Faculty Bibliography

Background: The management of patients with atrial fibrillation (AF) on warfarin who need treatment interruption for surgery/procedure is a common clinical problem. Bridging with low-molecular-weight heparin (LMWH) has been used to minimize the time that patients are not anticoagulated to mitigate the risk for arterial thromboembolism (ATE). The efficacy of bridging has not been validated, and bridging may increase bleeding. Aims: We aimed to determine the efficacy and safety of bridging anticoagulation. Methods: BRIDGE is a randomized, double-blind, placebo-controlled trial comparing bridging vs. no bridging in adults with non-valvular/ valvular AF or atrial flutter who required warfarin interruption for elective surgery/procedure. Patients with a mechanical heart valve or creatinine clearance < 30 mL min^-1 were excluded. After stopping warfarin 5 days pre-procedure, patients received dalteparin, 100 IU kg^-1, or matching placebo, both subcutaneous twice daily, for 3 days pre- and 5-9 days post-procedure. Dalteparin/placebo was resumed 12-24 h after minor and 48-72 h after major surgery/procedure. Warfarin was resumed < 24 h post-procedure. Follow-up was for 30 +/- 7 days post-procedure. Primary outcomes were ATE and major bleeding; secondary outcomes were minor bleeding, death, myocardial infarction, and venous thromboembolism. Results: We enrolled 1884 patients: median age was 72.7 (IQR 65.8- 78.2) years; 73.4% were male; median CHADS2 score = 2.0 (IQR 2.0- 3.0); and 336 (17.7%) had prior stroke or transient ischemic attack. Protocol adherence occurred in pre- and post-procedure periods in 1432 (81.0%) and 1669 (94.5%) patients, respectively. We lost 5 (0.3%) patients to follow-up. Trial enrollment ended in Dec. 2014, with results to be presented at the Congress. Conclusion: BRIDGE is the first randomized trial comparing the efficacy and safety of LMWH bridging vs. no bridging in patients with AF who require warfarin interruption for an elective surgery/procedure

Objectives: To study the MRI and PET/CT imaging of osteoradionecrosis of the sub-axial cervical spine, a serious long-term complication of radiation therapy for head and neck cancers that can lead to pain, vertebral instability, myelopathy, and cord compression. Methods and Materials: This is a single-institution retrospective review of patients diagnosed and treated for osteoradionecrosis of the sub-axial cervical spine following surgery and radiation for head and neck cancer. Results: We report PET/CT and MRI imaging for four patients, each with extensive treatment for recurrent head and neck cancer. Osteomyelitis and discitis are the end stage manifestations of osteoradionecrosis of sub-axial spine. Conclusions: Osteoradionecrosis of the sub-axial spine has variable imaging appearance and needs to be differentiated from recurrent or metastatic disease. Surgical violation of the posterior pharyngeal wall on top of compromised vasculature in patients treated heavily with radiation therapy may predispose the sub-axial cervical vertebrae to osteoradionecrosis, with possible resultant osteomyelitis and discitis. MRI and PET/CT imaging are complimentary in this setting. PET/CT images may be misinterpreted in view of history of head and neck cancer. MRI should be utilized for definitive diagnosis of osteomyelitis and discitis in view of its imaging specificity. Advances in Knowledge: We identify the end-stage manifestation of osteoradionecrosis in the sub-axial spine on PET/CT and MRI to facilitate its correct diagnosis.

BACKGROUND: Review patient and defect factors in which this donor site is an optimal choice for reconstruction and to discuss strategies to overcome the perceived drawbacks of this system of flaps. METHODS: A retrospective medical chart review was conducted on all patients who underwent the subscapular system of free flaps for head and neck reconstruction. RESULTS: Ninety-eight reconstructions were performed for mandibular defects, 4 for maxillary defects alone and 3 for combined mandible-maxilla defects. The overall success rate was 98%. CONCLUSION: The subscapular system of free flaps is an excellent option in patients for whom the alternative donor sites are either not usable or lack the associated soft tissue elements required for a successful reconstruction. This flap should also be considered as a first choice for patients with complex/extensive surgical defects requiring multiple, independently mobile, soft tissue components; in patients who will benefit from a large muscle flap placed over the vital structures in the neck; patients of advanced age; and patients in whom early mobilization is critical. (c) 2014 Wiley Periodicals, Inc. Head Neck, 2014.

Concomitant chemoradiotherapy provides organ preservation for those patients with head and neck cancer. We report the results of a prospective study that examined functional outcomes and quality of life (QOL) after chemoradiotherapy over the first 6 months post-treatment (tx). Twenty-nine patients with head and neck cancer were treated with chemoradiotherapy. All were seen baseline and 3 and 6 months post-tx. Assessments included the performance status scale (PSS), Karnofsky performance status scale, tongue strength, jaw opening, and saliva weight. QOL was patient-rated using the eating assessment tool (EAT-10), MD Anderson dysphagia inventory, speech handicap index (SHI), and the EORTC H&N35 scale. Repeated-measures ANOVAs were used, with significance at p < 0.05. PSS scores were significantly different across time points. Tongue strength, jaw range of motion (ROM), and saliva weight were significantly lower at 3 and 6 months than at baseline. QOL was significantly worse after tx, although it improved by 6 months as rated with the EAT-10 and the SHI scores were significantly worse at 3 and 6 months. EORTC domains of swallowing, senses, speech, dry mouth, and sticky saliva were significantly worse at 3 and 6 months. Concomitant chemoradiotherapy for treatment of head and neck tumors can result in impaired performance outcomes and QOL over the first 6 months post-tx. However, performance status, tongue strength, jaw ROM, and eating QOL were only mildly impaired by 6 months post-tx. Saliva production and speech QOL remained significantly impaired at 6 months post-treatment. Current studies are examining outcomes at 12 and 24 months post-treatment to better predict outcomes over time in this population.

Surgical resection in oral cancer patients can result in altered speech, swallowing, and patient perception of quality of life (QOL). Oral surgery can result in reduced lingual range of motion (ROM). However, few studies have quantified the degree of lingual restriction after surgery. This pilot study describes a new measurement system to define tongue ROM in surgically treated tongue cancer patients. This measurement system was validated by comparing results in these treated surgical patients versus healthy individuals. This scale was further validated by correlating ROM with performance status, oral outcomes, and patient-rated QOL. Thirty-six patients who underwent oral tongue surgery and 31 healthy individuals were included. Tongue ROM was assessed using a novel ROM assessment system. This novel system was examined in these patients versus healthy subjects. This measurement tool was further validated by correlating tongue ROM in treated patients with performance status, oral outcomes, and patient-rated QOL. Tongue ROM was found to be significantly lower in the surgically treated patients than in the healthy individuals (p = 0.0001). Tongue ROM correlated with performance status, oral outcomes, and all QOL measures. This new tongue ROM measurement system defined tongue deficits in surgically treated oral cancer patients. This tool was validated by comparing results to those in healthy individuals, as well as by correlating tongue ROM to performance status, oral outcomes, and QOL. This measurement tool can be used to define baseline and postsurgery tongue ROM in oral cancer patients, as well as track change over time with recovery and therapy. Future studies should examine use of this measurement tool with other populations demonstrating tongue deficits.

Oromotor and clinical swallow assessments are routinely performed by speech-language pathologists (SLPs) who see head and neck cancer (HNC) patients. However, the tools used to assess some of these variables vary. SLPs routinely identify and quantify abnormal functioning in order to rehabilitate the patient. However, function in terms of tongue range of motion (ROM) is typically described using a subjective severity rating scale. The primary objective of this study was to gain insight via survey into what variables SLPs consider important in assessing and documenting function after HNC treatment. A second objective was to seek feedback regarding a scale designed by the authors for assessing tongue ROM for this cohort of patients. This survey also was developed to elucidate salient factors that might have an impact on the prognosis for speech and swallow outcomes. Of the 1,816 SLPs who were sent the survey, 292 responded who work with HNC patients. Results revealed that although 95 % of SLPs assess tongue strength, only 13 % use instrumental methods. Although 98 % assess tongue ROM, 88 % estimate ROM based on clinical assessment. The majority of respondents agreed with the utility of the proposed tongue ROM rating scale. Several variables were identified by respondents as having an impact on overall prognosis for speech and swallow functioning. Tracking progress and change in function with treatment can be accomplished only with measurable assessment techniques. Furthermore, a consistent measuring system can benefit patients with other diagnoses that affect lingual mobility and strength.

PURPOSE: To retrospectively review our single institution experience of patients with tonsillar squamous cell carcinoma. MATERIAL AND METHODS: Between 1999 and 2005, a total of 79 patients were identified. Stage distribution was as follows: stages I-II, III, IVA, and IVB were in 6, 14, 43, and 16 patients, respectively. Sixty-three patients (80%) were male. Median age was 55.5 years. Treatment generally consisted of external beam radiation therapy (RT) (median dose, 70 Gy), concomitant chemotherapy (CCRT) (cisplatin 100 mg/m on days 1, 22, and 43), and neck dissection (ND), and was administered as follows: stages I/II, 6 patients received RT alone; stages III/IVA, 20, 5, and 32 patients received RT alone, CCRT, and CCRT followed by ND, respectively; stage IVB, 9 and 7 patients received CCRT and CCRT plus ND, respectively. RESULTS: After a median follow-up of 56 months (range, 12 to 122 mo), the 5-year local control (LC), regional control (RC), distant control (DC), and overall survival (OS) by stage were as follows: stage I-II 100%, 100%, 100%, 100%; stage III-IVA 98%, 96%, 95%, and 88%; stage IVB 100%, 100%, 69%, and 66%, respectively. Among stage IVB patients, DC was significantly lower (P=0.01) and a trend toward lower OS was noted (P=0.08). Long-term percutaneous endoscopic gastrostomy dependence was noted in 3% of them who had received CCRT. The effect of both chemotherapy and ND on treatment outcomes was analyzed; in stage III/IVA patients treated with or without chemotherapy, LC was 97% and 100% (P=0.43); RC was 92% and 100%(P=0.27); and DC was 91% and 94% (P=0.92), respectively. In stage III/IVA, patients treated with CCRT with or without ND, RC was 100% and 88%, respectively (P=0.087). CONCLUSIONS: Primary radiotherapy with or without CCRT followed by ND provides excellent tumor control with acceptable toxicity in treating squamous cell carcinoma of the tonsil.

AIM: Metastasis of unknown primary (MUP) is commonly treated with radiation therapy (RT) to the entire mucosal surfaces and bilateral neck nodes (LN). We report outcomes of oropharynx-targeted RT, retropharyngeal nodes (RPN) and bilateral LN in this context. PATIENTS AND METHODS: Single-Institution retrospective study of 68 patients. Forty percent were treated with intensity-modulated radiation therapy (IMRT). Fifty-six percent received concurrent chemoradiotherapy (CCRT). The median age was 58 years, 82% were Caucasian, and 75% males. Stage III disease was present in 9%, stage IVA in 75% and IVB in 16%. RESULTS: At a median follow-up of 3.5 years, the actuarial locoregional control was 95.5%. The emergence of primary developed in 1patient (1.5%) and 2patients (3%) failed in the neck. The median time-to-locoregional failure (LRF) was 18 months. Actuarial long-term RT toxicity was grade 1 xerostomia (68%), dysphagia (35%), neck stiffness (15%) and trismus (6%). CONCLUSION: RT to the oropharynx, RPN, and bilateral neck provides excellent oncological and functional outcomes in MUP in non-Asian patients. Sparing the mucosal surfaces of the nasopharynx, hypopharynx, and larynx seems reasonable without impacting on survival and locoregional control.