Faculty Bibliography

OBJECTIVE: Sinonasal undifferentiated carcinoma (SNUC) is a rare and aggressive malignancy with optimal management remains unclear. We performed a review of the impact of trimodality approach on SNUC outcome. METHODS: This is a single-institution retrospective study of 18 patients, who were managed between 1997 and 2009. The median age at presentation was 52 years (28 to 82). Nine patients (50%) were female. Three patients had stage II disease and underwent surgery alone, 12 had stages III and IVa and underwent surgery combined with chemoradiation, and 3 had stage IVb and underwent definitive chemoradiation. Patients who underwent preoperative, postoperative, and definitive chemoradiation received 60, 66, and 70 Gy of radiation, respectively. In all patients receiving concurrent chemoradiation, cisplatin was used, at a dose of 100 mg/m every 3 weeks for 3 cycles. Neoadjuvant chemotherapy included docetaxel, cisplatin, and 5-fluorouracil (TPF) every 3 weeks for 2 to 3 cycles. RESULTS: After a median follow-up of 26 months (16 to 120), a total of 8 patients (44%) have experienced the following: 1 persistent disease (5.5%), 4 local failure (22%), and 3 distant metastases (DM, 16.5%). Five of the 8 patients had preexisting cranial nerve deficits or gross cranial invasion. The 2-, 3-, and 4-year local control (LC), disease-free survival (DFS), and overall survival (OS) were 78%, 72%, and 56%; 75%, 65%, and 52%; and 75%, 50%, and 48%, respectively. Trimodality approach provided 83% LC and 92% DM-free survival, whereas other modalities provided 50% LC and 33% DM-free survival. The causes of death for the entire cohort were DM and local invasion. Acute chemoradiotherapy toxicity was 100% grades 1 and 2 dermatitis, mucositis, and fatigue, 55% developed grades 1 and 2 dysphagia, and 6% had grade 3 mucositis. Long-term toxicity was 28% grade 1 xerostomia, 11% retinopathy and optic neuropathy, and 6% orbital exenteration and grade 3 peripheral neuropathy. CONCLUSIONS: SNUC is an aggressive neoplasm that frequently presents at an advanced stage. Our data show that trimodality approach in the form of surgery combined with chemoradiation seems to offer better LC and lower DM compared with other modalities.

BACKGROUND CONTEXT: Although cervical spine reconstruction with osteocutaneous fibular flap microvascular grafting has been described, simultaneous reconstruction of the cervical vertebral column and laryngectomy have not been described. PURPOSE: To present a unique case of combined cervical spine and laryngectomy reconstruction. STUDY DESIGN: Case report. METHODS: We modified a previously reported procedure reconstituting the cervical spine and pharynx with a single fibular flap in a case of posterior pharyngeal ulceration and osteomyelitis/osteoradionecrosis without spinal deformity. RESULTS: We present a case of simultaneous cervical stabilization and pharynx reconstruction with a fibular graft in a life-saving treatment of osteoradionecrosis complicated by acute cervical kyphosis and spinal cord compression in a 55-year-old patient with extensive head and neck cancer history and recent recurrence of hypopharyngeal cancer. CONCLUSIONS: Rigid anterior plate fixation and subsequent posterior fixation were required after corpectomy and total laryngectomy in our patient with extensive surgical scarring and radiation history because of severe spinal deformity secondary to osteoradionecrosis. We achieved successful preservation of neurologic function and resolution of pain.

OBJECTIVES/HYPOTHESIS: To report tolerance and toxicity of radiotherapy (RT) with or without chemotherapy in HIV seropositive patients with squamous cell carcinoma of the head and neck (SCCHN). METHODS: This is a single institution retrospective study of 73 HIV seropositive patients with SCCHN treated from January 1997 through 2010. Stages I, II, III, and IV were 8%, 10%, 24%, and 58%, respectively. The median age at RT, HIV diagnosis. and the duration of HIV seropositive were 51 (32-72), 34 (25-50), and 11 (6-20) years, respectively. Patients were treated definitively with RT alone (35%) or concurrent chemo-RT (65%). Median dose of 70 Gy (66-70) was delivered to the gross disease. Median duration of treatment was 52 (49-64) days. Fifty patients (70%) were on HAART. RESULTS: RT+/- chemotherapy induced acute toxicity was: median weight loss 20 pounds (6-40), 100% developed dysgeusia and xerostomia (grades 1-3). Acute mucositis and dysphagia/odynophagia grades 2 were 26% and 23% of patients, respectively. CONCLUSION: Our data show that primary RT +/-chemotherapy for HIV seropositive SCCHN is less tolerated compared to the historical data for SCCHN without HIV. LEVEL OF EVIDENCE: 2b.

IMPORTANCE: Functional recovery for patients who undergo maxillomandibular reconstruction with vascularized bone free flaps (VBFFs) is potentially more attainable with computer-assisted implant rehabilitation. This prosthodontic-driven approach uses software planning and surgical templates for implant placement supporting fixed dental prostheses (FDP). Implant success with immediate load (IL) provisional and definitive FDP restorations in VBFFs is reported for the first time in a patient cohort. OBJECTIVES: To determine implant success for FDP restorations and IL restorations. To determine factors that may influence success and predictability to provide FDP restorations in VBFFs. DESIGN: A retrospective medical chart review was conducted of patients who underwent VBFF reconstruction and computer-assisted planning (CP) for FDP implant rehabilitation. This study was conducted with approval from the institutional review board at Beth Israel Medical Center, New York, New York. SETTING: Clinical procedures were conducted in operating room and outpatient facilities in a tertiary referral medical center. PARTICIPANTS: Twenty-eight consecutive patient treatments were reviewed. Inclusion criteria for all patients were VBFF reconstruction and CP for FDP restoration prior to stage 1 implant surgery. Patients were evaluated for implant success, surgical templates, IL provisional restorations, and prosthodontic framework design. A comparison is made between patients with IL provisional restorations and those patients who did not receive an immediate restoration. MAIN OUTCOMES AND MEASURES: Implants that achieved osseointegration and used for prosthetic reconstruction determined success. Prosthodontic design considerations included whether the patient received an IL provisional restoration and 3 categories of FDP metal framework design. RESULTS Ninety-nine implants of 116 implants placed were used for prosthetic restorations, achieving an 85.4% success rate. Twenty-five of 28 patients received FDP restorations. Thirteen of 28 patients received IL provisional restorations at stage 1 implant surgery. Fifty of 56 implants were successful (89.3%) in the IL group. CONCLUSIONS: Computer-assisted implant rehabilitation of reconstructed defects can achieve superior results to provide FDP and IL provisional restorations. This prosthodontic-driven approach also uses unique framework design to account for mandible height discrepancy after fibula free flap reconstruction. Patient management for FDP rehabilitation is also dependent on radiation status, soft-tissue modification, and patient selection.

BACKGROUND: The purpose of this article was to present the Beth Israel Medical Center experience using high-dose-rate intraoperative radiotherapy (HDR-IORT) in the management of recurrent head and neck cancer. METHODS: We conducted a retrospective review of all patients with locally or regionally recurrent head and neck cancer who underwent HDR-IORT at our institution between 2001 and 2010. RESULTS: Seventy-six patients were identified who underwent treatment to a total of 87 sites after gross-total resection. The 2-year estimate of in-field tumor control was found to be 62%. Median overall survival was 19 months with 42% of the patients surviving at least 2 years. Significantly longer survival was found for patients achieving in-field control versus infield progression (33 months vs 17 months, respectively; p = .01). CONCLUSION: HDR-IORT is well tolerated and associated with encouraging in-field disease control. In-field control is associated with improved survival. Further study is warranted to more fully investigate HDR-IORT in the salvage setting.

BACKGROUND: Patients with small, low-/intermediate-risk parotid cancers, treated with surgery, and who have the single prognostic factor of close and/or positive margins, constitute an unusual subset. This study evaluates local control and morbidity associated with postoperative radiation therapy for low/intermediate grade parotid cancer in these patients. METHODS: Between 1999 and 2006, 17 patients underwent postoperative radiation therapy at Beth Israel Medical Center for acinic cell carcinoma or low-intermediate-grade mucoepidermoid carcinoma of the parotid with close/positive margins. Pathology, treatment, and follow-up data were retrospectively analyzed for morbidity and local control. Two- and 5-year estimates of survival outcomes were performed followed by an analysis of complications. RESULTS: There were no local failures and no significant long-term complications. CONCLUSIONS: Patients with small, low-risk cancer of the parotid gland have excellent local control and low treatment-related morbidity when receiving postoperative radiation therapy for positive or close margins of resection.

OBJECTIVES/HYPOTHESIS: To assess the current state of mentorship in otolaryngology residency. STUDY DESIGN: Internet-based anonymous survey of chief residents in otolaryngology residency. METHODS: Nonidentifying demographic information, career plans, and general questions about residency experience were queried. Participants were asked to rate their mentorship experience in general and specifically with regard to research, personal quality of life, and career preparation. Responses were scored using a five-point ordinal Likert scale, with higher scores representing more favorable responses. RESULTS: The survey was completed by 47 (17.2%) respondents. Eighteen respondents (38%) were assigned an official faculty mentor, and 23 respondents (49%) were assigned a research mentor during their residency. Thirty-nine respondents (83%) reported receiving meaningful mentorship from faculty who were not officially assigned mentors. Overall, 18 respondents (38%) were neutral or not satisfied with the mentorship they received during residency. Statistically significant higher scores were noted for mentorship in career preparation (median, 4) versus mentorship in research (median, 4; P < .001) and resident quality of life (median, 3; P < .001). Lower scores were noted for availability of mentorship in preparation for a career in private practice versus academic medicine (median, 4 vs. 5; P < .001). Residents who were officially assigned mentors reported statistically significant higher scores with regard to satisfaction with the overall mentorship experience (median, 4 vs. 3; P = .05) and different aspects of mentorship in career preparation and research training. CONCLUSIONS: The current study reveals variability in the mentorship experience in otolaryngology residency. Potential deficiencies may exist, including absence of formal mentorship in some residency programs. Increased attention to mentorship, especially with regard to research, career preparation, and quality of life may improve the overall residency experience.