The data that supports the findings are available on request from the corresponding author.

Objectives: Salivary gland malignancies are an uncommon and heterogeneous group of cancers. We report our experience of clinicopathological variables that affect survival in patients treated by curative intent with surgery at a UK institution over a period of 15 years. Design: Retrospective cohort study Setting: Single centre study Participants We included 108 patients with malignant salivary gland tumours treated by curative intent with surgery from 2004 to 2019. Main outcome measures: The association between clinicopathological factors and their impact on overall survival (OS) and disease-free survival (DFS). Results: 77 (71.3%) presented with early pT classification and 81 (75%) of were node-negative. The parotid was the commonest site of malignancy (86, 79.6%). Perineural invasion (PNI) was present in 40 (37%) and lymphovascular invasion (LVI) was present in 20 (18.5%). 63 (58.3%) underwent adjuvant therapy. Median follow up was 36 months. Five-year OS and DFS were 81.7% and 71%. Age 50, pT classification 3-4, high tumour grade, PNI, and advanced TNM stage were all associated with worse OS and DFS, and LVI with worse DFS. There was no survival difference between a close (1-<5 mm) or negative (≥5 mm) resection margin. Conclusions: Age >50 years, advanced TNM stage, PNI and LVI are predictors of poor DFS. There was no difference in OS or DFS between patients with negative and close resection margins, indicating that close margins may be adequate for maintaining good oncologic outcomes in this group of patients.

Background: Current sentinel lymph node biopsy (SLNB) techniques, including use of radioisotopes, have disadvantages including the use of a radioactive tracer. Indocyanine green (ICG) based near-infrared (NIR) fluorescence imaging and cone beam CT (CBCT) have advantages for intraoperative use. However, limited literature exists regarding their use in head and neck cancer SLNB. Methods: This was a prospective, non-randomized study using a rabbit oral cavity VX2 squamous cell carcinoma model (n = 10) which develops lymph node metastasis. Pre-operatively, images were acquired by MicroCT. During surgery, CBCT and NIR fluorescence imaging of ICG was used to map and guide the SLNB resection. Results: Intraoperative use of ICG to guide fluorescence resection resulted in identification of all lymph nodes identified by pre-operative CT. CBCT was useful for near real time intraoperative imaging and 3D reconstruction. Conclusions: This pre-clinical study further demonstrates the technical feasibility, limitations and advantages of intraoperative NIR-guided ICG imaging for SLN identification as a complementary method during head and neck surgery.

The benefit of adding docetaxel, cisplatin and 5-fluorouracil (TPF) induction chemotherapy to chemoradiotherapy (CRT) in head and neck squamous cell carcinoma (HNSCC) remains uncertain. We aimed to investigate whether ICT is well tolerated when given with prophylactic treatment against predicted adverse effects and which patients benefit most.

Objectives Previously, we showed that pre-treatment tumour plasma perfusion (Fp) predicts RECIST response to induction chemotherapy (ICT) in locoregionally advanced head and neck squamous cell carcinoma (HNSCC). The aim here was to determine whether the pre-treatment tumour Fp estimate, changes in tumour Fp or RECIST response post 2 cycles of ICT were prognostic for long-term survival outcomes. Methods A prospective study enrolled patients with high stage HNSCC treated with docetaxel (T), cisplatin (P) and 5-fluorouracil (F) (ICT) followed by synchronous cisplatin and intensity modulated radiotherapy. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) before and after two cycles of ICT was used to measure Fp and RECIST response. Results Forty-two patients were recruited and 37 underwent two scans. The median follow-up was 36 (range 23-49) months. Pre-treatment tumour Fp (stratified by median) was not prognostic for overall survival (p = 0.42), disease specific survival (p = 0.20) and locoregional control (p = 0.64). Neither change in tumour Fp nor RECIST response post two cycles of ICT was prognostic for any outcome (p>0.21). Conclusion DCE-MRI parameters do not predict long-term survival outcomes following ICT and RECIST response to ICT may not be an appropriate endpoint to determine early efficacy of a treatment in HNSCC patients.

PURPOSE:Current nonvascular osseous reconstructive options for reconstruction of the orbital floor after maxillectomy include options such as scapular tip and iliac crest bone grafts. The aim of this study was to determine whether these donor sites were morphologically comparable with the orbital floor. MATERIALS AND METHODS:A retrospective cross-sectional study design was selected. By use of a pre-existing melanoma database (January 1, 2005, through September 20, 2015), computed tomography scans of the head, neck, thorax, and pelvis were obtained from patients without evidence of bony metastases. With the use of 3-dimensional software (Mimics; Materialise, Leuven, Belgium), grafts from the scapulae and iliac crests, the predictor variables, were digitally harvested, co-registered with the orbital floors bilaterally, and analyzed. The primary outcome was conformance. Data were analyzed using descriptive statistics and tests of statistical significance. The significance level was set at P<.05. RESULTS:The study sample included 10 patients (6 men and 4 women; mean age, 55 ± 18 years). Close conformance was observed when we analyzed the morphology of the orbital floor to the scapular (2.23 ± 0.31 mm) and iliac crest (2.13 ± 0.30 mm) bone grafts, with no significant difference between sites. Conformance mapping showed maximum conformance centrally (scapula, 0.001 ± 0.001 mm; iliac crest, 0.001 ± 0.001 mm), with decreased morphologic similarity peripherally (scapula, 6.09 ± 0.94 mm; iliac crest, 5.74 ± 0.88 mm). There was no significant difference in conformance between sides of graft harvest. CONCLUSIONS:When considering nonvascularized bone grafts for reconstruction of the orbital floor, both the scapula and iliac crest offer nearly complete conformance to the orbital floor structure and represent reasonable reconstructive options.

We illustrate a case of synchronous malignant solitary fibrous tumor of the thoracic cavity, and widely invasive thyroid Hurthle cell carcinoma. The Hurthle cell carcinoma was found to harbor distinct areas of malignant solitary fibrous tumor. This is a unique case of tumor-to-tumor metastasis that, to the best of our knowledge, has not been previously reported.

ABSTRACTBackgroundThe primary purpose of this study was to examine whether angiosarcoma outcomes differ for the scalp and face.MethodsWe conducted a retrospective outcomes analysis of 50 patients with cutaneous angiosarcoma treated by curative intent identified from the Princess Margaret Cancer Centre Registry (from 1958 to 2014).ResultsMedian survival was 26 months (95% confidence interval [CI], 17.6–34.6) and median follow‐up 29 months. For the scalp and face, respectively, the 5‐year locoregional control rate was 9% and 53% (p = .04); the recurrence‐free survival (RFS) rate was 5% and 27% (p = .017); and the overall survival (OS) rate was 9% and 26% (p = .017). Scalp lesions were larger, more likely to be multifocal, and presented more rapidly once noticed. In multivariate Cox proportional hazards analysis, scalp location was independently prognostic for mortality (hazard ratio [HR], 2.10; 95% CI, 1.03–4.28; p = .04).ConclusionScalp angiosarcoma has worse survival than angiosarcoma of the face. Scalp angiosarcoma tends to be larger at presentation, which may be because it is not noticed until more advanced. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1205–1211, 2017

Background We set out to determine the accuracy of 3D-navigated mandibular and maxillary osteotomies with the ultimate aim to integrate virtual cutting guides and 3D-navigation into ablative and reconstructive head and neck surgery. Methods Four surgeons (two attending, two clinical fellows) completed 224 unnavigated and 224 3D-navigated osteotomies on anatomical models according to preoperative 3D plans. The osteotomized bones were scanned and analyzed. Results Median distance from the virtual plan was 2.1 mm unnavigated (IQR 2.6 mm, ≥3 mm in 33%) and 1.2 mm 3D-navigated (IQR 1.1 mm, ≥3 mm in 6%) (P<0.0001); median pitch was 4.5° unnavigated (IQR 7.1°) and 3.5° 3D-navigated (IQR 4.0°) (P<0.0001); median roll was 7.4° unnavigated (IQR 8.5°) and 2.6° 3D-navigated (IQR 3.8°) (P<0.0001). Conclusion 3D-rendering enables osteotomy navigation. 3 mm is an appropriate planning distance. The next steps are translating virtual cutting guides to free bone flap reconstruction and clinical use.

Background. The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) is used in surgical decision-making according to malignancy risk in each category. Malignancy risk in atypia/follicular lesion of undetermined significance (AUS/FLUS) is estimated in BSRTC to be 5% to 15%, but institutional data have varied widely.Methods. We conducted a post-BSRTC 4-year retrospective analysis of index thyroid nodule cytology and histopathology in an academic head and neck endocrine surgery setting.Results. Of 2939 thyroid cytology reports from 1944 patients, the most advanced BSRTC category was AUS/FLUS in 233 patients (12.0%) of which 187 went to thyroidectomy. In AUS/FLUS, the upper and lower boundary estimates of the malignancy rate were 46% and 37%, accord-ingly. The malignancy rate did not vary significantly by cytopathologist or cytopathologic features.Conclusion. Malignancy rates in AUS/FLUS vary by institution from 6% to 46%. Given the subjective nature of thyroid cytopathology and interpretation of the BSRTC categories, guidelines should encourage the use of institution-specific data on malignancy risk in treatment decisions. (C) 2015 Wiley Periodicals, Inc.

Introduction: The external branch of the superior laryngeal nerve (EBSLN) is vulnerable to injury in thyroidectomy during dissection of the superior pole. EBSLN innervates the cricothyroid muscle, which acts as a tensor of the vocal cords assisting in high-pitched phonation. Subjective voice disturbance is common after thyroidectomy in cases where vocal cord mobility is normal.1 Unilateral EBSLN injury may adversely affect the voice in nonsingers as well as singers.2 The position of EBSLN in relation to the superior pole was classified by Cernea as follows: type 1 nerves cross the superior pole greater than 1 cm above the upper border of the thyroid, type 2a nerves cross within 1 cm of the thyroid, and type 2b nerves cross below the upper border of the thyroid.3 In a study from our institution, 175 of 178 EBSLNs were identified at operation, 7% were type 1, 45% were type 2a, and 48% type 2b.4 Consequently, we identify the EBSLN during thyroidectomy. The objective of this video presentation is to demonstrate our method for the routine identification of EBSLN. Materials and Methods: Informed consent for videography was obtained. Surgeon point-of-view video was shot using a head-mounted GoPro camera set to 1080p 60fps in narrow mode. Video and audio were edited using Adobe Premiere Pro CC. Under loupe magnification, the sternothyroid strap muscle was reflected from the superior pole, Jolls triangle was bluntly dissected, and the lateral surface of the cricothyroid muscle was exposed. The EBSLN was bluntly dissected with a pledget and traced laterally. An Allis clamp was placed on the superior pole and the superior thyroid vascular pedicle was ligated. Results: The EBSLN is routinely identifiable with negligible added operating time. Conclusions: The EBSLN can be identified routinely during dissection of the superior pole of the thyroid using loupe magnification. The EBSLN frequently overlies the superior pole and if not identified is at increased risk of injury. No competing financial interests exist. Runtime of video: 2 mins 6 secs

Objectives: Non-response to induction chemotherapy (IC) occurs in 30% of head and neck squamous cell carcinoma (HNSCC) and has been predicted by tumor plasma flow (F-p) derived by perfusion computed tomography. The present study was designed to test whether baseline tumor F-p determined by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) would predict IC response.Materials and methods: A prospective open study powered to test the relationship between tumor F-p and response to IC (docetaxel, cisplatin, 5-fluorouracil) enrolled 50 patients with stage IV HNSCC. Response after two IC cycles was measured by MRI using Response Evaluation Criteria in Solid Tumors in 37 patients. Tumor F-p (primary end point) and multiple parameters in tumors and lymph nodes (secondary end points) were generated at baseline. Differences in baseline DCE-MRI parameters according to IC response were assessed by the Mann-Whitney U test, and predictive value by receiver operating characteristic (ROC) analysis.Results: Median baseline tumor F-p was 53.2 ml/100 ml/min in 25 responders and 23.9 in 12 non-responders (U 82; P = 0.027; area under ROC curve (AUC) 0.73). Median baseline F-p in lymph nodes was 25.8 ml/100 ml/min for 37 nodes in 25 responders and 17.1 for 15 nodes in 12 non-responders (U 186, P = 0.066; AUC 0.67). Frequency of IC response in 37 patients was 68% overall, 83% for tumor F-p above the median (40.6 ml/100 ml/min) and 45% below the median. Other DCE-MRI parameters were not associated with IC response.Conclusion: Pre-treatment tumor F-p determined by DCE-MRI predicts IC response in HNSCC. (C) 2015 Elsevier Ltd. All rights reserved.

Objectives/HypothesisTo determine the prognostic value of hypoxia‐associated markers carbonic anhydrase‐9 (CA‐9) and hypoxia‐inducible factor‐1α (HIF‐1α) in advanced larynx and hypopharynx squamous cell carcinoma (SCCa) treated by organ preservation strategies.Study DesignRetrospective cohort study.MethodsPretreatment CA‐9 and HIF‐1α expression, clinicopathologic data, and tumor volume were analyzed in a series of 114 patients with T3–4 SCCa larynx or hypopharynx treated by (chemo)radiation.ResultsAdverse prognostic factors for locoregional control were T4 classification (P = 0.008), and for disease‐specific survival were CA‐9 positivity (P = 0.039), T4 classification (P = 0.001), larger tumor volume (P = 0.004), N1–3 classification (P = 0.002), and pretreatment hemoglobin < 13.0 g/dl (P = 0.014). With increasing CA‐9 expression, there was a trend to increasing tumor recurrence (Ptrend = 0.009) and decreasing survival (Ptrend = 0.002). On multivariate analysis, independent variables were T4 classification (hazard ratio [HR] 13.54, P = 0.01) for locoregional failure, and CA‐9 positivity (HR = 8.02, P = 0.042) and higher tumor volume (HR = 3.33, P = 0.007) for disease‐specific mortality.ConclusionThis is the first study to look specifically at T3 and T4 SCCa larynx and hypopharynx for a relationship between hypoxia‐associated marker expression and clinical outcome. Pretreatment immunohistochemical CA‐9 expression is an adverse prognostic factor for disease‐specific survival, indicating that CA‐9 expression may confer a more aggressive tumor phenotype.Level of Evidence4. Laryngoscope, 125:E8–E15, 2015

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) generates microvascular parameters from the tracer kinetic analysis of a series of MRI images obtained in under 15 min. DCE-MRI parameters are associated with tumour hypoxia, which is well-established as a cause of treatment failure in head and neck squamous cell carcinoma (HNSCC). A systematic review was conducted of prospective DCE-MRI parameter studies in HNSCC in the English language literature. Exclusion criteria were case reports and retrospective series. Six DCE-MRI marker studies in HNSCC met the inclusion criteria. Four studies contained 21–74 patients and two studies recruited 13 and 14 patients. In studies measuring the transfer coefficient (Ktrans), higher overall Ktrans or lower skewness of Ktrans were predictive of a good outcome following chemoradiation. DCE-MRI parameters have the potential to guide treatment in HNSCC. Progress in the field requires standardisation of methods, data sharing and large multi-centre collaborative validation studies.

AbstractObjective:We report a case of rhabdomyosarcoma of the trachea in a 14-month-old child, and we present the first reported use of proton beam therapy for this tumour.Case report:A 14-month-old girl presented acutely with a seven-day history of biphasic stridor. Emergency endoscopic debulking of a posterior tracheal mass was undertaken. Histological examination revealed an embryonal rhabdomyosarcoma with anaplasia. Multimodality therapy with surgery and chemotherapy was administered in the UK, and proton beam therapy in the USA.Conclusion:Only three cases of rhabdomyosarcoma of the trachea have previously been reported in the world literature. This is the first reported case of treatment of this tumour with proton beam therapy. Compared with conventional radiotherapy, proton beam therapy may confer improved long-term outcome in children, with benefits including reduced irradiation of the spinal cord.

BackgroundBell's palsy is an idiopathic, acute unilateral facial weakness that evolves rapidly and ismaximal within two days. Moderate ear discomfort, sensitivity to sound and reduced tearing may occur.ObjectivesTo assess the effects of hyperbaric oxygen therapy on recovery of facial function in adults with moderate to severe Bell's palsy.Search methodsWe searched the Cochrane Neuromuscular Disease Group Specialized Register (January 2012), CENTRAL (2011, Issue 4), MEDLINE (January 1966 to January 2012), EMBASE (January 1980 to January 2012), CINAHL (1937 to January 2012), AMED (1985 to January 2012), LILACS (January 1982 to January 2012). In addition we made a systematic search for relevant controlled trials in specific hyperbaric literature sources.Selection criteriaRandomised controlled trials or quasi-randomised controlled trials of adults (over 16 years of age) undergoing hyperbaric oxygen therapy for moderate to severe Bell's palsy. We considered studies to be of sufficient quality for inclusion in the review only if there was blinding in the assessment of the facial palsy grade. We planned to include studies of HBOT used as adjuvant therapy, or in addition to routine medical therapy (including corticosteroids or antivirals, or both). Both treatment and control groups were to receive the same baseline therapy. HBOT had to be delivered at concentrations greater than or equal to 1.2 ATA in a hyperbaric oxygen chamber as a series of dives of 30 to 120 minutes.Data collection and analysisTwo reviewers independently assessed eligibility and study quality and extracted data. We contacted study authors for additional information.Main resultsOur searches found no randomised controlled trials or quasi-randomised controlled trials that met the eligibility criteria for this review. There is very low quality evidence from one randomised trial involving 79 participants with acute Bell's palsy, but this study was excluded as the outcome assessor was not blinded to treatment allocation and thus did not meet pre-defined eligibility criteria. The trial compared 42 people who received hyperbaric oxygen therapy (2.8 atmospheres for 60 minutes twice daily, five days per week until the facial palsy resolved; maximum 30 'dives') and placebo tablets with 37 people who received placebo hyperbaric oxygen therapy (achieving only a normal partial pressure of oxygen) and prednisone (40 mg twice daily, reducing over eight days). Facial function recovered in more participants treated with hyperbaric oxygen therapy than with prednisone (hyperbaric oxygen therapy, 40/42 (95%); prednisone, 28/37 (76%); risk ratio 1.26, 95% CI 1.04 to 1.53). There were no reported major complications and all participants completed the trial.Authors' conclusionsVery low quality evidence from one trial suggests that hyperbaric oxygen therapy may be an effective treatment for moderate to severe Bell's palsy, but this study was excluded as the outcome assessor was not blinded to treatment allocation. Further randomised controlled trials are needed.

The hallmarks of cancer were updated by Hanahan and Weinberg in 2011. Here we discuss the updated hallmarks in relation to what is known of the molecular and cellular processes underlying the development of head and neck squamous cell carcinoma (HNSCC). Several mechanisms are described, and recent surveys of HNSCC suggest a limited number of mutations, from which more mechanisms may emerge. There are also epigenetic changes to the control of normal processes. More than one mechanism underlies each hallmark. Processes essential to the development of HNSCC need not be essential to the proliferation of the fully developed tumour. Attention is paid to the emerging hallmarks, deregulation of cellular energy metabolism and evasion of immune destruction, and enabling characteristics, genome instability and mutation and tumour-promoting inflammation. HNSCC may adapt to hypoxia, suppress HLA expression, and express Toll-like receptors to facilitate inflammation, which support the proliferation of the tumour.

Objective: We present a case series with airway compromise due to bilateral abductor vocal fold paralysis or fixation, treated with unilateral transverse cordotomy.Methods: Of eight consecutive patients with dyspnoea due to bilateral paramedian vocal fold immobility, seven underwent unilateral transverse cordotomy between August 2006 and April 2010 at University Hospital of South Manchester, UK. Airway and voice outcomes were compared before and after surgery.Results: All seven treated cases derived subjective airway function improvement; there was no aspiration. The eighth case had inadequate access. None of the seven treated patients required contralateral cordotomy or permanent tracheostomy. One treated case required a temporary tracheostomy; unilateral transverse cordotomy facilitated eventual decannulation. Two patients died of cancer at five and six weeks, variously. At a mean follow up of 22 months, four cases showed unchanged or slightly worse Voice Symptom Scale and Grade-Roughness-Breathiness-Asthenia-Strain scale scores.Conclusion: In patients with bilateral abductor vocal fold immobility, unilateral transverse cordotomy results in improved dyspnoea with either no voice change or only slight worsening. This is a more conservative procedure than bilateral transverse cordotomy, with the potential for better preservation of voice and breath support.