BACKGROUND:The adipofascial anterolateral thigh (AF-ALT) free flap represents a versatile technique in head and neck reconstructions, with its applications increasingly broadening. The objective was to detail the novel utilization of the AF-ALT flap in orbital and skull base reconstruction, along with salvage laryngectomy onlay in our case series. METHOD:We conducted a retrospective analysis at Roswell Park Comprehensive Cancer Center, spanning from July 2019 to June 2023, focusing on patient demographics and reconstructive parameters data. RESULTS:The AF-ALT flap was successfully employed in eight patients (average age 59, body mass index [BMI] 32.0) to repair various defects. Noteworthy outcomes were observed in skull base reconstructions, with no flap failures or major complications over an average 12-month follow-up. Donor sites typically healed well with minimal interventions. CONCLUSION:Our series is the first to report the AF-ALT flap's efficacy in anterior skull base and orbital reconstructions, demonstrating an additional innovation in complex head and neck surgeries.

Purpose/Objective(s) Reports are conflicting regarding impact of prophylactic PEG tube placement in head and neck cancer patients; we add to the paucity of literature of risk factors for long term PEG tube placement and weight loss in this patient cohort. The objective is to evaluate the impact of prophylactic PEG tube and risk factors for long term PEG tube placement and weight loss in patients undergoing treatment of head and neck cancer Materials/Methods This retrospective study included a total of 502 patients with head and neck cancer who were treated at a single institution. Univariate analyses, such as logistic regression or Cox regression, were performed to determine risk factors for long term PEG tube and weight loss. Outcomes that were significantly associated with prophylactic PEG were selected for a multivariate analysis. The Kaplan-Meier method was used to estimate the time to PEG completion, which was compared between acute and late PEG groups using log-rank tests. The proportion of patients who did not receive acute PEG, but received late PEG was estimated using exact binomial confidence interval. Results Of the 502 patients examined, median overall survival was measured to be 65.8 months, with a 95% confidence interval of 45.9 – 94.3. Progression free survival, which was measured to be the time from diagnosis to local/distant failure, or death, was found to have a median of 42.5 months, with a 95% CI of 31.9 – 64.6. The univariate analysis suggests higher risk of long-term feeding tube in patients received prophylactic PEG tube (p < 0.0001), with higher age (p = 0.0165), and with a cancer site of larynx compared to sites other than pharynx and lip/oral cavity (p = 0.0364). Multivariate tests confirmed that prophylactic PEG tube and the higher age are significantly associated with higher risk of long-term feeding tube, with p < 0.0001 and p = 0.0082, respectively. For weight loss, univariate analysis suggests patients tend to have higher percentage of weight loss if they did not receive prophylactic PEG tube (p < 0.00001) or they are in the lower age (p = 0.0034). In addition, patients also tend to have higher weight loss if they received CCRT treatment relative to Surgery + CCRT (p < 0.0001). Mostly consistent with the univariate analysis, the multivariable analysis suggests no prophylactic PEG tube (p < 0.00001), lower age (p = 0.0032), and surgery + CCRT treatment (p = 0.0005) were found to be significantly associated with higher weight loss. Prophylactic PEG tube was not found to be associated with quality-of-life overall health overall survival, or progression-free survival on univariate analysis. Conclusion This retrospective study found that prophylactic PEG tube and higher age are significantly associated with higher risk of long-term feeding tube. Lower age, no prophylactic PEG tube, and surgery + CCRT treatment were found to be significant associated with higher weight loss. Future studies are necessary to further elucidate optimizing weight loss and outcomes in this tenuous patient population.

Importance The role of prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement in head and neck cancer (HNC) patients treated with chemoradiation remains controversial and varies by center. Objective To evaluate the impact of prophylactic PEG tube placement in patients undergoing chemoradiation for HNC PEG tube use for more than 6 months and weight loss. Design, Setting, and Participants This single-institution retrospective study included 502 patients with head and neck cancer. Exposures Concurrent Chemoradiation (CCRT) and prophylactic PEG tube placement. Main Outcomes and Measures Univariate analyses were performed to determine risk factors for long term PEG tube and weight loss. Outcomes that were significantly associated with prophylactic PEG were selected for a multivariate analysis. The Kaplan-Meier method was used to estimate survival and the time to PEG removal, with comparisons between groups analyzed by log-rank tests. The global health status score from the EORTC QLQ30 was utilized to assess impact on quality of life. Results Significantly higher weight loss was seen with the following variables: 1) omitting prophylactic PEG tube (p < 0.00001), 2) younger age (p = 0.0032), and 3) adjuvant CCRT (p = 0.0005). There was significantly higher risk of feeding tube duration longer than 6 months in those who: received prophylactic PEG tube (p < 0.0001) and were older than the median age of 60.8 years (p = 0.0165) on multivariate analysis. Prophylactic PEG tube was not associated with improved global health status, overall survival, or progression-free survival on univariate analysis. Conclusions and Relevance Prophylactic feeding tubes significantly decreased weight loss during treatment. Prophylactic PEG tube and older than median age was significantly associated with higher risk of feeding tube duration longer than 6 months.

BackgroundSoft tissue defects and persistent cerebrospinal fluid (CSF) leaks can create complications after cervical spinal surgery. The supraclavicular artery island (SAI) flap is useful in closing tissue defects, particularly in these complex surgeries and multiple reinterventions. However, technical reports in this context are scarce. We describe application of the SAI flap technique to control persistent CSF leak in the first documented instance (to our knowledge) of a low-grade fibromyxoid sarcoma (LGFMS) in the cervical epidural space. Additionally, we conducted a comprehensive review of PubMed, Embase, and Google Scholar from their earliest records through December 17, 2023 using combined terms, “supraclavicular artery island flap AND spine” and “supraclavicular AND flap AND spine”.Technical NoteA 56-year-old woman with arm pain and weakness presented with a cervical epidural mass extending from C4–C6 and associated spinal cord compression. She underwent a 3-level corpectomy and tumor resection. Primary dural closure was impossible due to the dural invasion, and reintervention with an SAI flap and definitive lumboperitoneal shunting were required to control and seal the CSF leak.Systematic Literature ReviewSeven case reports describing SAI flap for spinal surgery complications were identified. The indications in those cases were correcting esophageal and hypopharyngeal perforations after cervical fusion and discectomy and persistent soft tissue coverage after cervical instrumentation.ConclusionThe SAI flap technique provided wound defect coverage in this case and is suitable for addressing issues such as persistent CSF leaks or soft tissue coverage after cervical spine surgery.

The National Comprehensive Cancer Network (NCCN) guideline recommends consideration of weekly cisplatin as an alternative option for patients with head and neck cancer undergoing definitive chemoradiation. However, in a recent phase III trial (ConCERT), 20

The COVID-19 pandemic has resulted in a delay in cancer diagnosis and treatment during this time. A potential cause of delayed diagnosis that may be underrecognized is a patient misinterpretation of symptoms. To illustrate this point, we present the case of a patient with a delayed diagnosis of olfactory neuroblastoma 2 years after the onset of anosmia.

As the introduction of autologous free tissue transfer, microsurgical techniques for mandibular reconstruction have improved patients' functional and esthetic outcomes. Several large series have reported excellent results with various osseous free flap donor sites, establishing microvascular free tissue transfer with bone and soft tissue as the gold standard for mandibular reconstruction.1 Vascularized tissue transfer can provide an appropriate reconstruction in one step after ablative surgery, allowing for timely adjuvant radiation therapy.

Background Given the role of systematic inflammation in cancer progression, lymphocyte-monocyte ratio (LMR) from peripheral blood has been suggested as a biomarker to assess the extent of inflammation in several solid malignancies. However, the role of LMR as a prognostic factor in head and neck cancer was unclear in several meta-analyses, and there is a paucity of literature including patients in North America. We performed an observational cohort study to evaluate the association of LMR with survival outcomes in North American patients with head and neck cancer. Methods A single-institution, retrospective database was queried for patients with non-metastatic head and neck cancer who underwent definitive chemoradiation from June 2007 to April 2021 at the Roswell Park Comprehensive Cancer Center. Primary endpoints were overall survival (OS) and cancer-specific survival (CSS). The association of LMR with OS and CSS was examined using nonlinear Cox proportional hazard model using restricted cubic splines (RCS). Cox multivariable analysis (MVA) and Kaplan–Meier method were used to analyze OS and CSS. Pre-radiation LMR was then stratified into high and low based on its median value. Propensity scored matching was used to reduce the selection bias. Results A total of 476 patients met our criteria. Median follow up was 45.3 months (interquartile range 22.8–74.0). The nonlinear Cox regression model showed that low LMR was associated with worse OS and CSS in a continuous fashion without plateau for both OS and CSS. On Cox MVA, higher LMR as a continuous variable was associated with improved OS (adjusted hazard ratio [aHR] 0,90, 95% confidence interval [CI] 0.82–0.99, p = 0.03) and CSS (aHR 0.83, 95% CI 0.72–0.95, p = 0.009). The median value of LMR was 3.8. After propensity score matching, a total of 186 pairs were matched. Lower LMR than 3.8 remained to be associated with worse OS (HR 1.59, 95% CI 1.12–2.26, p = 0.009) and CSS (HR 1.68, 95% CI 1.08–2.63, p = 0.02). Conclusion Low LMR, both as a continuous variable and dichotomized variable, was associated with worse OS and CSS. Further studies would be warranted to evaluate the role of such prognostic marker to tailor interventions.

Head and neck squamous cell carcinoma (HNSCC), in particular in oral cavity cancer, continues to pose a challenge to obtaining locoregional control and survival. Currently, there is a poor understanding of the HNSCC disease biology. While the depth of invasion and T-stage are the focus of clinical decision-making, molecular biology may yield additional actionable information. We sought to identify key oncogenic transcriptional networks within different anatomical subsites that correlate with tumor stage and survival outcome.

Key Points Question What is the association of overweight and obese body mass index (BMI) with posttreatment response, tumor recurrence, and survival outcomes among patients with head and neck cancer who underwent chemoradiotherapy? Findings In this cohort study involving 445 patients, both overweight and obese BMI were associated with complete metabolic response after chemoradiotherapy. Only overweight BMI was associated with improved overall survival, progression-free survival, and reduction in locoregional failure. Meaning This study suggests that overweight BMI is an independent factor favorably associated with complete metabolic response after chemoradiotherapy, survival, and locoregional failure.

Purpose/Objective(s) Recent systematic reviews suggested that hemoglobin (Hgb) level may play a role as biomarker for survival outcome among patients with head and neck cancer. However, the optimal threshold for anemia and its role in a current human papillomavirus (HPV) era remain unclear. To address this knowledge gap, we performed an observational cohort study to investigate pre-treatment Hgb and its association with survival outcomes in patients with head and neck cancer treated with radiation therapy. Materials/Methods A single-institution, retrospective database was queried for patients with non-metastatic head and neck cancer who underwent radiation therapy from January 2005 to April 2021. Pre-radiation Hgb was evaluated as a continuous variable using restricted cubic splines (RCS), and the model-derived threshold was used to stratify patients into low and high Hgb. Cox multivariable analysis (MVA) and Kaplan-Meier method were used to analyze overall survival (OS) and disease-specific survival (DSS). Logistic MVA was performed to identify variables associated with low Hgb level. Propensity score matching was used to construct matched pairs. A subgroup analysis was also performed among patients with available HPV data. Results Among a total of 753 patients, median follow up was 29.7 months (interquartile range 17.8-57.8). Cox MVA based on RCS showed a threshold of Hgb at 12.96, with worsening survival in a continuous fashion without plateau as Hgb decreases. Low Hgb was associated with worse OS (aHR 1.55, 95% CI 1.17-2.05, p=0.002) and DSS (aHR 1.79, 95% CI 1.28-2.51, p<0.001). Similar findings were observed in 178 matched pairs (OS: HR 1.47, 95% CI 1.05-2.06, p=0.03; DSS: HR 1.82, 95% CI 1.19-2.78, p=0.006). On logistic MVA, patients were more likely to have low Hgb if they were female, had a higher T staging, underwent induction chemotherapy or surgery prior to radiation therapy, and had feeding tubes placed. They were less likely to have low Hgb if they had a good performance status and HPV-associated head and neck cancer. Among 466 patients with available HPV data, low Hgb was associated with DSS (aHR 1.84, 95% CI 1.30-2.61, p<0.001), but not OS (aHR 1.32, 95% CI 0.89-1.95, p=0.16). Conclusion In this study, low Hgb was associated with worse survival outcomes even among those with available HPV data. Patients with significant primary disease burden, feeding tube placement, and poor performance status who underwent either induction chemotherapy or surgery were more likely to have low Hgb. Further studies would be warranted to investigate the role of Hgb to identify patients early with poor prognosis and tailor treatments based on their risk factors. Recent systematic reviews suggested that hemoglobin (Hgb) level may play a role as biomarker for survival outcome among patients with head and neck cancer. However, the optimal threshold for anemia and its role in a current human papillomavirus (HPV) era remain unclear. To address this knowledge gap, we performed an observational cohort study to investigate pre-treatment Hgb and its association with survival outcomes in patients with head and neck cancer treated with radiation therapy. A single-institution, retrospective database was queried for patients with non-metastatic head and neck cancer who underwent radiation therapy from January 2005 to April 2021. Pre-radiation Hgb was evaluated as a continuous variable using restricted cubic splines (RCS), and the model-derived threshold was used to stratify patients into low and high Hgb. Cox multivariable analysis (MVA) and Kaplan-Meier method were used to analyze overall survival (OS) and disease-specific survival (DSS). Logistic MVA was performed to identify variables associated with low Hgb level. Propensity score matching was used to construct matched pairs. A subgroup analysis was also performed among patients with available HPV data. Among a total of 753 patients, median follow up was 29.7 months (interquartile range 17.8-57.8). Cox MVA based on RCS showed a threshold of Hgb at 12.96, with worsening survival in a continuous fashion without plateau as Hgb decreases. Low Hgb was associated with worse OS (aHR 1.55, 95% CI 1.17-2.05, p=0.002) and DSS (aHR 1.79, 95% CI 1.28-2.51, p<0.001). Similar findings were observed in 178 matched pairs (OS: HR 1.47, 95% CI 1.05-2.06, p=0.03; DSS: HR 1.82, 95% CI 1.19-2.78, p=0.006). On logistic MVA, patients were more likely to have low Hgb if they were female, had a higher T staging, underwent induction chemotherapy or surgery prior to radiation therapy, and had feeding tubes placed. They were less likely to have low Hgb if they had a good performance status and HPV-associated head and neck cancer. Among 466 patients with available HPV data, low Hgb was associated with DSS (aHR 1.84, 95% CI 1.30-2.61, p<0.001), but not OS (aHR 1.32, 95% CI 0.89-1.95, p=0.16). In this study, low Hgb was associated with worse survival outcomes even among those with available HPV data. Patients with significant primary disease burden, feeding tube placement, and poor performance status who underwent either induction chemotherapy or surgery were more likely to have low Hgb. Further studies would be warranted to investigate the role of Hgb to identify patients early with poor prognosis and tailor treatments based on their risk factors.

ImportanceAfter 10 pack-years of smoking was initially established as a threshold for risk stratification, subsequent clinical trials incorporated it to identify candidates for treatment deintensification. However, several recent studies were unable to validate this threshold externally, and the threshold for smoking exposure remains unclear.ObjectiveTo estimate the threshold of pack-years of smoking associated with survival and tumor recurrence among patients with head and neck cancer.Design, Setting, and ParticipantsThis single-institution, cohort study included patients with nonmetastatic head and neck cancer receiving chemoradiation from January 2005 to April 2021. Data were analyzed from January to April 2022.ExposuresHeavy vs light smoking using 22 pack-years as a threshold based on maximizing log-rank test statistic.Main Outcomes and MeasuresOverall survival (OS), progression-free survival (PFS), locoregional failure (LRF), and distant failure (DF).ResultsA total of 518 patients (427 male [82.4%]; median [IQR] age, 61 [55-66] years) were included. Median (IQR) follow-up was 44.1 (22.3-72.8) months. A nonlinear Cox regression model using restricted cubic splines showed continuous worsening of OS and PFS outcomes as pack-years of smoking increased. The threshold of pack-years to estimate OS and PFS was 22. Cox multivariable analysis (MVA) showed that more than 22 pack-years was associated with worse OS (adjusted hazard ratio [aHR] 1.57; 95% CI, 1.11-2.22; P = .01) and PFS (aHR, 1.38; 95% CI, 1.00-1.89; P = .048). On Fine-Gray MVA, heavy smokers were associated with DF (aHR, 1.71; 95% CI, 1.02-2.88; P = .04), but not LRF (aHR, 1.07; 95% CI, 0.61-1.87; P = .82). When 10 pack-years of smoking were used as a threshold, there was no association for OS (aHR, 1.23; 95% CI, 0.83-1.81; P = .30), PFS (aHR, 1.11; 95% CI, 0.78-1.57; P = .56), LRF (aHR, 1.19; 95% CI, 0.64-2.21; P = .58), and DF (aHR, 1.45; 95% CI, 0.82-2.56; P = .20). Current smoking was associated with worse OS and PFS only among human papillomavirus (HPV)-positive tumors (OS: aHR, 2.81; 95% CI, 1.26-6.29; P = .01; PFS: aHR, 2.51; 95% CI, 1.22-5.14; P = .01).Conclusions and RelevanceIn this cohort study of patients treated with definitive chemoradiation, 22 pack-years of smoking was associated with survival and distant metastasis outcomes. Current smoking status was associated with adverse outcomes only among patients with HPV-associated head and neck cancer.

Objectives: We sought to define the optimal threshold for anemia in North American head and neck cancer patients and evaluate its role as a prognostic biomarker. Materials and Methods: A single-institution database was queried for patients with head and neck cancer who underwent chemoradiation from January 2005 to April 2021. An optimal threshold of hemoglobin (Hgb) level was defined based on maximum log-rank test statistic. Cox multivariable analysis (MVA), Kaplan-Meier, and propensity score matching were performed to evaluate treatment outcomes. Results: A total of 496 patients were identified. Threshold for Hgb was determined to be 11.4 for both overall survival (OS) and progression-free survival (PFS). Low Hgb was associated with worse OS (adjusted hazards ratio [aHR] 2.41, 95 % confidence interval [CI] 1.53-3.80, p < 0.001) and PFS (aHR 2.01, 95 % CI 1.30-3.11, p = 0.002). Similar findings were observed among 39 matched pairs for OS (5 year OS 22.3 % vs 49.0 %; HR 2.22, 95 % CI 1.23-4.03, p = 0.008) and PFS (5-year PFS 24.3 % vs 39.1 %; HR 1.78, 95 % CI 1.02-3.12, p = 0.04). Among those with HPV-negative tumors, low Hgb was associated with worse OS (aHR 13.90, 95 % CI 4.66-41.44, p < 0.001) and PFS (aHR 5.24, 95 % CI 2.09-13.18, p < 0.001). However, among those with HPV-positive tumors, low Hgb was not associated with both OS (aHR 1.75, 95 % CI 0.60-5.09, p = 0.31) and PFS (aHR 1.13, 95 % CI 0.41-3.14, p = 0.82). Conclusion and relevance: Low Hgb below 11.4 was an independent adverse prognostic factor for worse survival. It was also prognostic among patients with HPV-negative tumors, but not for HPV-positive tumors.

IMPORTANCE Given the role of inflammation in cancer progression, neutrophil-lymphocyte ratio (NLR) from peripheral blood has been suggested as a readout of systemic inflammation and a prognostic marker in several solid malignant neoplasms. However, optimal threshold for NLR in US patients with head and neck cancer remains unclear. OBJECTIVE To evaluate the optimal NLR threshold as a potential prognostic biomarker for survival outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted at a single institution. Participants included 496 patients with nonmetastatic head and neck cancer who underwent chemoradiation from April 2007 to March 2021. Statistical analysis was performed from September to December 2021. EXPOSURES High vs low NLR. MAIN OUTCOMES AND MEASURES Overall survival (OS) and cancer-specific survival (CSS). RESULTS A total of 496 patients (411 male patients [82.9%]; 432 White patients [87.1%]; 64 patients with other race or ethnicity [12.9%]; median [IQR] age, 61 [55-67] years) were identified. Median (IQR) follow-up was 44.4 (22.8-74.0) months. Thresholds of NLR for both OS and CSS were 5.71. High NLR above 5.71 was associated with worse OS (adjusted hazard ratio [aHR], 1.97; 95% CI, 1.26-3.09; P = .003) and CSS (aHR, 2.33; 95% CI, 1.38-3.95; P = .002). On logistic multivariable analysis, patients were more likely to have high NLR if they had higher T and N staging (T3-4: aOR, 4.07; 95% CI, 1.92-9.16; P < .001; N2: aOR, 2.97; 95% CI, 1.04-9.17; P = .049; N3: aOR, 11.21; 95% CI, 224-46.97; P < .001), but less likely if they had a good performance status (Karnofsky Performance Status 90-100: aOR, 0.29; 95% CI, 0.14-0.59; P < .001). Among 331 patients (66.7%) with available human pa pilloma virus (HPV) data, high NLR was not associated with OS (HPV-negative: aHR, 2.46; 95% CI. 0.96-6.31; P = .06; HPV-positive: aHR, 1.17; 95% CI, 0.38-3.56; P = .78) and CSS (HPV-negative: aHR, 2.55; 95% CI, 0.81-7.99; P = .11; HPV-positive: aHR, 1.45; 95% CI, 0.44-4.76; P = .54). CONCLUSIONS AND RELEVANCE High NLR was associated with worse survival. Patients with substantial disease burden and poor performance status were more likely to have high NLR. These findings suggest that further studies would be warranted to investigate the role of such prognostic marker to identify patients at risk to tailor interventions.

Purpose/Objective(s) Combined modality therapy with surgery, chemotherapy, and/or radiation often results in significant morbidity among patients with head and neck cancer, including dysphagia and weight loss. Given extensive side effect profiles, body mass index (BMI) has been shown to play a role in the clinical outcome of such patients. To validate this finding, we performed an observational cohort study to investigate BMI and its association with survival outcomes in patients with head and neck cancer treated with multimodal therapies. Materials/Methods A single-institution, retrospective database was queried for patients with non-metastatic head and neck cancer who underwent either definitive-intent chemoradiation or postoperative radiation therapy from 1/2005 to 4/2021. BMI was stratified by underweight, normal, overweight, and obese by <18.5, 18.5-24.9, 25.0-29.9, and 30.0 or above, respectively. Cox multivariable analysis (MVA) and Kaplan-Meier method were used to analyze overall survival (OS) and cancer-specific survival (CSS) outcomes. Logistic MVA was performed to identify variables associated with post-treatment responses. Propensity score matching was used to construct matched pairs based on nearest neighbor method in a 1:1 ratio with no replacement. Results A total of 738 patients (n=206 with normal BMI, n=27 with underweight, n=274 with overweight, and n=231 with obese BMI) were included for analysis. Median follow up was 31.0 months (interquartile range 18.5-58.0). On Cox MVA, being overweight was associated with improved OS (aHR 0.70, 95% CI 0.51-0.97, p=0.03), but not CSS (aHR 0.82, 95% CI 0.55-1.22, p=0.34). Similar findings were noted in 163 matched pairs of patients with normal BMI and overweight (OS: HR 0.69, 95% CI 0.48-0.99, p=0.04; CSS: HR 0.80, 95% CI 0.51-1.24, p=0.32). Among 683 patients with available treatment response, being overweight was associated with complete response after treatments (aOR 0.52, 95% CI 0.30-0.90, p=0.02). Being underweight (OS: aHR 0.84, 95% CI 0.49-1.44, p=0.53; CSS: aHR 1.83, 95% CI 0.98-3.41, p=0.06) or obese (OS: aHR 0.77, 95% CI 0.53-1.11, p=0.16; CSS: aHR 0.92, 95% CI 0.58-1.46, p=0.73) was not associated with survival outcomes. Conclusion In this study, being overweight was associated with improved OS and increased likelihood of complete response after treatments, while it had no association with CSS. However, having normal BMI or obesity were not associated with improved survival outcomes. Further studies would be warranted to investigate the role of BMI as a prognostic marker among patients who underwent multimodal therapies. Combined modality therapy with surgery, chemotherapy, and/or radiation often results in significant morbidity among patients with head and neck cancer, including dysphagia and weight loss. Given extensive side effect profiles, body mass index (BMI) has been shown to play a role in the clinical outcome of such patients. To validate this finding, we performed an observational cohort study to investigate BMI and its association with survival outcomes in patients with head and neck cancer treated with multimodal therapies. A single-institution, retrospective database was queried for patients with non-metastatic head and neck cancer who underwent either definitive-intent chemoradiation or postoperative radiation therapy from 1/2005 to 4/2021. BMI was stratified by underweight, normal, overweight, and obese by <18.5, 18.5-24.9, 25.0-29.9, and 30.0 or above, respectively. Cox multivariable analysis (MVA) and Kaplan-Meier method were used to analyze overall survival (OS) and cancer-specific survival (CSS) outcomes. Logistic MVA was performed to identify variables associated with post-treatment responses. Propensity score matching was used to construct matched pairs based on nearest neighbor method in a 1:1 ratio with no replacement. A total of 738 patients (n=206 with normal BMI, n=27 with underweight, n=274 with overweight, and n=231 with obese BMI) were included for analysis. Median follow up was 31.0 months (interquartile range 18.5-58.0). On Cox MVA, being overweight was associated with improved OS (aHR 0.70, 95% CI 0.51-0.97, p=0.03), but not CSS (aHR 0.82, 95% CI 0.55-1.22, p=0.34). Similar findings were noted in 163 matched pairs of patients with normal BMI and overweight (OS: HR 0.69, 95% CI 0.48-0.99, p=0.04; CSS: HR 0.80, 95% CI 0.51-1.24, p=0.32). Among 683 patients with available treatment response, being overweight was associated with complete response after treatments (aOR 0.52, 95% CI 0.30-0.90, p=0.02). Being underweight (OS: aHR 0.84, 95% CI 0.49-1.44, p=0.53; CSS: aHR 1.83, 95% CI 0.98-3.41, p=0.06) or obese (OS: aHR 0.77, 95% CI 0.53-1.11, p=0.16; CSS: aHR 0.92, 95% CI 0.58-1.46, p=0.73) was not associated with survival outcomes. In this study, being overweight was associated with improved OS and increased likelihood of complete response after treatments, while it had no association with CSS. However, having normal BMI or obesity were not associated with improved survival outcomes. Further studies would be warranted to investigate the role of BMI as a prognostic marker among patients who underwent multimodal therapies.

Background: The orbital complication rate during endoscopic sinus surgery (ESS) is <1%. Orbital fat exposure during ESS can herald orbital complications including orbital hematoma, extraocular muscle trauma, optic nerve injury, or blindness. The objective of this study was to evaluate the current consensus regarding diagnosis and management of orbital fat exposure during ESS. Methods: A 24-point survey focused on orbital fat exposure during ESS was distributed to American Rhinologic Society members. Also, a retrospective review of 25 cases of orbital fat exposure drawn from the principal investigator’s 30-year experience was performed. Results: Over 10 000 surgical cases of the principal investigator were reviewed. Twenty-five patients had orbital fat exposure. Five developed minor complications while 2 were major (ie, temporary vision changes). Two hundred thirty-six surgeons responded to the survey; 93% had encountered orbital fat during ESS; 88% of surgeons identify orbital fat by either its appearance endoscopically or the “bulb press” test. Almost every responding surgeon will cautiously avoid further manipulation in the area of orbital fat exposure. Nearly half will immediately curtail the extent of surgery. Surgeons do not significantly change postoperative management. Considerations regarding observation in postanesthesia care unit, close follow-up, and strict nose blowing precautions are common. Conclusion: Orbital fat exposure during ESS is a rarely discussed, but clinically important. Orbital fat exposure can be a harbinger for major orbital complications that should be recognized by endoscopic appearance and confirmed with the bulb press test. Caution with “no further manipulation” of orbital fat is the guiding principle for intraoperative management, while postoperative management is generally expectant. Level 4 Evidence

Background: To compare head and neck cancer (HNC) patients treated with three-weekly versus weekly cisplatin-based or other chemotherapy-based concurrent chemoradiation (CRT) and CRT with versus without induction chemotherapy (ICT) to investigate differences in overall survival (OS) and cancer-specific survival (CSS). Methods: HNC patients treated with definitive or adjuvant CRT at Roswell Park Comprehensive Cancer Center between 2003 and 2017 were retrospectively reviewed. Propensity score matching was performed to obtain three sets of balanced matched pairs: three-weekly and weekly cisplatin CRT, three weekly and non-cisplatin CRT, CRT with and without ICT. Multivariate Cox regression and Kaplan-Meier analyses were used to estimate and compare survival outcomes. Results: A total of 623 patients received either definitive (81%) or post-operative (19%) RT. Of these, 283 patients concurrently received three-weekly cisplatin (45%); 189 patients (30%) received weekly cisplatin; 151 patients (24%) received non-cisplatin regimen. Median follow-up was 55.4 months (interquartile range, 38.0-88.7). Patients who received CRT alone and those who received ICT and CRT had no difference in 5-year OS (51.5% and 41.0% respectively, P=0.53) and CSS (64.9% and 49.7% respectively, P=0.21). Compared to patients who received three-weekly cisplatin, patients who received weekly cisplatin had no difference in 5-year OS (59.3% vs. 54.1%, P=0.35) and CSS (70.3% vs. 62.4%, P=0.09); patients who received non-cisplatin CRT also had no difference in 5-year OS (54.5% vs. 58.3%, P=0.51) and CSS (67.5% vs. 64.7%, P=0.45). Conclusions: No significant difference in OS and CSS was observed in any of the three pairs of CRT regimens. ICT prior to CRT did not improve survival of CRT alone. Non-cisplatin and weekly cisplatin regimens did not prove to be inferior to the standard three-weekly cisplatin.

Prognostication for cancer patients is integral for patient counseling and treatment planning, yet providing accurate prediction can be challenging using existing patient-specific clinical indicators and host factors. In this work, we evaluated common machine learning models in predicting head and neck squamous cell carcinoma (HNSCC) patients’ overall survival based on demographic, clinical features and host factors. We found random survival forest had best performance among the models evaluated, which achieved a C-index of 0.729 and AUROC of 0.792 in predicting two-year overall survival. In addition, we verified that host factors are independently predictive of HNSCC overall survival, which improved the C-index by a margin of 0.026 and the AUROC by 0.034. Due to the strong correlation among host factors, we showed that proper dimension reduction is an important step before their incorporation into the machine learning models, which provides a host factor score reflecting the patients’ nutrition and inflammation status. The score by itself showed excellent discriminating capacity with the high-risk group having a hazard ratio of 3.76 (1.93–7.32, p < 0.0001) over the low-risk group. The hazard ratios were further improved to 7.41 (3.66–14.98, p < 0.0001) by the random survival forest model after including demographic and clinical features.