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Background We sought to develop mapping functions that use EORTC responses to approximate health utility (HU) scores for patients with head and neck cancer (HNC). Methods In total, 209 outpatients with HNC completed the EORTC QLQ-C30 & QLQ-H&N35 (EORTC), EQ-5D-5L and the HUI-3. Results of the EORTC were mapped onto both EQ-5D-5L and HUI-3 scores using ordinary least squares regression and two-part models. Results The OLS model mapping EORTC onto the EQ-5D-5L performed best (adjusted R2 = .75, 10-fold cross-validation RMSE = 0.064, MAE 0.050). The HUI-3 model mapping onto EORTC through OLS was more limited (adjusted R2 = .5746, 10-fold cross cross-validation RMSE = 0.168, MAE 0.080). The EQ-5D-5L model was able to discriminate between certain clinical indices of disease severity on subgroup analysis. Conclusion The EORTC to EQ-5D-5L mapping algorithm has good predictive validity and may enable researchers to translate EORTC scores into HU scores for head and neck patients with cancer.

Introduction The scapula tip free flap has been described for reconstruction of short mandible defects with extensive soft tissue needs. The versatility of this flap has not been extensively described. Methods Retrospective case series of patients who underwent mandibulectomy and reconstruction with the scapula tip free flap from 2005 to 2016. Outcomes include bony union, complications, dental rehabilitation, and donor site morbidity. Results A total of 120 patients were identified. Average harvested bone was 7.7 cm, with 54% undergoing one osteotomy, and 76.7% harvested as a chimeric flap. Radiographically, average inset bone was 6.6 cm. Complete or partial bony union was observed at 74.4% of proximal and 82.6% of distal osteotomies. A 95% of reconstructions met criteria for dental implants. Mean disabilities of the arm, shoulder and hand score was 21.2. Conclusions The scapular tip is an excellent option for reconstruction of segmental mandible defects with the option of osteotomy, excellent bony union rates, low donor site morbidity, and potential for dental rehabilitation.

Background Radiologic assessment of mandibular bone invasion is critical in evaluating the extent of bone resection required in patients with oral cancer. There are a few reports of improved sensitivity with cone-beam CT (CBCT) over conventional CT. Methods A prospective cohort study of patients with oral squamous cell carcinomas adjacent to the mandible requiring marginal or segmental mandibular resection was performed. Patients were treated based on clinical assessment and conventional cross-sectional imaging. Patients and surgeons were blinded to the results of CBCT performed preoperatively. Pathologic examination served as the gold standard. Results Forty-five patients were included in the study. Thirty-three percent of the patients underwent segmental mandibulectomy and 37% had bone invasion. The sensitivity and specificity of CBCT were 91% and 60%, respectively, compared to 86% and 68% for CT with bone windows. Conclusion A CBCT offers marginally improved sensitivity at the cost of reduced specificity for assessment of bone invasion compared to CT.

Background Given the dramatic changes in global head and neck cancer epidemiology, the purpose of this study was to present the findings of our investigation on patterns of head and neck cancer incidence/survival within the province of Ontario, Canada. Methods Temporal variations in age/sex adjusted incidence and survival were analyzed for all incident head and neck cancer cases (n = 20 781) managed within Ontario from 1993-2010. Results From 1993-2010, the incidence of oropharyngeal (average annual percentage change [AAPC] 4.56%; P

Background The primary purpose of this study was to examine whether angiosarcoma outcomes differ for the scalp and face. Methods We conducted a retrospective outcomes analysis of 50 patients with cutaneous angiosarcoma treated by curative intent identified from the Princess Margaret Cancer Centre Registry (from 1958 to 2014). Results Median survival was 26 months (95% confidence interval [CI], 17.6-34.6) and median follow-up 29 months. For the scalp and face, respectively, the 5-year locoregional control rate was 9% and 53% (p = .04); the recurrence-free survival (RFS) rate was 5% and 27% (p = .017); and the overall survival (OS) rate was 9% and 26% (p = .017). Scalp lesions were larger, more likely to be multifocal, and presented more rapidly once noticed. In multivariate Cox proportional hazards analysis, scalp location was independently prognostic for mortality (hazard ratio [HR], 2.10; 95% CI, 1.03-4.28; p = .04). Conclusion Scalp angiosarcoma has worse survival than angiosarcoma of the face. Scalp angiosarcoma tends to be larger at presentation, which may be because it is not noticed until more advanced. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1205-1211, 2017.

Background Body mass index (BMI) has been associated variably with head and neck cancer outcomes. We evaluated the association between BMI at either diagnosis or at early adulthood head and neck cancer outcomes. Methods Patients with invasive head and neck squamous cell cancer at Princess Margaret Cancer Centre in Toronto, Canada, were surveyed on tobacco and alcohol exposure, performance status, comorbidities, and BMI at diagnosis. A subset also had data collected for BMI at early adulthood. Results With a median follow-up of 2.5 years, in 1279 analyzed patients, being overweight (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.4-0.8; p = .001) at diagnosis was associated with improved survival when compared with individuals with normal weight. In contrast, underweight patients at diagnosis were associated with a worse outcome (HR, 1.89; 95% CI, 1.2-3.1; p Conclusion Being underweight at diagnosis was an independent, adverse prognostic factor, whereas being overweight conferred better prognosis. BMI in early adulthood was not associated strongly with head and neck cancer outcomes. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1226-1233, 2017.

Background The pupose of this study was to describe variations in incidence and resection rates of patients with oral cavity squamous cell carcinoma (SCC) in Ontario. Methods All oral cavity SCCs in Ontario between 2003 and 2010 were identified from the Ontario Cancer Registry. Incidence and resection rates along with variations in care were compared by sociodemographic factors and Ontario health regions. Results The 8-year incidence rates for oral cavity SCC was 21.3 per 100,000 with variations by sex, age group, neighborhood income, and community size. Seventy-four percent of patients underwent an oral cavity cancer resection, of which 91% were at a regional head and neck cancer center. Variations in resection rates existed by region of residence and treatment. Conclusion Oral cavity cancer incidence rates vary by sex, age, neighborhood income, community size, and health region. Resection rates vary by age and health region. Oral cavity cancer care is highly regionalized in Ontario. © 2015 Wiley Periodicals, Inc. Head Neck 38: 1113-1118, 2016.

BACKGROUND The prognostic significance of human papillomavirus (HPV) in the context of head and neck squamous cell carcinoma (HNSCC) of cancer of unknown primary (CUP) origin is unclear. METHODS Patients treated for CUP at the Princess Margaret Cancer Centre between 2001 and 2013 were stratified by p16 status and retrospectively reviewed. RESULTS Of the 73 patients included, those with p16-positive tumors (63%) had less advanced nodal status (N1-N2b; 52% vs 89%; p = .035) and less aggressive treatment. Patients with p16-positive tumors had improved 3-year disease-free survival (DFS; 79% vs 56%; p = .012) independent of nodal status and treatment in multivariable analysis (hazard ratio [HR] = 0.27; 95% confidence interval [CI] = 0.08-0.95). CONCLUSION Among patients with CUP, p16-positive status is an independent predictor of DFS but not overall survival (OS). © 2016 Wiley Periodicals, Inc. Head Neck, 2016 © 2016 Wiley Periodicals, Inc. Head Neck 38: 1347-1353, 2016.

Background The purpose of this study was to measure adherence rates to guideline-recommended process measures in patients with head and neck cancer. Methods A total of 5720 patients who underwent surgery for head and neck cancer in Ontario between 1993 and 2010 were identified from administrative databases. Adherence to 4 guideline-recommended processes of care was measured and stratified by hospital and physician case volume. Results Seventy-two percent of patients received preoperative head and neck imaging, 83% received preoperative chest imaging, 58% received preoperative multidisciplinary consultation, and 77% had appropriate follow-up visits. Higher surgeon and hospital surgical volumes were associated with higher adherence rates. Conclusion Adherence rates to guideline-recommended processes of care in the surgical management of patients with head and neck cancer in Ontario were moderate and should be improved. Although adherence rates seem proportional to surgical volume, even the highest volume centers have room to improve. © 2016 Wiley Periodicals, Inc. Head Neck, 2016

Background The purpose of this study was to determine the clinical outcomes of T4 laryngeal cancers. Methods T4 laryngeal cancers treated with curative intent from January 2003 to December 2010 were analyzed. Outcomes were evaluated in both primary radiotherapy (+/− chemotherapy) (RT/CRT) and primary surgery cohorts. Results Among the 65 primary RT/CRT and 42 primary surgery patients included, median follow-up was 4.4 years. There was a trend for improved locoregional control with surgery (74% vs 88%; p = .08). In the RT/CRT group the 3-year laryngectomy-free survival was 67%. The 2-year gastrostomy dependency rate was 23% with RT/CRT versus 6% with primary surgery (p = .07). Overall survival (OS) at 3 years was significantly lower in the RT/CRT versus primary surgery group (41% vs 70%; p < .01). Conclusion Laryngeal preservation is achieved in over two thirds of patients with primary RT/CRT. Patients with low volume minimal cartilage involvement T4 disease may be best suited to RT/CRT. © 2016 Wiley Periodicals, Inc. Head Neck, 2016

Background High resolution ultrasound has led to early detection of subclinical tumors and drastic increase in incidence of thyroid malignancy. To achieve a balance in appropriate investigation without perpetuating an overdiagnosis phenomenon, a concise set of evidence-based recommendations to stratify risk is required. Methods We sought to assemble an evidence-based diagnostic algorithm and accompanying pictorial review for workup of thyroid nodules that summarizes the most recent guidelines. In addition, we conducted a literature search and analysis of our imaging databases. Results Although many imaging features of benign and malignant nodules can be nonspecific, others, such as microcalcifications, lymphadenopathy, and peripheral invasion, are highly suggestive of malignancy. The predictive values of salient imaging characteristics are presented. Conclusion Evidence-based guidelines are available such that a cost-effective algorithm for thyroid nodule workup can be devised. Conservative management with a focus on periodic monitoring is the working clinical consensus on the approach to thyroid nodules.

Background Whether elective lymph neck dissection (ELND) is associated with improved survival in oral squamous cell carcinomas (SCC) of the maxillary alveolus/hard palate is not known. Methods One hundred ninety-nine patients presenting de novo and receiving treatment for clinically node negative SCC of the maxillary alveolus/hard palate at 2 cancer centers between 1985 and 2011 were analyzed. Results Forty-two patients (21%) received ELND. Occult nodal metastases were present in 29% of the dissected necks. The ELND group had more T3 to T4 status tumors (62% vs 34%; p < .001) and positive-margin resections (59% vs 38%; p = .019). Patients undergoing ELND experienced lower rates of neck recurrence (6% vs 21%; p = .031), superior 5-year recurrence-free survival (68% vs 45%; p = .026), and overall survival (86% vs 62%; p = .043). ELND was associated with a 2-fold decrease in risk of recurrence in multivariable analysis. Conclusion ELND was associated with lower rates of recurrence and improved survival in SCC of the maxillary alveolus/hard palate. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

Background Endoscopic approaches have been adopted as an alternative to craniofacial resection in the surgical management of olfactory neuroblastoma. Methods We conducted a systematic review and meta-analysis using MEDLINE, EMBASE, Cochrane, and CINAHL (2000–2014) to compare outcomes for open versus endoscopic approaches. Results Thirty-six studies containing 609 patients were included. Meta-analysis of (a) all patients, (b) Kadish C/D only, and (c) Hyams III/IV only, failed to show a difference in locoregional control and metastasis-free survival between approaches. However, endoscopic approaches were associated with improved overall survival (OS) for all 3 groups (p = .001, .04, and .001, respectively), and higher disease-specific survival (DSS) for all patients (p = .004) and Hyams III/IV only (p = .002). Conclusion The current study suggests that endoscopic approaches have comparable control rates to open approaches for olfactory neuroblastoma. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

Background The purpose of this article was to report outcomes of reirradiation for locoregionally recurrent nasopharyngeal carcinoma (NPC). Methods A retrospective review was conducted of all patients with locoregionally recurrent NPC who received reirradiation between 2001 and 2012. Overall survival (OS), local control, regional control, distant control, and Radiation Therapy Oncology Group (RTOG) grades 3 to 4 late toxicity were examined. Results A total of 42 recurrent cases treated with intensity-modulated radiotherapy (IMRT; 27 patients) or non-IMRT (stereotactic radiotherapy [RT], 12 patients; 3D conformal RT, 3 patients) were identified. Median time from initial RT to recurrence was 4.6 years. Hyperfractionation with 1.1 to 1.4 Gy/fraction twice daily to a total of 40 to 60 Gy was used in 27 IMRT and 5 non-IMRT patients. The remaining 10 patients received conventional fractionation 1.8 to 2.0 Gy/fraction to 50 to 60 Gy. Median follow-up was 3.0 years. The 3-year OS, local control, regional control, distant control, and late toxicity rates were 49%, 46%, 71%, 79%, and 37%, respectively. Conclusion Reirradiation for recurrent NPC, delivered mostly with hyperfractionated IMRT, can result in durable disease control with acceptable late toxicity. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

Background Salivary duct carcinoma is rare, with distinct morphology and behavior. We reviewed our institutional experience with salivary duct carcinoma, aiming to characterize clinical behavior and treatment outcomes. Methods All salivary duct carcinomas treated curatively between 1999 and 2010 were reviewed. Overall survival (OS), locoregional control, distant control, and patterns of failure were analyzed. Multivariate analysis identified predictors of OS. Results Fifty-four patients with salivary duct carcinoma (parotid gland = 49; submandibular gland = 5) were included in the analysis. Fifty-three patients underwent primary surgery, and 48 (89%) received postoperative radiotherapy (RT; median dose = 60 Gy). Median follow-up was 5.7 years. The 5-year OS, locoregional control, and distant control were 43%, 70%, and 48%, respectively. Nine local (6 involving facial nerve), 10 regional, and 28 distant failures were identified. Multiple pathologic involved lymph nodes (pN2b/N2c) predicted reduced OS (hazard ratio [HR] = 3.6; p = .02). Conclusion Distant recurrence is common. Presence of pN2b/N2c disease is associated with reduced OS. Local recurrence frequently involves the facial nerves. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

Background The present study is an economic evaluation comparing transoral robotic surgery (TORS) to (chemo)radiotherapy for the management of early T-classification oropharyngeal cancer. Methods A societal perspective was adopted. Treatment for TORS and (chemo)radiotherapy were modeled using decision analysis and recurrences were modeled over a 10 year horizon with a Markov model. Model parameters were derived from systematic review. Deterministic and probabilistic sensitivity analyses were used to test model robustness. Results TORS demonstrated a cost savings of $1366 and an increase of 0.25 quality-adjusted life years (QALYs) per case in comparison to (chemo)radiotherapy. TORS was sensitive to variations in adjuvant therapy, costs, utilities, complications, and recurrence rates in deterministic and probabilistic sensitivity analysis. In two-way sensitivity analysis, with increasing adjuvant therapy for TORS and decreasing concurrent chemotherapy for radiotherapy, TORS is decreasingly cost-effective. Conclusion TORS is cost-effective for treatment of early oropharyngeal cancer. Case selection to minimize adjuvant therapy ensures cost-effective treatment. © 2014 Wiley Periodicals, Inc. Head Neck, 2015

Background The purpose of this study was to evaluate the individual and combined relationship of comorbidity and performance status (PS) on head and neck squamous cell carcinoma (HNSCC) survival. Methods Six hundred patients with HNSCC were prospectively recruited. Comorbidity and PS were measured using the Charlson Comorbidity Index (CCI) and the Eastern Cooperative Oncology Group (ECOG) Scale. Outcomes were overall survival (OS) and cancer-specific survival (CSS). Results A total of 48.3% of the patients had at least 1 comorbidity, and 42.3% had impaired PS at baseline. There was no correlation between CCI and ECOG (Spearman's ρ = 0.033; p = .42). In multivariate analysis, CCI score was significantly associated with OS (p = .01). ECOG was not associated with OS, but seems to act as an effect modifier in the association between comorbidity and OS. CCI and ECOG were not associated with CSS. Conclusion CCI and ECOG scores both provide prognostic information in predicting OS in HNSCC, but a significant association with CSS was not observed. © 2015 Wiley Periodicals, Inc. Head Neck 38: 736–742, 2016

Background Adult laryngotracheal reconstruction for airway stenosis and after oncologic ablation can be extremely challenging. Methods Patients with the above conditions not amenable to or refractory to conventional treatments were offered specialized reconstruction by wrapping a contoured costal cartilage graft with a vascularized microvascular carrier. All constructs were lined with buccal mucosa grafts. Decannulation rates, quality of life questionnaires, and pulmonary function tests were performed and analyzed. Results Eleven patients underwent this procedure, 6 for stenosis and 5 for laryngotracheal oncologic defects. Ten patients were successfully decannulated after the procedure (91%). Median time to decannulation was 4 months. At mean follow-up of 76 months, all evaluated patients had a serviceable voice, tolerated a normal diet, and had minimal subjective shortness of breath. Conclusion Vascularized composite autograft can be successfully used to treat severe subglottic stenosis or reconstruct large laryngotracheal defects not amenable to or refractory to conventional treatments. © 2014 Wiley Periodicals, Inc. Head Neck 38: 253–259, 2016

Background In this cross-sectional study, the sensibility, test-retest reliability, and validity of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire were assessed in patients who underwent neck dissection. Methods Sensibility was assessed with a questionnaire. Test-retest reliability was performed with completion of the DASH questionnaire 2 weeks after initial completion; validity, by evaluating differences in scores between patients undergoing different types of neck dissections and correlating DASH scores with Neck Dissection Impairment Index (NDII) scores. Results The DASH questionnaire met sensibility criteria. For test-retest reliability analysis, the intraclass coefficient was 0.91. The DASH questionnaire showed differences between patients who underwent accessory nerve-sacrifice and nerve-sparing neck dissection. DASH questionnaire scores strongly correlated with NDII scores (r = -0.86). Conclusion Although this study provides preliminary data on some psychometric properties of the DASH questionnaire in patients who have undergone a neck dissection, further assessment of responsiveness and other properties are required. © 2014 Wiley Periodicals, Inc. Head Neck 37: 234-242, 2015

Background The purpose of this study was to compare outcomes between human papillomavirus (HPV)-related versus -unrelated head and neck cancer after pathological positive planned neck dissection. Methods Positive planned neck dissection for head and neck cancers from 1998 to 2010 were included in this study. Outcomes after planned neck dissection were compared between HPV-related versus -unrelated cohorts. Multivariate analysis identified survival predictors. Results HPV-related head and neck cancer (n = 32) had better 5-year overall survival (48% vs 27%; p = .021), marginally lower second malignancy (7% vs 16%; p = .13), but similar local, regional, and distant control (87% vs 89%; 94% vs 89%; 62% vs 58%, respectively) versus HPV unrelated (n = 38). HPV status conferred reduced risk of death (hazard ratio [HR], 0.5; p = .038) after adjusting for age, smoking, and initial T and N classifications. Conclusion This study reveals that positive planned neck dissection for HPV-related head and neck cancer represents a biologic unfavorable subset of the HPV population with unsatisfactory survival attributable to distant metastasis. The longer survival compared to the HPV-unrelated counterpart is likely related to a marginally lower second malignancy rather than better disease control. © 2014 Wiley Periodicals, Inc. Head Neck 37: 946–952, 2015

Background The prognostic utility of comorbidity on head and neck cancer may differ by subsite, stage, and human papillomavirus (HPV) status. Methods We reviewed the medical records of 4953 patients with head and neck cancer for comorbidity (Charlson Comorbidity Index [CCI]), smoking, and alcohol history. Multivariate proportional hazards assessed the association of CCI with survival. HPV status was determined using p16 immunohistochemistry. Results After accounting for stage, higher CCI was associated with worse overall survival (OS) in nasopharyngeal (hazard ratio [HR], 2.93; 95% confidence interval [CI], 1.53–5.62), oropharyngeal (HR, 1.99; 95% CI, 1.63–2.43), and oral cavity cancers (HR, 1.54; 95% CI, 1.27–1.86). These associations were most prominent in the early stage oral cavity (HR, 2.11; 95% CI, 1.50–2.96) and laryngeal (HR, 1.87; 95% CI, 1.35–2.58) cancers, and in advanced stage oropharyngeal (HR, 2.23; 95% CI, 1.81–2.74) and nasopharyngeal (HR, 3.50; 95% CI, 1.76–6.97) cancers. CCI was independently prognostic even in the HPV-adjusted oropharyngeal cancers. Conclusion Comorbidity was prognostic in subsets of nasopharyngeal, oropharyngeal, oral cavity, and laryngeal cancers. Comorbidity may be a partial surrogate for age and social habits. © 2013 Wiley Periodicals, Inc. Head Neck 36: 802–810, 2014

Background The purpose of this article was to provide a review of the literature on shoulder disability after neck dissection. Methods A literature review was performed using Ovid Medline and Embase databases. A total of 306 abstracts and 78 full-text articles were reviewed. Forty-two articles were eligible for inclusion. Results Patients undergoing nerve-sacrifice neck dissections have greater disability and lower quality of life scores than those undergoing neck dissections with the least manipulation (ie, selective neck dissections). Shoulder impairments can still occur in patients undergoing selective neck dissections. Disability typically improves over time in patients undergoing nerve-sparing neck dissections. Conclusion There was significant variability in the literature in terms of the prevalence and recovery of shoulder morbidity after neck dissection. This variability may not just be related to surgical technique or rehabilitation, but also to study design, definitions, and the variability in disability questionnaires used. © 2013 Wiley Periodicals, Inc. Head Neck 36: 299–308, 2014

Therapeutic central neck dissection for differentiated thyroid cancer is recommended in the setting of clinically positive disease. The role of lymphadenectomy in patients with clinically negative disease is a matter of controversy and therefore extent of surgery varies. The boundaries of the central neck are variably described, as are the components of a central neck dissection. Patients with aggressive disease are managed with a comprehensive dissection, yet there is no classification system to distinguish this from a less rigorous operation. Therefore, there is variability in reporting and difficulty in the interpretation of results in the published literature. Here we propose a novel classification system for central neck dissection in thyroid cancer that allows accurate reporting of extent of surgery. The objectives are to reduce ambivalence and allow documentation of extent of lymphadenectomy, such that comparisons can be made between the varied strategies in the management of the central compartment.

Background The aim of this study was to identify new target proteins in sebaceous gland carcinoma. Methods A tissue microarray containing 115 core biopsies was constructed and stained for proteins involved in carcinogenesis, angiogenesis, inflammation, and cell-to-cell contact. Two investigators independently determined protein expression of all antibodies. Results Vascular endothelial growth factor receptor 2 (VEGFR-2), platelet-derived growth factor receptor alpha and beta (PDGFR-α/-β), epidermal growth factor receptor (EGFR), cyclooxygenase 1 and 2 (Cox-1/-2), myeloid cell leukemia sequence 1 (Mcl-1), matrix metalloproteinase 1 (MMP-1), CD9, Bmi-1, 14-3-3σ, glutathione S-transferase pi (Gstπ), and members of the sonic hedgehog (SHH), AKT, and WNT pathways were significantly overexpressed in sebaceous gland carcinomas. Conclusions We have demonstrated for the first time that proteins related to angiogenesis, inflammation, and cell proliferation are overexpressed in sebaceous gland carcinomas. These proteins may hold promise as novel therapeutic targets for the treatment of sebaceous gland carcinoma. © 2012 Wiley Periodicals, Inc. Head Neck, 2013

Background The purpose of this study was to analyze the outcomes and treatment in patients with squamous cell carcinoma (SCC) of the oral tongue, as well as validate previously reported predictors of survival. Methods We retrospectively reviewed 259 patients treated with curative intent between 1994 and 2004. Kaplan–Meier estimates, log-rank test, and Cox regression models were used for statistical analysis. Results Two hundred fifty-nine patients were managed with surgery; 67 patients (25%) received adjuvant radiotherapy. Mean follow-up was 60 months. The 5-year local and regional control rates were 78% and 69.4%, respectively. The 5-year overall, disease-specific, and recurrence-free survival rates were 69%, 70.9%, and 53%, respectively. The only significant predictor of both overall survival (OS) and disease-free survival (DFS) on multivariable analysis was pathologic N classification. Conclusion Treatment of early tongue SCC effectively achieves local control and DFS. Nodal disease remains to be 1 of the most important prognostic factors in terms of recurrence and survival. © 2012 Wiley Periodicals, Inc. Head Neck, 2013

Background The purpose of this study was to discuss the appropriate management options for parathyroid carcinomas, which is still a subject of controversy. Methods A retrospective chart review of 16 patients with parathyroid carcinoma was undertaken to determine the clinical outcome. Results All patients were initially treated with surgery, and 11 patients received adjuvant radiotherapy. The 5- and 10-year disease-specific survival rates were 100% and 80%, respectively; the 5- and 10-year disease-free survival rates were 69% and 43%, respectively. The 5- and 10-year locoregional control rates were 69% and 52%, respectively; the 5- and 10-year distant control rates were 89% and 74%, respectively. In this cohort, none of the clinicopathologic parameters could be defined as a predictor. Conclusion In patients with parathyroid carcinoma, definition of prognostic factors and the role of adjuvant radiation treatment has still to be elucidated. Nevertheless, angioinvasion and positive resection margins are critical factors regarding disease-free survival in patients with parathyroid carcinomas. © 2012 Wiley Periodicals, Inc. Head Neck, 2013

Background The objective of the study was to evaluate the prognostic and therapeutic implications of an initial positive frozen section margin that was revised until negative (microscopic tumor cut-through), and to analyze the influence of microscopic margin status on oral carcinoma control. Methods The approach in our investigation was through a retrospective review of patients treated with primary surgery, with frozen section margin control in oral carcinoma. Inclusion criteria included availability of frozen and permanent section histology reports of resection margins and negative final resection margins. Results Of 547 patients studied, 175 received adjuvant radiation. Local and regional control and disease-specific survival rates were 81.6%, 78.4%, and 76.3%, respectively. Tumor cut-through and pathologic nodal (pN) stage had an independently adverse effect on local control. Tumor cut-through adversely affected cancer control and survival, but this effect diminished significantly in the absence of regional disease. Conclusions Microscopic tumor cut-through revised to negative margins is a powerful prognosticator that is observed only when regional disease is also present. The value of adjuvant therapeutic regimens is questionable in patients with microscopic tumor cut-through, revised to negative margins, and with no regional disease. © 2010 Wiley Periodicals, Inc. Head Neck, 2010

Background. We aimed to determine predictors of morbidity in patients undergoing microvascular free flap reconstruction of the head and neck. Methods. We prospectively evaluated 796 cases between 1999 and 2007 using univariate and multivariate analysis to determine predictors of morbidity and prolonged hospital stay. Results. Two hundred thirty-nine patients (30%) developed major complications. Age, body mass index (BMI), American Society of Anesthesiology (ASA) score, Kaplan Feinstein comorbidity index (KFI) score, preoperative hemoglobin, and tracheostomy were independent predictors of major complica- tion. Predictors of prolonged hospital stay included age, recent weight loss, alcohol excess, ASA, KFI, preoperative hemoglo- bin, mucosal surgery, anesthesia duration, and crystalloid replacement volume. Conclusion. Several variables are associated with an increased risk of development of major complications following free flap recon- struction of the head and neck. Although many of these variables are irreversible, they aid risk stratification of patients undergoing free flap reconstruction, and assist clinicians in making treatment decisions, consenting, and providing patients with realistic expectations regarding their perioperative course. V C 2010 Wiley Periodicals, Inc. Head Neck 32: 1345-1353, 2010

Background. The association between nodal ratio and survival has not been assessed in squamous cell carcino- mas of the head and neck. Methods. This is a population-based analysis, using the Surveillance, Epidemiology, and End-Results database, to determine whether nodal ratio impacts survival in patients with oral cavity squamous cell carcinoma. Results. Between 1988 and 2005, 2955 new diagnoses of N1 or N2 squamous cell carcinoma of the oral cavity were iden- tified. The mean nodal ratio was 16.9%. Nodal ratio was found to be strongly statistically associated with overall survival in both univariate and multivariate analyses. Patients could be stratified into low- (0% to 6%), moderate- (6% to 12.5%), and high-risk (>12.5%) groups based on nodal ratio. Conclusions. In patients with squamous cell carcinoma of the oral cavity, an increased nodal ratio is a strong predictor of decreased survival. Risk of death can be stratified based on nodal ratio. V C 2009 Wiley Periodicals, Inc. Head Neck 31: 1129-1136, 2009

Background. This cross-sectional study sought to determine patient quality of life and function after prosthetic rehabilitation for maxillary and palate defects following cancer resection. Methods. Sixty-nine patients were identified, 42 participated in the study (61%). The Obturator Functioning Scale (OFS) and 4 general quality of life measures (Mental Health Inventory (MHI), Impact of Events Scale (IES), Illness Intrusiveness Rat- ings Scale (IIRS), and Centre for Epidemiologic Studies Depres- sion Scale (CES-D)) were correlated with clinical parameters. Results. Leakage when swallowing foods was the most fre- quently reported problem with the obturator (29%). Positive correlation was noted between the OFS and both the IES sub- scales (p < .01) and CES-D (p < .001). Difficulty with speech and eating was associated with increased avoidance of social situations. The surgical approach had a significant effect on the OFS, IES, and MHI subscales (p < .01). Conclusion. These results support the findings that good ob- turator function is associated with a better quality of life. V

Background. In patients with extensive soft tissue fibrosis requiring circumferential pharyngeal reconstruction fol- lowing definitive radiotherapy and/or chemotherapy, we take advantage of abundant omental progenitor factors in the tubed gastro-omental free flap. This study reviews our experience with this flap. Methods. Review of 11 patients (median follow-up, 2.8 years) undergoing total pharyngolaryngectomy following organ preservation protocols for recurrent squamous cell carcinoma (n ¼ 9) and stricture (n ¼ 2). Results. Operative morbidity and mortality rates were 54% and 9%, respectively. One patient died following carotid rup- ture. Complications included: chyle leak (18%), pharyngocuta- neous fistula (9%), and late stricture (27%). Ten patients (91%) achieved oral diet, and all 7 patients (100%) considered suita- ble for tracheoesophageal speech rehabilitation achieved func- tional speech. Seven patients remain alive without disease at a median of 41 months following surgery. Conclusions. The gastro-omental flap provides a viable option in high-risk patients undergoing circumferential pharyn- geal reconstruction. V C 2009 Wiley Periodicals, Inc. Head Neck 31: 655-663, 2009

Background. A previous study at our institution noted that only 15% of newly diagnosed patients with oral cancer could identify smoking or alcohol abuse as major risk factors for the development of their cancer. The objective of this study was to determine the effectiveness of a simple educational intervention in 189 consecutively identified patients with head and neck malignancy. Methods. Patients were interviewed prior to and immediately following reading a written educational pamphlet. The patients were then interviewed 5 weeks later to determine longer-term recall. Recall success was correlated to patient demographic parameters including level of education, occupation, sex, age, and place of residence. Results. Immediate recall success increased, on average, 27% from preintervention knowledge, with the largest increase for the risk factor of alcohol abuse. Five-week postintervention recall success decreased on average 10.5% for all risk factors with the largest decrease being seen for smokeless tobacco use (12%). The immediate and 5-week recall success increases were both statistically significant when compared to the preintervention recall success (p < .05). Patient education level had the greatest impact on recall success at all time points (ANOVA, p < .001). Long-term recall for patients over the age of 60 was also statistically poorer. Conclusions. An educational intervention can have significant impact on patient knowledge of cancer risk. More effective educational interventions for poorly educated patients and the elderly may have to be devised to increase intervention success. Whether this knowledge translates into behavior change still needs to be studied. © 2008 Wiley Periodicals, Inc. Head Neck, 2009

Background. Esthesioneuroblastoma is rare. The aim of the study was to review our experience and to evaluate the staging system and treatment that best correlates with the patient outcome. Methods. Thirty-nine patients were identified between 1972 and 2006. Results. At presentation 10% had cervical metastases. None had distant metastasis. Five were treated with surgery, 2 with chemotherapy, 1 with radiotherapy, and 30 with surgery and radiation. Local disease control was 82.6% at 5 years. Recur- rence was seen in 33% with local and regional disease recur- rence at 15% and 18%, respectively. The 5- and 10-year overall survival rates were 87.9% and 69.2%, respectively. Dulguerov classification correlated most closely to survival and recurrence. Conclusions. Dulguerov classification best correlates with the patient's outcome. A combined approach is the preferred treat- ment. It makes no difference whether radiotherapy is given pre or postsurgical resection. Recurrence can occur even 15 years after treatment. Therefore, long-term follow-up is essential. V C 2008

Background. The aim of this study was to identify the prognostic variables in mucosal melanoma of the head and neck. Methods. A retrospective review of 61 cases over a 41-year period was undertaken. Local, regional, and distant failures were major outcome measures. Demographic, clinical, and pathological parameters were identified and correlated with out- comes. Results. The median age at diagnosis was 68 years. Sino- nasal cavity involvement occurred in 80.3% of patients and 16.4% occurred in the oral cavity. Local, regional, and distant recurrences were 60.7%, 19.7%, and 49.2%, respectively. Two- year and 5-year disease-free survivals were 25.8% and 8%, respectively. Disease-specific survival at 5 years was 28.7%. Age

Background. Head and neck solitary extramedul- lary plasmacytomas are rare plasma cell neoplasms. Literature review reveals only small numbers of reports. The objective was to review our experience with treating patients with this neo- plasm. Methods. A retrospective chart review between 1960 and 2000 was performed. Sixty-eight patients with head and neck extramedullary plasmacytomas were included. Results. The sinonasal tract was the most common site. Thirty-nine patients were treated with radiation, 8 with surgery, 14 with surgery and radiation, and 3 with chemoradiation. Me- dian follow-up was 8 years. The 5-year local recurrence-free rate (LRFR) was 81%. There was a trend toward improved LRFR in patients treated primarily with radiation. Regional recurrence at 5 years was 5%. Multiple myeloma developed in 23% of patients. The 5-year survival was 76%. Conclusions. Radiation is the treatment of choice with sur- gery reserved for large tumors and extensive bone destruction. Long-term follow-up is essential because local recurrence and disseminated disease can occur many years postdiagnosis. V C 2008 Wiley Periodicals, Inc. Head Neck 30: 1012-1019, 2008

Background Laryngeal adenoid cystic carcinoma (ACC) is a rare disease. We reviewed our experience at the Princess Margaret Hospital (PMH) with its treatment. Methods This is a retrospective chart review of 15 cases treated at PMH between 1963 and 2005. Results The mean age was 48.6 years. There was no sex predilection. The subglottis was the most common subsite involved. Only 2 patients had regional metastasis. Local or regional recurrence was noted in 5 patients (33.3%). The distant metastasis rate was 66.7% and involved the lungs. The median follow-up time was 6.9 years. The 5- and 10-year overall and disease-specific survival rates were 64% and 46%, and 69% and 49%, respectively. Conclusion Laryngeal ACC is a rare disease with a high rate of distant recurrence. Its management should emphasize maximizing local and regional disease control by surgery followed by radiotherapy with distant disease failure eventually dictating survival. © 2008 Wiley Periodicals, Inc. Head Neck, 2008

Background. As the methodologies for evaluating health-related quality of life (HRQOL) in head and neck cancer patients have matured over the past 10 years, there has been an increasing focus on reporting longitudinal data. These studies have primarily focused on long-term survivors. This study addresses the HRQOL of both long-term and short-term survivors. Methods. This is a prospective, longitudinal study of 479 head and neck cancer patients followed for at least 3 years after diagnosis. Analysis of longitudinally collected HRQOL scores was based on survivorship status. Results. The HRQOL for 3 survivorship groups: short-term (died 3 years) were different at all time points (pretreatment, 3, 6, and 12 months). Differences were greatest between the short-term and long-term survivors. Long-term survivors demonstrated the best HRQOL and an improving HRQOL trajectory at 12 months. The HRQOL of short-term survivors declined precipitously throughout all available follow-up. Intermediate-term survivors did show some improvement following treatment but had a declining HRQOL trajectory at 12 months. Conclusion. The HRQOL profiles of head and neck cancer patients differed significantly depending on survivorship status. Long-term HRQOL results should be analyzed within the context of the results for all of the patients eligible to have been included in the initial study cohort. © 2006 Wiley Periodicals, Inc. Head Neck, 2007.

The vacuum-assisted closure system (V.A.C.), or negative pressure dressings, has been successfully used to manage complex wounds of the torso and extremities, but its role in the head and neck region has not been frequently described.A retrospective study was performed. The V.A.C. system (Kinetic Concepts Inc., San Antonio, TX) was used at the University of Iowa Hospitals and Clinics for management of complicated head and neck wounds.The V.A.C. system was utilized at 13 sites for 12 patients. Nine subjects had exposed calvarium (4 had failed pedicled reconstructive flaps, 3 had ablative or Moh's defects, and 2 had traumatic scalping injuries) necessitating bony coverage. Three subjects had the V.A.C. system used as a bolster dressing placed over split-thickness skin grafts (STSGs) used to reconstruct large defects of the face and skull, and 1 patient had a large soft tissue neck defect after radical surgical resection for necrotizing fascitis. One subject used the V.A.C. system for the management of 2 distinct wounds. All patients had successful healing of their wounds with the V.A.C. system without complication. All STSGs had 100% viability after 5 to 7 days of the V.A.C. system use as a bolster dressing.This study demonstrates the V.A.C. system is a valuable tool in the management of complicated head and neck wounds.

Background Several questionnaires have been used to evaluate shoulder disability after neck dissection. The purpose of this study was to review these measures and highlight their strengths and weaknesses. Methods A literature review was performed to identify measures of shoulder disability after head and neck cancer surgery. These measures were evaluated in terms of their methods of development and assessment of their psychometric properties. Results Seven questionnaires were identified. Several of the other questionnaires have been well developed but have not had their psychometric properties assessed in the head and neck cancer population. Each questionnaire has its strengths and weaknesses. Conclusion The strengths and weaknesses of the shoulder disability questionnaires should be considered when deciding which questionnaire to use. Efforts should be focused on using well-designed questionnaires that have been assessed in this patient population rather than developing or using other questionnaires. © 2013 Wiley Periodicals, Inc. Head Neck, 36: 1453–1458, 2014