203 results on '"Enver Ozer"'
Search Results
2. Bone Union of Osseous Microvascular Free Tissue Transfer in Mandibular Reconstruction
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Akina Tamaki MD, Shruthi Sethuraman BS, Lucy Shi MD, Songzhu Zhao MS, Keith C. Carver DMD, MD, MS, Angel Hatef MD, Michael Luttrull MD, Nolan B. Seim MD, Stephen Y. Kang MD, Enver Ozer MD, Amit Agrawal MD, and Matthew O. Old MD
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Otorhinolaryngology ,RF1-547 ,Surgery ,RD1-811 - Abstract
Objectives Osseous microvascular free tissue transfer (MFTT) is the gold standard for reconstruction for most segmental mandibulectomy defects. The most common osseous MFTT utilized in reconstruction is the fibular, scapular, and osteocutaneous radial forearm (OCRF) free flap. We evaluated postoperative bone union as well as clinical complications following MFTT and the impact of various patient and reconstructive characteristics, including type of osseous MFTT. Study Design Retrospective cohort study. Setting Tertiary care academic hospital. Methods This study examined patients who underwent osseous MFTT for mandibular defects from January 2017 to January 2019. Results An overall 144 osteotomies in 58 patients were evaluated. Of the 144 junctions, 28 (19.4%) showed radiographic nonunion. Patients who underwent preoperative (odds ratio [OR] = 0.30, P = .027) and postoperative (OR = 0.28, P = .003) radiation had a significantly lower bone union score. Time from surgery to postoperative imaging was associated with higher bone union scores (OR = 1.07, P = .024). When bone union scores were compared among types of MFTT, fibular (OR = 5.62, P = .008) and scapular (OR = 4.69, P = .043) MFTT had significantly higher scores than OCRF MFTT. Twelve (20.7%) patients had postoperative complications. There was no statistically significant correlation between clinical complications and various variables, including type of osseous MFTT. Conclusion Pre- and postoperative radiation and time from surgery have an impact on bone union. Regarding the type of MFTT, fibular and scapular MFTT appeared to have higher bone union when compared with OCRF. There was no impact of bone union or type of osseous MFTT on clinical complications.
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- 2022
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3. The Use of Vasopressor Agents in Free Tissue Transfer for Head and Neck Reconstruction: Current Trends and Review of the Literature
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Akash N. Naik, Taylor Freeman, Michael M. Li, Scarlett Marshall, Akina Tamaki, Enver Ozer, Amit Agrawal, Stephen Y. Kang, Matthew O. Old, and Nolan B. Seim
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vasopressors ,anesthesia management ,microvascular surgery ,head and neck reconstruction ,free tissue transfer ,Therapeutics. Pharmacology ,RM1-950 - Abstract
Background/ObjectivesMicrovascular free tissue transfer has become essential to head and neck reconstruction and recent advancements in microvascular surgery have led to excellent surgical outcomes. However, there continues to be controversy and a stigma associated with the use of perioperative intravenous vasopressor agents among both surgeons and anesthesiologists. Due to concern for vasoconstriction of peripheral vasculature flowing to the denervated tissue flap, there remains concerns about potential thrombosis, decreased tissue perfusion and ultimately flap failure. This topic becomes even more important as vasopressors play an essential role in new Extended Recovery After Surgery (ERAS) protocols being put in place to optimize postoperative recovery for patients. The purpose of this study was to comprehensively review the role and safety as well as discuss current trends with intraoperative vasopressor agents in free tissue transfer for head and neck reconstruction.MethodsA scoping literature review was conducted of all studies that examined the use of vasopressor agents during head and neck free flap tissue transfer. Primary and secondary outcomes included free flap survival, arterial thrombosis, venous congestion, need for revision surgery, and other postoperative complications.ResultsOne prospective and nine retrospective studies were identified. Phenylephrine and ephedrine were the most common vasopressors reported; the rate of vasopressor use ranged from 53% to 85% and administration methods included both bolus and infusion. The included studies did not show any significant association between the use of vasopressors and free flap failure, pedicle thrombosis, or other flap complications.ConclusionThe administration of vasopressors during microvascular free tissue transfer for head and neck reconstruction does not seem to be associated with increased flap failure rates or other postoperative morbidities. Moreover, vasopressors may provide overall improved hemodynamic stability and help to limit overall fluid administration and subsequent postoperative complications. Additional prospective investigation is warranted to further elucidate and establish evidence-based recommendations regarding the type, timing, and dose of vasopressors to further enhance free flap survival and patient outcomes.
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- 2020
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4. Transoral robotic surgery frontiers
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James R. Bekeny and Enver Ozer
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Otorhinolaryngology ,RF1-547 ,Surgery ,RD1-811 - Abstract
Transoral robotic surgery is a exciting field that continues to develop and push the boundaries of current procedural ability and challenges historical treatment paradigms. With the first use of a surgical robot in 1985, to the first clinical use of the robot transorally in 2005, there was some lag in adoption of robotic techniques in the head and neck region. However, since 2005 transoral robotic surgery has rapidly gained momentum amongst head and neck surgeons. With FDA approval of the da Vinci robot in 2009, transoral robotic surgery is currently offered as a treatment modality for malignant and nonmalignant disease of the head and neck region. This new technology is being used to reconsider historical treatment paradigms for malignancies of the upper aerodigestive tract due to the fact that minimally invasive surgical access to the oropharynx and larynx has been improved. Along with this enhanced access have come innovative procedures and uses of the technology for multiple facets of head and neck disease. Technology continues to improve and innovation in surgical robotics is expected to continue as more companies attempt to capture this market. This article aims to provide a view at the landscape of transoral robotic surgery and explore the future frontiers. Keyword: Robotic surgery
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- 2016
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5. Identification of Clinical and Socioeconomic Predictors of Adjuvant Therapy after Trans-Oral Robotic Surgery in Patients with Oropharyngeal Squamous Cell Carcinoma
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Sujith Baliga, Brett Klamer, Sachin Jhawar, Mauricio Gamez, Darrion Mitchell, Adriana Blakaj, John Grecula, Ulysses Gardner, Khaled Dibs, Matthew Old, Nolan Seim, Stephen Kang, Ricardo Carrau, Amit Agrawal, Vidhya Karivedu, Priyanka Bhateja, Enver Ozer, James Rocco, Marcelo Bonomi, and Dukagjin Blakaj
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TORS ,adjuvant therapy ,radiation therapy ,chemotherapy ,Neoplasms. Tumors. Oncology. Including cancer and carcinogens ,RC254-282 - Abstract
Trans-oral robotic surgery (TORS) has emerged as an important surgical treatment option in the management of human papillomavirus (HPV)-positive and -negative oropharynx cancer. However, treatment selection is paramount to ensure that patients will not require multimodality adjuvant therapy. In this study, we determined predictors of adjuvant therapy in TORS-treated patients. The National Cancer Database (NCDB) was used to identify patients with newly diagnosed clinical T1-T4, N0-N3 oropharyngeal squamous cell carcinoma who underwent TORS between 2010–2016. Kaplan–Meier survival analysis was used to estimate overall survival (OS). A total of 2999 patients were studied, and the five-year OS for the entire cohort was 82.5%, and for HPV-positive and -negative cohorts it was 88.3% and 67.9%, respectively (p < 0.001). Among all patients treated with TORS, 35.1% of patients received no additional treatment, 33.5% received adjuvant radiation alone (RT), and 31.3% received adjuvant chemoradiation. The N stage was pathologically upstaged in 629 (20.9%) patients after TORS. Patients treated at higher-volume centers were more likely to have negative surgical margins (OR: 0.96, 95% CI: 0.94, 0.98, p < 0.001), but this did not influence the receipt of adjuvant therapy. The high rate of adjuvant multimodality treatment after TORS suggests a need for improved patient selection. Limitations of this study, including lack of data on loco-regional control, progression free survival, acute and late toxicities, and utilization of pretreatment PET/CT imaging, should be addressed in future studies.
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- 2020
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6. Multiparameter analysis, including EMT markers, on negatively enriched blood samples from patients with squamous cell carcinoma of the head and neck.
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Priya Balasubramanian, James C Lang, Kris R Jatana, Brandon Miller, Enver Ozer, Mathew Old, David E Schuller, Amit Agrawal, Theodoros N Teknos, Thomas A Summers, Maryam B Lustberg, Maciej Zborowski, and Jeffrey J Chalmers
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Medicine ,Science - Abstract
Epithelial to mesenchymal transition (EMT) has been hypothesized as a mechanism by which cells change phenotype during carcinogenesis, as well as tumor metastasis. Whether EMT is involved in cancer metastasis has a specific, practical impact on the field of circulating tumor cells (CTCs). Since the generally accepted definition of a CTC includes the expression of epithelial surface markers, such as EpCAM, if a cancer cell loses its epithelial surface markers (which is suggested in EMT), it will not be separated and/or identified as a CTC. We have developed, and previously reported on the use of, a purely negative enrichment technology enriching for CTCs in the blood of squamous cell carcinoma of the head and neck (SCCHN). This methodology does not depend on the expression of surface epithelial markers. Using this technology, our initial data on SCCHN patient blood indicates that the presence of CTCs correlates with worse disease-free survival. Since our enrichment is not dependent on epithelial markers, we have initiated investigation of the presence of mesenchymal markers in these CTC cells to include analysis of: vimentin, epidermal growth factor receptor, N-cadherin, and CD44. With the aid of confocal microscopy, we have demonstrated not only presumed CTCs that express and/or contain: a nucleus, cytokeratins, vimentin, and either EGFR, CD44, or N-cadherin, but also cells that contain all of the aforementioned proteins except cytokeratins, suggesting that the cells have undergone the EMT process. We suggest that our negative depletion enrichment methodology provides a more objective approach in identifying and evaluating CTCs, as opposed to positive selection approaches, as it is not subjective to a selection bias and can be tailored to accommodate a variety of cytoplasmic and surface markers which can be evaluated to identify a multitude of phenotypic patterns within CTCs from individual patients, including so-called EMT as presented here.
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- 2012
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7. Immediate resection of positive margins improves local control in oral tongue cancer
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Lisa Zhang, Ryan T. Judd, Songzhu Zhao, Chandler Rygalski, Michael Li, Ashleigh Briody, Brian Swendseid, Dukagjin M. Blakaj, Amit Agrawal, Enver Ozer, Ricardo L. Carrau, Theodoros N. Teknos, Kyle VanKoevering, James W. Rocco, Matthew O. Old, Nolan B. Seim, Sidharth V. Puram, Catherine T. Haring, and Stephen Y. Kang
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Cancer Research ,Oncology ,Oral Surgery - Published
- 2023
8. Combined karapandzic and radial forearm free flap with dual palmaris longus tendons for complex lip reconstruction
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Matthew O. Old, Ryan J Ivancic, Nolan B. Seim, Stephen Y. Kang, Enver Ozer, Amit Agrawal, and Taylor Freeman
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Novel technique ,Orthodontics ,Cosmetic appearance ,business.industry ,Microstomia ,Oral commissure ,medicine.disease ,Tissue transfer ,stomatognathic diseases ,03 medical and health sciences ,0302 clinical medicine ,Otorhinolaryngology ,Radial forearm free flap ,030220 oncology & carcinogenesis ,Lip reconstruction ,Medicine ,Surgery ,030223 otorhinolaryngology ,business - Abstract
Near-total lip defects present a unique challenge preserving both oral competence and aesthetics. While lip reconstruction is commonly accomplished with local flaps to preserve function, in large defects, this technique alone can result in microstomia, speech inarticulation, and facial distortion. Free tissue transfer has become an attractive alternative, yet this approach presents its own set of functional challenges. For complex lip defects, the goal of reconstruction is preserving function and cosmetic appearance while avoiding debilitating microstomia. In this pictorial essay, we describe the anatomy, harvest, inset, and reconstructive approaches for using a combined Karapandzic and radial forearm free flap with dual palmaris longus tendons as an effective option for lip reconstruction in large ablative defects involving the oral commissure. This novel technique uses local, regional, and free tissue to provide an excellent functional and cosmetic reconstructive option for this and similar large lip defects.
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- 2021
9. The role of computer aided design/computer assisted manufacturing (CAD/CAM) and 3- dimensional printing in head and neck oncologic surgery: A review and future directions
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Sarah C. Nyirjesy, Margaret Heller, Natalia von Windheim, Amelia Gingras, Stephen Y. Kang, Enver Ozer, Amit Agrawal, Matthew O. Old, Nolan B. Seim, Ricardo L. Carrau, James W. Rocco, and Kyle K. VanKoevering
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Models, Anatomic ,Titanium ,Cancer Research ,Oncology ,Surgery, Computer-Assisted ,Printing, Three-Dimensional ,Computer-Aided Design ,Humans ,Oral Surgery ,Plastic Surgery Procedures - Abstract
Microvascular free flap reconstruction has remained the standard of care in reconstruction of large tissue defects following ablative head and neck oncologic surgery, especially for bony structures. Computer aided design/computer assisted manufacturing (CAD/CAM) and 3-dimensionally (3D) printed models and devices offer novel solutions for reconstruction of bony defects. Conventional free hand techniques have been enhanced using 3D printed anatomic models for reference and pre-bending of titanium reconstructive plates, which has dramatically improved intraoperative and microvascular ischemia times. Improvements led to current state of the art uses which include full virtual planning (VP), 3D printed osteotomy guides, and patient specific reconstructive plates, with advanced options incorporating dental rehabilitation and titanium bone replacements into the primary surgical plan through use of these tools. Limitations such as high costs and delays in device manufacturing may be mitigated with in house software and workflows. Future innovations still in development include printing custom prosthetics, 'bioprinting' of tissue engineered scaffolds, integration of therapeutic implants, and other possibilities as this technology continues to rapidly advance. This review summarizes the literature and serves as a summary guide to the historic, current, advanced, and future possibilities of 3D printing within head and neck oncologic surgery and bony reconstruction. This review serves as a summary guide to the historic, current, advanced, and future roles of CAD/CAM and 3D printing within the field of head and neck oncologic surgery and bony reconstruction.
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- 2022
10. Custom Presurgical Planning for Midfacial Reconstruction
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Matthew O. Old, Sasha Valentin, Stephen Y. Kang, Amit Agrawal, Enver Ozer, Nolan B. Seim, and Mead VanPutten
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medicine.medical_specialty ,Preoperative planning ,Reconstructive Surgeon ,business.industry ,medicine.medical_treatment ,030206 dentistry ,Esthetics, Dental ,Plastic Surgery Procedures ,Prosthodontist ,Surgical Flaps ,03 medical and health sciences ,0302 clinical medicine ,Multidisciplinary approach ,Presurgical planning ,Face ,030220 oncology & carcinogenesis ,Preoperative Period ,medicine ,Humans ,Surgery ,Medical physics ,Craniofacial ,Prosthodontics ,business - Abstract
Resection and reconstruction of midface involve complex ablative and reconstructive tools in head and oncology and maxillofacial prosthodontics. This region is extraordinarily important for long-term aesthetic and functional performance. From a reconstructive standpoint, this region has always been known to present challenges to a reconstructive surgeon due to the complex three-dimensional anatomy, the variable defects created, combination of the medical and dental functionalities, and the distance from reliable donor vessels for free tissue transfer. Another challenge one faces is the unique features of each individual resection defect as well as individual patient factors making each preoperative planning session and reconstruction unique. Understanding the long-term effects on speech, swallowing, and vision, one should routinely utilize a multidisciplinary approach to resection and reconstruction, including head and neck reconstructive surgeons, prosthodontists, speech language pathologists, oculoplastic surgeons, dentists, and/or craniofacial teams as indicated and with each practice pattern. With this in mind, we present our planning and reconstructive algorithm in midface reconstruction, including a dedicated focus on dental rehabilitation via custom presurgical planning.
- Published
- 2020
11. A series of typical and atypical cases of Bazex syndrome: Identifying the red herring to avoid delaying cancer treatment
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Daniel Hawkins, Angita Jain, V.M. Diavolitsis, Aashish D. Bhatt, Jacob Matthew Eckstein, Robert Rupert, Quoc‐Anh Ho, Amit Agrawal, Enver Ozer, and E. Healy
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medicine.medical_specialty ,Bazex syndrome ,lcsh:Medicine ,Early detection ,Case Report ,Case Reports ,030204 cardiovascular system & hematology ,Malignancy ,03 medical and health sciences ,0302 clinical medicine ,Medicine ,lcsh:R5-920 ,business.industry ,lcsh:R ,Head and neck cancer ,Cancer ,General Medicine ,medicine.disease ,Dermatology ,paraneoplastic dermatosis ,Cancer treatment ,030220 oncology & carcinogenesis ,Acrokeratosis paraneoplastica ,head and neck cancer ,lcsh:Medicine (General) ,business - Abstract
Bazex syndrome is a rare paraneoplastic dermatosis that precedes diagnosis of cancer. Awareness of this syndrome is important, as it allows early detection of underlying malignancy and may prevent misdiagnosis and delays in cancer treatment.
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- 2020
12. Salvage Free Tissue Transfer for Clival Osteoradionecrosis After Repeat Proton Beam Therapy
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Mostafa Shahein, Giuliano Silveira-Bertazzo, Samuel Vieira, Enver Ozer, Daniel M. Prevedello, Ricardo L. Carrau, Kyle K. VanKoevering, Ahmed Nabil, Guillermo Maza, Krupal B. Patel, and Thiago Albonette-Felicio
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medicine.medical_specialty ,Leak ,medicine.diagnostic_test ,Cerebrospinal fluid leak ,business.industry ,Osteoradionecrosis ,medicine.medical_treatment ,Magnetic resonance imaging ,medicine.disease ,Radiation therapy ,03 medical and health sciences ,0302 clinical medicine ,medicine.anatomical_structure ,Cerebrospinal fluid ,Tongue ,030220 oncology & carcinogenesis ,Medicine ,Surgery ,Neurology (clinical) ,Chordoma ,Radiology ,business ,030217 neurology & neurosurgery - Abstract
Background Craniocervical junction chordoma treated with surgery and Proton Beam Therapy evolved with Osteonecrosis and CSF leak. As the vascularization of the head was compromised, we harvested an Anterolateral thigh musculofascial flap to seal the leak. Case Description A 56-year-old man presented with a history of chronic headaches and dysarthria with tongue deviation to the right. Magnetic resonance imaging showed a lesion at the craniocervical junction with imaging characteristics compatible with chordoma. Endoscopic endonasal resection was followed by proton beam therapy. Recurrence of the chordoma was subsequently resected via far lateral approach again followed by proton beam therapy accumulating a total dose of 75 Gy. Unfortunately, this led to osteoradionecrosis of the skull base resulting in a cerebrospinal fluid (CSF) leak more than 1 year after treatment. After multiple failed attempts to seal the defect using local vascularized tissue and free fat grafts, the defect was reconstructed with a vastus lateralis free tissue transfer. Six weeks later, the flap had mucosalized, the patient was pain free, and there was no evidence of a CSF leak. Conclusions In select cases, vascularized free flaps offer a superior reconstruction for osteoradionecrosis because radiotherapy often compromises the blood supply of local tissues.
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- 2020
13. Treatment decision and estimation of growth of head and neck paragangliomas
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Akina Tamaki, Sarah Nyirjesy, Claudia I. Cabrera, Peter Lancione, Angel Hatef, Robin Rice, Songzhu Zhao, Stephen Y. Kang, Enver Ozer, Amit Agrawal, Matthew O. Old, and Nolan B. Seim
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Paraganglioma ,Otorhinolaryngology ,Head and Neck Neoplasms ,Disease Progression ,Humans ,Cranial Nerve Diseases ,Retrospective Studies - Abstract
Head and neck paragangliomas are slow growing tumors where observation has become more widely accepted. Tumor growth rate as well as predictors of increased tumor growth were analyzed with the goal to identify factors to better predict disease progression and counsel patients.Multi-institutional retrospective cohort study from 2011 to 2020.130 head and neck paragangliomas in 125 patients were analyzed. 38 were observed (30.4%), 16 radiated (12.8%), and 71 underwent surgery (56.8%). Surgical patients were significantly younger (p = 0.038) and with more genetically mediated paragangliomas (p = 0.026). Significantly more patients were asymptomatic in the observation group (p = 0.005). Of the 39 observed tumors, 43.6% (n = 17) grew with a tumor doubling time of 5.67 years. More than half of the observed paragangliomas had no growth. When examining symptoms postoperatively and at follow-up, the surgical cohort had significantly more worsening symptoms (p = 0.007) and new cranial neuropathies (p = 0.031).Head and neck paragangliomas have slow growth rates if they grow at all. Patients in the surgical cohort had more clinical symptoms at presentation and worsening postoperative symptoms.
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- 2021
14. Bone Union of Osseous Microvascular Free Tissue Transfer in Mandibular Reconstruction
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Akina Tamaki MD, Shruthi Sethuraman BS, Lucy Shi MD, Songzhu Zhao MS, Keith C. Carver DMD, MD, MS, Angel Hatef MD, Michael Luttrull MD, Nolan B. Seim MD, Stephen Y. Kang MD, Enver Ozer MD, Amit Agrawal MD, and Matthew O. Old MD
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musculoskeletal diseases ,RF1-547 ,RD1-811 ,Otorhinolaryngology ,microvascular free tissue transfer ,bone union ,Surgery ,musculoskeletal system ,segmental mandibulectomy ,Original Research - Abstract
Objectives Osseous microvascular free tissue transfer (MFTT) is the gold standard for reconstruction for most segmental mandibulectomy defects. The most common osseous MFTT utilized in reconstruction is the fibular, scapular, and osteocutaneous radial forearm (OCRF) free flap. We evaluated postoperative bone union as well as clinical complications following MFTT and the impact of various patient and reconstructive characteristics, including type of osseous MFTT. Study Design Retrospective cohort study. Setting Tertiary care academic hospital. Methods This study examined patients who underwent osseous MFTT for mandibular defects from January 2017 to January 2019. Results An overall 144 osteotomies in 58 patients were evaluated. Of the 144 junctions, 28 (19.4%) showed radiographic nonunion. Patients who underwent preoperative (odds ratio [OR] = 0.30, P = .027) and postoperative (OR = 0.28, P = .003) radiation had a significantly lower bone union score. Time from surgery to postoperative imaging was associated with higher bone union scores (OR = 1.07, P = .024). When bone union scores were compared among types of MFTT, fibular (OR = 5.62, P = .008) and scapular (OR = 4.69, P = .043) MFTT had significantly higher scores than OCRF MFTT. Twelve (20.7%) patients had postoperative complications. There was no statistically significant correlation between clinical complications and various variables, including type of osseous MFTT. Conclusion Pre- and postoperative radiation and time from surgery have an impact on bone union. Regarding the type of MFTT, fibular and scapular MFTT appeared to have higher bone union when compared with OCRF. There was no impact of bone union or type of osseous MFTT on clinical complications.
- Published
- 2021
15. Phase II Randomized Trial of Transoral Surgery and Low-Dose Intensity Modulated Radiation Therapy in Resectable p16+ Locally Advanced Oropharynx Cancer: An ECOG-ACRIN Cancer Research Group Trial (E3311)
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Giovana R. Thomas, Miriam N. Lango, Gregory S. Weinstein, Christine H. Chung, Robert L. Ferris, Ranee Mehra, Joaquin J. Garcia, Neil D. Gross, Umamaheswar Duvvuri, Enver Ozer, Maura L. Gillison, Bert W. O'Malley, Yael Flamand, Harry Quon, R. Bryan Bell, Nabil F. Saba, Shuli Li, Barbara Burtness, Eduardo Mendez, and Wayne M. Koch
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Oncology ,Cancer Research ,medicine.medical_specialty ,Group trial ,business.industry ,Low dose ,Papillomavirus Infections ,Locally advanced ,Cancer ,Radiotherapy Dosage ,ORIGINAL REPORTS ,Intensity-modulated radiation therapy ,medicine.disease ,law.invention ,Oropharyngeal Neoplasms ,Randomized controlled trial ,law ,Internal medicine ,Toxicity ,medicine ,Humans ,Transoral surgery ,business - Abstract
PURPOSE Definitive or postoperative chemoradiation (CRT) is curative for human papillomavirus–associated (HPV+) oropharynx cancer (OPC) but induces significant toxicity. As a deintensification strategy, we studied primary transoral surgery (TOS) and reduced postoperative radiation therapy (RT) in intermediate-risk HPV+ OPC. METHODS E3311 is a phase II randomized trial of reduced- or standard-dose postoperative RT for resected stage III-IVa (American Joint Committee on Cancer-seventh edition) HPV+ OPC, determined by pathologic parameters. Primary goals were feasibility of prospective multi-institutional study of TOS for HPV+ OPC, and oncologic efficacy (2-year progression-free survival) of TOS and adjuvant therapy in intermediate-risk patients after resection. TOS plus 50 Gy was considered promising if the lower limit of the exact 90% binomial confidence intervals exceeded 85%. Quality of life and swallowing were measured by functional assessment of cancer therapy-head and neck and MD Anderson Dysphagia Index. RESULTS Credentialed surgeons performed TOS for 495 patients. Eligible and treated patients were assigned as follows: arm A (low risk, n = 38) enrolled 11%, intermediate risk arms B (50 Gy, n = 100) or C (60 Gy, n = 108) randomly allocated 58%, and arm D (high risk, n = 113) enrolled 31%. With a median 35.2-month follow-up for 359 evaluable (eligible and treated) patients, 2-year progression-free survival Kaplan-Meier estimate is 96.9% (90% CI, 91.9 to 100) for arm A (observation), 94.9% (90% CI, 91.3 to 98.6]) for arm B (50 Gy), 96.0% (90% CI, 92.8 to 99.3) for arm C (60 Gy), and 90.7% (90% CI, 86.2 to 95.4) for arm D (66 Gy plus weekly cisplatin). Treatment arm distribution and oncologic outcome for ineligible or step 2 untreated patients (n = 136) mirrored the 359 evaluable patients. Exploratory comparison of functional assessment of cancer therapy-head and neck total scores between arms B and C is presented. CONCLUSION Primary TOS and reduced postoperative RT result in outstanding oncologic outcome and favorable functional outcomes in intermediate-risk HPV+ OPC.
- Published
- 2021
16. Outcomes with culture-directed antibiotics following microvascular free tissue reconstruction for osteonecrosis of the jaw
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Riddhima Agarwal, Taylor E. Freeman, Michael M. Li, Akash N. Naik, Ramez W. Philips, Stephen Y. Kang, Enver Ozer, Amit Agrawal, Ricardo L. Carrau, James W. Rocco, Matthew O. Old, and Nolan B. Seim
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Cancer Research ,Treatment Outcome ,Diphosphonates ,Oncology ,Osteonecrosis ,Humans ,Bisphosphonate-Associated Osteonecrosis of the Jaw ,Oral Surgery ,Anti-Bacterial Agents ,Retrospective Studies - Abstract
Radiation (ORNJ) and bisphosphonate-related (BRONJ) osteonecrosis of the jaw represent challenging entities to treat, with many patients requiring segmental resection and reconstruction with microvascular free tissue transfer (MFTT) in the setting of failed conservative therapy. Microvascular reconstruction is associated with higher post-operative complication rates when performed for advanced osteonecrosis versus oncologic defects. We hypothesize that basing antibiotic therapy on cultures obtained from the healthy bone marrow following resection during MFTT for ORNJ or BRONJ reduces rates of post-operative wound and surgical complications.In a retrospective cohort study spanning January 2016 to October 2018, 44 patients undergoing MFTT for ORNJ or BRONJ were identified. Patients were categorized into two cohorts: residual healthy marrow culture (n = 11; RHM), treated with antibiotics guided by cultures from healthy appearing mandible, and all others (n = 33; AO), treated with antibiotics guided by cultures from resected necrotic bone or purulent drainage. Patient, reconstruction, and outcome variables were compared via appropriate statistical tools.81.8% of the RHM cohort versus 24.2% of the AO cohort received long-term IV antibiotics. Rates of post-operative wound complications, including those necessitating operative management, were significantly lower in the RHM cohort. Rates of flap failure were similar across both groups.Administration of long-term IV antibiotics directed by native mandible cultures may decrease complication rates following MFTT for ORNJ or BRONJ by treating residual, smoldering infection. Concurrently, transplantation of well-vascularized free tissue likely improves antibiotic delivery. Findings are crucial for the development of a standardized treatment algorithm following microvascular reconstruction for advanced osteonecrosis.
- Published
- 2022
17. Diverse tumorigenic consequences of human papillomavirus integration in primary oropharyngeal cancers
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Mark Zucker, Du Z, Anne-Katrin Emde, Amit Agrawal, Adel K. El-Naggar, Jingfeng Li, Enver Ozer, Maura L. Gillison, David E. Symer, Guojun Li, Stache-Crain B, Keiko Akagi, Kevin R. Coombes, Jitesh B. Shewale, Weihong Xiao, Hartmut Geiger, Nicolas Robine, Song Y, and Bo Jiang
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Genetics ,Genome instability ,Whole genome sequencing ,SOX2 ,Somatic cell ,Gene expression ,medicine ,Biology ,Carcinogenesis ,medicine.disease_cause ,Genomic imprinting ,Gene - Abstract
SUMMARYHuman papillomavirus (HPV) causes 5% of all cancers and frequently integrates into host chromosomes, but the impacts of integration in tumorigenesis remain unclear. Analysis of 105 HPV-positive oropharyngeal cancers by whole genome sequencing detects viral integration in 77%, revealing five statistically significant integration hotspots near genes that regulate epithelial stem cell maintenance (i.e. SOX2, TP63, FGFR, MYC) and immune evasion (i.e. CD274). Somatic hyperamplification is enriched 16-fold near HPV integrants, and the extent of focal host genomic instability increases with local density of HPV integrants. Genes expressed at extreme outlier levels are increased 86-fold within +/- 150 kb of integrants. Across 95% of tumors with integration, host gene transcription is disrupted via intragenic integrants, chimeric transcription, outlier expression, gene breaking and/or de novo expression of noncoding or imprinted genes. We conclude that HPV integration contributes substantively to cancer development by causing extensive disruption of host genome structure and gene expression.
- Published
- 2021
18. Diverse tumorigenic consequences of human papillomavirus integration in primary oropharyngeal cancers
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David E. Symer, Keiko Akagi, Heather M. Geiger, Yang Song, Gaiyun Li, Anne-Katrin Emde, Weihong Xiao, Bo Jiang, André Corvelo, Nora C. Toussaint, Jingfeng Li, Amit Agrawal, Enver Ozer, Adel K. El-Naggar, Zoe Du, Jitesh B. Shewale, Birgit Stache-Crain, Mark Zucker, Nicolas Robine, Kevin R. Coombes, and Maura L. Gillison
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Oropharyngeal Neoplasms ,Carcinogenesis ,Papillomavirus E7 Proteins ,Virus Integration ,Research ,Genetics ,Humans ,Oncogene Proteins, Viral ,Alphapapillomavirus ,Papillomaviridae ,Genetics (clinical) - Abstract
Human papillomavirus (HPV) causes 5% of all cancers and frequently integrates into host chromosomes. The HPV oncoproteins E6 and E7 are necessary but insufficient for cancer formation, indicating that additional secondary genetic events are required. Here, we investigate potential oncogenic impacts of virus integration. Analysis of 105 HPV-positive oropharyngeal cancers by whole-genome sequencing detects virus integration in 77%, revealing five statistically significant sites of recurrent integration near genes that regulate epithelial stem cell maintenance (i.e., SOX2, TP63, FGFR, MYC) and immune evasion (i.e., CD274). Genomic copy number hyperamplification is enriched 16-fold near HPV integrants, and the extent of focal host genomic instability increases with their local density. The frequency of genes expressed at extreme outlier levels is increased 86-fold within ±150 kb of integrants. Across 95% of tumors with integration, host gene transcription is disrupted via intragenic integrants, chimeric transcription, outlier expression, gene breaking, and/or de novo expression of noncoding or imprinted genes. We conclude that virus integration can contribute to carcinogenesis in a large majority of HPV-positive oropharyngeal cancers by inducing extensive disruption of host genome structure and gene expression.
- Published
- 2021
19. The high stakes of head and neck surgery following radiation and chemotherapy – An assessment of complications and survival
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Stephen Y. Kang, Anna M. Marcinow, Matthew O. Old, Nolan B. Seim, James W. Rocco, Amit Agrawal, Ramez Philips, Ricardo L. Carrau, and Enver Ozer
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Male ,Cancer Research ,medicine.medical_specialty ,medicine.medical_treatment ,03 medical and health sciences ,Liver disease ,0302 clinical medicine ,medicine ,Overall survival ,Humans ,030223 otorhinolaryngology ,Survival analysis ,Aged ,Retrospective Studies ,Salvage Therapy ,Chemotherapy ,business.industry ,Head and neck cancer ,Confounding ,Retrospective cohort study ,Middle Aged ,medicine.disease ,Surgery ,Survival Rate ,Oncology ,Head and Neck Neoplasms ,030220 oncology & carcinogenesis ,Female ,Personalized medicine ,Oral Surgery ,business - Abstract
To investigate variables that predict medical and surgical complications in patients undergoing salvage surgery after primary organ-preserving therapy for head and neck cancer and to investigate the effect of complications on 5-year overall survival.A retrospective study was conducted on patients undergoing salvage surgery after primary organ-preserving therapy for head and neck cancer at a tertiary institution from 2006 to 2011. Multivariable regression analysis was used to assess association between independent variables and medical and surgical complications. A Kaplan-Meier survival curve was plotted to assess effect of surgical and medical complications on 5-year overall survival.One hundred thirty-six patients undergoing salvage surgery after primary organ-preservation surgery met inclusion criteria. Surgical complications occurred in 68/136 (50.0%) of patients. After adjusting for confounders, young age and history of hypothyroidism were significant predictors of surgical complications (p 0.05). Medical complications occurred in 37/136 (27.2%) of patients. After adjusting for confounders, older age and history of hepatic disease were significant predictors of having a medical complication (p 0.05). Patients with no complications had better overall survival than patients with medical complications (p = 0.009). There was no difference in overall survival between patients without complications and patients with surgical complications only (p = 0.259).Risk factors for medical and surgical complications include history of hypothyroidism, liver disease, and age. Survival outcomes are not affected by surgical complications but are significantly affected by medical complications highlighting the importance of personalized patient care and medical co-management.
- Published
- 2019
20. Outcomes by tobacco history in E3311, a phase II trial of transoral surgery (TOS) followed by pathology-based adjuvant treatment in HPV-associated (HPV+) oropharynx cancer (OPC): A trial of the ECOG-ACRIN Cancer Research Group
- Author
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Ranee Mehra, Yael Flamand, Harry Quon, Joaquin J. Garcia, Gregory S. Weinstein, Umamaheswar Duvvuri, Bert W. O'Malley, Enver Ozer, Giovana R. Thomas, Wayne Koch, Neil D. Gross, Richard Bryan Bell, Nabil F. Saba, Miriam Lango, Rodrigo Bayon, Barbara Burtness, and Robert L. Ferris
- Subjects
Cancer Research ,Oncology - Abstract
6077 Background: E3311 is a phase II randomized study which showed favorable outcomes among intermediate (INT) risk HPV+ OPC patients (pts) who underwent TOS followed by pathology-guided or adapted, deintensified adjuvant treatment. Among HPV+ pts treated with definitive chemoradiation, survival outcomes are worse among those who smoked > 10 pack years (pk-yrs). Methods: We retrospectively analyzed demographics, pathologic results, and efficacy outcomes from E3311 by smoking group (current (C) vs. former (F) and > 10 vs. ≤10 pk-yrs the latter a pre-specified stratification factor for INT patients). Binary and categorical variables were compared using a chi-square test (or Fishers exact test for small sample sizes). Ordinal variables were compared using a Wilcoxon rank sum test. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method and compared using a log-rank test. Results: Among 359 evaluable pts, performance status (PS) was significantly worse for pts with > 10 pk-yrs vs. ≤10 pk-yrs (15.4% vs. 7.9% with PS of 1, p = 0.034). Primary site, margin status, histologic grade, stage, and extranodal extension were not significantly different between the groups of > 10 vs. ≤10 pk-yrs. Smoking status (F vs. C) was available for 182 pts with a history of smoking. Slightly more C vs. F smokers had tonsil as primary site (79.5% vs. 65.0%, p = 0.09). Positive margins were significantly more frequent among C smokers (10.3% vs. 2.1%; p = 0.029). Overall, there were no significant differences in PFS (p = 0.55) or OS (p = 0.94), comparing those with > 10 vs. ≤10 pk-yrs, or comparing C vs. F smokers (p = 0.76, p = 0.82, respectively). Similarly, no significant differences were observed within the treatment arms. (Table 1) Conclusions: In this analysis of smoking status in E3311, INT risk HPV+ OPC pts who are C smokers or have a history of > 10 pk-yrs had favorable 3-yr PFS and OS rates that were not significantly worse than those with < 10 pk-yrs history. This data represents the first treatment approach for HPV+ OPC in which outcomes were not influenced by smoking status. Clinical trial information: NCT01898494. [Table: see text]
- Published
- 2022
21. Patient-Directed Home Drain Removal in Head and Neck Surgery
- Author
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Stephen Y. Kang, Kelly Vala, Nolan B. Seim, Ricardo L. Carrau, Amanda Selhorst, Matthew O. Old, Kyle K. VanKoevering, Amit Agrawal, Laura Skoracki, Rishabh Sethia, Katherine Mead, Enver Ozer, Megan Adelman, Taylor Freeman, and James W. Rocco
- Subjects
Male ,medicine.medical_specialty ,Time Factors ,Coronavirus disease 2019 (COVID-19) ,Efficiency ,Infections ,Tertiary care ,Patient satisfaction ,Patient Education as Topic ,medicine ,Humans ,Prospective Studies ,Device Removal ,Postoperative Care ,Hematoma ,business.industry ,SARS-CoV-2 ,General surgery ,COVID-19 ,Evidence-based medicine ,Middle Aged ,medicine.disease ,Home Care Services ,Patient Discharge ,Seroma ,Otorhinolaryngology ,Head and neck surgery ,Drainage ,Neck Dissection ,Female ,Drain removal ,Safety ,business ,Emergency Service, Hospital ,Healthcare providers - Abstract
OBJECTIVES/HYPOTHESIS: The purpose of this study was to evaluate the efficacy and safety of at home drain removal in head and neck surgery patients. METHODS: The study population included patients who underwent head and neck surgery at an academic tertiary care center between February 2020 and November 2020 and were discharged with one to four drains with instructions for home removal. Prior to discharge, patients received thorough drain removal education. Patients were prospectively followed to evaluate for associated outcomes. RESULTS: One hundred patients were evaluated in the study. There was record for ninety-seven patients receiving education at discharge. The most common methods of education were face-to-face education and written instructions with educational video link provided. Of 123 drains upon discharge, 110 drains (89.4%) were removed at home while 13 (10.6%) were removed in office. Most drains were located in the neck (86.4%). There was one seroma, two hematomas, two drain site infections, and five ED visits; however, none of these complications were directly associated with the action of drain removal at home. Calculated cost savings for travel and lost wages was $259.82 per round trip saved. CONCLUSIONS: The results demonstrate that home drain removal can provide a safe and efficacious option for patients following head and neck surgery. This approach was safe and associated with patient cost savings and better utilization of provider's time. Furthermore, patients and healthcare providers avoided additional in-person encounters and exposures during the COVID-19 pandemic. Our findings warrant further investigation into cost savings and formal patient satisfaction associated with home drain removal. LEVEL OF EVIDENCE: 4 Laryngoscope, 2021.
- Published
- 2021
22. Future of Robotics in Otolaryngology–Head and Neck Surgery
- Author
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Enver Ozer and Kiran Kakarala
- Subjects
medicine.medical_specialty ,business.industry ,General surgery ,medicine.medical_treatment ,Head and neck cancer ,technology, industry, and agriculture ,Thyroidectomy ,Neck dissection ,Robotics ,medicine.disease ,body regions ,surgical procedures, operative ,Otorhinolaryngology ,Transoral robotic surgery ,Head and neck surgery ,Medicine ,Robotic surgery ,Artificial intelligence ,business ,human activities - Abstract
Indications for robotic surgery continue to expand within the field of Otolaryngology–Head and Neck Surgery. Transoral robotic surgery (TORS) for benign and malignant diseases of the tonsils and base of tongue is the most common procedure and can be performed using different robotic platforms. However, recent advances in surgical techniques and robotic technologies may lead to increased interest in transoral and/or transcervical robotic approaches to the neck for procedures such as thyroidectomy, salivary gland excision, and neck dissection. The anterior and lateral skull base may also become more favorable targets for robotic interventions as the technology continues to improve. This chapter briefly reviews the history and current cutting edge of robotics in this field and highlights important trends for the future.
- Published
- 2021
23. The Role of Hyperbaric Oxygen in Head and Neck Reconstruction and Facial Cosmetic Surgery
- Author
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Dustin A. Silverman, Enver Ozer, and Akina Tamaki
- Subjects
medicine.medical_specialty ,Hyperbaric Oxygenation ,business.industry ,Dermal Fillers ,Surgical Flaps ,Surgery ,Oxygen ,03 medical and health sciences ,0302 clinical medicine ,Hyperbaric oxygen ,Treatment modality ,Head and Neck Neoplasms ,030220 oncology & carcinogenesis ,medicine ,Humans ,Surgery, Plastic ,030223 otorhinolaryngology ,business ,Head and neck - Abstract
Hyperbaric oxygen (HBO) is a treatment modality with the primary mechanism of therapy being the delivery of oxygen to hypoxic tissues. A review of HBO applications in the field of head and neck reconstruction and facial cosmetic surgery is provided. HBO can be useful in the management of radiation sequelae and treatment of compromised flaps and grafts. It may also have application in tissue compromise following cosmetic surgery and dermal fillers. We provide evidence from the available literature as well as highlight our experience in using HBO in head and neck reconstruction.
- Published
- 2020
24. The Use of Vasopressor Agents in Free Tissue Transfer for Head and Neck Reconstruction: Current Trends and Review of the Literature
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Matthew O. Old, Michael M. Li, Stephen Y. Kang, Scarlett Marshall, Taylor Freeman, Amit Agrawal, Enver Ozer, Akash N. Naik, Nolan B. Seim, and Akina Tamaki
- Subjects
0301 basic medicine ,medicine.medical_specialty ,endocrine system ,Free flap ,Review ,microvascular surgery ,Vasopressor agents ,03 medical and health sciences ,0302 clinical medicine ,Bolus (medicine) ,Medicine ,Pharmacology (medical) ,Head and neck ,Pharmacology ,free tissue transfer ,business.industry ,lcsh:RM1-950 ,anesthesia management ,Retrospective cohort study ,vasopressors ,Perioperative ,medicine.disease ,Thrombosis ,Surgery ,030104 developmental biology ,lcsh:Therapeutics. Pharmacology ,head and neck reconstruction ,030220 oncology & carcinogenesis ,business ,Perfusion ,hormones, hormone substitutes, and hormone antagonists - Abstract
Background/objectives Microvascular free tissue transfer has become essential to head and neck reconstruction and recent advancements in microvascular surgery have led to excellent surgical outcomes. However, there continues to be controversy and a stigma associated with the use of perioperative intravenous vasopressor agents among both surgeons and anesthesiologists. Due to concern for vasoconstriction of peripheral vasculature flowing to the denervated tissue flap, there remains concerns about potential thrombosis, decreased tissue perfusion and ultimately flap failure. This topic becomes even more important as vasopressors play an essential role in new Extended Recovery After Surgery (ERAS) protocols being put in place to optimize postoperative recovery for patients. The purpose of this study was to comprehensively review the role and safety as well as discuss current trends with intraoperative vasopressor agents in free tissue transfer for head and neck reconstruction. Methods A scoping literature review was conducted of all studies that examined the use of vasopressor agents during head and neck free flap tissue transfer. Primary and secondary outcomes included free flap survival, arterial thrombosis, venous congestion, need for revision surgery, and other postoperative complications. Results One prospective and nine retrospective studies were identified. Phenylephrine and ephedrine were the most common vasopressors reported; the rate of vasopressor use ranged from 53% to 85% and administration methods included both bolus and infusion. The included studies did not show any significant association between the use of vasopressors and free flap failure, pedicle thrombosis, or other flap complications. Conclusion The administration of vasopressors during microvascular free tissue transfer for head and neck reconstruction does not seem to be associated with increased flap failure rates or other postoperative morbidities. Moreover, vasopressors may provide overall improved hemodynamic stability and help to limit overall fluid administration and subsequent postoperative complications. Additional prospective investigation is warranted to further elucidate and establish evidence-based recommendations regarding the type, timing, and dose of vasopressors to further enhance free flap survival and patient outcomes.
- Published
- 2020
25. Mega Fibula Free Flap for Reconstruction of an Extensive Mandibulofacial Defect
- Author
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Enver Ozer, Akina Tamaki, and Chen Lin
- Subjects
Orthodontics ,Aged, 80 and over ,business.industry ,General Medicine ,Free flap ,030230 surgery ,Plastic Surgery Procedures ,Mega ,Free Tissue Flaps ,03 medical and health sciences ,0302 clinical medicine ,Otorhinolaryngology ,Fibula ,030220 oncology & carcinogenesis ,Carcinoma, Squamous Cell ,Medicine ,Humans ,Female ,Mouth Neoplasms ,Mandibular Reconstruction ,business - Abstract
Objective: Extensive mandibulofacial defects can be challenging to reconstruct. We present the case of a complex mandibulofacial defect reconstructed with a mega, chimeric fibula free flap. Methods: Ablation of the oral cavity tumor resulted in a large defect involving mandible, floor of mouth, and tongue. Skin of the chin and neck as well as the lower lip were also resected. A fibula free flap was harvested with the skin paddle involving most of the lateral compartment. Results: The fibula free flap was split into proximal (80 cm2) and distal (120 cm2) skin paddle islands, which were supplied by separate perforators off the peroneal artery. The intraoral soft tissue defect was reconstructed with the proximal skin paddle while the skin was recreated with the distal skin paddle. A Karapandzic flap was used to reconstruct the lower lip. Conclusions: The traditional fibula free flap skin paddle often does not provide sufficient soft tissue coverage for large mandibulofacial defects. Some surgeons opt to harvest a second free flap. We describe our technique for using the mega fibula free flap – one of the largest reported in the literature – as a single mode of reconstruction.
- Published
- 2020
26. The use of medical modeling in microvascular free tissue transfer reconstruction with osseointegrated implantation in complex midface defects
- Author
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Matthew O. Old, Meade VanPutten, Akina Tamaki, Stephen Y. Kang, Enver Ozer, Amit Agrawal, Nolan B. Seim, and Sasha Valentin
- Subjects
Adult ,Male ,Models, Anatomic ,Cancer Research ,Population ,Free Tissue Flaps ,Osseointegration ,03 medical and health sciences ,0302 clinical medicine ,medicine ,Humans ,030223 otorhinolaryngology ,education ,Aged ,Orthodontics ,education.field_of_study ,Bone-Anchored Prosthesis ,business.industry ,Head and neck cancer ,Middle Aged ,Plastic Surgery Procedures ,medicine.disease ,Tissue transfer ,Treatment Outcome ,Oncology ,030220 oncology & carcinogenesis ,Maxilla ,Face ,Female ,Oral Surgery ,business - Abstract
Osseointegrated implants in conjunction with microvascular free tissue transfer reconstruction has been increasingly adopted in our head and neck cancer population. However, the majority of the literature on dental rehabilitation in free flaps have been for mandibular defects. Midface and maxillectomy defects are challenging defects for reconstruction. The utilization of medical modeling technology has allowed for improved efficiency and accuracy of microvascular free tissue transfer reconstruction of these midface defects and opened the possibility of immediate osseointegrated implant placement. Medical modeling in microvascular free tissue transfer reconstruction with immediate dental rehabilitation in complex midface defects will be discussed. A review of the literature as well as our experience in the surgical management of these patients is provided.
- Published
- 2020
27. A potential protective effect of metformin in adenoid cystic carcinoma
- Author
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Peter J. Lancione, Ricardo L. Carrau, Bhavna Kumar, Enver Ozer, Stephen Y. Kang, James W. Rocco, Songzhu Zhao, Edmund A. Mroz, Amit Agrawal, Guy Brock, Nolan B. Seim, and Matthew O. Old
- Subjects
Adult ,Aged, 80 and over ,Male ,Cancer Research ,medicine.medical_specialty ,Adenoid cystic carcinoma ,business.industry ,Middle Aged ,medicine.disease ,Gastroenterology ,Carcinoma, Adenoid Cystic ,Metformin ,Article ,Young Adult ,Oncology ,Internal medicine ,medicine ,Humans ,Hypoglycemic Agents ,Female ,Oral Surgery ,business ,medicine.drug ,Aged - Published
- 2020
28. Impact of age and comorbidity on survival among patients with oral cavity squamous cell carcinoma
- Author
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Theodoros N. Teknos, Amit Agrawal, Ricardo L. Carrau, Bhavna Kumar, Krupal B. Patel, James W. Rocco, Matthew O. Old, Enver Ozer, Songzhu Zhao, Daniel Martin, Stephen Y. Kang, Guy Brock, and David E. Schuller
- Subjects
Oncology ,medicine.medical_specialty ,Prognostic variable ,Comorbidity ,Article ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,Adjuvant therapy ,Medicine ,Humans ,030212 general & internal medicine ,Oral Cavity Squamous Cell Carcinoma ,Cancer staging ,Neoplasm Staging ,Proportional Hazards Models ,Retrospective Studies ,business.industry ,Squamous Cell Carcinoma of Head and Neck ,Head and neck cancer ,Cancer ,Retrospective cohort study ,medicine.disease ,Prognosis ,Otorhinolaryngology ,Head and Neck Neoplasms ,030220 oncology & carcinogenesis ,Carcinoma, Squamous Cell ,business - Abstract
Objective To identify predictors of overall survival (OS) and to stratify patients according to significant prognostic variables. Methods A retrospective study of 274 consecutive patients with primary Oral Cavity Squamous Cell Carcinoma. Kaplan-Meier, Cox proportional hazard models, and recursive partitioning analysis (RPA) were used for analysis of OS. These results were further validated using National Cancer Database cohort of 21 895 patients. Results Median OS was 3.65 years. T-classification and N-classification, alcoholic beverages/week, age, and adjuvant treatment were significant predictors of OS. RPA identified high-risk subpopulations: N0-1 patients with CCI ≥ 4.5 and N2-3 patients ordered by those not receiving adjuvant treatment, those with T3-4 disease despite adjuvant therapy, and those having T1-2 disease with adjuvant therapy. Conclusions This study utilized significant prognostic indicators and RPA to highlight the importance of age, N-classification, T-classification, comorbidity, and adjuvant therapy in conjunction with American Joint Committee on Cancer staging to improve preoperative counseling.
- Published
- 2020
29. Predictors of gastrostomy tube dependence in surgically managed oropharyngeal squamous cell carcinoma
- Author
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Antoine Eskander, Amit Agrawal, Vivek R. Varma, Peter T. Dziegielewski, Michael J. Cipolla, Enver Ozer, Guy Brock, Stephen Y. Kang, Ricardo L. Carrau, Bhavna Kumar, Songzhu Zhao, Nicole V. Brown, James W. Rocco, Theodoros N. Teknos, David E. Schuller, and Matthew O. Old
- Subjects
medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Odds ratio ,Perioperative ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,medicine.anatomical_structure ,Otorhinolaryngology ,Quality of life ,Tongue ,030220 oncology & carcinogenesis ,Transoral robotic surgery ,medicine ,Stage (cooking) ,Oropharyngeal squamous cell carcinoma ,030223 otorhinolaryngology ,business ,Adjuvant - Abstract
OBJECTIVES To elucidate predictive factors in the perioperative period resulting in gastrostomy tube (G-tube) dependence for patients undergoing primary surgical treatment of oropharyngeal squamous cell carcinoma (OPSCC) in the modern era. METHODS Two hundred and thirty patients with known OPSCC treated with primary surgery were screened and selected from a retrospective database spanning from 2002 to 2012 at The Ohio State University Wexner Medical Center (Columbus, Ohio), with univariable and multivariable logistic regression modeling used to determine independent predictive factors resulting in G-tube dependence (defined as tube persistence/presence 1 year after surgery). RESULTS Surgical approach, baseline characteristics, tumor (T)-nodal-metastasis stage, human papillomavirus status, extent of tissue resected, surgical complications, reconstructive technique, preoperative G-tube presence, and adjuvant treatment were recorded. Patients undergoing open surgery for OPSCC without adjuvant treatment had 42.9% G-tube dependence (44.6% with adjuvant chemoradiation [CRT]) compared to 0% for those undergoing transoral nonrobotic surgery (8.1% with adjuvant CRT) and 0% for those undergoing transoral robotic surgery (10.3% with adjuvant CRT). In multivariable analysis, greater than 25% of the oral tongue resected (odds ratio [OR] 12.29; P = 0.03), an open surgical approach (OR 5.72; P
- Published
- 2018
30. The future of robotic surgery in otolaryngology - head and neck surgery
- Author
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James W. Rocco, Enver Ozer, and Akina Tamaki
- Subjects
Cancer Research ,medicine.medical_specialty ,03 medical and health sciences ,Otolaryngology ,0302 clinical medicine ,Robotic Surgical Procedures ,Transoral robotic surgery ,medicine ,Humans ,Robotic surgery ,030223 otorhinolaryngology ,Head and neck ,business.industry ,General surgery ,technology, industry, and agriculture ,Disease Management ,Robotics ,medicine.disease ,body regions ,Clinical trial ,Obstructive sleep apnea ,Treatment Outcome ,Oncology ,Otorhinolaryngology ,030220 oncology & carcinogenesis ,Head and neck surgery ,Oral Surgery ,business ,human activities ,Laryngeal disease - Abstract
Robotic surgery for management of head and neck pathologies has only been in practice for little more than a decade. Since then, there has been a rapid development in the field of transoral robotic surgery (TORS) and robotic surgery in otolaryngology. TORS has emerged as a tool in the treatment of both malignant and benign oropharyngeal, hypopharyngeal, and laryngeal disease. TORS is also a critical component of ongoing clinical trials seeking to improve the treatment of oropharyngeal squamous cell carcinoma. In addition, it's application has expanded to treatment of obstructive sleep apnea, thyroid and parathyroid disease, and skull base pathologies. This review will provide an overview of the current application of robotics in otolaryngology as well as highlight the developing robotic platforms and technologies, and future of the field.
- Published
- 2019
31. Predictors of Complications in Patients Receiving Head and Neck Free Flap Reconstructive Procedures
- Author
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Amit Agrawal, Enver Ozer, James W. Rocco, Antoine Eskander, Theodoros N. Teknos, Stephen Y. Kang, Jigar Sitapara, Ben Tweel, Matthew O. Old, and Ricardo L. Carrau
- Subjects
Male ,Reconstructive surgery ,medicine.medical_specialty ,Operative Time ,Free flap ,Free Tissue Flaps ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Risk Factors ,Diabetes mellitus ,medicine ,Humans ,030223 otorhinolaryngology ,Aged ,Retrospective Studies ,Wound Healing ,integumentary system ,business.industry ,Head and neck cancer ,Cancer ,Middle Aged ,Plastic Surgery Procedures ,medicine.disease ,Comorbidity ,Surgery ,Malnutrition ,Otorhinolaryngology ,Head and Neck Neoplasms ,030220 oncology & carcinogenesis ,Female ,business ,Complication - Abstract
Objective To (1) determine the overall complication rate, wound healing, and wound infection complications and (2) identify preoperative, intraoperative, and postoperative predictors of these complications. Study Design Case series with chart review. Setting Tertiary academic cancer hospital. Subjects and Methods All head and neck free flap patients at The Ohio State University (2006-2012) were assessed. Multivariable logistic regression assessed the impact of patient factors, flap and wound factors, and intraoperative factors on the aforementioned quality metric outcomes. Results Of the 515 patients identified, 54% had a complication predicted by longer operating room (OR) time, higher comorbidity index, and oral cavity and pharyngeal tumor sites. Predictors of wound-healing complications (15%) were longer OR time, volume of crystalloid given intraoperatively, and oral cavity and pharyngeal tumor sites. Predictors of wound infection (12%) were younger age, diabetes mellitus, and malnutrition. Conclusions Wound healing and infectious complications account for most complications in patients with head and neck cancer undergoing free flap reconstruction. Clean contaminated wounds are a significant predictor of wound complications. Advanced OR time, advanced age, and comorbidity status, including diabetes mellitus and malnutrition, are other important predictors. Crystalloid administration is also an important predictor of wound-healing complications, and this warrants further study.
- Published
- 2018
32. Effect of adjuvant radiotherapy treatment center volume on overall survival
- Author
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Matthew O. Old, Theodoros N. Teknos, Antoine Eskander, Bhavna Kumar, Ricardo Carrau, Daniel R. Martin, Ramez Philips, James W. Rocco, David E. Schuller, Nicole V. Brown, Songzhu Zhao, Stephen Y. Kang, Jeffrey Schord, Enver Ozer, Aashish D. Bhatt, Syed Farooq Ali, Guy Brock, John C. Grecula, Amit Agrawal, V.M. Diavolitsis, and Dukagjin Blakaj
- Subjects
Male ,Oncology ,Cancer Research ,medicine.medical_specialty ,medicine.medical_treatment ,Article ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,medicine ,Adjuvant therapy ,Overall survival ,Humans ,030212 general & internal medicine ,Oral Cavity Squamous Cell Carcinoma ,Aged ,Neoplasm Staging ,Retrospective Studies ,Proportional hazards model ,business.industry ,Head and neck cancer ,Retrospective cohort study ,Middle Aged ,medicine.disease ,Survival Rate ,Radiation therapy ,Oropharyngeal Neoplasms ,030220 oncology & carcinogenesis ,Carcinoma, Squamous Cell ,T-stage ,Female ,Radiotherapy, Adjuvant ,Oral Surgery ,business - Abstract
OBJECTIVES: to examine the impact of radiotherapy center volume on overall survival in patients with oral cavity and oropharyngeal squamous cell carcinoma getting adjuvant radiation therapy after receiving surgery at a high-volume center. MATERIALS AND METHODS: a retrospective study was conducted on patients with oral cavity squamous cell carcinoma or oropharyngeal squamous cell carcinoma treated surgically at a tertiary institution from 2000 to 2012 who received adjuvant radiotherapy. The outcome variable was overall survival and the independent variable was location of adjuvant radiation therapy: high-volume center (HVC) versus low-volume center (LVC). Cox proportional hazards models were used to assess associations between predictors of death. Variables that were found to be significant at the α = 0.10 were included in a multivariable model. RESULTS: 336 patients met inclusion criteria. One-hundred thirty-nine patients received adjuvant radiation therapy at HVC and 197 patients received adjuvant radiation therapy at LVC. A univariate Cox proportional hazards model identified the variables location, age, marital status, subsite, T stage, extracapsular extension, and smoking status to include in a multivariable model. Age, subsite, T stage, and extracapsular extension were independent predictors of overall survival (p < .05). Location (p=.55), marital status (p=.29), and smoking status (p=.22) were not statistically significant predictors of survival. CONCLUSION: After surgery at a HVC, the volume of adjuvant radiation therapy center was not significantly associated with overall survival. Significant predictors of survival included age, subsite, T stage, and extracapsular extension.
- Published
- 2018
33. Supine positioning for the subscapular system of flaps: A pictorial essay
- Author
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Amit Agrawal, Enver Ozer, Stephen Y. Kang, Antoine Eskander, Theodoros N. Teknos, James W. Rocco, Ricardo L. Carrau, and Matthew O. Old
- Subjects
Reconstructive surgery ,medicine.medical_specialty ,Supine position ,business.industry ,Duty hours ,Plastic Surgery Procedures ,Free Tissue Flaps ,Patient Positioning ,Surgery ,Scapula ,03 medical and health sciences ,Position (obstetrics) ,0302 clinical medicine ,Otorhinolaryngology ,030220 oncology & carcinogenesis ,mental disorders ,Scapular flap ,Supine Position ,medicine ,Head and neck surgery ,Humans ,Closure (psychology) ,030223 otorhinolaryngology ,business - Abstract
BACKGROUND This pictorial essay demonstrates a modification to the positioning, prepping, and draping technique for the subscapular system of flaps allowing the patient to be placed supine and without the need for a second assistant during the harvest or closure. METHODS AND RESULTS We performed a literature review focusing on the positioning of the patient during the harvest of the subscapular system of flaps. A supine modification harvest prepping, draping, and position is then described in pictorial essay format. The technique is made possible with the use of a Mayo stand to position the arm. DISCUSSION A literature review demonstrates limited description of nonlateral decubitus position harvest of the scapular flap. A novel positioning technique is described in pictorial essay format to demonstrate the ease and feasibility without the need for a second assistant during the case, an important goal in the era of limited resident duty hours.
- Published
- 2018
34. Salvage Skull Base Reconstruction in the Endoscopic Era: The Vastus Lateralis Free Tissue Transfer
- Author
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Ricardo L. Carrau, Antoine Eskander, Daniel M. Prevedello, Ralph Abi-Hachem, Enver Ozer, Stephen Y. Kang, Matthew O. Old, and Theodoros N. Teknos
- Subjects
03 medical and health sciences ,Skull ,0302 clinical medicine ,medicine.anatomical_structure ,business.industry ,030220 oncology & carcinogenesis ,medicine ,Neurology (clinical) ,Anatomy ,business ,Base (exponentiation) ,030217 neurology & neurosurgery ,Tissue transfer - Published
- 2018
35. Submental artery island flap with simultaneous level I neck dissection
- Author
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Nolan B. Seim, Daniel Strigenz, Antoine Eskander, and Enver Ozer
- Subjects
Male ,medicine.medical_specialty ,Reconstructive surgery ,medicine.medical_treatment ,Palatine Tonsil ,Risk Assessment ,Surgical Flaps ,03 medical and health sciences ,0302 clinical medicine ,medicine.artery ,Humans ,Medicine ,Basal cell ,030223 otorhinolaryngology ,Head and neck ,business.industry ,Graft Survival ,Neck dissection ,Middle Aged ,Plastic Surgery Procedures ,Surgery ,Submental artery ,Oropharyngeal Neoplasms ,Treatment Outcome ,medicine.anatomical_structure ,Otorhinolaryngology ,Gastrostomy tube ,030220 oncology & carcinogenesis ,Tonsil ,Carcinoma, Squamous Cell ,Quality of Life ,Neck Dissection ,Neoplasm Recurrence, Local ,business ,After treatment ,Follow-Up Studies - Abstract
Background The purpose of this study was to illustrate the submental island flap elevation technique with simultaneous level I neck dissection followed by the inset and reconstruction of an oropharyngeal defect. Methods A 63-year-old patient with a T2N1M0 human papillomavirus-positive squamous cell carcinoma of the tonsil was treated with concurrent chemoradiotherapy (cisplatin + 66 Gy). A local recurrence 2.5 years after treatment was treated surgically and reconstructed with a submental island flap. Results There were no complications and oral diet was initiated at 2 weeks and the gastrostomy tube was removed 1 month postoperatively. A video demonstration of the submental island flap elevation is included with a focus on how levels 1A and 1B can be dissected safely and this can be viewed online on Head & Neck's home page at http://onlinelibrary.wiley.com/. Conclusion The submental island flap can be performed safely with a level I neck dissection for head and neck reconstruction.
- Published
- 2018
36. Quality Indicators: Measurement and Predictors in Head and Neck Cancer Free Flap Patients
- Author
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Ricardo L. Carrau, James W. Rocco, Enver Ozer, Theodoros N. Teknos, Jigar Sitapara, Amit Agrawal, Antoine Eskander, Stephen Y. Kang, Matthew O. Old, and Benjamin Tweel
- Subjects
Male ,Reoperation ,medicine.medical_specialty ,Reconstructive surgery ,Blood transfusion ,medicine.medical_treatment ,Operative Time ,Blood Component Transfusion ,Comorbidity ,Free flap ,Lower risk ,Free Tissue Flaps ,Patient Readmission ,Hospitals, University ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,medicine ,Humans ,030223 otorhinolaryngology ,Ohio ,Quality Indicators, Health Care ,Retrospective Studies ,business.industry ,Head and neck cancer ,Cancer ,Length of Stay ,Middle Aged ,Plastic Surgery Procedures ,medicine.disease ,Surgery ,Radiation therapy ,Treatment Outcome ,Otorhinolaryngology ,Head and Neck Neoplasms ,030220 oncology & carcinogenesis ,Female ,Complication ,business - Abstract
Objective To determine the predictors of length of stay (LOS), readmission within 30 days, and unplanned return to the operating room (OR) within 30 days in head and neck free flap patients. Study Design Case series with chart review. Setting Tertiary academic cancer hospital. Subjects and Methods All head and neck free flap patients at The Ohio State University (OSU, 2006-2012) were assessed. Multivariable logistic regression to assess the impact of patient factors, flap and wound factors, and intraoperative factors on the aforementioned quality metric outcomes. Results In total, 515 patients were identified, of whom 66% had oral cavity cancers, 33% had recurrent tumors, and 28% underwent primary radiotherapy. Of the patients, 31.5% had a LOS greater than 9 days, predicted by longer operative time, oral cavity and pharyngeal tumor sites, blood transfusion, diabetes mellitus, and any complication. A total of 12.6% of patients were readmitted within 30 days predicted by absent OSU preoperative assessment clinic attendance and any complication, and 14.8% of patients had an unplanned OR return predicted by advanced age. Conclusions When assessing quality metrics, adjustment for the complexity involved in managing patients with head and neck cancer with a high comorbidity index, clean contaminated wounds, and a high degree of primary radiotherapy is important. Patients seen in a preoperative assessment clinic had a lower risk of readmission postoperatively, and this should be recommended for all head and neck free flap patients. Quality improvement projects should focus on predictors and prevention of complications as this was the number one predictor of both increased length of stay and readmission.
- Published
- 2018
37. Appraisal of the AJCC 8th edition pathologic staging modifications for HPV−positive oropharyngeal cancer, a study of the National Cancer Data Base
- Author
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James W. Rocco, Kevin Y. Zhan, Matthew O. Old, Enver Ozer, Ricardo L. Carrau, Stephen Y. Kang, Antoine Eskander, Amit A. Agrawal, and Theodoros N. Teknos
- Subjects
Male ,Oncology ,Cancer Research ,medicine.medical_specialty ,Databases, Factual ,Pathologic staging ,Nodal staging ,Disease ,HPV-positive oropharyngeal cancer ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,medicine ,Humans ,Stage (cooking) ,030223 otorhinolaryngology ,Papillomaviridae ,Aged ,Neoplasm Staging ,business.industry ,Extranodal Extension ,Cancer ,Middle Aged ,medicine.disease ,Cancer data ,Oropharyngeal Neoplasms ,030220 oncology & carcinogenesis ,Carcinoma, Squamous Cell ,Female ,Oral Surgery ,business - Abstract
The American Joint Commission on Cancer (AJCC) recently created new staging for human papillomavirus associated oropharyngeal cancer (HPV+ OPSCC) for its 8th edition. These proposals have not yet been validated in a national registry.Review of National Cancer Database (NCDB) for surgically-treated HPV+ OPSCC for years 2010-2014 to validate the new staging system using the Kaplan Meier method to explore survival outcomes.3745 cases were analyzed. Median follow-up was 31.3months. Most patients were Caucasian males with tonsillar cancer. Distribution of stage I disease increased from 3.7% to 80.2% in AJCC 8th. pN1 disease shifted from 17.3% to 75.9%. Treatment and distribution of T-stage varied by pathologic nodal (pN) staging. Extranodal extension (ENE) was positive in 41% cases. Four-year overall survival (OS) for AJCC 8th stages I (92%), II (81%), and stage III (62%) showed excellent hazard discrimination (all pairwise p0.001). Only 4-year OS by pN staging showed significantly different curves when comparing pN2 (79%) with others (pN0 88%; pN1 91%, p=0.01 and0.001 respectively). Presence of ENE confers a negative effect on overall survival (92% ENE- vs. 85% ENE+, p0.001).The NCDB shows improved hazard discrimination and outcome prediction in the AJCC 8th edition staging for HPV+ OPSCC. While overall staging had excellent hazard discrimination, this accounted for poorer discrimination between pN0 and pN1. The majority of patients are reclassified as overall stage I. Presence of extranodal extension demonstrated a statistically significant but modest negative effect on overall survival. CONDENSED ABSTRACT (2 SENTENCES): Using NCDB data for validation, the AJCC 8th ed. pathologic staging system offers much improved hazard discrimination and prognostication in HPV oropharyngeal cancer, with the majority of cases reclassified as pStage I. Of note, only pN2 offered hazard discrimination within nodal staging and presence of pathologic extranodal extension has a modest negative effect on survival.
- Published
- 2017
38. Updated report of a phase II randomized trial of transoral surgical resection followed by low-dose or standard postoperative therapy in resectable p16+ locally advanced oropharynx cancer: A trial of the ECOG-ACRIN cancer research group (E3311)
- Author
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Jolie Ringash, Joaquin J. Garcia, Richard Bryan Bell, Wayne M. Koch, Enver Ozer, Umamaheswar Duvvuri, Gregory S. Weinstein, Yael Flamand, Lynne I. Wagner, Robert L. Ferris, Jan S. Lewin, Shuli Li, Ranee Mehra, Michael E. Kupferman, Nabil F. Saba, Harry Quon, Barbara Burtness, Giovana R. Thomas, Bert W. O'Malley, and Miriam N. Lango
- Subjects
Surgical resection ,Cancer Research ,medicine.medical_specialty ,business.industry ,Low dose ,Locally advanced ,Cancer ,medicine.disease ,Surgery ,law.invention ,Oncology ,Randomized controlled trial ,law ,Toxicity ,medicine ,business - Abstract
6010 Background: Definitive or postoperative chemoradiation (CRT) is highly curative for human papillomavirus-associated (HPV+) oropharynx cancer (OPC) but induces significant toxicity. As a potential deintensification strategy, we studied primary transoral surgery (TOS) and, in intermediate pathologic risk patients, reduced dose postoperative RT (PORT). Methods: E3311 is a phase II trial with randomization to reduced- or standard-dose PORT for resected stage III-IVa (AJCC7) intermediate pathologic risk HPV+ OPC, stratified by smoking history. Primary endpoints have been reported; we now present updated 3-year PFS and patient-reported outcomes (PRO), including head and neck-cancer specific quality of life (FACT-H&N) and swallowing perception and performance (MDADI). Results: Of 519 enrolled patients, 495 underwent TOS. The primary oncologic endpoint was 2-year PFS for 50 Gy (Arm B) or 60Gy (Arm C). Among 360 eligible and treated patients (ETP), Arm A (observation, N = 38) enrolled 11%, Arms B (N = 100) or C (N = 109) randomized 58%, and Arm D (66Gy + weekly cisplatin, N = 113) enrolled 31%. With 35.1 months median follow-up, 3-year PFS Kaplan-Meier estimate is 96.9% (90% CI [91.9%, 100%]) for Arm A; 94.9% (90% CI [91.3%, 98.6%]) for Arm B; 93.5% (90% CI [89.4%, 97.9%]) for Arm C; and 90.7% (90% CI [86.2%, 95.4%]) for Arm D. Recurrences and death without recurrence were 4 and 1 in Arm B, and 5 and one in Arm C. Smokers ( > 10 pack-years) did not have worse 3-year PFS in Arms B or C. Treatment arm distribution and outcome for ineligible patients who started adjuvant therapy mirrored the 360 ETP. A comparison combining arms B/C versus arm D in the proportion of patients stable/improved in FACT-H&N total score, from baseline to 6 months post-treatment as a pre-specified endpoint, was 56% vs. 38% (p value = 0.011, one-sided Fisher’s exact test); however, underlying differences in treatment and risk may be confounding. An exploratory comparison between Arms B and C revealed improvement in FACT H&N (63% in Arm B vs. 49% in Arm C had a stable/improved score, p-value = 0.056). Conclusions: Primary TOS and reduced PORT retained outstanding oncologic outcome at 35 months follow up, with favorable QOL and functional outcomes, in intermediate risk HPV+ OPC. Clinical trial information: NCT 01898494.
- Published
- 2021
39. Transoral robotic surgery for tonsillar cancer: Addressing the contralateral tonsil
- Author
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Theodoros N. Teknos, Amit Agrawal, Enver Ozer, Peter T. Dziegielewski, Brian J. Boyce, Hafiz S. Patwa, and Matthew O. Old
- Subjects
Adult ,Male ,Natural Orifice Endoscopic Surgery ,medicine.medical_specialty ,medicine.medical_treatment ,Tonsillar Neoplasms ,Physical examination ,Tonsillar Neoplasm ,Neoplasms, Multiple Primary ,03 medical and health sciences ,0302 clinical medicine ,Robotic Surgical Procedures ,Risk Factors ,Transoral robotic surgery ,medicine ,Humans ,Tonsil cancer ,030223 otorhinolaryngology ,Aged ,Retrospective Studies ,Tonsillectomy ,Mouth ,medicine.diagnostic_test ,business.industry ,Retrospective cohort study ,Perioperative ,Middle Aged ,medicine.disease ,Surgery ,Treatment Outcome ,medicine.anatomical_structure ,Otorhinolaryngology ,030220 oncology & carcinogenesis ,Tonsil ,Carcinoma, Squamous Cell ,Female ,business - Abstract
Background The purpose of this study is to determine the incidence and risk factors for bilateral tonsillar cancers treated with transoral robotic surgery (TORS) and to determine the morbidity of the procedure. Methods Patients undergoing TORS for known tonsillar cancer were retrospectively reviewed. Perioperative variables and surgical outcomes were analyzed to determine predictive factors for bilateral disease and morbidity rates. Results Seventy-nine consecutive patients with tonsillar cancers underwent primary TORS radical tonsillectomy. Thirty of these patients also underwent contralateral tonsillectomy. Three patients (10%) were found to have contralateral tonsillar cancers on final pathology. These were not identified on preoperative positron emission tomography (PET)-CT or clinical examination. There were no differences in complications, gastrostomy tube (G-tube) rates, or length of stay (P > .05). Blood loss was 11.5 cc more in the contralateral tonsillectomy group (P = .001). Conclusion All patients undergoing primary TORS for tonsillar cancers should also undergo contralateral tonsillectomy to optimize oncologic outcomes with no increase in morbidity.
- Published
- 2017
40. Novel approach to maxillary reconstruction using osteocutaneous free tissue transfer with a customized stent
- Author
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Matthew O. Old, Tiffany L. Kessling, Amit Agrawal, Meade C. van Putten, Theodoros N. Teknos, Vivek R. Varma, Enver Ozer, Stephen Y. Kang, and Yin Yiu
- Subjects
Reconstructive Flap ,Maxillary reconstruction ,medicine.medical_specialty ,Osteoradionecrosis ,business.industry ,medicine.medical_treatment ,Stent ,030206 dentistry ,Free flap ,medicine.disease ,Surgery ,Tissue transfer ,03 medical and health sciences ,0302 clinical medicine ,Otorhinolaryngology ,Virtual planning ,030220 oncology & carcinogenesis ,medicine ,Malocclusion ,business - Abstract
Background Computer-guided 3D virtual planning and customized templates are novel and effective methods aiding maxillary reconstruction, particularly during osteocutaneous free tissue transfer of complex defects. However, virtual planning and modelling is often expensive. Methods We present a new method to reconstruct complex defects with a surgical stent designed from presurgical casts. We present 2 patients who underwent this technique. Reconstruction in both cases was aided by a surgical stent fashioned preoperatively to approximate the anatomic dimensions of the defect, guiding the shape and orientation of the flap during inset to aid in dental rehabilitation. Results Surgery was performed without evidence of malocclusion, oronasal separation, or osteoradionecrosis with both patients undergoing successful rehabilitation and showing good postoperative oral intake. Conclusion Utilization of our novel surgical stent allowed reconstruction of complex maxillectomy defects and facilitated the design of a reconstructive flap without the need of pre-bent plates, cutting guides, or associated expenses.
- Published
- 2017
41. Robotics in Sinus and Skull Base Surgery
- Author
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Ricardo L. Carrau, Daniel M. Prevedello, André Beer-Furlan, Ralph Abi Hachem, Sanjeet Rangarajan, and Enver Ozer
- Subjects
medicine.medical_specialty ,Glottis ,03 medical and health sciences ,0302 clinical medicine ,Robotic Surgical Procedures ,Paranasal Sinuses ,Transoral robotic surgery ,medicine ,Humans ,Robotic surgery ,030223 otorhinolaryngology ,Sinus (anatomy) ,Skull Base ,business.industry ,Robotics ,General Medicine ,Surgery ,Skull ,medicine.anatomical_structure ,Otorhinolaryngology ,Skull base surgery ,Quality of Life ,Artificial intelligence ,Supraglottis ,business ,030217 neurology & neurosurgery - Abstract
Transoral robotic surgery (TORS) has been proven to be safe and to yield acceptable oncological and functional outcomes for surgery of the oropharynx, hypopharynx, supraglottis, and glottis. TORS has been successful at reducing morbidity, improving quality of life, and providing access to areas that previously required mandibulotomy or other more radical approaches in the past. This has changed the paradigm of management of tumors in these anatomic locations. In this article, the authors review the recent literature discussing the role of robotic surgery in managing sinonasal and skull base pathology and discuss its current advantages and limitations.
- Published
- 2017
42. One-year quality of life and functional outcomes of transoral robotic surgery for carcinoma of unknown primary
- Author
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Amit Agrawal, Matthew O. Old, Theodoros N. Teknos, Ali Cemal Yumusakhuylu, Lai Wei, Isa Ozbay, Enver Ozer, and Rishabh Sethia
- Subjects
Male ,medicine.medical_specialty ,Tonsillar Neoplasms ,03 medical and health sciences ,0302 clinical medicine ,Robotic Surgical Procedures ,carcinoma of unknown primary ,Quality of life ,Transoral robotic surgery ,medicine ,Carcinoma ,Humans ,In patient ,030223 otorhinolaryngology ,business.industry ,Head and neck cancer ,medicine.disease ,Tongue Neoplasms ,Surgery ,Treatment Outcome ,quality of life ,Otorhinolaryngology ,Head and Neck Neoplasms ,030220 oncology & carcinogenesis ,aesthetics ,Unknown primary ,Neoplasms, Unknown Primary ,Female ,head and neck cancer ,transoral robotic surgery ,business - Abstract
Background: The purpose of this study was to assess the quality of life (QOL) outcomes in patients who underwent transoral robotic surgery (TORS) for carcinoma of unknown primary (CUP). Methods: Twenty-nine patients with CUP were administered the Head and Neck Cancer Inventory (HNCI) prospectively to evaluate QOL preoperatively and postoperatively. Results: There was statistically and clinically significant deterioration in 2 of 4 domains (eating and social disruption) in the immediate aftermath of TORS. There was statistically and clinically meaningful deterioration in all 4 domains at 3 months relative to baseline, and there remained statistically and clinically meaningful deterioration in 2 of 4 domains at 6 months compared to baseline. These 2 domains remained statistically and clinically worse than baseline at 12 months. Speech and aesthetics domain scores were comparable at baseline and 12 months. Conclusion: Patients reported difficulties with eating and social disruption over the course of 1 year, but problems with speech and appearance abated. © 2017 Wiley Periodicals, Inc.
- Published
- 2017
43. The Role of Robotic Surgery in Sinonasal and Ventral Skull Base Malignancy
- Author
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Ralph Abi Hachem, Ricardo L. Carrau, Sanjeet Rangarajan, André Beer-Furlan, Enver Ozer, and Daniel M. Prevedello
- Subjects
medicine.medical_specialty ,Glottis ,Nose Neoplasms ,Malignancy ,Skull Base Neoplasms ,03 medical and health sciences ,0302 clinical medicine ,Robotic Surgical Procedures ,Transoral robotic surgery ,otorhinolaryngologic diseases ,Humans ,Medicine ,Robotic surgery ,Stage (cooking) ,030223 otorhinolaryngology ,Head and neck ,Skull Base ,business.industry ,technology, industry, and agriculture ,General Medicine ,medicine.disease ,Surgery ,Skull ,medicine.anatomical_structure ,Otorhinolaryngology ,Supraglottis ,business ,030217 neurology & neurosurgery - Abstract
Over the past decade, robotic surgery has gained wide popularity, making a significant impact on multiple surgical specialties. In the head and neck arena, transoral robotic surgery has proven to be safe and associated with acceptable oncological and superior functional outcomes for surgery of the oropharynx, hypopharynx, supraglottis, and glottis; thus, changing the paradigm for the management of tumors in these anatomic locations. Robotic surgery of the ventral skull base is at an early stage of development. In this article reviews the literature discussing the role of robotic surgery in managing sinonasal and ventral skull base malignant lesions.
- Published
- 2017
44. NUT Midline Carcinoma of the Sublingual Gland: Clinical Presentation and Review
- Author
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Ramez Philips, Nolan B. Seim, Theodoros N. Teknos, Amit Agrawal, Ricardo L. Carrau, Matthew O. Old, James W. Rocco, Stephen Y. Kang, Enver Ozer, and Lynn Schoenfield
- Subjects
Adult ,Male ,medicine.medical_specialty ,Pathology ,Sublingual Salivary Gland ,Malignancy ,Proto-Oncogene Mas ,Pathology and Forensic Medicine ,03 medical and health sciences ,Fatal Outcome ,0302 clinical medicine ,Cervical lymphadenopathy ,medicine ,Carcinoma ,Humans ,NUT midline carcinoma ,Original Paper ,business.industry ,Head and neck cancer ,Sublingual Gland Neoplasms ,Mediastinum ,Sublingual gland ,030206 dentistry ,medicine.disease ,Surgery ,medicine.anatomical_structure ,Oncology ,Otorhinolaryngology ,030220 oncology & carcinogenesis ,medicine.symptom ,business - Abstract
NUT midline carcinoma (NMC) is a rare and aggressive disease encountered in the midline of the head and neck or mediastinum. Due to its sparse incidence and subtle pathologic features, we aim to increase knowledge and awareness for this pathologic entity. We present an exemplary case of a young, healthy male presenting with oral cavity pain and cervical lymphadenopathy. This patient was initially diagnosed with an unspecified, highly aggressive sublingual gland malignancy and underwent locoregional resection with free flap reconstruction however suffered a rapid local recurrence and widely extensive metastasis within just 1 month. After rigorous analysis, final pathologic diagnosis revealed a poorly differentiated carcinoma with evidence of squamous differentiation that eventually, post-mortem tested positive for NMC. Only one prior case of sublingual gland NMC has been previously reported as we discuss the literature regarding all sublingual gland malignancies as well as the pathologic features and treatment options for NMC. We recommend consideration of testing for the NUT proto-oncogene at the time of biopsy in the clinical setting of a poorly differentiated midline carcinoma, especially with squamous differentiation, of the head or neck in order to identify patients for clinical trial enrollment and appropriately counsel on the poor clinical prognosis. Improving clinician awareness is critical to increase diagnostic accuracy and need to study prospective treatment outcomes as the first step toward improving management of this difficult disease.
- Published
- 2017
45. 948P Pre-treatment characteristics and long-term outcomes of recurrent-metastatic head and neck cancer patients treated with immune checkpoint inhibitors
- Author
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M. Xu, Stephen Y. Kang, Ricardo L. Carrau, James W. Rocco, P. Bhateja, John C. Grecula, Nolan B. Seim, Amit Agrawal, Khaled Dibs, Mauricio E. Gamez, Sujith Baliga, Dukagjin Blakaj, D.L. Mitchell, Enver Ozer, Sachin R. Jhawar, Marcelo Bonomi, M. Old, Vidhya Karivedu, Majd Issa, and Thomas E Schultz
- Subjects
Oncology ,Pre treatment ,medicine.medical_specialty ,business.industry ,Immune checkpoint inhibitors ,Internal medicine ,Head and neck cancer ,medicine ,Long term outcomes ,Hematology ,medicine.disease ,business - Published
- 2020
46. A nomogram based prognostic score to predict overall survival (OS) in recurrent-metastatic (R/M) head and neck squamous cell carcinoma (HNSCC) patients (pts) treated with immune checkpoint inhibitors (ICI)
- Author
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M. Old, Amit Agrawal, Majd Issa, Stephen Y. Kang, Jeff Pan, P. Bhateja, D.L. Mitchell, James W. Rocco, L. Mousa, Dukagjin Blakaj, Brett Klamer, Marcelo Bonomi, Ricardo L. Carrau, Sachin R. Jhawar, Robert Rupert, Mauricio E. Gamez, and Enver Ozer
- Subjects
medicine.medical_specialty ,education.field_of_study ,Performance status ,business.industry ,Proportional hazards model ,Population ,Hazard ratio ,Cancer ,Hematology ,Nomogram ,medicine.disease ,Gastroenterology ,Head and neck squamous-cell carcinoma ,Confidence interval ,stomatognathic diseases ,Oncology ,Internal medicine ,otorhinolaryngologic diseases ,medicine ,education ,business - Abstract
Background ICIs are pivotal therapies in the treatment of pts with R/M HNSCC. The dismal OS of some pts underscores the need to detect pre-treatment prognostic scores. Methods Pts with R/M HNSCC receiving pembrolizumab (P) or nivolumab (N) were included in this retrospective analysis. We analyzed the impact of the following pre-treatment variables for OS using a Cox proportional hazards regression model: drug type, age, sex, tumor site, line of therapy, p-16, albumin (alb), hemoglobin (Hb), lactic dehydrogenase (LDH), lymphocyte count (LC), platelets (PLT), and neutrophil counts (NC). Results 66 pts (55%) treated with N and 55 (45%) with P were included. Characteristics: Sex: Male 100 pts (83%), female 21 pts (17%); Mean Age: 62 (SD 11); Performance Status 0-1: 63 pts (52%), 2-3: 58 pts (48%); Line of therapy, 1: 43 pts (36%), 2: 58 pts (48%), 3-4: 20 pts (16%); P-16: positive 44 pts (36%), negative 77 pts (64%); Tumor site: oropharynx 54 pts (45%), oral cavity 23 pts (19%), larynx 16 pts (13%), other 28 pts (23%); Response: complete 11 pts (9%), partial 3 pts (2%), stable disease 47 pts (39%); and disease progression: 60 pts (50%). The OS at 1 and 2 years were 52% (95% confidence interval (CI), 43%-62%) and 27% (CI 17%-42%), respectively. Age, sex, PLT, NC, LC, p-16, alb, Hb, and LDH were included in the multivariable Cox model. Adjusted hazard ratio estimates are: P-16: 0.53 (CI 0.3-0.95, P = 0.03); LC: 0.67 (CI 0.46-0.97, P = 0.03); NC: 1.25 (CI 1.01-1.56, P = 0.04); LDH: 1.67 (CI 1.01-2.78, P = 0.04); Hb: 1.69 (CI 1.00-2.87, P = 0.05); alb: 1.69 (CI 0.94-3.02, P = 0.08); PLT: 1.06 (CI 0.82, 1.37, P = 0.7); Age: 1.02 (CI 0.78-1.34, P = 0.9); and Sex: 0.98 (CI 0.5-1.91, P = 0.9). This model was used to create a nomogram based prognostic score for 1 and 2 year OS probability and median OS time. Internal model validation using bootstrapped based bias corrected estimates showed Nagelkerke’s R2 = 0.18, calibration slope of 0.67, and C-index of 0.7. Conclusions Pre-treatment LC, NC as well as LDH, Hb, alb, and p-16 had the largest impact on OS based on a prognostic nomogram. The nomogram may help treatment decisions regarding ICI use in this population. Legal entity responsible for the study The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute. Funding Has not received any funding. Disclosure All authors have declared no conflicts of interest.
- Published
- 2019
47. Free flap salvage from venous thrombosis by creation of a venocutaneous fistula: Case report and review of the literature
- Author
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Ricardo L. Carrau, Stephen Y. Kang, Amit Agrawal, Zahir Allarakhia, Sidharth V. Puram, Rishabh Sethia, Enver Ozer, Matthew O. Old, and James W. Rocco
- Subjects
medicine.medical_specialty ,business.industry ,Fistula ,medicine.medical_treatment ,Neck dissection ,Free flap ,medicine.disease ,eye diseases ,Surgery ,Venous thrombosis ,medicine.anatomical_structure ,Otorhinolaryngology ,Radial forearm free flap ,medicine ,Complication ,business ,Vein ,Internal jugular vein - Abstract
Background Venous congestion is the most frequently reported complication of free flap tissue transfer in head and neck patient with cancer. Numerous methods are utilized and prompt correction is necessary to prevent flap failure. Methods A 77-year-old woman underwent oral cavity resection and neck dissection for squamous cell carcinoma followed by radial forearm free flap for reconstruction. Three days later, the flap became congested and surgical exploration revealed extensive venous thrombosis throughout the free flap venous system and internal jugular vein. The flap vein was evacuated and flowing, and a venocutaneous fistula was created thereafter. Results Venocutaneous fistula resulted in flap decongestion and successful salvage. The patient was discharged from the hospital with no further flap or surgical complications. Conclusion When anatomical revision of the venous anastomosis is not feasible in a venous-congested free flap, the creation of a venocutaneous fistula should be considered as a viable option for salvage.
- Published
- 2019
48. National treatment trends in human papillomavirus-positive oropharyngeal squamous cell carcinoma
- Author
-
Stephen Y. Kang, Matthew O. Old, Danny Enepekides, James W. Rocco, Amit A. Agrawal, Antoine Eskander, Sidharth V. Puram, Kevin Y. Zhan, Ricardo L. Carrau, Zain A. Husain, Kevin Higgins, Michael M. Li, Enver Ozer, and Dustin A. Silverman
- Subjects
Human Papillomavirus Positive ,Male ,Cancer Research ,medicine.medical_specialty ,Hospitals, Low-Volume ,medicine.medical_treatment ,Health Services Accessibility ,Statistics, Nonparametric ,03 medical and health sciences ,0302 clinical medicine ,Pharyngectomy ,Internal medicine ,medicine ,Humans ,Robotic surgery ,030212 general & internal medicine ,Neoplasm Staging ,Retrospective Studies ,Chi-Square Distribution ,business.industry ,Incidence (epidemiology) ,Papillomavirus Infections ,Age Factors ,Cancer ,Margins of Excision ,Chemoradiotherapy, Adjuvant ,Middle Aged ,medicine.disease ,Combined Modality Therapy ,United States ,Oropharyngeal Neoplasms ,Oncology ,Quartile ,030220 oncology & carcinogenesis ,Carcinoma, Squamous Cell ,Regression Analysis ,Female ,Positive Surgical Margin ,business ,Adjuvant ,De-escalation ,Hospitals, High-Volume - Abstract
BACKGROUND Human papillomavirus (HPV)-mediated oropharyngeal cancer (OPC) is associated with dramatically improved survival in comparison with HPV-negative OPC and can be successfully treated with surgical and nonsurgical approaches. National treatment trends for OPC were investigated with the National Cancer Data Base (NCDB). METHODS The NCDB was reviewed for primary HPV-mediated OPC in 2010-2014. Multivariable regression was used to identify predictors of both nonsurgical therapy and receipt of adjuvant chemoradiation (CRT). RESULTS There were 13,363 patients identified with a median age at diagnosis of 58 years. The incidence of triple-modality treatment (surgery with adjuvant chemotherapy) decreased from 23.7% in 2010 to 16.9% in 2014 (R2 = 0.96), whereas the incidence of nonsurgical treatment increased from 63.9% to 68.7% (R2 = 0.89). Hospitals in the top treatment volume quartile (quartile 1 [Q1]; n = 29) had a lower rate of positive margins (16.3%) than bottom-quartile centers (n = 741; rate of positive margins, 36.4%; P
- Published
- 2019
49. Salvage Vastus Lateralis Free Tissue Transfer for Postoperative CSF Leaks after Multiple Redo-Surgeries and Proton Beam Radiotherapy for Clival Chordoma
- Author
-
Guillermo Maza, Enver Ozer, Samuel Vieira, Mostafa Shahein, Ricardo L. Carrau, Daniel M. Prevedello, Ahmed Nabil, Krupal B. Patel, and Kyle K. VanKoevering
- Subjects
Radiation therapy ,Proton ,business.industry ,medicine.medical_treatment ,medicine ,Nuclear medicine ,business ,Beam (structure) ,Tissue transfer ,Clival Chordoma - Published
- 2019
50. A novel surgeon credentialing and quality assurance process using transoral surgery for oropharyngeal cancer in ECOG-ACRIN Cancer Research Group Trial E3311
- Author
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Jay O. Boyle, James P. Malone, Elin R. Sigurdson, Benjamin L. Judson, R. Bryan Bell, Harry Quon, Erich M. Sturgis, J. Scott Magnuson, Kerry A. Higgins, Shuli Li, Giovana R. Thomas, Mihir R. Patel, Michael L. Hinni, Yael Flamand, Gregory S. Weinstein, Russel B. Smith, Michael E. Kupferman, Jeremy D. Richmon, Rodrigo Bayon, Umamaheswar Duvvuri, Robert L. Ferris, Joaquin J. Garcia, Ranee Mehra, Daniel W. Karakla, Nabil F. Saba, John A. Ridge, Wayne M. Koch, Bert W. O'Malley, Barbara Burtness, F. Christopher Holsinger, Eduardo Mendez, Enver Ozer, and Neil D. Gross
- Subjects
Adult ,Cancer Research ,Quality Assurance, Health Care ,Credentialing ,Article ,law.invention ,Surgical pathology ,03 medical and health sciences ,0302 clinical medicine ,Robotic Surgical Procedures ,Randomized controlled trial ,Surgical oncology ,law ,Humans ,Medicine ,Prospective Studies ,Stage (cooking) ,030223 otorhinolaryngology ,Aged ,Surgeons ,business.industry ,Head and neck cancer ,Cancer ,Middle Aged ,medicine.disease ,Oropharyngeal Neoplasms ,Oncology ,030220 oncology & carcinogenesis ,Cancer research ,Female ,Oral Surgery ,business ,Quality assurance - Abstract
PURPOSE: Understanding the role of transoral surgery in oropharyngeal cancer (OPC) requires prospective, randomized multi-institutional data. Meticulous evaluation of surgeon expertise and surgical quality assurance (QA) will be critical to the validity of such trials. We describe a novel surgeon credentialing and QA process developed to support the ECOG-ACRIN Cancer Research Group E3311 (E3311) and report outcomes related to QA. PATIENTS AND METHODS: E3311 was a phase II randomized clinical trial of transoral surgery followed by low- or standard-dose, risk-adjusted post-operative therapy with stage III-IVa (AJCC 7(th) edition) HPV-associated OPC. In order to be credentialed to accrue to this trial, surgeons were required to demonstrate active hospital credentials and technique-specific surgical expertise with ≥20 cases of transoral resection for OPC. In addition,10 paired operative and surgical pathology reports from the preceding 24 months were reviewed by an expert panel. Ongoing QA required
- Published
- 2020
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