Publications by authors named "Joseph M Curry"

67 Publications

Microvascular Reconstruction of Osteonecrosis: Assessment of Long-term Quality of Life.

Otolaryngol Head Neck Surg 2021 Feb 23:194599821990682. Epub 2021 Feb 23.

School of Medicine, Oregon Health and Science University, Portland, Oregon, USA.

Objective: Review long-term clinical and quality-of-life outcomes following free flap reconstruction for osteonecrosis.

Study Design: Retrospective multi-institutional review.

Setting: Tertiary care centers.

Methods: Patients included those undergoing free flap reconstructions for osteonecrosis of the head and neck (N = 232). Data included demographics, defect, donor site, radiation history, perioperative management, diet status, recurrence rates, and long-term quality-of-life outcomes. Quality-of-life outcomes were measured using the University of Washington Quality of Life (UW-QOL) survey.

Results: Overall flap success rate was 91% (n = 212). Relative to preoperative diet, 15% reported improved diet function at 3 months following reconstruction and 26% at 5 years. Osteonecrosis recurred in 14% of patients (32/232); median time to onset was 11 months. Cancer recurrence occurred in 13% of patients (29/232); median time to onset was 34 months. Results from the UW-QOL questionnaire were as follows: no pain (45%), minor or no change in appearance (69%), return to baseline endurance level (37%), no limitations in recreation (40%), no changes in swallowing following reconstruction (28%), minor or no limitations in mastication (29%), minor or no speech difficulties (93%), no changes in shoulder function (84%), normal taste function (19%), normal saliva production (27%), generally excellent mood (44%), and no or minimal anxiety about cancer (94%).

Conclusion: The majority of patients maintained or had advancement in diet following reconstruction, with low rates of osteonecrosis or cancer recurrence and above-average scores on UW-QOL survey suggesting good return of function and quality of life.
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http://dx.doi.org/10.1177/0194599821990682DOI Listing
February 2021

Free tissue transfer for central skull base defect reconstruction: Case series and surgical technique.

Oral Oncol 2021 Feb 13;115:105220. Epub 2021 Feb 13.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, United States. Electronic address:

Objectives: Local reconstruction of central skull base defects may be inadequate for large defects or reoperative cases; free tissue transfer may be necessary. Inset of the flap and management of the pedicle can be challenging. We report our experience and approaches.

Methods: Retrospective review identifying seven patients with central skull base defects who underwent free flap reconstruction from 2016 to 2020.

Results: Four patients with recurrent nasopharyngeal carcinoma, one with recurrent craniopharyngioma, one with clival-cervical chordoma, and one with meningioma of the middle cranial fossa were analyzed. Six defects were closed with an anterolateral thigh free flap and one with a radial forearm free flap. In two patients, the flap was secured in an onlay fashion to the defect via a Caldwell-Luc transmaxillary approach. In one patient, the flap was passed transorally, and the pedicle was delivered into the neck via Penrose drain. In two patients, a parapharyngeal technique and in two others, a retropharyngeal was used for nasopharyngeal inset with endoscopic assistance. There were no flap failures, with an average follow-up time of 20.1 (range 3.2-47.1) months. One patient required flap repositioning on postoperative day three due to midline shift and intracranial contents compression. The transoral inset flap necessitated flap repositioning on postoperative day 13 to improve the nasopharyngeal airway.

Conclusion: Free flap reconstruction of the central skull base is challenging, but transmaxillary, transoral, parapharyngeal, and retropharyngeal approaches can be used with endoscopic assistance to ensure secure inset flap and avoid airway obstruction.
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http://dx.doi.org/10.1016/j.oraloncology.2021.105220DOI Listing
February 2021

Head and neck surgery global outreach: Ethics, planning, and impact.

Head Neck 2021 Feb 14. Epub 2021 Feb 14.

Department of Head and Neck Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Background: Head and neck surgical oncology and reconstruction are uniquely suited to address burdens of disease in underserved areas. Since these efforts are not well known in our specialty, we sought to understand global outreach throughout our society of surgeons.

Methods: Survey distributed to members of the American Head and Neck Surgery involved in international humanitarian head and neck surgical outreach trips.

Results: Thirty surgeons reported an average of seven trips to over 70 destinations. Identification of candidates, finances, on-site patient care, complications, long-term post-surgical care, ethics, and educational goals are reported. We report a success rate of 90% on 125 free flaps performed in these settings.

Conclusions: The effort to answer the call for alleviating the global burden of surgical disease is strong within our specialty. There is a shared focus on humanitarian effort and teaching. Ethics of high resource surgeries such as free flap reconstruction remains controversial.
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http://dx.doi.org/10.1002/hed.26643DOI Listing
February 2021

Improved efficiency of sialendoscopy procedures at an ambulatory surgery center.

Am J Otolaryngol 2021 Jan 22;42(3):102927. Epub 2021 Jan 22.

Thomas Jefferson University Hospital, Department of Otolaryngology - Head and Neck Surgery, 925 Chestnut St, Philadelphia, PA 19107, United States of America.

Objectives: To compare time spent on day of surgery and post-surgical outcomes for sialendoscopy procedures at an ambulatory surgery center versus in a hospital operating room.

Methods: Retrospective chart review for patients who underwent sialendoscopy for sialadenitis or sialolithiasis from March 2017 to May 2020 were included. Surgery location (ambulatory surgery center or hospital operating room) was compared. Primary outcomes included total time in hospital, operative time, total time in operating room. and recovery time. Secondary outcomes included rate of symptoms resolutions, requiring further medical management, and requiring further surgical intervention.

Results: A total of 321 procedures were included. Sialendoscopy in an ambulatory surgery center compared to main operating room decreased median hospital time (166 min reduction, p < 0.001), operative time (18 min reduction, p < 0.001), total time in operating room (34 min reduction, p < 0.001), and recovery time (64 min reduction, p < 0.001). Sialendoscopy in an ambulatory surgery center had similar rates of post-operative resolution of symptoms and further medical or surgical intervention compared to procedures in a hospital operating room.

Conclusion: Sialendoscopy can be safely performed in an ambulatory surgery center for sialadenitis or appropriate sialolithiasis cases while decreasing hospital time, operative time, total time in operating room time, and recovery time.
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http://dx.doi.org/10.1016/j.amjoto.2021.102927DOI Listing
January 2021

Functional Swallow-Related Outcomes Following Transoral Robotic Surgery for Base of Tongue Carcinoma.

Dysphagia 2021 Jan 25. Epub 2021 Jan 25.

Division of Biostatistics, Thomas Jefferson University, 1015 Chestnut Street, Suite 520, Philadelphia, PA, 19107, USA.

In an era where the incidence of oropharyngeal cancer is growing steadily, there have been few studies exploring functional outcomes for individuals whose definitive cancer management approach includes transoral robotic surgical (TORS) resection. This study was designed to examine swallow-related outcomes in individuals newly diagnosed with base of tongue cancer whose treatment plan included surgical resection via TORS. The aims of this study were to determine whether TORS resection for early stage BOT SCCA affected: (a) lingual strength, (b) swallow safety and efficiency, (c) oral intake, and (d) swallowing-related quality of life. Nine individuals meeting the inclusion criteria were recruited to participate from March 2017 to April 2018. Each participant was evaluated at four distinct time points: (a) preoperatively, (b) 1 week postoperatively, (c) 1 month postoperatively, and (d) 3 months postoperatively. The following data were collected at each time point: (a) maximum isometric lingual pressure, (b) Penetration-Aspiration Scale score, (c) Yale Pharyngeal Residue Severity Rating Scale scores, (d) Functional Oral Intake Scale score, and (e) EAT-10 score. Data analysis revealed that a significant decline in maximum isometric lingual pressure, EAT-10 scores, and Functional Oral Intake Scale scores occurred between preoperative baseline measurements and 1 week post surgery. All participants in the study demonstrated a return to levels at or near their baseline level of function for maximum isometric lingual pressure, EAT-10 score, and Functional Oral Intake Scale score by 1 or 3 months post surgery. There were no significant changes in swallow safety or efficiency observed at any time point during the study.
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http://dx.doi.org/10.1007/s00455-021-10246-yDOI Listing
January 2021

Cancer-Associated Fibroblast Density, Prognostic Characteristics, and Recurrence in Head and Neck Squamous Cell Carcinoma: A Meta-Analysis.

Front Oncol 2020 27;10:565306. Epub 2020 Nov 27.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, United States.

Introduction: The progression and clinical course of head and neck squamous cell carcinoma (HNSCC) relies on complex interactions between cancer and stromal cells in the tumor microenvironment (TME). Among the most abundant of these stromal cells are cancer-associated fibroblasts (CAFs). While their contribution to tumor progression is widely acknowledged, and various CAF-targeted treatments are under development, the relationship between CAF density and the clinicopathologic course of HNSCC has not been clearly defined. Here we examine the published evidence investigating the relationship of cancer-associated fibroblasts to local recurrence and indicators of prognostic significance in HNSCC.

Methods: We conducted a meta-analysis of existing publications that compare the relationship between CAF density, local recurrence, and clinically significant pathologic criteria of disease development (T stage, nodal positivity, clinical stage, vascular invasion, perineural invasion, Ki67 expression, and differentiation). Thirteen studies met the selection criteria, providing a total study population of 926 patients. Forest plots and risk ratios were generated to illustrate overall relationships.

Results: Higher CAF density within the tumor microenvironment is associated with advanced T stage, nodal infiltration, clinical stage, vascular invasion, perineural invasion, Ki67 expression, and differentiation (p <0.05). High CAF density is also associated with increased rates of local recurrence (p <0.001).

Conclusions: Across multiple studies, increased CAF density is correlated with histopathological criteria of poor prognosis in HNSCC. These findings highlight that CAFs may play a pivotal role in HNSCC development and progression. Staining for CAFs may represent a valuable addition to current pathologic analysis and help to guide prognosis and treatment. Understanding the mechanisms by which CAFs reciprocally interact with cancer cells will be crucial for optimization of TME-focused treatment of HNSCC.
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http://dx.doi.org/10.3389/fonc.2020.565306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729160PMC
November 2020

Anastomotic Revision in Head and Neck Free Flaps.

Laryngoscope 2020 Sep 10. Epub 2020 Sep 10.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A.

Objectives/hypothesis: Predictors of free tissue transfer (FTT) failure and the need for postoperative revision (POR) have been extensively studied; however, there are little data evaluating outcomes when intraoperative revision (IOR) at initial surgery is required. This study seeks to better understand the impact IOR of the pedicle has on FTT outcomes.

Study Design: Retrospective review of 2482 consecutive patients across three tertiary institutions.

Methods: Adult patients (>18) who received a FTT and underwent anastomotic revision from 2006 to 2019 were included. Logistic regression was performed to predict revision, and recursive partitioning was performed to classify risk of failure based on type of revision and vessels revised.

Results: Failure rates for IOR (19%) and POR (27%) were higher compared to a nonrevised failure rate of 2% (P < .01 and P < .01, respectively). Intraoperative venous revision (IORv, n = 13), arterial (IORa, n = 114), and both (IORb, n = 11) were associated with failure rates of 8% (odds ratio [OR] 3.5, P = .23), 18% (OR = 9.0, P < .01), 45% (OR = 35.3, P = <.01), respectively. Arterial revision was most common among IOR (83%, P < .01). Postoperative venous revision (PORv, n = 35), arterial (PORa, n = 36), and both (PORb, n = 11) were associated with failure rates of 20% (OR = 15.7, P < .01), 27% (OR = 10.6, P < .01), and 39% (OR = 27.0, P < .01), respectively. Failure rate for flaps that had POR after IOR (PORi, n = 11) was 45% (OR = 18.2, P < .01). Diabetes predicted IOR (P = .006); tobacco use, heavy alcohol use, and prior radiation predicted POR (P = .01, P = .05, and P = .01, respectively).

Conclusion: Both IOR and POR were associated with increased failure compared to nonrevised flaps. The risk of failure increases sequentially with intraoperative or POR of the vein, artery, or both vessels. Revision of both vessels and POR after IOR are strongly predictive of failure.

Level Of Evidence: 3 Laryngoscope, 2020.
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http://dx.doi.org/10.1002/lary.29094DOI Listing
September 2020

Comparison of general anesthesia and monitored anesthesia care for sialendoscopy procedures.

Am J Otolaryngol 2021 Jan - Feb;42(1):102809. Epub 2020 Oct 24.

Thomas Jefferson University Hospital, Department of Otolaryngology - Head and Neck Surgery, 925 Chestnut St, Philadelphia, PA 19107, United States of America.

Objectives: The literature remains scarce in terms of comparing different anesthesia modalities in sialendoscopy. Due to the lack of a standard of care or guidelines to anesthetic care, it is generally accepted that surgeons perform these surgeries under the anesthetic modality in which they are most comfortable. In this study, we evaluate time spent on the day of surgery and post-surgical outcomes for patients receiving sialendoscopy under monitored anesthesia care versus general anesthesia.

Materials And Methods: We retrospectively assessed patients who underwent sialendoscopy using a solely endoscopic approach for sialadenitis or sialolithiasis from March 2017 to December 2019. Anesthesia modality (monitored anesthesia care versus general anesthesia) was compared. Main outcomes included total time in hospital, operative time, total time in operating room, anesthesia time, and recovery time. Secondary outcomes included rate of resolution of symptoms, requiring further medical management, requiring further surgical intervention, and complications.

Results: A total of 172 procedures were included. Sialendoscopy under monitored anesthesia care center compared to general anesthesia decreased median hospital time (141 min reduction), anesthesia time (46 min reduction), operative time (24 min reduction), time in operating room (43 min reduction), and recovery time (56 min reduction). Utilizing monitored anesthesia care demonstrated similar rates of post-operative resolution of symptoms, complications, and further medical or surgical intervention compared to the general anesthesia cohort.

Conclusion: Sialendoscopy can be safely performed under monitored anesthesia care for appropriate sialadenitis or sialolithiasis cases while decreasing hospital time, operative time, time in operating room, anesthesia time, and recovery time while maintaining similar post-operative outcomes. Monitored anesthesia care should be considered for solely endoscopic cases as guided by surgeon and patient comfort.
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http://dx.doi.org/10.1016/j.amjoto.2020.102809DOI Listing
October 2020

Outcomes of Venous End-to-Side Microvascular Anastomoses of the Head and Neck.

Laryngoscope 2020 Oct 19. Epub 2020 Oct 19.

Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A.

Objectives/hypothesis: The literature on outcomes of end-to-side (ETS) anastomoses for microvascular reconstruction of the head and neck is limited. This series reviews ETS in free tissue transfer (FTT) across multiple institutions to better understand their usage and associated outcomes.

Study Design: Retrospective review of 2482 consecutive patients across three tertiary institutions.

Methods: Adult patients (> 18) who received a FTT from 2006 to 2019 were included.

Results: Two hundred and twenty-one FTT were identified as requiring at least one ETS anastomosis. These ETS cases had a failure rate of 11.2% in comparison to 3.8% in a cohort of end-to-end (ETE) cases (P < .001). ETS cases were significantly more likely to have a prior neck dissection (P < .001), suggesting the ETS method was utilized in select circumstances. A second ETS anastomosis improved survival of the FTT (P = .006), as did utilization of a coupler over suture (P = .002). Failure due to venous thrombosis was significantly more common with one ETS anastomosis instead of two ETS anastomoses (P = .042).

Conclusions: ETS is effective but is often used as a secondary technique when ETE is not feasible; as such, in this series, ETS was associated with higher failure. A second anastomosis and the use of the coupler for completing the anastomoses were associated with lower rates of failure.

Level Of Evidence: 3 Laryngoscope, 2020.
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http://dx.doi.org/10.1002/lary.29134DOI Listing
October 2020

Initial Experience Using 3-Dimensional Printed Models for Head and Neck Reconstruction in Haiti.

Ear Nose Throat J 2020 Aug 10:145561320938920. Epub 2020 Aug 10.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.

This report describes the first use of a novel workflow for in-house computer-aided design (CAD) for application in a resource-limited surgical outreach setting. Preoperative computed tomography imaging obtained locally in Haiti was used to produce rapid-prototyped 3-dimensional (3D) mandibular models for 2 patients with large ameloblastomas. Models were used for patient consent, surgical education, and surgical planning. Computer-aided design and 3D models have the potential to significantly aid the process of complex surgery in the outreach setting by aiding in surgical consent and education, in addition to expected surgical applications of improved anatomic reconstruction.
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http://dx.doi.org/10.1177/0145561320938920DOI Listing
August 2020

Management of the Acute Loss of a Free Flap to the Head and Neck-A Multi-institutional Review.

Laryngoscope 2021 03 27;131(3):518-524. Epub 2020 Jul 27.

Department of Otolaryngology, Oregon Health and Science University, Portland, Oregon, USA.

Objectives/hypothesis: To review the management of failed free tissue transfers among four large institutions over a 13-year period to provide data and analysis for a logical, algorithmic, experience-based approach to the management of failed free flaps.

Study Design: Retrospective case series.

Methods: A multi-institutional retrospective chart review of free tissue transfers to the head and neck region between 2006 and 2019 was performed. Patients with a failed free flap during their hospitalization after surgery to the head and neck were identified and reviewed. Patient age, co-morbidities, risk factors, flap characteristics, tumor specifics, and length of hospital stay were reviewed, collected, and analyzed.

Results: One hundred eighteen flap failures met criteria. The most common failed flap in this review was the osteocutaneous flap 52/118 (44%). The recipient site of the initial free flap (P < .001) was the only statistically significant parameter strongly correlated with management. Osteocutaneous flap failures, fasciocutaneous, bowel, and muscle-only flaps tended to be managed most commonly with a second free flap. Myocutaneous flap failures were managed equally with either a second free flap or a regional flap.

Conclusions: The most important factor in management of a failed free flap is the recipient site. A second free flap is often the preferred treatment, but in the acute setting, local or regional flaps may be viable options depending on the recipient site, circumstances of flap loss, and patient- specific comorbidities. An algorithm for management of the acute flap loss is presented in this review.

Level Of Evidence: 4 Laryngoscope, 131:518-524, 2021.
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http://dx.doi.org/10.1002/lary.28886DOI Listing
March 2021

The underappreciated role of auriculotemporal nerve involvement in local failure following parotidectomy for cancer.

Head Neck 2020 Nov 20;42(11):3253-3262. Epub 2020 Jul 20.

Department of Otolaryngology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA.

Background: Locoregional recurrence rates following parotidectomy for cancer remain as high as 20-30%. The auriculotemporal nerve (ATN) may allow parotid cancers to spread from the facial nerve (FN) toward the skull base, causing local recurrence.

Methods: Retrospective review of 173 parotidectomies for malignancy. Preoperative and post-recurrence imaging were reviewed by a neuroradiologist for signs of tumor adjacent to the ATN.

Results: Clinical and imaging signs of possible ATN involvement correlated with FN weakness and sacrifice. Eight patients had pathologically confirmed tumor from the ATN or V3. Forty-four percent of local recurrences had post-recurrence imaging showing tumor along the course of the ATN. Locoregional failure along the ATN was also associated with preoperative FN weakness, intraoperative FN sacrifice, and failure to complete recommended adjuvant therapy.

Conclusions: Parotid cancers may invade the FN and spread to the skull base via the ATN. If not appropriately managed, this may lead to local recurrence.
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http://dx.doi.org/10.1002/hed.26372DOI Listing
November 2020

SMARCB1 (Integrase Interactor 1)-Deficient Sinonasal Carcinoma of the Maxillary Sinus: A Newly Described Sinonasal Neoplasm.

J Oral Maxillofac Surg 2020 Oct 30;78(10):1870.e1-1870.e6. Epub 2020 May 30.

Associate Professor of Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA.

SMARCB1 (integrase interactor 1) is a tumor suppressor gene encoded on chromosome 22q11.2 that encodes a core subunit of SWI/SNF chromatin remodeling complexes and plays a critical role in regulating gene expression and chromatin structure. We describe a case of SMARCB1 (integrase interactor 1)-deficient sinonasal carcinoma of the left maxillary sinus in a 63-year-old woman with an initial presentation of numbness of the maxillary teeth and facial swelling.
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http://dx.doi.org/10.1016/j.joms.2020.05.033DOI Listing
October 2020

Natural History and Consequences of Nonunion in Mandibular and Maxillary Free Flaps.

Otolaryngol Head Neck Surg 2020 Nov 16;163(5):956-962. Epub 2020 Jun 16.

Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA.

Objective: To describe the natural history of bone segment union in head and neck free flap procedures and detail the association of poor segment union with postoperative complications.

Study Design: Case series with chart review.

Setting: Single tertiary care referral center.

Subjects And Method: Patients with mandibular or maxillary defects reconstructed with osseous or osteocutaneous free flaps were analyzed (n = 104). Postoperative computed tomography or positron emission tomography/computed tomography scans were reviewed for signs of osseointegration and nonunion. Postoperative wound complications were correlated with imaging findings.

Result: Thirty-seven percent of appositions had partial union on nonunion. Appositions between osteotomized free flap segments form complete unions at a higher rate than appositions with native bone (65% vs 53%, = .0006). If an apposition shows a gap of ≥1 mm, the chances of failing to form a complete union are greatly increated (79% vs 8%, = .0009). Radiographic nonunion was associated with an increased likelihood of postoperative wound complications (40% vs 19%, = .025) and in most cases was present before development of complications.

Conclusion: Radiographic evidence of partial union or nonunion of free flap osseous segments greatly exceeds reported rates of clinically evident nonunion. Unions likely form between free flap appositions before unions to the native bone. If initial bone segments are >1-mm apart, the chance of progression to complete union is low. Incomplete osseointegration appears to be a marker for development of wound complications.
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http://dx.doi.org/10.1177/0194599820931069DOI Listing
November 2020

Long-Term Complications of Osteocutaneous Free Flaps in Head and Neck Reconstruction.

Otolaryngol Head Neck Surg 2020 May 24;162(5):641-648. Epub 2020 Mar 24.

Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA.

Objective: To determine the frequency at which patients with osteocutaneous free flap reconstruction of the head and neck develop long-term complications and identify predisposing perioperative factors.

Study Design: A prospectively maintained database of free flaps performed at a single institution over a 10-year period was queried.

Setting: Single tertiary care referral center.

Subjects And Methods: In total, 250 osseous or osteocutaneous free flaps (OCFFs) for mandibular or maxillary reconstruction were analyzed. Data were collected on demographics, preoperative therapy, resection location, adjuvant treatment, complications, and subsequent surgeries, and multivariate analysis was performed. Subgroup analysis based on perioperative factors was performed.

Results: The median follow-up time was 23 months. In 185 patients with at least 6 months of follow-up, 17.3% had at least 1 long-term complication, most commonly wound breakdown, fistula or plate extrusion (13.5%), osteoradionecrosis or nonunion (6.5%), and infected hardware (5.9%). Prior chemoradiotherapy and cancer diagnosis predisposed patients to long-term complications. At the 5-year follow-up, 21.7% of patients had experienced a long-term complication.

Conclusions: Long-term complications after OCFF occurred in 17% of patients. In this series, a preoperative history of chemoradiation and those undergoing maxillary reconstruction were at high risk for the development of long-term complications and thus warrant diligent follow-up. However, OCFFs can often enjoy long-term viability and survival, even in the case of perioperative complications and salvage surgery.
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http://dx.doi.org/10.1177/0194599820912727DOI Listing
May 2020

Evaluating the impact of smoking on disease-specific survival outcomes in patients with human papillomavirus-associated oropharyngeal cancer treated with transoral robotic surgery.

Cancer 2020 01 7;126(9):1873-1887. Epub 2020 Feb 7.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania.

Background: When treated nonsurgically with definitive chemoradiation, smokers with human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) have a worse prognosis compared with their nonsmoking counterparts. To the authors' knowledge, the prognostic significance of smoking in surgically treated patients is unknown.

Methods: The current study is a retrospective case series of patients with HPV-positive OPSCC who underwent upfront transoral robotic surgery at a single institution from 2010 through 2017. Exclusion criteria were nonoropharyngeal primary tumors, histology other than SCC, HPV-negative tumors, previous history of head and neck cancer, and/or previous head and neck radiotherapy. Recurrence-free survival (RFS), overall survival, and disease-specific survival were compared using the Kaplan-Meier method and the log-rank test. Smoking history was categorized as never smokers (<1 pack-year), current smokers (smoking at the time of the cancer diagnosis), and former smokers.

Results: A total of 258 patients met the study criteria. The average age was 60 years, and approximately 87% of patients were male. A total of 148 patients (57.4%) were smokers whereas 110 (42.6%) reported never smoking. There were 44 active smokers (17.1%) and 104 former smokers (40.3%). The median follow-up was 3.23 years. There were 17 patients of disease recurrence. Smoking pack-year history was not found to be significant for RFS (hazard ratio, 1.01; 95% CI, 0.99-1.03 [P = .45]). There was no significant difference in RFS noted between never and ever smokers (92% vs 89.8%; P = .85) nor was there a difference observed between never, former, and current smokers (92% vs 91.5% vs 86.1%, respectively; P = .69).

Conclusions: A smoking history is common in patients with HPV-positive OPSCC. In the current study, HPV-positive smokers were found to have excellent survival and locoregional control, similar to their nonsmoking counterparts. The results of the current study do not support the exclusion of smokers with early-stage, HPV-positive OPSCC from transoral robotic surgery-based deintensification trials.
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http://dx.doi.org/10.1002/cncr.32739DOI Listing
January 2020

Virtual Surgical Planning in Subscapular System Free Flap Reconstruction of Midface Defects.

Oral Oncol 2020 02 19;101:104508. Epub 2019 Dec 19.

Thomas Jefferson University, Department of Otolaryngology - Head & Neck Surgery, Philadelphia, PA, USA.

Objectives: Reconstruction of the midface has many inherent challenges, including orbital support, skull base reconstruction, optimizing midface projection, separation of the nasal cavity and dental rehabilitation. Subscapular system free flaps (SF) have sufficient bone stock to support complex reconstruction and the option of separate soft tissue components. This study analyzes the effect of virtual surgical planning (VSP) in SF for midface on subsite reconstruction, bone segment contact and anatomic position.

Materials And Methods: Retrospective cohort of patients with midface defects that underwent SF reconstruction at a single tertiary care institution.

Results: Nine cases with VSP were compared to fourteen cases without VSP. VSP was associated with a higher number of successfully reconstructed subunits (5.9 vs 4.2, 95% CI of mean difference 0.31-3.04, p = 0.018), a higher number of successful bony contact between segments (2.2 vs 1.4, 95% CI of mean difference 0.0-1.6, p = 0.050), and a higher percent of segments in anatomic position (100% vs 71%, 95% CI of mean difference 2-55%, p = 0.035). When postoperative bone position after VSP reconstruction was compared to preoperative scans, the difference in anteroposterior, vertical and lateral projection compared to the preoperative 'ideal' bone position was <1 cm in 82% of measurements. There were no flap losses.

Conclusion: VSP may augment SF reconstruction of the midface by allowing for improved subunit reconstruction, bony segment contact and anatomically correct bone segment positioning. VSP can be a useful adjunct for complex midface reconstruction and the benefits should be weighed against cost.
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http://dx.doi.org/10.1016/j.oraloncology.2019.104508DOI Listing
February 2020

Mutation signature analysis identifies increased mutation caused by tobacco smoke associated DNA adducts in larynx squamous cell carcinoma compared with oral cavity and oropharynx.

Sci Rep 2019 12 17;9(1):19256. Epub 2019 Dec 17.

Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, 19107, USA.

Squamous cell carcinomas of the head and neck (HNSCC) arise from mucosal keratinocytes of the upper aero-digestive tract. Despite a common cell of origin and similar driver-gene mutations which divert cell fate from differentiation to proliferation, HNSCC are considered a heterogeneous group of tumors categorized by site of origin within the aero-digestive mucosa, and the presence or absence of HPV infection. Tobacco use is a major driver of carcinogenesis in HNSCC and is a poor prognosticator that has previously been associated with poor immune cell infiltration and higher mutation numbers. Here, we study patterns of mutations in HNSCC that are derived from the specific nucleotide changes and their surrounding nucleotide context (also known as mutation signatures). We identify that mutations linked to DNA adducts associated with tobacco smoke exposure are predominantly found in the larynx. Presence of this class of mutation, termed COSMIC signature 4, is responsible for the increased burden of mutation in this anatomical sub-site. In addition, we show that another mutation pattern, COSMIC signature 5, is positively associated with age in HNSCC from non-smokers and that larynx SCC from non-smokers have a greater number of signature 5 mutations compared with other HNSCC sub-sites. Immunohistochemistry demonstrates a significantly lower Ki-67 proliferation index in size matched larynx SCC compared with oral cavity SCC and oropharynx SCC. Collectively, these observations support a model where larynx SCC are characterized by slower growth and increased susceptibility to mutations from tobacco carcinogen DNA adducts.
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http://dx.doi.org/10.1038/s41598-019-55352-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6917707PMC
December 2019

Reconstructive trends and complications following parotidectomy: incidence and predictors in 11,057 cases.

J Otolaryngol Head Neck Surg 2019 Nov 19;48(1):64. Epub 2019 Nov 19.

Thomas Jefferson University Hospital Department of Otolaryngology- Head and Neck Surgery, 925 Chestnut Street, 6th Floor, Philadelphia, PA, ,19107, USA.

Background: Parotidectomy is a common treatment option for parotid neoplasms and the complications associated with this procedure can cause significant morbidity. Reconstruction following parotidectomy is utilized to address contour deformity and facial nerve paralysis. This study aims to demonstrate national trends in parotidectomy patients and identify factors associated with adverse postoperative outcomes. This study includes the largest patient database to date in determining epidemiologic trends, reconstructive trends, and prevalence of adverse events following parotidectomy.

Methods: A retrospective review was performed for parotidectomies included in the ACS-NSQIP database between January 2012 and December 2017. CPT codes were used to identify the primary and secondary procedures performed. Univariate and multivariate analysis was utilized to determine associations between pre- and perioperative variables with patient outcomes. Preoperative demographics, surgical indications, and common medical comorbidities were collected. CPT codes were used to identify patients who underwent parotidectomy with or without reconstruction. These pre- and perioperative characteristics were compared with 30-day surgical complications, medical complications, reoperation, and readmission using uni- and multivariate analyses to determine predictors of adverse events.

Results: There were 11,057 patients who underwent parotidectomy. Postoperative complications within 30 days were uncommon (1.7% medical, 3.8% surgical), with the majority of these being surgical site infection (2.7%). Free flap reconstruction, COPD, bleeding disorders, smoking, and presence of malignant tumor were the strongest independent predictors of surgical site infection. Readmission and reoperation were uncommon at an incidence of 2.1% each. The strongest factors predictive of readmission were malignant tumor and corticosteroid usage. The strongest factors predictive of reoperation were free flap reconstruction, malignant tumor, bleeding disorder, and disseminated cancer. Surgical volume/contour reconstruction was relatively uncommon (18%). Facial nerve sacrifice was uncommon (3.7%) and, of these cases, only 25.5% underwent facial nerve reinnervation and 24.0% underwent facial reanimation.

Conclusions: There are overall low rates of complications, readmissions, and reoperations following parotidectomy. However, certain factors are predictive of adverse postoperative events and this data may serve to guide management and counseling of patients undergoing parotidectomy. Concurrent reconstructive procedures are not commonly reported which may be due to underutilization or underreporting.
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http://dx.doi.org/10.1186/s40463-019-0387-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6862743PMC
November 2019

Risk factors for unplanned readmission in total laryngectomy patients.

Laryngoscope 2020 07 26;130(7):1725-1732. Epub 2019 Aug 26.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A.

Objective: To determine which patient or surgical factors affect the likelihood of unplanned readmission (within 30 days) after total laryngectomy (TL).

Methods: Retrospective chart review of all patients who underwent TL at a single institution from April 2007 through August 2016. Primary outcome was unplanned readmission to the hospital within 30 days of discharge. Univariable and multivariable logistic regression were performed to identify risk factors for unplanned readmission.

Results: Two hundred seventy-eight patients met inclusion criteria. Twenty-nine patients (10.4%) had unplanned readmissions within 30 days. The most common reasons for readmission were pharyngocutaneous fistula (n = 15), neck abscess (n = 3), and wound breakdown (n = 4). Average time to unplanned readmission was 11.2 days (range 0-27 days). Fistula (OR 30.259; 95% CI, 9.186, 118.147; P ≤ .001), postoperative pneumonia (OR 9.491; 95% CI, 1.783, 53.015; P = .008), and history of cardiac disease (OR 7.074; 95% CI, 2.324, 25.088, P = .001) were independently associated with an increased risk of 30-day unplanned readmission on multivariate analysis. However, return to OR on initial admission was associated with a lower risk of unplanned readmission (OR 0.075; 95% CI, 0.009, 0.402; P = .007). Unplanned readmission was associated with a delay in initiation of adjuvant radiation (OR 1.494; 95% CI, 1.397, 1.599; P < .001).

Conclusion: Unplanned readmission occurs in a small but significant number of TL patients. Patients who have a 30-day unplanned readmission may be at risk for a delay in initiation of adjuvant therapy.

Level Of Evidence: 4 Laryngoscope, 130:1725-1732, 2020.
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http://dx.doi.org/10.1002/lary.28255DOI Listing
July 2020

Response to "Letter to the Editor": Eagle's Syndrome Requires Further Consideration.

Ann Otol Rhinol Laryngol 2019 09 1;128(9):880. Epub 2019 May 1.

1 Department of Otolaryngology/Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA.

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http://dx.doi.org/10.1177/0003489419845618DOI Listing
September 2019

Assessment of quality and consistency of monoclonal antibodies for CB1 and CB2 in head and neck squamous cell carcinoma.

Head Neck 2019 09 29;41(9):3105-3113. Epub 2019 Apr 29.

Department of Dermatology & Cutaneous Biology, Thomas Jefferson University, Philadelphia, Pennsylvania.

Background: Marijuana has numerous roles as an agonist in the endocannabinoid signaling system (ESS). This study evaluated monoclonal antibodies across experimental techniques to establish a framework for studying ESS receptors, CB1 and CB2.

Methods: Tissue from five patients with head and neck cancer were used to generate cell lines and formalin-fixed paraffin-embedded (FFPE) sections, which were analyzed by western blot (WB), immunohistochemistry (IHC), and immunofluorescence (IF). Subgroup analysis was performed on FFPE sections from 8 marijuana users and 10 controls by IHC. Results were compared across methods for consistency.

Results: In all patients, WB and IF were CB1 positive, whereas IHC was negative. Select samples were CB2 positive by WB, but failed IF and IHC applications. In subgroup analysis, 1 of 8 users and 3 of 10 nonusers were CB1 positive.

Conclusions: Interpretation of CB1/CB2 antibody data should be performed cautiously and confirmation of findings across multiple experimental methods is recommended.
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http://dx.doi.org/10.1002/hed.25794DOI Listing
September 2019

Sensitivity of Fine-Needle Aspiration and Imaging Modalities in the Diagnosis of Low-Grade Mucoepidermoid Carcinoma of the Parotid Gland.

Ann Otol Rhinol Laryngol 2019 Aug 16;128(8):755-759. Epub 2019 Apr 16.

1 Department of Otolaryngology-Head and Neck Surgery, BS, Thomas Jefferson University, Philadelphia, PA, USA.

Objective: To determine the diagnostic accuracy of fine-needle aspiration (FNA) and imaging modalities for low-grade mucoepidermoid carcinoma (MEC) of the parotid gland.

Methods: Retrospective chart review of patients diagnosed with low-grade MEC of the parotid gland following surgical excision between January 2010 and June 2018. Imaging from patients with MEC were randomly mixed with imaging from patients with benign pathology and reviewed in a blinded fashion. Main outcome measure was sensitivity.

Results: A total of 24 patients were confirmed to have had low-grade MEC on final pathology, with a total of 31 FNAs performed between them. Twelve of 31 FNAs were positive for low-grade MEC, with a sensitivity of 39%. A total of 27 imaging studies were reviewed, which included 16 patients with low-grade MEC and 11 patients with benign pathology. Of these 27 imaging studies, 10 were declared indeterminate. Of the remaining 17 imaging studies, 13 were reviewed as malignant (11 true positive and 2 false positive) and 4 as benign (4 true negative). Overall magnetic resonance imaging (MRI) sensitivity for low-grade MEC was 100% (9/9) with 95% CI (0.66-1.0) when considering indeterminate results as positive for malignancy.

Conclusion: This study reaffirms that for low-grade MEC, sensitivity of FNA is poor. MRI provides an important diagnostic tool in the evaluation of salivary gland neoplasms, due to its increased sensitivity for low-grade MEC when considering indeterminate results as positive. This provides confidence in the diagnosis of benign tumors and allows appropriate counseling of all options to the patient, including observation. Imaging and low threshold of excision should be considered despite an inflammatory or benign FNA.
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http://dx.doi.org/10.1177/0003489419842582DOI Listing
August 2019

INI1/SMARCB1-Deficient Carcinoma (Rhabdoid Tumor) of the Lacrimal Gland.

Ophthalmic Plast Reconstr Surg 2019 Mar/Apr;35(2):e41-e43

Wills Eye Hospital, Philadelphia, Pennsylvania, U.S.A.

Integrase interactor 1 (INI1) is a tumor suppressor gene that is ubiquitously expressed in all nucleated cells. The loss of INI1 protein activity was first demonstrated in aggressive pediatric tumors, including atypical teratoid/rhabdoid (AT/RT) tumor of the central nervous system and malignant rhabdoid tumor of the kidney. Subsequently, INI1 deficiency was discovered in other pediatric and some adult neoplasms. The spectrum of INI1-negative tumors includes a wide variety of neoplasms that occur over a wide age range, are variably aggressive, and have a variable rhabdoid component on histopathologic evaluation. In this report, the authors describe a 27-year-old gravid woman with INI1-deficient carcinoma of the lacrimal gland, previously not described in this location.
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http://dx.doi.org/10.1097/IOP.0000000000001311DOI Listing
December 2019

Loss of CD169 Subcapsular Macrophages during Metastatic Spread of Head and Neck Squamous Cell Carcinoma.

Otolaryngol Head Neck Surg 2019 07 12;161(1):67-73. Epub 2019 Feb 12.

1 Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Objective: The purpose of this study is to assess CD169 expression in metastatic and nearby tumor-free lymph nodes of patients with head and neck squamous cell carcinoma (SCC).

Study Design: Retrospective analysis based on immunohistochemistry.

Setting: Tertiary care center.

Subjects And Methods: The abundance of CD169 cells in the subcapsular sinuses (SCSs) of lymph nodes was assessed immunohistochemically in paraffin-embedded tissue samples derived from 22 patients with oral cavity and oropharyngeal SCC.

Results: SCSs of lymph nodes harboring metastatic SCC contained significantly fewer CD169 macrophages (106.5 ± 113.6 cells/mm) compared to nearby tumor-free lymph nodes (321.3 ± 173.4 cells/mm, < .001). This observation extended to 21 of the 22 cases investigated. In addition, 6 patients who later developed recurrent disease contained lower numbers of CD169 cells (268.6 ± 169.5 cells/mm) in nearby tumor-free lymph nodes compared to 341.0 ± 176.1 cells/mm in those who remained disease free ( = .399). Human papillomavirus (HPV)-positive patients (n = 4) had a 6-fold lower number of CD169 cells in metastatic nodes (61.2 ± 85.5 cells/mm) compared to nearby tumor-free lymph nodes (369.5 ± 175.5 cells/mm, = .028). In comparison, HPV-negative patients had only a 3-fold reduction (116.6 ± 118.5 cells/mm vs 310.6 ± 176.2 cells/mm, < .001).

Conclusion: Metastatic spread of SCC to regional lymph nodes is associated with lower abundance of CD169 macrophages in the SCSs of draining lymph nodes. These results set the stage for an in-depth investigation into the mechanism(s) by which metastatic SCC controls CD169 macrophage abundance and its significance as it relates to prognosis and treatment response.
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http://dx.doi.org/10.1177/0194599819829741DOI Listing
July 2019

The Role of Free Tissue Transfer in the Management of Chronic Frontal Sinus Osteomyelitis.

Laryngoscope 2019 07 14;129(7):1497-1504. Epub 2018 Dec 14.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Objectives/hypothesis: Chronic frontal sinus infection is managed with a combination of medical and surgical interventions. Frontal bone osteomyelitis due to recurrent infection following trauma or prior open surgery may require more significant debridement. Free tissue transfer may allow for extensive debridement with replacement of tissue, and definitive eradication of osteomyelitis.

Study Design: Retrospective chart review.

Methods: Patients undergoing free flap obliteration of the frontal sinus for frontal bone osteomyelitis at a single institution were included in the study. Clinical, radiologic, and surgical data were collected. Surgeries before and after free flap obliteration were compared by Wilcoxon signed rank test.

Results: Fifteen patients were identified; however, one patient had less than 6 months of follow-up and was excluded from analysis. Of the remaining 14 patients, mean follow-up duration was 26 months (range, 6-120 months). Mean number of surgeries prior to free flap was 3.7 (range, 1-8 surgeries). Free flap obliteration resolved chronic frontal sinusitis in all patients. Two patients experienced postoperative infection, and the overall complication rate was 29%. Eight patients underwent cranioplasty (six immediate, two delayed) without complication. All patients received planned courses of postoperative antibiotics. A statistically significant decrease in the number of surgeries after free flap obliteration was observed P ≤ .01).

Conclusions: Extensive debridement followed by free tissue transfer and antibiotics offers a definitive treatment for complicated, recurrent frontal osteomyelitis. Simultaneous cranioplasty provides immediate protective and aesthetic benefit without complication. Consideration should be given for free tissue transfer and cranioplasty earlier in the algorithm for treatment of refractory frontal sinus osteomyelitis.

Level Of Evidence: 4 Laryngoscope, 129:1497-1504, 2019.
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http://dx.doi.org/10.1002/lary.27669DOI Listing
July 2019

Surgical Management of Stylohyoid Pain (Eagle's) Syndrome: A 5-Year Experience.

Ann Otol Rhinol Laryngol 2019 Mar 10;128(3):220-226. Epub 2018 Dec 10.

Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA.

Objectives: (1) To define patient demographics and common symptoms in patients who undergo styloidectomy for stylohyoid pain syndrome (Eagle's syndrome). (2) To evaluate the effectiveness of styloidectomy in reducing symptoms of Eagle's syndrome.

Methods: Retrospective chart review and prospective case series. We retrospectively gathered demographic data on all patients at a single institution who underwent styloidectomy during a 5-year period. Using a patient symptom survey, we also gathered prospective data on a cohort of these patients presenting during the second half of the timeframe.

Results: Thirty-two patients underwent styloidectomy for Eagle's syndrome between November 2010 and June 2015. Of these patients, 22 (68.8%) were female, 29 (90.6%) were Caucasian, and 10 (31.3%) reported history of tonsillectomy. Mean age was 46.0 years, and mean BMI was 26.1 kg/m. Nineteen patients completed the prospective survey. Average styloid length was 45.3 mm. Most severe preoperative symptoms were neck pain, otalgia, globus, facial pain, headache, and discomfort with neck turning. Thirteen of 17 individual symptoms demonstrated significant decrease in symptom scores after styloidectomy. Aggregate symptom scores also showed significant decrease postsurgically. Longer styloid length correlated with increased scores for dysphagia and odynophagia but not with conglomerate symptom scores.

Conclusions: Patients with Eagle's syndrome were mostly female, Caucasian, and had near-normal BMI. There is wide variability in presenting symptoms of Eagle's syndrome, but nearly all demonstrate improvement after styloidectomy. Thus, in appropriately selected patients, styloidectomy can effectively and reliably produce improvement in patient symptoms.
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http://dx.doi.org/10.1177/0003489418816999DOI Listing
March 2019

Metformin Clinical Trial in HPV+ and HPV- Head and Neck Squamous Cell Carcinoma: Impact on Cancer Cell Apoptosis and Immune Infiltrate.

Front Oncol 2018 11;8:436. Epub 2018 Oct 11.

Department of Medical Oncology, Thomas Jefferson University Philadelphia, Philadelphia, PA, United States.

Metformin, an oral anti-hyperglycemic drug which inhibits mitochondrial complex I and oxidative phosphorylation has been reported to correlate with improved outcomes in head and neck squamous cell carcinoma (HNSCC) and other cancers. This effect is postulated to occur through disruption of tumor-driven metabolic and immune dysregulation in the tumor microenvironment (TME). We report new findings on the impact of metformin on the tumor and immune elements of the TME from a clinical trial of metformin in HNSCC. Human papilloma virus-(HPV-) tobacco+ mucosal HNSCC samples ( = 12) were compared to HPV+ oropharyngeal squamous cell carcinoma (OPSCC) samples ( = 17) from patients enrolled in a clinical trial. Apoptosis in tumor samples pre- and post-treatment with metformin was compared by deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay. Metastatic lymph nodes with extra-capsular extension (ECE) in metformin-treated patients ( = 7) were compared to archival lymph node samples with ECE ( = 11) for differences in immune markers quantified by digital image analysis using co-localization and nuclear algorithms (PD-L1, FoxP3, CD163, CD8). HPV-, tobacco + HNSCC (mean Δ 13.7/high power field) specimens had a significantly higher increase in apoptosis compared to HPV+ OPSCC specimens (mean Δ 5.7/high power field) ( < 0.001). Analysis of the stroma at the invasive front in ECE nodal specimens from both HPV-HNSCC and HPV+ OPSCC metformin treated specimens showed increased CD8+ effector T cell infiltrate (mean 22.8%) compared to archival specimens (mean 10.7%) ( = 0.006). Similarly, metformin treated specimens showed an increased FoxP3+ regulatory T cell infiltrate (mean 9%) compared to non-treated archival specimens (mean 5%) ( = 0.019). This study presents novel data demonstrating that metformin differentially impacts HNSCC subtypes with greater apoptosis in HPV-HNSCC compared to HPV+ OPSCC. Moreover, we present the first human evidence that metformin may also trigger increased CD8+ Teff and FoxP3+ Tregs in the TME, suggesting an immunomodulatory effect in HNSCC. Further research is necessary to assess the effect of metformin on the TME of HNSCC.
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http://dx.doi.org/10.3389/fonc.2018.00436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6193523PMC
October 2018

Therapeutic Cannabis and Endocannabinoid Signaling System Modulator Use in Otolaryngology Patients.

Laryngoscope Investig Otolaryngol 2018 Jun 16;3(3):169-177. Epub 2018 Apr 16.

Thomas Jefferson Hospital-Otolaryngology Head & Neck Surgery Philadelphia Pennsylvania U.S.A.

Objectives: 1) review benefits and risks of cannabis use, with emphasis on otolaryngic disease processes; 2) define and review the endocannabinoid signaling system (ESS); and 3) review state and federal regulations for the use and research of cannabis and ESS modulators.

Methods: This manuscript is a review of the current literature relevant to the stated objectives.

Results: Cannabis (marijuana) use is increasing. It is the most widely used illicit substance in the world. There is increasing interest in its therapeutic potential due to changing perceptions, new research, and legislation changes controlling its use. The legal classification of cannabis is complicated due to varied and conflicting state and federal laws. There are currently two synthetic cannabinoid drugs that are FDA approved. Current indications for use include chemotherapy-related nausea and vomiting, cachexia, and appetite loss. Research has demonstrated potential benefit for use in many other pathologies including pain, inflammatory states, and malignancy. Data exists demonstrating potential antineoplastic benefit in oral, thyroid, and skin cancers.

Conclusions: ESS modulators may play both a causal and therapeutic role in several disorders seen in otolaryngology patients. The use of cannabis and cannabinoids is not without risk. There is a need for further research to better understand both the adverse and therapeutic effects of cannabis use. With increasing rates of consumption, elevated public awareness, and rapidly changing legislation, it is helpful for the otolaryngologist to be aware of both the adverse manifestations of use and the potential therapeutic benefits when talking with patients.
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http://dx.doi.org/10.1002/lio2.154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6057224PMC
June 2018

AJCC-8ed nodal staging does not predict outcomes in surgically managed HPV-associated oropharyngeal cancer.

Oral Oncol 2018 07 28;82:138-143. Epub 2018 May 28.

Department of Otolaryngology-Head and Neck Surgery, Philadelphia, PA, United States.

Objective: To assess the pathological outcomes of surgically-managed human papillomavirus (HPV) positive oropharyngeal squamous cell carcinoma (OPSCC) using the 8th Edition of the American Joint Committee on Cancer Staging Manual (AJCC-8ed).

Materials And Methods: A retrospective review was conducted of 156 patients with previously untreated OPSCC who underwent primary TORS between March 2010 and February 2015 to evaluate the impact of the new AJCC-8ed pathologic staging system. Only patients who had complete pathologic staging with neck dissection and at least 2 years of follow-up records or disease recurrence within 2 years were included for analysis.

Results And Conclusions: Of the 156 patients, 116 patients had neck dissections and adequate follow-up data. There were 10 total recurrences, including 2 regional recurrences and 1 local recurrence. Lymph node size, number of positive lymph nodes, and presence of any positive nodes were not associated with recurrence for HPV-positive patients. The presence of extranodal extension approached significance. Pathologic N-stage was not predictive of recurrence under the AJCC-7ed or the AJCC-8ed systems. Cancer staging under the AJCC-8ed, but not the AJCC-7ed system was significantly associated with recurrence. In conclusion, pathologic node status as defined in the AJCC-8ed pathologic staging system does not appear to drive prognosis for surgically managed patients. While the new AJCC-8ed staging is an improvement in prognostication, the use of T-stage alone is still a better predictor of recurrence. TORS with adjuvant therapy determined by pathologic findings provides excellent locoregional control for HPV-positive OPSCC.
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http://dx.doi.org/10.1016/j.oraloncology.2018.05.016DOI Listing
July 2018