis of nonspecific symptoms.
BACKGROUND:Locoregional recurrence remains a clinically relevant problem in oral squamous cell carcinoma (OSCC). Whether local, ipsilateral nodal, and contralateral nodal failure represent distinct disease processes with different clinicopathological associations has not been systematically evaluated. METHODS:This retrospective single-center study included patients only with primary OSCC of the tongue or floor of mouth undergoing surgical resection and neck dissection (2011-2021; n = 438). Oncologic recurrence patterns were evaluated in patients with at least six months of follow-up (n = 363) using multivariable Cox regression adjusted for adjuvant therapy and Kaplan-Meier analyses. RESULTS:Nodal involvement at primary surgery was associated with depth of invasion, bone infiltration, and posterior tongue subsites. In the follow-up cohort, 120 patients (33.1%) developed recurrence. Local recurrence (18.5%) was independently associated with extranodal extension (HR 1.88, 95% CI 1.04-3.40; p = 0.037). Ipsilateral nodal recurrence (11.0%) was associated with lymph node ratio (LNR) > 0.1 versus LNR = 0 (HR 4.90, 95% CI 1.76-13.63; p = 0.002). Contralateral nodal recurrence (8.5%) was not predicted by any evaluated parameter. Patients with LNR > 0.1 experienced recurrence after a median of 19.2 versus 103.0-112.4 months (p < 0.001). CONCLUSION:Local and ipsilateral recurrences showed distinct associations with clinicopathological factors, while contralateral recurrence remained poorly predicted by routine parameters. Lymph node ratio was associated with ipsilateral recurrence risk and shorter event-free survival, supporting its use as a potential stratification marker for risk-adapted surveillance.
OBJECTIVES:The goal was to determine the incidence and risk factors of malignant transformation of oral lichen planus (OLP); oral lichenoid lesions without (OLL) or oral dysplasia with lichenoid features (ODLF). METHODS:We identified a retrospective cohort of 188 patients with a pathological diagnosis of OLP, OLL, or ODLF, and a minimal 12-month follow-up. In each subgroup, we analyzed the rate of malignant transformation and performed a uni- and multivariate analysis of factors associated with malignant transformation. RESULTS:Diagnoses of OLL, OLP, and ODLF were made in 80.9%, 15.4%, and 3.7% of patients, respectively. The average follow-up was 51.5 months. The malignant transformation rates for OLL, OLP, and ODLF were 5.9% (n = 9), 0% (n = 0), and 42.9% (n = 3), respectively. Multivariate analysis performed on the entire cohort showed that the presence of dysplasia was significantly associated with transformation to OSCC (OR = 7.40; p = 0.01) as well as the asymmetry of lesion (OR = 8.81; p = 0.009), whereas there was a trend toward an association between plaque-like lesions and malignant transformation (p = 0.07). CONCLUSIONS:The risk of malignant transformation was only observed in OLL and ODLF. The presence of dysplasia is associated with a higher risk of malignant transformation. Clinical and histological diagnosis of plaque-like OLP is challenging, highlighting the need for future genomic investigations to enable a better molecular characterization of this condition.
BACKGROUND:Adenoid cystic carcinoma (ACC) is a rare malignancy with a propensity for perineural invasion and hematogenous spread. Central nervous system (CNS) involvement is uncommon, and detailed clinical and genomic data on this aspect of the disease remain limited. METHODS:We performed a single-institution retrospective cohort study of patients with biopsy-confirmed ACC and CNS involvement treated at the University of Pennsylvania. Clinical features, CNS disease patterns, treatment modalities, molecular alterations, and survival outcomes were abstracted from the electronic medical record. RESULTS:Seventeen patients were identified. CNS involvement occurred a median of 40 months after initial ACC diagnosis. CNS disease included parenchymal metastases, leptomeningeal disease, and patterns suggestive of neurotropic or perineural intracranial extension. Leptomeningeal involvement was present in 6 patients. Targeted next-generation sequencing demonstrated NOTCH1 alterations in 7 patients, with additional recurrent alterations in CREBBP, BAP1, FGFR2, and PI3K-pathway genes. CNS-directed therapy included surgery, stereotactic radiosurgery, hypofractionated radiotherapy, whole-brain radiotherapy, and conventionally fractionated radiotherapy. Median progression-free survival was 5.4 months, and median overall survival was 9.4 months after CNS involvement. CONCLUSIONS:CNS involvement in ACC was associated with poor outcomes despite multimodal therapy. NOTCH1 alterations and leptomeningeal disease were frequent in this cohort, but these findings should be interpreted as hypothesis-generating given the small sample size and absence of a matched non-CNS comparator cohort.
BACKGROUND:Epistaxis related to hereditary hemorrhagic telangiectasia (HHT) can be life-threatening and decreases quality of life (QoL). Current medical and surgical options are limited, particularly in the advanced stages of the disease. METHODS:We assess the feasibility and outcome of HHT-related epistaxis management by resurfacing the nasal cavity with an endoscopically placed free flap. The Epistaxis Severity Score (ESS) was compared to the preoperative score at one-year post-surgery. RESULTS:The nasal cavity was successfully resurfaced with a radial forearm free flap. The ESS decreased from 8.9 to 3.5 one-year postoperatively. CONCLUSION:Resurfacing endoscopic free flap (REFF) is a safe and effective procedure for the management of HHT-related epistaxis refractory to other treatment options. Nasal function is maintained, with a significant long-term decrease in epistaxis.
BACKGROUND:The robotic-assisted extended "Sistrunk" approach (RESA) is a minimally invasive technique providing access to hypopharyngeal and laryngeal structures via a submental incision and vallecular pharyngotomy, bypassing the base of tongue. METHODS:We report 10 RESA procedures in previously irradiated head and neck cancer patients, including six organ-preservation surgeries and four total laryngectomies. RESULTS:RESA enabled completion of the planned surgery, achieving R0 margins in all cases. Postoperative bleeding occurred in four patients (three Clavien-Dindo IIIb; one II). One cervical abscess was managed endoscopically. After total laryngectomy, three patients developed a subclinical pharyngeal dehiscence visualized on barium swallow exam, without evidence of a pharyngo-cutaneous fistula. Disease-specific survival was 100% (median 15.5 months); two patients died of unrelated causes. Swallowing improved or remained stable in seven patients at 1 year (three developed recurrence, a second primary, or died). CONCLUSION:RESA is a feasible salvage option with acceptable oncologic and functional outcomes in selected patients.
BACKGROUND:Temporal bone resection (TBR) may result in large defects and facial nerve sacrifice. METHODS:Retrospective review of adults undergoing TBR from 2008 to 2019. RESULTS:One hundred and forty patients were reviewed. The extent of TBR was lateral (n = 135), subtotal (n = 2), and total (n = 3). Defects were reconstructed with free flaps (n = 72), regional flaps (n = 45), and cervicofacial flaps (n = 31). Complications included wound dehiscence (n = 20), infection (n = 15), hematoma (n = 6), cerebrospinal fluid leak (n = 2), and meningitis (n = 1). Smoking history was associated with wound complications (OR = 1.23, p = 0.03). Prior resection (OR = 2.34, p = 0.03) and advanced T stage (OR = 1.38, p = 0.04) were associated with free flap reconstruction. Forty-seven patients underwent facial nerve sacrifice. Facial reanimation techniques included primary neurorrhaphy (n = 2), interposition nerve grafting (n = 28), masseteric (n = 7), or hypoglossal (n = 5) to nerve transfers, temporalis tendon transfer (n = 21), ectropion repair (n = 31), brow lift (n = 21), and upper eyelid loading (n = 40). CONCLUSION:Advanced T stage and re-resection are associated with free flap reconstruction after TBR.
BACKGROUND:Eagle's syndrome is a condition caused by an elongated styloid process and is characterized by various symptoms such as cervicofacial pain, foreign body sensation, headache, odynophagia, and otalgia. However, the occurrence of a unilateral peripheral facial palsy as a symptom of Eagle's syndrome has been described only rarely. METHODS:We report the case of a 60-year-old male patient who presented with a sudden and unprovoked onset of retroauricular pain on the left side, accompanied by peripheral left facial palsy. Imaging revealed an extensively elongated styloid process on the left side. Based on the clinical and radiological findings, a spontaneous fracture of the styloid process with subsequent inflammatory reaction compromising the nearby facial nerve was suspected. Surgical resection of the elongated styloid process was performed. RESULTS:Three months after surgery, the peripheral left facial palsy, which had shown no preoperative improvement for many weeks, had improved from House-Brackmann grade IV° to II°. No other symptoms were present postoperatively. CONCLUSIONS:We present a rare case of Eagle's syndrome complicated by unilateral peripheral facial palsy that improved following surgical resection of the elongated styloid process.
BACKGROUND:Head and neck squamous cell carcinoma (HNSCC) lacks an established screening program, and most cases are diagnosed at advanced stages. Multi-cancer early detection (MCED) blood-based assays represent a promising approach, yet real-world clinical experience with MCED-identified HNSCC remains limited. METHODS:We retrospectively reviewed patients referred to our Otolaryngology department with a positive Galleri MCED result indicating HNSCC between January 2020 and March 2026. Physical exam findings, flexible laryngoscopy findings, imaging, and treatment data for each patient was reviewed. RESULTS:Three patients were included in this case report. All three patients were diagnosed with early-stage p16+ oropharyngeal squamous cell carcinoma despite absent symptoms and largely unremarkable physical examinations. All underwent successful resection with no evidence of recurrent disease at early follow-up. CONCLUSIONS:MCED testing can potentially identify early-stage HNSCC in asymptomatic patients. Otolaryngologists should be prepared to systematically evaluate patients referred following a positive MCED result.
BACKGROUND:The role of virtual surgical planning (VSP) in mandibular osteoradionecrosis (ORN) surgery remains uncertain due to the challenges posed by irradiated tissues METHODS: A consecutive series of patients with mandibular ORN undergoing resection and reconstruction with vascularized hard-tissue free flaps between 1996 and 2004 was included. VSP was analyzed as a predictor variable for ORN recurrence, fixation plate removal, and malocclusion. RESULTS:Among 120 patients with mandibular ORN, 49 patients underwent VSP-guided resection and reconstruction. Multivariable Cox proportional hazards regression demonstrated a hazard ratio of 0.544 (95% CI: 0.098-3.010, p = 0.485) for ORN recurrence and 0.349 (95% CI: 0.145-0.841, p = 0.019) for plate removal. VSP was significantly associated with reduced malocclusion in 2 out of 30 dentate patients, compared to 10 out of 29 dentate patients in the non-VSP group (p = 0.010). CONCLUSIONS:VSP appears to be safe for ORN surgery with reduced rates of postoperative complications of plate removal and malocclusion.
BACKGROUND:Neoadjuvant chemoimmunotherapy is being explored in locally advanced head and neck squamous cell carcinoma (HNSCC), yet the spatial patterns of pathologic response and clinical implications remain poorly characterized. METHODS:A 79-year-old female with recurrent left oral tongue SCC (PD-L122C3 Combined Positive Score 90) who underwent prior resection and free flap reconstruction received neoadjuvant pembrolizumab, paclitaxel, and carboplatin followed by definitive surgical resection with intraoperative positron emission tomography/computed tomography (PET/CT) imaging. RESULTS:Final histopathology revealed two discrete foci of residual poorly differentiated SCC, measuring 1.8 and 0.5 cm, separated by an 8 mm intervening bridge of inflammation without viable tumor. Intraoperative PET/CT with 3D specimen mapping confirmed the spatial relationship between residual foci and intervening treatment effect. CONCLUSIONS:Pathologic response to neoadjuvant chemoimmunotherapy in HNSCC can manifest as a multifocal regression pattern. Intraoperative real-time approaches to assessing treatment response warrant further investigation. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT06915454.
Squamous cell carcinoma of the head and neck (HNSCC) is a global public health issue. Traditionally diagnosed in individuals over 60 years old, there has been a rising incidence among young patients (< 45 years). This retrospective and descriptive study analyzes the epidemiological, clinical, and biochemical profiles of young patients diagnosed with HNSCC between 2015 and 2022 at the Cancer Hospital of Muriaé, Minas Gerais, Brazil. A comparative analysis between young and older patients revealed significant differences in inflammatory profiles and disease progression. Young patients showed higher counts of leukocytes, monocytes, and neutrophils compared to older patients, suggesting an exacerbated inflammatory response. The 60-month survival rate was 41.5% among young patients and 38.1% among older ones, with no statistically significant difference. A strong association between poor oral hygiene and HNSCC was observed, with 61.43% of young patients presenting poor hygiene-a factor that may contribute to increased local inflammation and tumor progression. These findings underscore the need for preventive strategies and early diagnosis.
BACKGROUND:Intraoperative neuromonitoring (IONM) is a reliable tool to detect electromyographic loss of signal (LOS). Here, we investigated the effect of electromyography features of traction-related LOS on prognosis. METHODS:Thyroidectomy patients with a traction-related LOS were included. The cases were divided into four groups as follows: Type 1 LOS with no amplitude (0 μV) (Group 1), Type 1 LOS with low-amplitude (1-99 μV) (Group 2), Type 2 LOS with no amplitude (Group 3), and Type 2 LOS with low-amplitude (Group 4). RESULTS:A total of 788 patients (1429 nerves) were analyzed. Traction-related LOS was found in 74 patients (9.4%) and 77 nerves (5.4%). Intraoperative recovery was observed in 21 (48.8%) nerves in Group 4, and significantly higher (p = 0.011). Vocal cord paralysis was less in Group 4 (p = 0.001). CONCLUSIONS:In traction-related injury, electromyography features may contribute to the decision-making process. Type 2 LOS with low-amplitude is associated with a high likelihood of intraoperative recovery, potentially reducing the need for staged thyroidectomy.
BACKGROUND:NUT midline carcinoma (NMC) is an aggressive malignancy driven by NUTM1 fusions in poorly differentiated tumor cells. This pooled analysis evaluates the impact of primary tumor location on overall survival (OS) in head and neck (HN) NMC. METHODS:A systematic review of case reports was performed. Kaplan-Meier survival analysis was used to assess OS differences by subsite, age, and genetic profile. RESULTS:Of 261 screened articles, 81 met inclusion criteria. Overall, 138 cases were included in demographic analyzes and 65 in survival analyzes. Tracheo-laryngopharyngeal tumors trended toward worse OS (HR 2.45, 95% CI 1.01-5.95, p = 0.047). Orbito-sinonasal tumors trended toward improved OS (HR 0.75, 95% CI 0.46-1.24, p = 0.25). BRD4-NUTM1 fusions were associated with worse OS (HR 8.3, 95% CI 4.26-16.23, p = 0.0003). CONCLUSIONS:HN NMC carries a poor prognosis, and BRD4-NUTM1 fusions have worse outcomes. Primary subsite is a potential prognostic variable that may inform future studies.
PURPOSE:Systematic inflammation plays an integral role in tumor development and metastasis. High neutrophil counts, among various peripheral blood biomarkers, have been shown to be associated with worse outcomes in multiple cancer types. To evaluate the absolute neutrophil count (ANC) as a prognostic biomarker in head and neck cancer, we performed an observational cohort study of patients undergoing definitive chemoradiation. METHODS:Our institutional database was queried for patients with non-metastatic head and neck cancer who underwent definitive chemoradiation between June 2007 and April 2023. ANC was analyzed as a continuous variable. Cox multivariable analysis (MVA), Fine-Gray MVA, and propensity score matching with its median value as a cutoff were performed. Subgroup analyses were performed among p16-positive cohorts. RESULTS:A total of 668 patients who met our criteria. Median follow up was 30.3 months (interquartile range 9.9-60.7). Elevated ANC as a continuous variable was associated with worse overall survival (OS; adjusted hazards ratio [aHR] 1.02, 95% confidence interval [CI] 1.01-1.04, p = 0.003), progression free survival (PFS; aHR 1.03, 95% CI 1.01-1.04, p < 0.001), and distant failure (DF; aHR 1.03, 95% CI 1.01-1.05, p = 0.007), but not locoregional failure (LRF; aHR 1.02, 95% CI 1.00-1.05, p = 0.10). Similar findings were noted among 278 matched pairs. Among 344 patients with p16-positive tumors, high ANC was associated with worse OS (aHR 1.03, 95% CI 1.00-1.06, p = 0.046), PFS (aHR 1.05, 95% CI 1.02-1.07, p < 0.001), LRF (aHR 1.08, 95% CI 1.05-1.12, p < 0.001), and DF (aHR 1.04, 95% CI 1.01-1.08, p = 0.02). CONCLUSIONS:Our study suggested that elevated ANC was an independent, adverse prognostic factor for worse survival and distant metastasis outcomes. It was also associated with worse locoregional failure among patients with p16-positive tumors.
