Publications by authors named "William R Ryan"

77 Publications

The Science and Art of Salivary Care.

Otolaryngol Clin North Am 2021 Jun;54(3):xv-xvi

Department of Otolaryngology-Head and Neck Surgery, Helen Diller Comprehensive Cancer Center, University of California, San Francisco, Mission Bay Medical Center, 1825 4th Street, 5th Floor, San Francisco, CA 94158, USA. Electronic address:

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http://dx.doi.org/10.1016/j.otc.2021.03.004DOI Listing
June 2021

Transoral Excision of Parapharyngeal Space Tumors.

Otolaryngol Clin North Am 2021 Jun;54(3):531-541

Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, 1825 4th Street, Fifth Floor, San Francisco, CA 94158, USA.

Transoral excision of parapharyngeal space (PPS) tumors has increased in popularity along with the increased use of robotic and endoscopic surgical technology. Here, the authors highlight the indications, techniques, outcomes, and complications of transoral approaches to PPS tumors, with a special emphasis on salivary tumors of the PPS and the transoral robotic surgery approach.
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http://dx.doi.org/10.1016/j.otc.2021.03.001DOI Listing
June 2021

Oncologic outcomes of human papillomavirus-associated oropharynx carcinoma treated with surgery alone: A 12-institution study of 344 patients.

Cancer 2021 May 6. Epub 2021 May 6.

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

Background: The oncologic outcomes of surgery alone for patients with American Joint Committee on Cancer 7th edition (AJCC 7th) pN2a and pN2b human papillomavirus-associated oropharynx squamous cell carcinoma (HPV+OPSCC) are not clear.

Methods: The authors performed a 12-institution retrospective study of 344 consecutive patients with HPV+OPSCC (AJCC 7th pT0-3 N3 M0) treated with surgery alone with 6 months or more of follow-up using univariate and multivariate analyses.

Results: The 2-year outcomes for the entire cohort were 91% (182 of 200) disease-free survival (DFS), 100% (200 of 200) disease-specific survival (DSS), and 98% (200 of 204) overall survival (OS). The 18 recurrences within 2 years were 88.9% (16 of 18) local and/or regional recurrences and 11.1% (2 of 18) distant metastases. Recurrences were not significantly associated with smoking, pT stage, or pN stage. The 16 patients with locoregional recurrences within 2 years all underwent successful salvage treatments (median follow-up after salvage: 13.1 months), 43.8% (7 of 16) of whom underwent salvage surgery alone for a 2-year overall salvage radiation need of 4.5% (9 of 200). The 2-year outcomes for the 59 evaluable patients among the 109 AJCC 7th pT0-2 N2a-N2b patients with 1 to 3 pathologic lymph nodes (LNs) were as follows: local recurrence, 3.4% (2 of 59); regional recurrence, 8.4% (5 of 59); distant metastases, 0%; DFS, 88.1% (52 of 59); DSS, 100% (59 of 59); OS, 96.7% (59 of 61); and salvage radiation, 5.1% (3 of 59).

Conclusions: With careful selection, surgery alone for AJCC 7th pT0-2N0-N2b HPV+OPSCC with zero to 3 pathologic LNs without perineural invasion, extranodal extension, or positive margins results in high DFS, DSS, OS, and salvage treatment success. Because of the short-term follow-up, these data support further investigation of treatment de-escalation in this population.
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http://dx.doi.org/10.1002/cncr.33611DOI Listing
May 2021

Impact of surgical margins on local control in patients undergoing single-modality transoral robotic surgery for HPV-related oropharyngeal squamous cell carcinoma.

Head Neck 2021 Apr 15. Epub 2021 Apr 15.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA.

Background: The impact of close surgical margins on oncologic outcomes in HPV-related oropharyngeal squamous cell carcinoma (HPV + OPSCC) is unclear.

Methods: Retrospective case series including patients undergoing single modality transoral robotic surgery (TORS) for HPV + OPSCC at three academic medical centers from 2010 to 2019. Outcomes were compared between patients with close surgical margins (<1 mm or requiring re-resection) and clear margins using the Kaplan-Meier method.

Results: Ninety-nine patients were included (median follow-up 21 months, range 6-121). Final margins were close in 22 (22.2%) patients, clear in 75 (75.8%), and positive in two (2.0%). Eight patients (8.1%) recurred, including two local recurrences (2.0%). Four patients died during the study period (4.0%). Local control (p = 0.470), disease-free survival (p = 0.513), and overall survival (p = 0.064) did not differ between patients with close and clear margins.

Conclusions: Patients with close surgical margins after TORS for HPV + OPSCC without concurrent indications for adjuvant therapy may be considered for observation alone.
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http://dx.doi.org/10.1002/hed.26708DOI Listing
April 2021

Patient-Reported Outcomes of Split-Thickness Skin Grafts for Floor of Mouth Cancer Reconstruction.

ORL J Otorhinolaryngol Relat Spec 2021;83(3):151-158. Epub 2021 Feb 12.

Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA,

Introduction: Patient-reported outcome measures (PROM) on quality of life (QOL) for early-stage floor of mouth carcinoma (FOM-CA) undergoing surgical resection and split-thickness skin graft (STSG) reconstruction have not been established. We have performed a cross-sectional QOL analysis of such patients to define functional postoperative outcomes.

Methods: Patients with pathologic stage T1/T2 FOM-CA who underwent resection and STSG reconstruction at a tertiary academic cancer center reported outcomes with the University of Washington QOL (v4) questionnaire after at least 6 months since surgery.

Results: Twenty-four out of 49 eligible patients completed questionnaires with a mean follow-up of 41 months (range: 6-88). Subsites of tumor involvement/resection included the following: (1) lateral FOM (L-FOM) (n = 17), (2) anterior FOM (A-FOM) (n = 4), and (3) alveolar ridge with FOM, all of whom underwent lateral marginal mandibulectomy (MM-FOM) (n = 3). All patients reported swallowing scores of 70 ("I cannot swallow certain solid foods") or better. Ninety-six percent (23/24) reported speech of 70 ("difficulty saying some words, but I can be understood over the phone") or better. A-FOM patients reported worse chewing than L-FOM patients (mean: 50.0 vs. 85.3; p = 0.01). All 4 A-FOM patients reported a low chewing score of 50 ("I can eat soft solids but cannot chew some foods"). Otherwise, there were no significant differences between subsite groups in swallowing, speech, or taste.

Conclusion: STSG reconstructions for pathologic T1-T2 FOM-CA appear to result in acceptable PROM QOL outcomes with the exception of A-FOM tumors having worse chewing outcomes.
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http://dx.doi.org/10.1159/000512085DOI Listing
May 2021

Nasogastric tube feeding after transoral robotic surgery for oropharynx carcinoma.

Am J Otolaryngol 2021 May-Jun;42(3):102857. Epub 2021 Jan 22.

Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, 1825 4th Street, 5th Floor, San Francisco, CA 94158, United States of America. Electronic address:

Purpose: To determine the need for and predictors of nasogastric tube feeding (NGTF) use and duration after transoral robotic surgery (TORS) for oropharynx squamous cell carcinoma (OPSCC).

Materials And Methods: This is a retrospective cohort study. For 95 OPSCC patients undergoing TORS with or without concurrent unilateral or bilateral neck dissections (ND), we evaluated NGTF use and duration, along with demographic, clinical, histopathologic, and treatment risk factors.

Results: 23.2% (22/95) of patients received NGTF. Univariate analysis found that NGTF was significantly more likely in larger tumor specimens (mean: 2.32 cm vs. 1.84 cm; p = 0.043) and after concurrent bilateral (46.7%) compared to unilateral (17.4%) ND (p = 0.043). Multivariable analysis also found increased tumor size (p = 0.035) and concurrent bilateral ND (p = 0.04) to be significant risk factors for NGTF. The following were not statistically significantly associated with NGTF use: sex, age, smoking history, HPV status, base of tongue (BOT) resection (20%) vs. radical tonsillectomy (25.9%), pT2 (27.0%) vs. pT1 (20.4%) vs pT0 (16.7%), BOT with (28.6%) vs. without epiglottis resection (22.2%), and surgery for additional margins the same day (27.3%) (all p > 0.1). Patients who underwent NGTF had a mean duration of 18 days (2-96, SD: 20.7 days) with 12 (55.6%) having over 2 weeks of use. No significant predictors of longer duration of NGTF were identified.

Conclusions: A majority of patients undergoing TORS do not need NGTF. When NGTF is needed, the duration of use is usually longer than 14 days. Larger tumor size and concurrent bilateral ND are risk factors for NGTF.
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http://dx.doi.org/10.1016/j.amjoto.2020.102857DOI Listing
January 2021

Predicting Adverse Histopathology and Need for Postsurgical Adjuvant Therapy for Human Papilloma Virus-Associated Oropharynx Carcinoma.

Otolaryngol Head Neck Surg 2021 Jan 5:194599820982913. Epub 2021 Jan 5.

Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA.

Objective: For human papillomavirus-associated oropharynx carcinoma treated with definitive surgery, we aimed to find predictors of adverse histopathology indicating the possible need for adjuvant therapy.

Study Design: Retrospective review.

Setting: National Cancer Database.

Methods: We analyzed 2347 eligible patients from 2010 to 2015. We evaluated (1) the ability of clinical nodal staging and extranodal extension designation per the AJCC, seventh edition (American Joint Committee on Cancer), to predict histopathology and (2) the likelihoods for adverse postsurgery histopathology by common clinical stages.

Results: Clinical nodal staging predicted pathologic nodal staging 65% of the time, with 24% (569/2347) being upstaged and 11% (251/2347) being downstaged. In patients with cN+ disease, clinical extranodal extension distinction had the following accuracy for pathologic extranodal extension: positive predictive value, 81% (88/109); negative predictive value, 73.1% (505/691); sensitivity, 32.1% (88/274); and specificity, 96.0% (505/526). Patients with cT1-2, N0-N2c, without clinical extranodal extension had the following proportions of pN2+ without pathologic extranodal extension (indicating consideration for adjuvant radiation): cN0, 11%; cN1, 31%; cN2a, 67% (8% downstaged); cN2b, 66% (6% downstaged); and cN2c, 35% (17% downstaged). From this group, patients had the following proportions of pathologic extranodal extension (indicating consideration for adjuvant chemoradiation): cN0, 6%; cN1, 20%; cN2a, 27%; cN2b, 28%; and cN2c, 48%.

Conclusion: For human papillomavirus-associated oropharynx carcinoma, nodal clinical staging per the American Joint Committee on Cancer, seventh edition, predicts pathologic stage about two-thirds of the time, leading to up- and downstaging. Clinical extranodal extension assessment has low sensitivity and moderate predictive capability. With careful selection, definitive surgery can allow patients to often avoid adjuvant chemotherapy and sometimes avoid adjuvant radiation.
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http://dx.doi.org/10.1177/0194599820982913DOI Listing
January 2021

Head and neck surgery during the coronavirus-19 pandemic: The University of California San Francisco experience.

Head Neck 2021 02 23;43(2):622-629. Epub 2020 Oct 23.

Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, USA.

Background: Guidelines regarding head and neck surgical care have evolved during the coronavirus-19 (COVID-19) pandemic. Data on operative management have been limited.

Methods: We compared two cohorts of patients undergoing head and neck or reconstructive surgery between March 16, 2019 and April 16, 2019 (pre-COVID-19) and March 16, 2020 and April 16, 2020 (COVID-19) at an academic center. Perioperative, intraoperative, and postoperative outcomes were recorded.

Results: There were 63 operations during COVID-19 and 84 operations during pre-COVID-19. During COVID-19, a smaller proportion of patients had benign pathology (12% vs 20%, respectively) and underwent thyroid procedures (2% vs 23%) while a greater proportion of patients underwent microvascular reconstruction±ablation (24% vs 12%,). Operative times increased, especially among patients undergoing microvascular reconstruction±ablation (687 ± 112 vs 596 ± 91 minutes, P = .04). Complication rates and length of stay were similar.

Conclusions: During COVID-19, perioperative outcomes were similar, operative time increased, and there were no recorded transmissions to staff or patients. Continued surgical management of head and neck cancer patients can be provided safely.
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http://dx.doi.org/10.1002/hed.26514DOI Listing
February 2021

Sialendoscopy in Chronic Obstructive Sialadenitis Without Sialolithiasis: A Prospective Cohort Study.

Otolaryngol Head Neck Surg 2021 03 29;164(3):595-601. Epub 2020 Sep 29.

Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, CA, USA.

Objectives: To evaluate long-term chronic sialadenitis symptoms in patients without sialolithiasis following sialendoscopy-assisted salivary duct surgery (SASDS) compared to a control group managed conservatively.

Study Design: Prospective cohort study.

Setting: Tertiary care center.

Methods: Thirty-six patients (52 glands) with chronic sialadenitis without sialolithiasis completed the Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire at presentation and at 3-month time intervals thereafter for 1 year. Lower COSS scores represent lower symptom severity. We compared 27 patients who underwent SASDS to 9 control patients who elected conservative management.

Results: COSS gland-specific scores from 38 SASDS-treated glands (cases) and 14 control glands were similar at baseline. At 6 to 12 months (mean, 8.4 months), the surgically treated group had significantly lower scores and a greater score reduction from baseline compared to controls (mean score change [95% confidence interval] cases: 20.7 points [15.7-25.8]; controls: 11.7 points [4.9-18.4]; = .04). There was a significant difference in scores between the 2 groups over time ( < .001). A greater proportion (72%) of cases reported partial or complete resolution of overall sialadenitis symptoms at 6 to 12 months compared to the controls (22%, < .05).

Conclusion: Compared to patients electing for conservative management, patients with sialadenitis without sialolithasis treated with SASDS had improved symptom scores and a greater reduction of symptom severity after 6 months. With SASDS, patients had higher rates of significant overall symptom improvement. In evaluating chronic sialadenitis, assessment at multiple time points is necessary to capture the intermittent and cyclical pattern of obstructive symptoms.
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http://dx.doi.org/10.1177/0194599820957256DOI Listing
March 2021

Patterns of Nodal Metastases and Predictors of Occult Disease in HPV-Associated Oropharynx Cancer.

Otolaryngol Head Neck Surg 2021 03 8;164(3):624-630. Epub 2020 Sep 8.

Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, California, USA.

Objective: For human papilloma virus-associated oropharynx squamous cell carcinoma (HPV+ OPSCC), we evaluated the distribution of neck-level lymph node (LN) metastasis, based on postsurgical histopathology, and the incidence of and risk factors for occult LN metastases, as these patterns need clarification for this newer cancer subset.

Study Design: Retrospective cohort study.

Setting: National Cancer Database (NCDB).

Methods: We analyzed 2358 patients in the NCDB with HPV+ OPSCC who underwent neck dissection (ND) from 2010 to 2015. Incidence and distribution of LN metastases were calculated for neck levels I to V. Variables associated with occult LN metastasis were assessed by multivariate logistic regression.

Results: In therapeutic NDs (n = 1935), the following proportions of positive LNs were found: level I, 9.0% (n = 175); level II, 81.0% (n = 1568); level III, 29.6% (n = 573); level IV, 11.9% (n = 230); and level V, 4.9% (n = 95). In elective NDs (n = 423), occult-positive LNs were found in 35.8% (n = 152), with the following proportions by level: level I, 3.3% (n = 14); level II, 26.9% (n = 114); level III, 8.7% (n = 37); level IV, 4.0% (n = 17); and level V, 0.2% (n = 1). The presence of occult LNs was independently associated with a Charlson-Deyo score of 1 (odds ratio, 2.26; 95% CI, 1.18-4.31; = .014) and lymphovascular invasion (odds ratio, 5.91; 95% CI, 3.21-11.18; < .001). Occult LN metastases were not significantly associated with pT classification, primary site, or number of LNs resected.

Conclusion: For HPV+ OPSCC, occult nodal disease is common. Therapeutic NDs should encompass at least levels II, III, and IV and possibly I, whereas elective NDs could possibly encompass levels II and III.

Level Of Evidence: 4.
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http://dx.doi.org/10.1177/0194599820951473DOI Listing
March 2021

Salivary and lacrimal dysfunction after radioactive iodine for differentiated thyroid cancer: American Head and Neck Society Endocrine Surgery Section and Salivary Gland Section joint multidisciplinary clinical consensus statement of otolaryngology, ophthalmology, nuclear medicine and endocrinology.

Head Neck 2020 11 19;42(11):3446-3459. Epub 2020 Aug 19.

Department of Otolaryngology - Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.

Background: Postoperative radioactive iodine (RAI) administration is widely utilized in patients with differentiated thyroid cancer. While beneficial in select patients, it is critical to recognize the potential negative sequelae of this treatment. The prevention, diagnosis, and management of the salivary and lacrimal complications of RAI exposure are addressed in this consensus statement.

Methods: A multidisciplinary panel of experts was convened under the auspices of the American Head and Neck Society Endocrine Surgery and Salivary Gland Sections. Following a comprehensive literature review to assess the current best evidence, this group developed six relevant consensus recommendations.

Results: Consensus recommendations on RAI were made in the areas of patient assessment, optimal utilization, complication prevention, and complication management.

Conclusion: Salivary and lacrimal complications secondary to RAI exposure are common and need to be weighed when considering its use. The recommendations included in this statement provide direction for approaches to minimize and manage these complications.
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http://dx.doi.org/10.1002/hed.26417DOI Listing
November 2020

Modified technique of submandibular gland transfer followed by intensity modulated radiotherapy to reduce xerostomia in head and neck cancer patients.

Head Neck 2020 09 13;42(9):2340-2347. Epub 2020 May 13.

Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA.

Background: Xerostomia is one of the most common long-term adverse effects of radiotherapy for head and neck cancer patients. Contralateral submandibular gland transfer (SMG-T) before radiotherapy was shown to reduce xerostomia compared to pilocarpine. We sought to evaluate a modification of this surgery preserving the ipsilateral facial artery and vein to simplify the SMG-T.

Methods: Eighteen patients planned for head and neck intensity modulated radiotherapy to both necks were reviewed. Surgical complications were recorded. The grade of xerostomia was assessed after treatment completion.

Results: There were no minor or major complications resulting from the modified SMG-T. At 24.5-months follow up, the incidence of post-treatment moderate to severe xerostomia was 16.7%. No locoregional recurrence occurred. Only one patient had distant solitary lung metastasis.

Conclusion: The modified SMG-T technique is a practical and effective method to reduce the dose of radiation to the contralateral SMG and limit post-treatment xerostomia.
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http://dx.doi.org/10.1002/hed.26249DOI Listing
September 2020

Improved Tumor Control Related to Radiotherapy Technological Development for Hypopharyngeal Cancer.

Laryngoscope 2021 02 12;131(2):E452-E458. Epub 2020 May 12.

Department of Radiation Oncology, University of California San Francisco, San Francisco, California.

Objectives/hypothesis: Squamous cell carcinoma of the hypopharynx (SCCHP) is associated with worse survival compared to other head and neck subsites. This report quantifies the impact of technological improvements in radiotherapy (RT) on outcomes over 6 decades.

Methods: Patients with SCCHP receiving curative-intent treatment between 1962 and 2015 were retrospectively reviewed. Kaplan-Meier analyses of freedom from local recurrence (FFLR), progression-free survival (PFS), and overall survival (OS) were compared across treatment eras and radiation techniques. Multivariable Cox proportional hazards modeling was performed to specify the effect of RT technique.

Results: One hundred thirty-four patients had a median follow-up of 17 months (IQR = 9-38). There were no differences in staging or use of surgery over time, but use of chemotherapy concurrent with RT increased (P < .001) beginning in the 2000s. The 24-month FFLR using two-dimensional RT (2D-RT), three-dimensional conformal RT (3D-CRT), and intensity-modulated RT (IMRT) was 52%, 55%, and 80%, respectively; 24-month PFS was 39%, 46%, and 73%, respectively; and 24-month OS was 27%, 40%, and 68%, respectively. OS (P = .01), PFS (P = .03), and FFLR (P = 0.02) were improved with IMRT over 2D-RT, and FFLR appeared to be improved over 3D-CRT (P = .06). Controlling for chemotherapy use and other major variables, IMRT produced a strong influence over FFLR (adjusted hazard ratio [HR] = 0.2, 95% confidence interval [CI]: 0.0-1.2, P = .08) and a benefit in OS (adjusted HR = 0.1, 95% CI: 0.0-0.4, P = .005).

Conclusions: Across 6 decades, patient and tumor characteristics remained similar whereas use of chemoradiation increased and IMRT was adopted. The introduction of IMRT was associated with improved FFLR, PFS, and OS, and a reduction in acute toxicity as compared to earlier radiation technologies.

Level Of Evidence: 4 Laryngoscope, 131:E452-E458, 2021.
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http://dx.doi.org/10.1002/lary.28726DOI Listing
February 2021

Patient-Reported Quality of Life After Resection With Primary Closure for Oral Tongue Carcinoma.

Laryngoscope 2021 02 7;131(2):312-318. Epub 2020 May 7.

Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, U.S.A.

Objectives/hypothesis: For early-stage oral tongue carcinoma and carcinoma in situ (ESOTCCIS), we evaluated patient-reported quality-of-life (QOL) outcomes following resection with primary closure (R-PC).

Study Design: Retrospective review at an academic cancer center.

Methods: Thirty-nine ESOTCCIS patients (Tis, T1, T2) who underwent R-PC without radiation completed the University of Washington Quality of Life Questionnaire Version 4 (UW-QOL) at least 6 months since R-PC (mean = 2.39 years; range = 0.5-6.7 years). We compared UW-QOL scores for pain, swallowing, chewing, speech, and taste to established normative population scores. Multivariable regression analysis evaluated factors associated with QOL impairment.

Results: ESOTCCIS patients who underwent R-PC in comparison to the normative population reported significantly worse mean speech (87.7 vs. 98, P < .001) and taste (85.6 vs. 95, P = .002) scores and no significant differences in mean pain (91.7 vs. 86, P = .96), swallowing (100 vs. 98, P = .98), chewing (97.4 vs. 94, P = .98) scores. For speech and taste, 59% (23/39) reported no postoperative change from baseline, whereas 41% (16/39) and 35.9% (14/39) reported mild impairment, respectively. Overall, postoperative QOL was reported as good, very good, or outstanding by 87.2% (34/39). Higher American Society of Anesthesiologists class, cT1 compared to CIS, and ventral tongue involvement were independently associated with worse speech. Age < 60 years was independently associated with worse taste.

Conclusions: ESOTCCIS patients who undergo R-PC without radiation can expect long-term swallowing, chewing, and pain to be in the normative range. Although a majority of patients can expect to achieve normative speech and taste outcomes, R-PC carries the risks of mild speech and/or taste impairments.

Level Of Evidence: 4 Laryngoscope, 131:312-318, 2021.
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http://dx.doi.org/10.1002/lary.28723DOI Listing
February 2021

HPV-positive Squamous Cell Carcinoma of the Larynx, Oral Cavity, and Hypopharynx: Clinicopathologic Characterization With Recognition of a Novel Warty Variant.

Am J Surg Pathol 2020 05;44(5):691-702

Departments of Pathology.

Human papillomavirus (HPV) is a principal driver for most oropharyngeal squamous cell carcinomas (OPSCCs), where it is strongly associated with improved survival. HPV is much less frequently detected in squamous cell carcinomas arising in nonoropharyngeal sites (non-OPSCCs), and its pathogenic role and prognostic value in these tumors is unclear. We evaluated the clinicopathologic features of 52 non-OPSCCs considered HPV-positive based upon p16 immunohistochemistry and direct HPV detection using RNA in situ hybridization (ISH), DNA ISH, or real-time DNA polymerase chain reaction. The HPV-positive non-OPSCCs were from the larynx (n=27), oral cavity (n=21), and hypopharynx (n=4). While most cases (n=34, 65%) showed classic histologic features of HPV-positive OPSCC, including endophytic growth, minimal keratinization, and hyperchromatic nuclei without koilocytic changes, a subset (n=13, 25%) were characterized by exophytic growth, exuberant surface hyperkeratosis and parakeratosis, marked nuclear pleomorphism, and prominent koilocytic atypia. These antithetical features were highly reminiscent of the warty variant of HPV-positive squamous cell carcinoma described in anogenital sites. Compared with tumors without warty features, the warty tumors presented at lower stage and were not associated with lymph node metastasis, local recurrence, or distant spread (4 y disease-free survival of 100% vs. 66%, P=0.069). The presence of transcriptionally active HPV as detected by RNA ISH suggests a pathogenic role for HPV in these nonoropharyngeal sites. While most HPV-positive non-OPSCCs are morphologically similar to their tonsillar counterparts, this study highlights a previously unrecognized warty variant that may be associated with a highly favorable clinical outcome.
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http://dx.doi.org/10.1097/PAS.0000000000001433DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885126PMC
May 2020

Distinct biomarker and behavioral profiles of human papillomavirus-related oropharynx cancer patients by age.

Oral Oncol 2020 02 24;101:104522. Epub 2019 Dec 24.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, United States. Electronic address:

Background: HPV-positive oropharynx squamous cell cancer (HPV-OPC) patients were initially described as younger, however incidence has increased among older age-groups. It is unknown why some patients present at a younger age and others at a later age.

Methods: Multi-institutional prospective study of HPV-OPC cases (n = 163) and matched controls (n = 345) with detailed behavioral survey, and serum tested for HPV antibodies by fluorescent bead-based technology. Age at diagnosis was used to stratify patients into younger (≤50 years), middle-age (51-65), and older (>65).

Results: By age, demographic characteristics were largely similar, but HPV biomarkers and sexual acts differed. Younger cases were more likely to be HPV16-positive than older cases (100% vs 77%, p = 0.009). Similarly, younger cases were more likely to be HPV16 E6 or E7 seropositive (100% vs 82%, p = 0.03). Younger cases had a higher number of oral sex partners per year, a marker of sexual intensity (sex-years, p = 0.003), but a similar number of lifetime oral sex partners (measure of cumulative sexual exposure), compared to older cases. While sex-years were higher for younger cases and controls, cases had significantly higher sex-years than matched controls in each age-group (p < 0.001). Younger patients were also more likely to perform oral sex at sexual debut, and were younger at sexual debut (each p < 0.03).

Conclusions: Younger, middle-age and older HPV-OPC have distinct biomarker and behavioral profiles. Younger HPV-OPC cases have higher intensity of sexual exposure than older cases and controls, which may in part explain earlier disease onset. The distribution of HPV16-positive tumors among HPV-OPC differs by age group.
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http://dx.doi.org/10.1016/j.oraloncology.2019.104522DOI Listing
February 2020

Predictors of Mortality in HPV-Associated Oropharynx Carcinoma Treated With Surgery Alone.

Laryngoscope 2020 07 1;130(7):E423-E435. Epub 2019 Nov 1.

Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California.

Objective: Survival outcomes for human papillomavirus-associated oropharynx squamous cell carcinoma (HPV + OPSCC) treated with surgery alone are unclear. To increase understanding, we assessed overall survival (OS) outcomes using the national cancer database (NCDB).

Methods: We conducted a retrospective analysis of OS of 736 NCDB HPV + OPSCC patients who underwent surgery alone from 2010 to 2014 using univariate and multivariate analyses and the Kaplan-Meir method.

Results: Multivariable analysis found the following independent risk factors for death: American Joint Commission on Cancer (AJCC) 8th edition pathologic stage(p)N2 versus pN0 disease (hazard ratio [HR], 5.5; P = 0.000006), macroscopic extranodal extension (ENE) versus non-ENE (HR, 4.9; P < 0.02), a positive lymph nodes (LN) percentage of ≥10% (HR, 4.2; P = 0.0002), and five or more positive LNs (HR, 4.9; P = 0.00004). Three-year OS was significantly worse for AJCC 8th edition pN2 versus pN0 but not for 7th edition pN2 versus pN0 disease. Five-year OS was significantly worse for positive versus negative surgical margins, AJCC 8th edition stage II versus I, and either microscopic or macroscopic ENE versus non-ENE positive LNs. For 523 (71%) AJCC 8th edition stage I patients and for 283 (38%) patients who were pT1-T2, with negative margins, pN0-N1, with ≤4 pathologic LNs, without ENE, and with >20 LNs removed during neck dissection, the 3-year OS rates were 93% and 95%, respectively, and the 5-year OS rates were 91% and 95%, respectively.

Conclusion: In the context of the lack of detail and possible inaccuracies found in the NCDB, surgery alone for AJCC 8th edition stage I HPV + OPSCC, particularly pT1-T2, pN0-N1 with ≤4 pathologic LNs, without ENE, and with negative surgical margins has a high OS.

Level Of Evidence: 4 Laryngoscope, 130:E423-E435, 2020.
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http://dx.doi.org/10.1002/lary.28344DOI Listing
July 2020

Patterns of care and survival impact of adjuvant chemoradiotherapy for oropharyngeal cancer with intermediate-risk features.

Head Neck 2019 09 20;41(9):3177-3186. Epub 2019 May 20.

Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California.

Background: Survival outcomes for adjuvant chemoradiotherapy (aCRT) and adjuvant radiotherapy (aRT) were compared in patients with oropharyngeal squamous cell carcinoma (OPSCC) with intermediate-risk features.

Methods: We identified 2164 patients with OPSCC in the National Cancer Database without positive margins or extracapsular extension and with at least one intermediate-risk feature: pT3-T4 disease, ≥two positive lymph nodes, level IV/V nodal disease, and/or lymphovascular invasion. We assessed predictors of aCRT use and covariables impacting overall survival.

Results: aCRT was commonly used for both human papillomavirus (HPV)-positive (62.0%) and HPV-negative (64.3%) patients with OPSCC. Higher N stage, level IV/V neck disease, and younger age strongly predicted aCRT utilization. There was no significant survival benefit associated with aCRT vs aRT in HPV-positive (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.62-1.38; P = .71) or HPV-negative (HR, 0.75; 95% CI, 0.51-1.10; P = .15) disease.

Conclusions: Despite high rates of utilization, aCRT is not associated with better survival vs aRT for OPSCC with intermediate-risk features, including HPV-negative tumors.
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http://dx.doi.org/10.1002/hed.25808DOI Listing
September 2019

Treatment modality impact on quality of life for human papillomavirus-associated oropharynx cancer.

Laryngoscope 2020 02 27;130(2):E48-E56. Epub 2019 Mar 27.

Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, San Francisco, California.

Objectives/hypothesis: Compare treatment-related quality of life (QOL) impact for early-stage human papillomavirus-associated oropharynx squamous cell carcinoma (HPV+ OPSCC) patients.

Study Design: Retrospective cohort at a tertiary center.

Methods: Stage I (T0-2/N0-1) HPV+ OPSCC patients (n = 76) with pretreatment Karnofsky scores ≥80 reported QOL after surgery alone (n = 17, 22%), surgery with adjuvant radiation ± chemotherapy (S-a[C]XRT) (n = 23, 30%), or definitive radiation ± chemotherapy (d[C]XRT) (n = 36, 47%) with the University of Washington QOL version 4 (UW-QOL); European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, Core Module (EORTC QLQ-C30) and Head and Neck Module (EORTC QLQ-HN35); University of Michigan Xerostomia, and Neck Dissection Impairment Index questionnaires (median follow-up = 2.2 years, interquartile range = 1.0-4.2 years). Treatment adverse events and gastrostomy tube rates were assessed.

Results: Over 87% of each treatment group reported good or better overall QOL. Each group had low gastrostomy tube and treatment-specific complication rates. S-a(C)XRT and d(C)XRT patients had similar mean scores with wide ranges for most individual and all composite categories. S-a(C)XRT compared to d(C)XRT patients reported significantly fewer dental problems (EORTC QLQ-C30/HN35 means = 10.1 vs. 34.3, P = .007), worse appearance (UW-QOL means = 72.8 vs. 82.6, P = .02), and worse coughing (EORTC QLQ-C30/HN35 means = 31.9 vs. 15.7, P = .007). Surgery alone compared to d(C)XRT and S-a(C)XRT patients reported significantly better salivary/taste/oral functions and less pain, financial, oral/dental, and sexual problems.

Conclusions: For early-stage HPV+ OPSCC, patients usually achieve acceptable QOL regardless of treatment. S-a(C)XRT and d(C)XRT patients report generally similar QOL including neck/shoulder pain/function, but with a wide range in a limited patient sample. Surgery alone should be considered, when oncologically and functionally safe, given the better associated QOL.

Level Of Evidence: 4 Laryngoscope, 130:E48-E56, 2020.
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http://dx.doi.org/10.1002/lary.27937DOI Listing
February 2020

Sex differences in HPV immunity among adults without cancer.

Hum Vaccin Immunother 2019 19;15(7-8):1935-1941. Epub 2019 Mar 19.

a Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, School of Medicine , Baltimore , MD , USA.

The incidence of human papillomavirus (HPV)-associated head and neck cancers is rising, particularly among men. Whether observed epidemiological differences in sex are explained by differences in sexual exposure and/or by immune response is unclear. In this cross-sectional, multi-institutional study, seroprevalence of antibodies to HPV L1 capsid antigen was compared by patient characteristics among 374 adult patients without cancer. A significantly higher seroprevalence was observed among women compared with men for HPV16 (OR = 2.96, 95% CI = 1.21-7.21) and HPV18 (OR = 2.84, 95% CI = 1.06-7.60) L1 antibodies. This difference persisted for HPV16 after controlling for lifetime and recent sexual behavior. After controlling for sex, HPV16 and HPV18 L1 seroprevalence was also significantly associated with higher number of lifetime (HPV16 OR = 1.05, 95% CI = 1.01-1.08; HPV18 OR = 1.04, 95% CI = 1.01-1.08) and recent (HPV16 OR = 1.54, 95% CI = 1.15-2.07; HPV18 OR = 1.40, 95% CI = 1.07-1.82) oral but not vaginal sexual partners. These findings potentially suggest a more robust immune response to HPV16/18 among women compared with men that may not be explained by differences in number of sexual partners, and thereby presumably HPV exposure. The independent association of HPV16/18 L1 seroprevalence with higher number of oral sexual partners suggests a possible role for site of mucosal exposure in the HPV immune response.
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http://dx.doi.org/10.1080/21645515.2019.1568157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746519PMC
March 2020

Socioeconomic disparities in a population of patients undergoing total thyroidectomy for benign disease.

Head Neck 2019 03 6;41(3):715-721. Epub 2018 Dec 6.

Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California.

Background: This study examines the effect of insurance status (as a measure of socioeconomic status) on patient with benign thyroid disease.

Methods: A retrospective review was performed among 60 patients undergoing total thyroidectomy for benign thyroid disease. Univariate and multivariable analyses examined the relationship between insurance status and thyroid volume (sum of the left and right lobe volumes).

Results: Twenty-eight (47%) patients were considered of underinsured/uninsured status, and 32 (53%) patients were considered of private/government/military insurance status. Median pathologic whole thyroid volume was 66 mL (range, 2-855). After multivariable linear regression, underinsured/uninsured status was the only significant predictor of larger volume (correlation coefficient [r] = 118; 95% CI, 42 to 194; P = .003), after adjusting for age, sex, body mass index, and presence of concomitant thyroid disease and compressive symptoms.

Conclusion: Patients of underinsured/uninsured status suffered more severe disease presentations at time of thyroidectomy, as measured by larger thyroid volumes.
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http://dx.doi.org/10.1002/hed.25421DOI Listing
March 2019

Human Papillomavirus-Associated Oropharyngeal Cancer: Patterns of Nodal Disease.

Otolaryngol Head Neck Surg 2019 03 2;160(3):502-509. Epub 2018 Oct 2.

4 Division of Head and Neck Oncologic and Endocrine, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA.

Objective: To characterize patterns of neck lymph node (LN) metastases in human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma, represented by p16 positivity (p16+OPSCC).

Study Design: Case series with chart review.

Setting: Tertiary care center.

Subjects And Methods: Neck dissection (ND) specimens of nonirradiated p16+OPSCC patients were analyzed for frequencies of clinically evident and occult LNs by neck level. Local, regional, and distant recurrences were reviewed.

Results: Seventy p16+OPSCC patients underwent primary site transoral robotic surgery and 82 NDs of varying levels. Metastatic pathologic LNs were found at the following frequencies: 0% (0/28) in level I, 75.6% (62/82) in level II with 57.4% (35/61) in level IIA and 13.1% (8/61) in level IIB, 22.0% (18/82) in level III, 7.0% (5/71) in level IV, and 6.3% (1/16) in level V. The level V LN was clinically evident preoperatively. Five of 21 (23.8%) elective NDs contained occult LNs, all of which were in level II and without extranodal extension. Twenty-seven (38.6%) patients underwent adjuvant radiation; 19 (27.1%) patients underwent adjuvant chemoradiation. With a mean follow-up of 29 months, 3 patients had developed recurrences, with all but 1 patient still alive. All patients who recurred had refused at least a component of indicated adjuvant treatment.

Conclusions: For p16+OPSCC, therapeutic NDs should encompass any levels bearing suspicious LNs and levels IIA-B, III, and IV, while elective NDs should be performed and encompass at least levels IIA-B and III. These selective ND plans, followed by indicated adjuvant treatment, are associated with a low nodal recurrence rate.
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http://dx.doi.org/10.1177/0194599818801907DOI Listing
March 2019

Advanced head and neck surgical techniques: A survey of US otolaryngology resident perspectives.

Auris Nasus Larynx 2019 Apr 28;46(2):272-278. Epub 2018 Aug 28.

Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, CA, United States. Electronic address:

Objectives: To assess the perspectives of OHNS residents with regards to their training in the following advanced head and neck surgery techniques: transoral robotic surgery (TORS), transoral laser microsurgery (TLM), sialendoscopy, and surgeon-performed ultrasound (SP-US) for possible curricula development.

Methods: Cross-sectional survey. A 20-item questionnaire was electronically distributed to OHNS residency programs assessing volume of cases, training barriers, satisfaction, additional training preferences, and pertinence to future practice.

Results: One hundred thirty-one residents completed the questionnaire. Trainee satisfaction with advanced techniques did not vary significantly with level of training (PGY) or intent to pursue fellowship. Residents who participated in more TLM, sialendoscopy, and SP-US cases were significantly more likely to be satisfied with their training (all p<0.05). The most frequently reported limitation to training was low home institution procedure volume. Seventy-eight of 123 respondents (63.4%) indicated insufficient opportunity to participate in TORS, with most residents reporting that TORS was preferentially performed by attendings (59/78, 75.6%). Forty-five of 126 (35.7%) reported having adequate access to skills training in TORS, compared to 43.6%, 48.4%, and 54.8% for sialendoscopy, TLM, and SP-US, respectively. A vast majority expressed interest in home institution-sponsored training courses in SP-US (120/127, 94.5%) and sialendoscopy (105/129, 81.4%). Many anticipated using SP-US (63.3%) and sialendoscopy (49.6%) in their future practices.

Conclusion: Greater resident participation in advanced head and neck surgical procedures is associated with higher trainee satisfaction. There is a possible need for additional home institution-sponsored training courses, especially in sialendoscopy and SP-US.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1016/j.anl.2018.08.007DOI Listing
April 2019

One-year outcomes of sialendoscopic-assisted salivary duct surgery for sialadenitis without sialolithiasis.

Laryngoscope 2019 04 27;129(4):890-896. Epub 2018 Aug 27.

the Division of Head and Neck Oncologic and Endocrine Surgery, Salivary Gland Surgery Center, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A.

Objectives: To prospectively examine durability of long-term outcomes in sialendoscopy-assisted salivary duct surgery (SASDS) in chronic obstructive sialadenitis without sialolithiasis (COSWS).

Methods: A prospective cohort study of adult patients with COSWS who completed Chronic Obstructive Sialadenitis Symptoms (COSS) Questionnaire prior to and at 3 months and 1 year following SASDS. COSS scores scaled to 0 to 100 were analyzed by statistically significant improvements and previously published ranges corresponding to complete, partial, and nonresolution of symptoms.

Results: Twenty-nine patients with COSWS affecting 41 glands had statistically significant improvements in COSS scores at 3 months following SASDS. These improvements usually were sustained at 1 year, supporting durability of treatment effect over time. A majority of cases (30 of 41, 73%) achieved at least a partial resolution of sialadenitis symptoms (COSS score ≤ 25) at 1-year follow-up. Symptom improvement after SASDS was noted in 14 of 18 (78%) glands with radioiodine-induced sialadenitis (RAI-IS). The highest proportion of persistent or recurrent disease at 1-year post-SASDS was found in autoimmune sialadenitis (2 of 4, 50%) and glands with proximal or multifocal stenoses (6 of 12, 50%). At 1 year, distal duct stenoses achieved a significantly higher proportion of partial or complete symptom resolution (18 of 21, 86%) than cases with proximal or multifocal stenoses (6 of 12, 50%; P = 0.044).

Conclusions: SASDS is effective in reducing symptoms in duct stenosis and RAI-IS, usually with durable treatment benefits at long-term follow-up. Distal stenoses appear to be more amenable to sialendoscopic treatment, achieving greater symptom reduction than proximal/multifocal stenoses. Additional larger multi-center studies are needed to further characterize risk factors for COSWS refractory to SASDS.

Level Of Evidence: 2 Laryngoscope, 129:890-896, 2019.
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http://dx.doi.org/10.1002/lary.27433DOI Listing
April 2019

One-Year symptom outcomes after sialolithiasis treatment with sialendoscopy-assisted salivary duct surgery.

Laryngoscope 2019 02 27;129(2):396-402. Epub 2018 Aug 27.

the Division of General Otolaryngology, Salivary Gland Surgery Center, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California.

Objectives: For chronic obstructive sialadenitis, there is a paucity of long-term prospective evidence of disease-specific symptom outcomes after sialendoscopy-assisted salivary duct surgery (SASDS). We prospectively assessed patients with sialolithiasis before and at 3 months and 1 year after SASDS using the Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire.

Methods: A prospective cohort study of adult patients with sialolithiasis who underwent SASDS and completed the COSS questionnaire over a 1-year follow-up period. The COSS questionnaire consists of 20 disease-specific symptom questions. COSS score outcomes were classified by complete, partial, and nonresolution, as well as by clinically significant improvement.

Results: Ninety-six patients underwent SASDS in 110 glands, of which 69 glands (63%) had findings of sialolithiasis. The following median COSS scores were reported for sialolithiasis glands: preoperative, 27.5 (interquartile range [IQR]: 12.5-44); 3 months, 1 (IQR: 0-5); and 1 year, 1 (IQR: 0-5.5). Patients with sialolithiasis reported statistically significant improvements in COSS scores from preoperative to 3 months post-SASDS (P > 0.05). A vast majority of patients maintained this improvement from 3 months to 1 year, indicating durability. Complete resolution of symptoms was attained in 95% and 85% of glands at 3 months and 1 year, respectively. Open/hybrid compared to endoscopic-only sialolithiasis extraction achieved similar 3-month and 1-year COSS outcomes. Potential risk factors for symptom persistence after SASDS included nonreachable parenchymal sialoliths and concurrent inflammatory disease and/or stenosis.

Conclusion: SASDS for sialolithiasis extraction is associated with durable, long-term benefit regardless of endoscopic or open technique or sialolith location, suggesting that subsequent ductal stenosis from iatrogenic or sialolithiasis-related inflammation fibrosis is unlikely.

Level Of Evidence: 4 Laryngoscope, 129:396-402, 2019.
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http://dx.doi.org/10.1002/lary.27398DOI Listing
February 2019

A natural killer-dendritic cell axis defines checkpoint therapy-responsive tumor microenvironments.

Nat Med 2018 08 25;24(8):1178-1191. Epub 2018 Jun 25.

Department of Pathology, University of California San Francisco, San Francisco, CA, USA.

Intratumoral stimulatory dendritic cells (SDCs) play an important role in stimulating cytotoxic T cells and driving immune responses against cancer. Understanding the mechanisms that regulate their abundance in the tumor microenvironment (TME) could unveil new therapeutic opportunities. We find that in human melanoma, SDC abundance is associated with intratumoral expression of the gene encoding the cytokine FLT3LG. FLT3LG is predominantly produced by lymphocytes, notably natural killer (NK) cells in mouse and human tumors. NK cells stably form conjugates with SDCs in the mouse TME, and genetic and cellular ablation of NK cells in mice demonstrates their importance in positively regulating SDC abundance in tumor through production of FLT3L. Although anti-PD-1 'checkpoint' immunotherapy for cancer largely targets T cells, we find that NK cell frequency correlates with protective SDCs in human cancers, with patient responsiveness to anti-PD-1 immunotherapy, and with increased overall survival. Our studies reveal that innate immune SDCs and NK cells cluster together as an excellent prognostic tool for T cell-directed immunotherapy and that these innate cells are necessary for enhanced T cell tumor responses, suggesting this axis as a target for new therapies.
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http://dx.doi.org/10.1038/s41591-018-0085-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6475503PMC
August 2018

Shorter interval between radiation therapy and salvage laryngopharyngeal surgery increases complication rates following microvascular free tissue transfer.

Am J Otolaryngol 2018 Sep - Oct;39(5):548-552. Epub 2018 Jun 6.

Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, CA, USA. Electronic address:

Purpose: To evaluate how the interval between radiation and salvage surgery for advanced laryngeal cancer with free tissue transfer reconstruction influences complication rates.

Materials And Methods: This is a retrospective series of 26 patients who underwent salvage laryngectomy or laryngopharyngectomy with vascularized free tissue reconstruction (anterolateral thigh or radial forearm) following radiation or chemoradiation between 2012 and 2017 at a single academic center. The primary outcome was incidence of postoperative complications, including pharyngocutaneous fistula. Secondary outcomes included the need for a second procedure, time to resumption of oral feeding, feeding tube dependence, and hospital length of stay.

Results: Salvage surgery was performed for persistence (7/26, 27%), recurrence/new primary (12/26, 46%), and dysfunctional larynges (7/26, 27%). Twenty-two (85%) defects were reconstructed with an anterolateral thigh free flap and 4/26 with a radial forearm free flap (15%). There were no flap failures. There were significantly more complications in patients undergoing surgery within 12 months of completion of radiation therapy (7/12, 58%) versus those undergoing surgery after 12 months (1/14, 7%; p = .02). Patients experiencing complications more often required a second procedure (4/7 vs. 0/1; p = .02), experienced a longer delay to initiation of oral diet (61 vs. 21 days; p = .04), and stayed in the hospital longer (28 vs. 9 days; p = .01).

Conclusions: Shorter intervals between definitive radiation and salvage laryngopharyngeal surgery with free tissue reconstruction increases postoperative complications, hospital length of stay, and the likelihood of feeding tube dependence. Reconstructive surgeons can use these findings to help guide preoperative patient counseling and assess postoperative risk.
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http://dx.doi.org/10.1016/j.amjoto.2018.06.009DOI Listing
December 2018

Human Papillomavirus in the Mouth and Throat: More Widespread Than Expected?

JAMA Otolaryngol Head Neck Surg 2018 06;144(6):525-526

Head and Neck Oncologic Surgery, University of California, San Francisco School of Medicine, San Francisco.

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http://dx.doi.org/10.1001/jamaoto.2018.0389DOI Listing
June 2018

Surgeon-performed ultrasound for the assessment of parotid masses.

Am J Otolaryngol 2018 Sep - Oct;39(5):467-471. Epub 2018 Apr 16.

Division of Head and Neck Oncologic and Endocrine Surgery, Salivary Gland Center, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, CA, United States. Electronic address:

Background: Studies on parotid gland ultrasound assessments performed specifically by surgeons are seldom reported.

Methods: Retrospective series of a single academic surgeon experience, analyzing 70 new parotid masses with evaluable preoperative SP-US characteristics, location measurements, and perioperative events.

Results: 31/70 masses were malignant. SP-US characteristics significantly associated with both malignancy and positive margins included extraparenchymal extension, irregular borders, hypervascularity, infiltration, and the lack of deep enhancement. The larger the skin-to-deep-aspect-of-tumor distance, the more likely the tumor was deep to FN. For the 39 cytologically benign tumors, neither CT nor MRI provided additional information to change management except for full delineation of parapharyngeal space extension in 2 cases.

Conclusion: SP-US can help predict parotid mass benignity/malignancy, positive margin risk, and tumor relation to FN. SP-US may be used as the sole imaging in cytologically benign tumors unless the deep tumor extent cannot be identified.
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http://dx.doi.org/10.1016/j.amjoto.2018.04.011DOI Listing
December 2018

Squamous Cell Carcinoma of the Soft Palate in the United States: A Population-Based Study.

Otolaryngol Head Neck Surg 2018 10 8;159(4):662-668. Epub 2018 May 8.

1 Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, California, USA.

Objectives To describe the incidence and determinants of survival of patients with squamous cell carcinoma of the soft palate (SCCSP) using the Surveillance, Epidemiology, and End Results (SEER) database. Study Design Retrospective, population-based cohort study of patients. Setting SEER cancer registry. Subjects and Methods Patients from the SEER cancer registry from 1973 to 2015 were used to analyze demographics and survival of SCCSP. Results A total of 4366 cases were identified. The average overall survival (OS) and disease-specific survival (DSS) were 68.7 months and 161.3 months, respectively. Multivariate analysis revealed that male sex, stage, and treatment (hazard ratio [HR] = 0.690, P = .019; HR = 1.73, P < .001; HR = 0.64, P < .001, respectively) were independent determinants of better or worse DSS. Age, stage, and treatment (HR = 1.02, P < .001; HR = 1.49, P < .001; HR = 0.66, P < .001; HR = 0.48, P < .001, respectively) were independent determinants of better or worse OS. For stages I, II, and III, radiation alone and surgery alone have nearly equivalent OS. Patients with stage IV disease who underwent both surgery and radiation had a significantly higher median OS at 50.0 months. Conclusion Radiation alone and surgery alone both have nearly equivalent OS benefit for stages I to III, while surgery and radiation provide the most survival benefit for stage IV disease. The large discrepancy between OS and DSS can be due to significant comorbidities. Future studies should aim to address the determinants of quality-of-life variables that help direct treatment decisions and might indirectly affect survival.
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http://dx.doi.org/10.1177/0194599818771931DOI Listing
October 2018