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Background Treatment of Zenker’s diverticulum has evolved from open surgery to endoscopic techniques, including flexible and rigid endoscopic septotomy, and more recently, peroral endoscopic myotomy (Z-POEM). This study compared the effectiveness of flexible and rigid endoscopic septotomy with that of Z-POEM. Methods Consecutive patients who underwent endoscopic septotomy (flexible/rigid) or Z-POEM for Zenker’s diverticulum between 1/2016 and 9/2019 were included. Primary outcomes were clinical success (decrease in Dakkak and Bennett dysphagia score to ≤ 1), clinical failure, and clinical recurrence. Secondary outcomes included technical success and rate/severity of adverse events. Results 245 patients (110 females, mean age 72.63 years, standard deviation [SD] 12.37 years) from 12 centers were included. Z-POEM was the most common management modality (n = 119), followed by flexible (n = 86) and rigid (n = 40) endoscopic septotomy. Clinical success was 92.7 % for Z-POEM, 89.2 % for rigid septotomy, and 86.7 % for flexible septotomy (P = 0.26). Symptoms recurred in 24 patients (15 Z-POEM during a mean follow-up of 282.04 [SD 300.48] days, 6 flexible, 3 rigid [P = 0.47]). Adverse events occurred in 30.0 % rigid septotomy patients, 16.8 % Z-POEM patients, and 2.3 % flexible septotomy patients (P Conclusions There was no difference in outcomes between the three treatment approaches for symptomatic Zenker’s diverticulum. Rigid endoscopic septotomy was associated with the highest rate of complications, while flexible endoscopic septotomy appeared to be the safest. Recurrence following Z-POEM was similar to flexible and rigid endoscopic septotomy. Prospective studies with long-term follow-up are required.

BACKGROUND There is a paucity of information regarding the incidence and survival of parotid malignancies over time. METHODS The Surveillance, Epidemiology, and End Results population-based cancer registry was queried for parotid malignancies from 1973 to 2015. RESULTS The age-adjusted incidence of parotid malignancies has increased by 58.1% (7.87-12.44 per 1 000 000). Analysis of histologic type revealed an increased annual percent change (APC) of acinar cell carcinoma (1.38) and squamous cell carcinoma (1.58), but decreased APC of adenoid cystic carcinoma (-1.63) and adenocarcinoma NOS (-0.86) (P

Objective: To provide an understanding of the incidence of anaplastic thyroid cancer within the United States. Methods: Patients in the Surveillance, Epidemiology, and End Results (SEER) database were included from 1973 to 2014 based on a diagnosis of anaplastic thyroid cancer using ICD O-3 codes. Patients were categorized into cohorts based on their year of diagnosis. Results: 1527 patients were diagnosed with anaplastic thyroid cancer within the SEER 18 registries. The age-adjusted incidence rate was 0.2 per 1,000,000 people (95% CI: 0.0–0.5) in 1973 and was 1.2 per 1,000,000 people (95% CI: 0.8–1.6) in 2014 (average annual percent change: 3.0% [95% CI: 2.2%–3.7%]). Patients tended to be of older age (mean age: 70.5 [range 15.0–102.0]), of female sex (62.8%), and Caucasian (81.1%). Finally, survival over time remained the same, as median disease specific survival months was 4.00 (95% CI: 2.26–5.74) from 1995 to 1999 and 4.00 (95% CI: 3.26–4.74) from 2010 to 2014. Conclusions: The incidence rate of anaplastic thyroid cancer has increased from 1973 to 2014. Interestingly, median survival in months did not greatly change overtime. Based on this increasing incidence, physicians must act appropriately to identify patients with anaplastic thyroid cancer as it possesses a high morbidity and mortality. Level of evidence: 4. Keywords: Anaplastic thyroid cancer, Thyroid cancer, Head and neck, Head and neck endocrine surgery, Head and neck oncology

To evaluate the treatment efficacy of transcutaneous electrical nerve stimulation (TENS) in patients with obstructive sleep apnea (OSA).Primary studies were identified though PubMed, Scopus, OVID, and Cochrane Library.Systematic review was conducted by querying databases for articles published through July 2019. The search identified randomized controlled trial, randomized comparison, or observational studies pertaining to TENS treatment for OSA. Meta-analysis was performed on pre- and posttreatment apnea-hypopnea index (AHI), mean oxygen saturation (SaOLiterature search identified 10 studies that reported sufficient outcome measures to be considered for analysis. A total of 198 patients were identified with a mean age of 50.9 years with a male to female ratio of 1.6:1. Average body mass index (BMI) of the cohort was 29.8 kg/mThe TENS treatment of upper airway dilator muscles resulted in reduction of AHI in patients with OSA. However, its effects on SaO

To compare the effectiveness of transoral robotic surgery (TORS) versus plasma ablation (PA) in tongue base reduction surgery for obstructive sleep apnea (OSA).PubMed, Scopus, Cochrane Library, OVID.Keywords searched included OSA, tongue base surgery, TORS, and coblation. Outcomes included pre- to postoperative apnea-hypopnea index, Epworth Sleepiness Scale (ESS), and lowest oxygen saturation. Additional outcomes included surgical success rate, postoperative bleeding, operative time, and length of stay.A total of 690 unique articles were identified, of which 60 underwent full-text review. Twenty-six articles were included in final analysis, comprising 18 studies on TORS (834 patients) and 11 studies on PA (294 patients). Mean differences of apnea-hypopnea index, ESS, and lowest oxygen saturation for TORS were -23.92, -7.6, and 5.83% (allTongue base reduction with TORS or PA each effectively treats OSA and provides comparable results. The choice between techniques might depend on patient factors, availability of technology, and associated costs.

Background Greater auricular nerve (GAN) sacrifice can alter sensation; however, the impact on quality of life (QoL) is unclear. Objective The aim of this study was to evaluate patients' QoL following GAN sacrifice versus preservation. Methods Patients who underwent parotidectomy from 2010 to 2019 at a single institution completed two QoL surveys. Results between GAN-sacrificed versus preserved cohorts and short (≤ 1 year) versus long-term (> 1 year) follow-up were compared. Results Of 404 patients, 67 with known GAN status completed the surveys. GAN-sacrificed patients more frequently experienced sensation loss of the lobule and concha than GAN-preserved patients (P = .042 and P = .041, respectively). Interference with daily activities or amount of regained sensation was not different based on GAN status. Short-term follow-up patients had a higher number of symptoms and affected areas than long-term follow-up patients (P = .014 and P = .002, respectively). Conclusion GAN sacrifice leads to sensation loss of the lobule and concha; however, it does not significantly impair QoL.

OBJECTIVES. To characterize the temporal trajectory of body image disturbance (BID) in patients with surgically treated head and neck cancer (HNC). STUDY DESIGN. Prospective cohort study. SETTING. Academic medical center. SUBJECTS AND METHODS: Patients with HNC who were undergoing surgery completed the Body Image Scale (BIS), a validated patient-reported outcome measure of BID, pretreatment and 1, 3, 6, 9, and 12 months posttreatment. Changes in BIS scores (ΔBIS) relative to pretreatment (primary endpoint) were analyzed with a linear mixed model. Associations between demographics, clinical characteristics, psychosocial attributes, and persistently elevated BIS scores and increases in BIS scores ≥5 points relative to pretreatment (secondary endpoints) were analyzed through logistic regression. RESULTS. Of the 68 patients, most were male (n = 43), had oral cavity cancer (n = 37), and underwent microvascular reconstruction (n = 45). Relative to baseline, mean ΔBIS scores were elevated at 1 month postoperatively (2.9; 95% CI, 1.3–4.4) and 3 (3.2; 95% CI, 1.5–4.9) and 6 (1.8; 95% CI, 0.02–3.6) months posttreatment before returning to baseline at 9 months posttreatment (0.9; 95% CI, −0.8 to 2.5). Forty-three percent of patients (19 of 44) had persistently elevated BIS scores at 9 months posttreatment relative to baseline, and 51% (31 of 61) experienced an increase in BIS scores ≥5 relative to baseline. CONCLUSIONS. In this cohort of patients surgically treated for HNC, BID worsens posttreatment before returning to pretreatment (baseline) levels at 9 months posttreatment. However, 4 in 10 patients will experience a protracted course with persistent posttreatment body image concerns, and half will experience a significant increase in BIS scores relative to pretreatment levels.

BACKGROUND Sialoendoscopy is the standard treatment for sialolithiasis; however, some patients may be unlikely to benefit from an endoscopic approach. This study assesses predictors of failure in the endoscopic management of sialoliths. METHODS Patients treated for sialolithiasis from 2012 to 2017 at two centers were stratified into 3 groups: successful interventional sialendoscopy, incisional sialolithotomy, and gland excision. Patient, disease, and surgical factors were compared. RESULTS Interventional sialendoscopy was attempted in 156 of 206 cases and successful for 42 (27%). Endoscopically retrieved calculi were smaller (4.96 mm) compared to incisional sialolithotomy (7.90 mm). Nonendoscopic approaches were required more often in submandibular cases 87% (P ≤ .005). Palpable stones were present in 74% of incisional sialolithotomies (P

Objective To evaluate the frequency of brain metastasis at the time of diagnosis for patients with cutaneous head and neck melanoma (CHNM). Methods Patients in the Surveillance, Epidemiology, and End Results (SEER) database were included from 2010 to 2014 based on a diagnosis of CHNM using ICD O-3 histology codes and primary site location documentation. Patients were also included if they had a “yes” or “no” documented in the “Mets at Dx–Brain” category. Results In this study, 46 out of 19,066 (0.2%) patients diagnosed with CHNM presented with brain metastasis at diagnosis. Of the 19,066 patients, 14,124 (74.1%) were male. Caucasian race was noted in 18,299 cases (96.0%). 16.8% of patients with AJCC 7 Stage IV/M1 CHNM had brain metastasis at the time of diagnosis as compared to 0% in Stage I-III/M0 lesions (p Conclusions and relevance The 2018 NCCN guidelines recommend healthcare providers consider ordering a baseline brain MRI for patients with stage IIIC or greater melanoma. This study demonstrates the very low frequency of brain metastasis at time of diagnosis in patients with CHNM and supports the NCCN recommendations demonstrating that only very advanced stages of CHNM require baseline brain imaging.

BACKGROUND Patients who travel a long distance (≥50 miles) for cancer care have improved outcomes. However, to the authors' knowledge, the prevalence of long travel distances for treatment by patients with head and neck squamous cell carcinoma (HNSCC), and the effect of travel distance on overall survival (OS), remains unknown. METHODS The authors used the National Cancer Data base from 2004 through 2013 to identify patients with HNSCC undergoing definitive treatment. Travel distance for treatment was categorized as short (

OBJECTIVES/HYPOTHESIS To examine the evolving changes in management of pediatric mucoepidermoid carcinoma of the parotid gland. STUDY DESIGN Retrospective analysis of a large population database. METHODS Pediatric patients in the Surveillance, Epidemiology, and End Results database were included from 1973 to 2014 based on a diagnosis of mucoepidermoid carcinoma of the parotid gland using the International Classification of Diseases for Oncology, Third Edition codes: C07.9: parotid gland and 8430/3: mucoepidermoid carcinoma. Patients were included from ages 0 to 18 years. Patients were categorized into 5- or 6-year cohorts based on their year of diagnosis. Two-year and 5-year survival was calculated using actuarial or life-table analysis. RESULTS One hundred sixty-nine pediatric cases were identified. Eighty of the 169 cases (47.4%) were diagnosed from 2005 to 2014. The number of cases increased steadily across cohorts over time since 1995. Pediatric patients tended to be diagnosed in adolescence (mean age: 13.4 years, range: 3.0-18.0 years). Most patients received surgical management as a part of their case (95.3% of total cohort). The 5-year disease-specific survival was > 90% for each cohort. CONCLUSIONS The age-adjusted incidence rate of pediatric mucoepidermoid carcinoma of the parotid gland remains low and is not greatly changing. This cancer is most likely diagnosed in adolescence affecting both male and female patients equally. Analysis of cases since 1973 revealed that most patients continue to receive surgical care. Survival for these pediatric patients continues to remain excellent. Healthcare providers should note these updates in pediatric mucoepidermoid carcinoma of the parotid gland as effective diagnosis and management continues to lead to good survival outcomes. LEVEL OF EVIDENCE 4 Laryngoscope, 128:2408-2414, 2018.

Summary Oral cavity squamous cell carcinoma (OCSCC) is a prevalent surgically treated subset of head and neck cancer with frequent recurrence and poor survival. Immunotherapy has demonstrated efficacy in recurrent/metastatic head and neck cancer. However, whether antitumor responses could be fostered by neoadjuvant presurgical immunotherapy remains unclear. Using a Simon’s two-stage design, we present results of a single-arm phase-II trial where 12 patients with stage II-IVA OCSCC received 3 to 4 biweekly doses of 3 mg/kg nivolumab followed by definitive surgical resection with curative intent. Presurgical nivolumab therapy in this cohort shows an overall response rate of 33% (n = 4 patients; 95% CI: 12%–53%). With a median follow up of 2.23 years, 10 out of 12 treated patients remain alive. Neoadjuvant nivolumab is safe, well-tolerated, and is not associated with delays in definitive surgical treatment in this study. This work demonstrates feasibility and safety for incorporation of nivolumab in the neoadjuvant setting for OCSCC (ClinicalTrials.gov: NCT03021993)., Graphical abstract, Highlights • Presurgical nivolumab in patients with resectable oral cancer has an ORR of 33% • 10 out of 12 treated patients remain alive with a median follow up of 2.23 years • Neoadjuvant nivolumab is safe, well-tolerated, and not associated with treatment delays • This shows feasibility of nivolumab in the neoadjuvant setting for OCSCC (NCT03021993), Oral cavity squamous cell carcinoma is a prevalent subset of head and neck cancer with high recurrence rates and poor survival outcomes despite complex multimodality therapy. The current study by Knochelmann et al. demonstrates that presurgical nivolumab therapy has an overall response rate of 33% in this patient population.

OBJECTIVE The malignant fibrous histiocytoma (MFH) is the most common soft tissue sarcoma of the head and neck. Currently, most of the data on this tumor relies on small retrospective studies. The objective of this study is to use the Surveillance, Epidemiology, and End Results (SEER) database to compare characteristics of this tumor based on location to better understand its prognosis in the head and neck region. This article represents the largest study analyzing prognosis of this tumor in the head and neck to date. STUDY DESIGN Retrospective analysis of SEER database. METHODS Using the SEER database, 395 patients with MFH of the head and neck were compared with 3,968 patients with MFH of the trunk and extremities. Disease-specific survival was carried out comparing these two cohorts, as well as univariate and multivariate analysis to determine hazard ratios. RESULTS Head and neck MFH had a significantly higher disease-specific survival compared with trunk and extremity disease. However, head and neck tumors were more frequently a smaller size (P < .0001) and lower grade (P < .0001). Larger tumors and grade III and IV tumors conferred a worse prognosis (P < .0001). CONCLUSION Head and neck malignant fibrous histiocytoma presents at a smaller size and lower grade, likely due to earlier presentation in this region. Because of this, head and neck malignant fibrous histiocytoma represents a more favorable survival prognosis compared with trunk and extremity disease. LEVEL OF EVIDENCE 4. Laryngoscope, 128:885-888, 2018.

BACKGROUND The objective of this study was to determine the effects of National Comprehensive Cancer Network (NCCN) guideline–adherent initiation of postoperative radiation therapy (PORT) and different time-to-PORT intervals on the overall survival (OS) of patients with head and neck squamous cell carcinoma (HNSCC). METHODS The National Cancer Data Base was reviewed for the period of 2006-2014, and patients with HNSCC undergoing surgery and PORT were identified. Kaplan-Meier survival estimates, Cox regression analysis, and propensity score matching were used to determine the effects of initiating PORT within 6 weeks of surgery and different time-to-PORT intervals on survival. RESULTS This study included 41,291 patients. After adjustments for covariates, starting PORT >6 weeks postoperatively was associated with decreased OS (adjusted hazard ratio [aHR], 1.13; 99% confidence interval [CI], 1.08-1.19). This finding remained in the propensity score–matched subset (hazard ratio, 1.21; 99% CI, 1.15-1.28). In comparison with starting PORT 5 to 6 weeks postoperatively, initiating PORT earlier was not associated with improved survival (aHR for ≤ 4 weeks, 0.93; 99% CI, 0.85-1.02; aHR for 4-5 weeks, 0.92; 99% CI, 0.84-1.01). Increasing durations of delay beyond 7 weeks were associated with small, progressive survival decrements (aHR, 1.09, 1.10, and 1.12 for 7-8, 8-10, and >10 weeks, respectively). CONCLUSIONS Nonadherence to NCCN guidelines for initiating PORT within 6 weeks of surgery was associated with decreased survival. There was no survival benefit to initiating PORT earlier within the recommended 6-week timeframe. Increasing durations of delay beyond 7 weeks were associated with small, progressive survival decrements. Cancer 2017;123:4841-50. © 2017 American Cancer Society.

BACKGROUND Adherence to evidence-based treatment guidelines has been proposed as a measure of cancer care quality. The objective of this study was to determine the rate and predictors of care that does not adhere to National Comprehensive Cancer Network guidelines regarding commencing postoperative radiation therapy (PORT) within 6 weeks of surgery for patients with head and neck squamous cell carcinoma (HNSCC). METHODS The National Cancer Data Base was reviewed from 2006 to 2014, and patients with HNSCC who underwent curative-intent surgery followed by PORT were identified. Multivariable logistic regression analysis was used to determine the factors associated with nonadherence to guidelines regarding the timing of initiating PORT. RESULTS In total, 47,273 patients were included in the study. 55.7% of patients (26,340/47,273) failed to commence PORT within 6 week of surgery. The percentage of patients who failed to initiate PORT within 6 week of surgery increased over time. On multivariable analysis, the factors associated with failure to initiate timely, guideline-adherent PORT included black race, public insurance [Medicare, Medicaid] or uninsured status, lower levels of education, increased severity of comorbidity, increased postoperative length of stay, 30-day unplanned hospital readmission, treatment at an academic medical center, and the receipt of surgery and PORT at different facilities. CONCLUSIONS Over 50% of patients with HNSCC who undergo surgery and PORT receive care that does not adhere to National Comprehensive Cancer Network guidelines with regard to initiating PORT within 6 weeks of surgery. Sociodemographic, oncologic, treatment, and hospital factors are all associated with failure to receive guideline-directed care and should be explored in future studies. Cancer 2017. © 2017 American Cancer Society.

Background The current study was conducted to determine the effect of postoperative radiotherapy (PORT) on overall survival in patients with surgically managed pT3-T4aN0 laryngeal squamous cell carcinoma (SCC). Methods A review of the National Cancer Data Base from 2004 through 2013 was performed. Patients with surgically managed pT3-4aN0 laryngeal SCC with negative surgical margins were included. Univariable and multivariable Cox regression analyses were used to determine factors associated with survival. Results A total of 1460 patients were included, 46.2% of whom had pT3N0 disease (674 patients) and 53.8% of whom had pT4aN0 disease (786 patients). Approximately 72.0% of the patients with pT3N0 disease (485 patients) and 50.1% of the patients with pT4aN0 disease (394 patients) received PORT. PORT was not found to be associated with improved overall survival on univariable analysis for patients with pT3N0 disease (hazard ratio [HR], 0.84; 95% confidence interval [95% CI], 0.62-1.14), but was for patients with pT4aN0 disease (HR, 0.57; 95% CI, 0.45-0.71). For patients with pT3N0 SCC of the larynx, in a multivariable Cox regression analysis adjusting for age >65 years, severity of comorbidities, larynx subsite, extent of laryngectomy, and number of lymph nodes removed, PORT was not found to be associated with improved survival (adjusted HR, 0.88; 95% CI, 0.64-1.21). For patients with pT4aN0 disease, the administration of PORT was associated with improved survival on multivariable analysis adjusting for age >65 years, severity of comorbidities, larynx subsite, number of lymph nodes removed, and type of hospital (adjusted HR, 0.58; 95% CI, 0.46-0.73). Conclusions For patients with surgically managed pT3N0 laryngeal SCC with negative margins, PORT does not appear to be associated with improved survival. Despite a survival benefit, nearly 50% of patients with pT4aN0 laryngeal SCC and negative surgical margins do not receive standard-of-care PORT. Cancer 2017;123:2248-2257. © 2017 American Cancer Society.

Objectives: Ewing sarcoma is a rare tumor of the head and neck. Previous efforts to characterize Ewing sarcoma of the head and neck (ES-HN) have been limited to small retrospective series. The objective of this study was to analyze the demographic, clinicopathologic, treatment, and survival characteristics of ES-HN compared to Ewing sarcoma at other locations (ES-other). Methods: Using the Surveillance, Epidemiology, and End Results (SEER) database, we compared 183 patients with ES-HN to 3177 patients with ES-other. Patient characteristics were analyzed with chi-square or t test. Ten-year disease-specific survival (DSS) and overall survival (OS) were estimated via the Kaplan-Meier method and compared using the log-rank test. Multivariate Cox regression analysis was used to determine if HN location was an independent prognosticator. Results: The ES-HN displayed a lower tumor size ( P < .001) and metastatic rate ( P < .001) compared to ES-other. The ES-HN had a better 10-year DSS and OS than ES-other ( P = .001, P = .015, respectively). The HN location did not achieve statistical significance on multivariate Cox regression analysis ( P = .88). Conclusion: ES-HN does not appear to be a separate clinical entity compared to ES-other; rather, its associated improved prognosis is likely secondary to its smaller size and lower metastatic rate compared to ES-other.

Objectives/hypothesis Carcinosarcomas represent a rare entity of mixed malignant tumors of the salivary gland with limited evidence regarding management strategies. We aim to demonstrate the incidence, prognostic factors, and conduct a survival analysis for this aggressive malignancy. Study design Retrospective database review. Methods The Surveillance, Epidemiology, and End Results database was queried for all cases of major salivary carcinosarcoma and its incidence from 1973 to 2015 to identify 66 patients. Results The incidence of this tumor was 0.02 cases per 1 million, with a rising number of absolute cases in the past 2 decades. The parotid gland was the most common site (78.8%) of involvement. The 5-year overall survival was 37% and 5-year disease-specific survival was 62%. Surgery was most common management strategy (95.5%), with total parotidectomy and facial nerve sacrifice procedures for those with parotid disease. Radiotherapy was commonly performed (75.8%) and chemotherapy use was rare (18.2%). Patients with distant metastasis had a greater than threefold increase in mortality, and those with total parotidectomy surgery had decreased mortality. Conclusions Carcinosarcomas of major salivary glands are extremely rare and highly aggressive tumors. We recommend prompt surgical management and postoperative radiation for this tumor with a poor prognosis. Level of evidence NA Laryngoscope, 130:E335-E339, 2020.

Background Diffuse Large B-Cell Lymphoma (DLBCL) of the major salivary glands is a rare high-grade malignancy that often presents with vague symptoms. This study aimed to evaluate its incidence and prognosis on a population level. Methods The Surveillance, Epidemiology, and End Results database was queried for cases of major salivary gland DLBCL. Results 896 patients had DLBCL affecting the parotid gland (78.3%) or submandibular gland (19.8%). The incidence was increasing at 1.5% (P = 0.005) per year from 1973 to 2016. 24.4% of patients underwent parotidectomy, 16% had biopsy, and the remaining provided no details of diagnostic method. Five-year disease-specific survival increased from 59.8% to 84.0%. Late-stage disease (HR = 1.7, P = 0.003) and female sex (HR = 2.1, P = 0.018) were associated with increased risk of mortality. Conclusion Despite the rising incidence of major salivary gland DLBCL, chemotherapy and radiation treatment has resulted in increasingly favorable survival outcomes. The otolaryngologist - head and neck surgeon continues to play a critical role in establishing the diagnosis of salivary gland DLBCL.

Objective Major salivary gland large-cell undifferentiated carcinoma (LCUC) is rare and has a poor prognosis. Characterization of patient demographics, tumor characteristics, and predictors of outcome have been limited by low case numbers, as well as grouped analysis with other salivary malignancies. The objective of this study was to address these issues using large-scale national data. Study Design Retrospective case series. Methods Data from the National Cancer Database, including cases diagnosed from 1998 to 2012, was analyzed, identifying 247 records of LCUC. Tumor, demographic, and survival information was extracted and analyzed retrospectively. Results Large-cell undifferentiated carcinoma comprised < 1% of all major salivary gland cancers. Seventy percent of patients presented with advanced-stage disease. The incidence of occult nodal disease was 39%. Surgery followed by radiation was the most common treatment. Five-year overall survival was 36%. Comorbidity, distant metastasis, and positive surgical margins were found to be predictors of overall survival. Conclusion To our knowledge, this represents the largest reported case series of LCUC. The survival analysis demonstrates poorer survival in patients with positive surgical margins; therefore, efforts to complete resection are reasonable. Reported high rates of occult nodal disease also strongly support elective treatment of the neck. Level of Evidence 4. Laryngoscope, 2016

Objectives/Hypothesis We sought to better characterize patient, tumor, and long-term survival characteristics of parotid small cell carcinoma (SmCC) with the National Cancer Database (NCDB). Study Design Retrospective database review. Methods We reviewed the NCDB (1998–2012) for all cases of parotid SmCC. Relevant demographic, tumor, and survival variables were extracted and analyzed. Cox multivariate regression was performed to identify prognosticators. Results Out of 30,813 parotid gland cancers in the NCDB, we found 344 cases of parotid SmCC (1.11%). Age at diagnosis ranged from 23 to 91 years (mean = 73 years). Most patients (73.0%) were male. Most tumors were 2 to 4 cm in size (51.4%). Regional metastases were common (50.8% cN+ and 65.1% pN+) and distant metastasis (7.3%) was uncommon. Occult nodes were found in 14.4% of cases. Overall survival at 5 and 10 years was 37% and 20%, respectively. Although numerous variables were found to significantly impact survival on univariate regression analysis, age (hazard ratio [HR]: 1.05, 95% confidence interval [CI]: 1.03-1.08, P 4 cm (HR: 3.44, 95% CI: 1.63-7.27) and distant metastasis (HR: 2.06, 95% CI: 1.02-4.14, P = .043) remained significant prognosticators in our multivariate model. Nodal disease was not a significant risk factor after adjustment (P = .055). Conclusions SmCC is a rare parotid malignancy with a poor prognosis. Regional metastases were common, whereas distant metastases were uncommon. Elective neck treatment should be considered due to the incidence of occult nodal disease. Level of Evidence 4 Laryngoscope, 2015

To describe the clinical, demographic, and prognostic features of salivary gland mucinous adenocarcinoma, a rare head and neck malignancy.Population-based national cancer registry analysis.Academic medical center.A review was performed with the National Cancer Database from 1998 to 2012. Demographic, clinical, and survival characteristics were compiled and analyzed. Cox multivariate regression was used to identify predictors of survival. Log-rank tests were used to test survival differences unless otherwise specified.A total of 170 cases were identified. The most common site of involvement was the parotid gland. Rates of nodal and distant metastases were 45.9% and 10.6%, respectively. High histologic grade was associated with nodal disease (P.001) and advanced-stage disease (P = .006). Overall 5- and 10-year survival rates were 60% and 44%, respectively. Multivariate analysis found tumor size ≥2 cm (hazard ratio, 22.6; 95% confidence interval: 4.06-126.09; P.001) and distant metastases (hazard ratio, 17.6; 95% confidence interval: 3.75-82.68; P.001) to predict poor outcomes.Mucinous adenocarcinoma of the salivary gland is a rare otolaryngic cancer. Regional metastases and advanced stage are more common with high histologic grade. Tumor size and distant metastases negatively influence survival.

Background Oncocytic carcinomas of the major salivary glands are extremely rare, with

Primary malignant melanoma of the larynx is extremely rare with fewer than 70 reported cases in the literature. Here we present the case of an 80-year-old gentleman who was referred to our institution for the treatment of a laryngeal mass. Initial immunostains were positive for SOX10 and S-100 and negative for HMB-45 and preoperative tissue biopsies were thought to be consistent with a malignant peripheral nerve sheath tumor. The endolaryngeal tumor was completely resected with negative margins and final surgical pathology with immunostaining was positive for primary malignant melanoma. Post-operative imaging via PET/CT demonstrated hypermetabolic lesions in the lungs and spine consistent with metastatic disease and the patient was referred for chemoradiation. Here, we review the literature and discuss diagnostic and therapeutic challenges associated with mucosal melanoma owing to its rarity and propensity for distant spread.

Objective: To use the Surveillance, Epidemiology, and End Results (SEER) database to verify the findings of a recent National Cancer Database (NCDB) study that identified factors predicting occult nodal involvement in cutaneous head and neck melanoma (CHNM) while identifying additional predictors of occult nodal metastasis and comparing two distinct cancer databases. Methods: Cases of CHNM in the SEER database diagnosed between 2004 and 2014 were identified. Demographic information and oncologic data were obtained. Univariate and multivariate analysis were performed to identify factors associated with pathologic nodal positivity. Results: There were 34002 patients with CHNM identified. Within this population, 16232 were clinically node-negative, 1090 of which were found to be pathologically node-positive. On multivariate analysis, factors associated with an increased risk of occult nodal metastasis included increasing depth of invasion (stepwise increase in adjusted odds ratio [OR]), nodular histology (aOR: 1.47 [95% CI: 1.21–1.80]), ulceration (aOR: 1.74 [95% CI: 1.48–2.05]), and mitoses (aOR: 1.86 [95% CI: 1.36–2.54]). Factors associated with a decreased risk of occult nodal metastasis included female sex (aOR: 0.80 [0.67–0.94]) and desmoplastic histology (aOR: 0.37 [95% CI: 0.24–0.59]). Between the SEER database and the NCDB, factors associated with occult nodal involvement were similar except for nodular histology and female sex, which did not demonstrate significance in the NCDB. Conclusion: Regarding clinically node-negative CHNM, the SEER database and the NCDB have similarities in demographic information but differences in baseline population sizes and tumor characteristics that should be considered when comparing findings between the two databases. Level of evidence: 4. Keywords: Head and neck melanoma, Lymph node metastasis, Occult nodal metastasis, Sentinel lymph node biopsy

Objectives/Hypothesis We sought to better characterize patient, tumor, and long-term survival characteristics of basal cell adenocarcinoma (BCAC) of the major salivary glands with the National Cancer Database (NCDB). Study Design Retrospective database review of the NCDB (1998–2012). Methods We retrospectively reviewed the NCDB for all cases of major salivary gland BCAC with histologic code 8147/3. Relevant demographic, tumor, and survival variables were extracted and analyzed. COX multivariate regression was performed to identify prognosticators. Results Out of 36,224 major salivary gland cancers in the NCDB, we found 509 cases of BCAC (1.4%), 88% of which were in the parotid glands, 11.2% in the submandibular glands, and 0.8% in the sublingual glands. Age at diagnosis ranged from 18 to 92 years (average 64). No gender preference was found (50.7% male). Most tumors were 2 to 4 cm in size (47.3%). Regional (11.9%) and distant metastasis (1.8%) were uncommon. Overall survival at 5 and 10 years was 79% and 62%, respectively. Although numerous variables were found to significantly impact survival on univariate regression analysis, only age ≥ 65 (hazard ratio [HR] 2.55; 95% confidence interval [CI], 1.56–4.19; P < 0.001) and high primary tumor (T)-stage (HR 1.85; 95% CI, 1.16–2.95; P = 0.010) remained significant prognosticators in our multivariate model. For high T-stage disease, surgery with radiation had significantly better survival than surgery alone. Conclusion Basal cell adenocarcinoma is a rare salivary malignancy with a good prognosis. Regional and distant metastasis were uncommon. Radiation with surgery may help for higher T-stage disease. Old age and high T-stage were significant predictors of worse survival. Level of Evidence 4. Laryngoscope, 2015

Theoretically, completion lymph node dissection (CNLD) should have the lowest benefit in the absence of nonsentinel lymph node (NSLN) metastases. For this reason, substantial research efforts have attempted to define specific criteria that are associated with a low-enough risk of NSLN positivity so that CLND can be deferred. Our objectives were (1) to identify features associated with low risk of NSLN positivity in sentinel lymph node-positive cutaneous melanoma of the head and neck (CMHN) and (2) to analyze the effect of CLND on 5-year disease-specific survival (DSS) among subgroups stratified by risk of NSLN metastasis.Retrospective analysis of population-based data.SEER database.Patients with sentinel lymph node-positive CMHN were categorized according to lymph node treatment following sentinel lymph node biopsy (SLNB): 210 underwent CLND and 140 deferred. Clinicopathologic characteristics and survival were compared between SLNB+CLND and SLNB-only groups. Survival analyses were stratified by age and characteristics associated with NSLN positivity.Minimal tumor thickness and nonulceration were associated with lowest risk of positive NSLN (P.025). In the subgroup with the lowest risk of metastasis, patients aged60 years who underwent CLND+SLNB had markedly better DSS than those receiving SLNB only (90% vs25%; P.0025). Paradoxically, in subgroups with a higher risk of NSLN metastasis, DSS was similar whether CLND was performed or not (P.25).Selecting patients for CLND according to risk of NSLN metastasis may be a suboptimal strategy for improving DSS. We believe that CLND should not be withheld on the basis of "low risk" features in CMHN.

We performed an extensive review of the literature to compare the efficacy of photodynamic therapy (PDT) to surgical resection, the current standard of care, in the treatment of adults with early-stage (T1-2N0M0) squamous cell carcinoma (SCC) of the oral cavity. Since patients who receive PDT are chosen with a high degree of selectivity, particular care was taken when extracting data for comparison. For outcomes measures, PDT was assessed in terms of a complete response to therapy, and surgery was evaluated in terms of locoregional control. Recurrences were also analyzed. We found 24 studies—12 for each treatment—to compare for this meta-analysis. In comparing a complete response to PDT and locoregional control with surgery, we found no statistically significant difference (mean difference [MD]: 1.166; 95% confidence interval [CI]: 0.479 to 2.839). With respect to recurrences, again no statistically significant difference was observed (MD: 0.552; 95% CI: 0.206 to 1.477). We conclude that PDT is as effective as primary surgical resection for the treatment of early-stage SCC of the oral cavity and that it is a valid function-preserving approach to treatment.

The malignant fibrous histiocytoma (MFH) is the most common soft tissue sarcoma of the head and neck. Currently, most of the data on this tumor relies on small retrospective studies. The objective of this study is to use the Surveillance, Epidemiology, and End Results (SEER) database to compare characteristics of this tumor based on location to better understand its prognosis in the head and neck region. This article represents the largest study analyzing prognosis of this tumor in the head and neck to date.Retrospective analysis of SEER database.Using the SEER database, 395 patients with MFH of the head and neck were compared with 3,968 patients with MFH of the trunk and extremities. Disease-specific survival was carried out comparing these two cohorts, as well as univariate and multivariate analysis to determine hazard ratios.Head and neck MFH had a significantly higher disease-specific survival compared with trunk and extremity disease. However, head and neck tumors were more frequently a smaller size (P.0001) and lower grade (P.0001). Larger tumors and grade III and IV tumors conferred a worse prognosis (P.0001).Head and neck malignant fibrous histiocytoma presents at a smaller size and lower grade, likely due to earlier presentation in this region. Because of this, head and neck malignant fibrous histiocytoma represents a more favorable survival prognosis compared with trunk and extremity disease.4. Laryngoscope, 128:885-888, 2018.

Adherence to evidence-based treatment guidelines has been proposed as a measure of cancer care quality. The objective of this study was to determine the rate and predictors of care that does not adhere to National Comprehensive Cancer Network guidelines regarding commencing postoperative radiation therapy (PORT) within 6 weeks of surgery for patients with head and neck squamous cell carcinoma (HNSCC).The National Cancer Data Base was reviewed from 2006 to 2014, and patients with HNSCC who underwent curative-intent surgery followed by PORT were identified. Multivariable logistic regression analysis was used to determine the factors associated with nonadherence to guidelines regarding the timing of initiating PORT.In total, 47,273 patients were included in the study. 55.7% of patients (26,340/47,273) failed to commence PORT within 6 week of surgery. The percentage of patients who failed to initiate PORT within 6 week of surgery increased over time. On multivariable analysis, the factors associated with failure to initiate timely, guideline-adherent PORT included black race, public insurance [Medicare, Medicaid] or uninsured status, lower levels of education, increased severity of comorbidity, increased postoperative length of stay, 30-day unplanned hospital readmission, treatment at an academic medical center, and the receipt of surgery and PORT at different facilities.Over 50% of patients with HNSCC who undergo surgery and PORT receive care that does not adhere to National Comprehensive Cancer Network guidelines with regard to initiating PORT within 6 weeks of surgery. Sociodemographic, oncologic, treatment, and hospital factors are all associated with failure to receive guideline-directed care and should be explored in future studies. Cancer 2017;123:2651-60. © 2017 American Cancer Society.

Background Acinic cell carcinoma is an uncommon salivary neoplasm with clinical and histologic features known to influence prognosis. The purpose of this study was to further describe variables influencing survival in a large cohort of patients with acinic cell carcinoma. Methods Using the Surveillance, Epidemiology, and End Results (SEER) registry, we obtained demographic, clinicopathologic, and treatment data pertaining to patients diagnosed with acinic cell carcinoma. Kaplan–Meier and Cox regression analyses were performed to compare survival with various clinical and pathological parameters. Results We identified 2061 patients with acinic cell carcinoma from 1973 to 2009. Sex, staging, grade, subsite, and treatment were significant predictors of disease-specific survival (DSS). Patients who received surgery alone had the highest 20-year DSS (92.4%), followed by those treated with surgery and radiation (71.9%) or radiation alone (62.3%). Conclusion Our results suggest that histologic grade is a stronger predictor of survival than TNM classification, survival after surgical resection alone is excellent, and adjuvant radiation may be of limited benefit. © 2014 Wiley Periodicals, Inc. Head Neck 37: 870–877, 2015

Objectives/Hypothesis To determine if elderly patients with oropharyngeal squamous cell carcinoma (OPSCC) are receiving less treatment and to evaluate the benefit of aggressive therapy in this population. Study Design Retrospective analysis of a large population database. Methods Patients in the Surveillance, Epidemiology, and End Results database with OPSCC diagnosed from 2004 to 2009 were included. The patients were categorized into age groups 45 to 54, 55 to 64, 65 to 74, 75 to 84, and 85 years and older, then further categorized by treatment status. Kaplan-Meier analysis of disease-specific survival (DSS) for late-stage (III and IV) OPSCC was performed for all age and treatment categories, followed by a multivariate cox regression of treatment status, tumor site, race, stage, and sex per age group. Results A total of 14,909 patients with OPSCC were identified. In our demographic data, we observed a significant increase in the number of patients who did not receive treatment (surgery, radiation, or combined therapy) after age 55. Kaplan-Meier analysis showed that age groups 65 to 74 and 75 to 84 had substantial benefits in DSS with surgery, radiation, or combined therapy. Multivariable analysis did not demonstrate any statistically significant difference in the hazard ratios for combined treatment among age groups 45 to 54, 55 to 64, 65 to 74, and 75 to 84. Conclusions Proportionally fewer elderly patients with OPSCC are being treated than younger individuals. These patients can have significant benefits from aggressive treatments despite their older age as shown by our survival analysis. We recommend the use of objective measures to assess patient fitness to reduce the potential for undertreatment in the elderly population. Level of Evidence 2b Laryngoscope, 124:2057–2063, 2014

Summary Objectives Though the effect of age has been studied in some cancer types, its prognostic significance in oropharyngeal squamous cell carcinoma (OPSCC) remains controversial. Our purpose is to determine the impact of age at diagnosis on overall survival ( OS ) and disease-specific survival ( DSS ) in patients with OPSCC. If the effect is significant, we aim to clarify the age at which prognosis worsens. Materials and methods 15,978 Patients with OPSCC were identified from the Surveillance, Epidemiology, and End Results (SEER) database and separated into 10 year age groups. We obtained data on age at diagnosis, primary location, race, stage, sex, radiological treatment status, and surgical treatment status. Kaplan–Meier methods were used to calculate the OS and DSS for each age group. DSS analysis was supported by a Simple Multivariable Cox Proportional Hazard Regression of all significant variables studied. Results Significant disadvantage in OS and DSS was found with increasing age. A three-group stratification was depicted with the best survival in patients aged 1–44, mildly inferior survival in patients aged 45–64, and increasingly worse survival in patients 65 and older. Multivariable analysis demonstrated statistically significant increases in hazard ratio (HR) after age 65 when compared to ages 1-64. Conclusion Increasing age after 65 is associated with worsening OS and DSS in OPSCC. Poorer prognosis is due to multiple factors, possibly including the effects of aging, which make elderly patients more susceptible to the pathogenesis of OPSCC.

Objectives: We sought to better characterize spindle cell carcinoma (SpCC) of the upper aerodigestive tract, a rare and aggressive variant, through comparison of a large cohort of head and neck SpCCs against a cohort of conventional head and neck squamous cell carcinoma (SCC) patients. Methods: We compared epidemiologic and clinicopathologic characteristics of 341 SpCCs with 67 882 SCCs of the head and neck, drawing data from the SEER national database. We also compared disease-specific survivals (DSS) for SpCC and SCC based on tumor site and mode of treatment. Results: SpCCs were predominantly laryngeal (46.4%, P < .001) and were more likely to be high grade ( P > .001). SpCCs were also more likely than SCCs to present at an early stage ( P < .001 to P < .05). Rates of distant metastasis were similar between the tumor types. DSS was similar between SpCCs and SCCs, although site-specific survival rates were higher for SpCCs of the larynx ( P = .017) and lower for those of the oral cavity ( P = .008). Conclusion: SpCC of the head and neck is more likely than SCC to present at an early stage, with fewer nodal metastases. Survival rates appear to depend on anatomic site as well.

Background Acinic cell carcinoma (AciCC) is an uncommon malignant-epithelial salivary gland cancer. In very rare cases, this tumor may arise from sinonasal subsites, with only 19 cases described in the English-language literature. Methods We performed a retrospective analysis of 18 cases of AciCC, obtained from searching the Surveillance, Epidemiology, and End Results (SEER) database between 1973 and 2009. Results Patient demographics, including age, gender, and race, were similar to AciCC cases found in more common locations. However, all patients had low-grade tumors without regional or distant metastases. Comparing these patients to a stage, grade, and treatment–matched cohort of parotid AciCC, we found a lower 10-year overall survival (52.3%) with no significant difference in disease-specific survival (88.9%). Our meta-analysis of survival from cases in the literature estimated 10-year recurrence-free survival at 92.9%. Conclusion To our knowledge, this is the largest cohort of patients with AciCC reported in the English-language literature. Our results suggest that patients with sinonasal AciCC have excellent disease-specific survival, comparable to matched patients with AciCC in more common salivary gland subsites.

Background and Objectives Head and neck basaloid squamous cell carcinoma (BSCC) is increasingly recognized as a malignancy with an evolving duel behavior. Our objective was to describe the site-specific presentation and prognosis of head and neck BSCC in comparison to conventional-type squamous cell carcinoma (SCC) using population-based data. Methods A total of 1,083 BSCC patients and 66,929 conventional-type SCC patients, diagnosed between 2000 and 2008, were identified using the Surveillance, Epidemiology, and End Results database. Clinicopathologic data were compared using χ2 analysis. Kaplan–Meier analysis was used to estimate site-stratified disease-specific survival (DSS). BSCC's independent effect on DSS was assessed by multivariable regression analysis. Results The oropharynx (61.9%) was the most frequent BSCC site; compared to the larynx (33.3%) in conventional-type SCC. More BSCC patients presented with advanced-stage disease (78.4% vs. 60.1%, P

Purpose Identify variables that are independent predictors of survival in carcinoma ex pleomorphic adenoma (CXPA) of the major salivary glands using a population-based database and evaluate the incidence and management strategies for this rare malignancy. Materials and Methods The Surveillance, Epidemiology, and End Results (SEER) database was queried for all cases of major salivary gland CXPA from 1973 to 2015. Results Of the 619 patients identified, the parotid gland was the most common site of involvement (76.9%, 476/619). The reported incidence of CXPA has risen in the past decade (2005–2015, 0.24 to 0.63 per 1,000,000). The 2-year and 5-year disease-specific survival (DSS) rates were 90.3% and 80.4%, respectively. On univariate analysis, facial nerve sacrifice was not a statistically significant predictor of survival (HR = 1.213, 95% CI [0.588–2.058], P = 0.602). Patients with a tumor size >4 cm, multiple positive lymph nodes, and distant metastatic disease had a 2 to 4-fold statistically significant increase in mortality using a multivariate analysis. Statistical significance was not demonstrated in the DSS of patients who underwent partial versus total parotidectomy procedures. Conclusions CXPA is a rare salivary malignancy that has a reported increased incidence in the last decade. Tumor size >4 cm, multiple positive lymph nodes, and distant metastatic disease are predictors of disease-specific mortality. Further research should be conducted to improve early detection and survival strategies for this salivary cancer. Level of Evidence: 4.

Objectives/Hypothesis To determine if sex independently affects disease-specific survival (DSS) in patients with cutaneous head and neck melanoma. Study Design Retrospective analysis of a large population database. Methods Our study included patients in the Surveillance, Epidemiology, and End Results database with cutaneous head and neck melanoma diagnosed from 2004 to 2009. Any cases with a history of previous malignancy or with multiple primaries were excluded. We obtained data on stage, race, age at diagnosis, radiological treatment status, and surgical treatment status. Our analysis consisted of a Kaplan-Meier analysis of DSS by sex [correction made here after initial online publication] that was supported by a multivariate Cox regression of all significant variables studied. Results There were 13,507 patients identified with cutaneous head and neck melanoma who were diagnosed between 2004 and 2009. We observed that female patients had a better prognosis than their male counterparts, with 5-year DSS of 90.40% (95% confidence interval [CI], 89.03%-91.72%) and 87.10% (95% CI, 86.12%-88.08%), respectively. Multivariable analysis demonstrated a statistically significant decrease in disease-specific hazard ratio due to female sex independent of stage, treatment, age, or race. Conclusions Our study concludes that female sex is an independent prognostic factor for cutaneous head and neck melanoma. We demonstrated better 5-year DSS in female compared to male patients. Better prognosis could be due to multiple factors including differing hair, levels of sun exposure, and advanced male age. Level of Evidence 2b Laryngoscope, 124:1363–1367, 2014

Objective/Hypothesis To evaluate age as an independent prognostic factor in cutaneous head and neck melanoma. Study Design Prospective case-control study. Methods We selected 12,195 patients from the Surveillance, Epidemiology, and End Results database with cutaneous head and neck melanoma diagnosed from 2004 to 2009. Patients were stratified into ages 1 to 44 years, 45 to 64 years, and 65+ years. Meanwhile, stage was stratified into early (American Joint Committee on Cancer [AJCC] stage I-II) versus late (AJCC stage III-IV). We calculated overall survival and compared it to age-matched cancer-free controls to obtain overall relative survival. Finally, we performed a Cox multivariate regression by age and stage. Results Age had a statistically significant (P

Background Basaloid squamous cell carcinoma (BSCC) is a rare subtype squamous cell carcinoma (SCC) that frequently occurs in the larynx. BSCC is generally considered an aggressive SCC variant; however, because of its rarity, most studies are underpowered to detect statistical differences in disease-specific survival (DSS). Methods Using the Surveillance, Epidemiology, and End Results (SEER) database, we compared clinicopathologic data and DSS between patients with laryngeal BSCC and SCC. Results Patients with relative SCC, those with laryngeal BSCC, presented with more advanced local, regional, and distant disease (p < .001). Patients with BSCC had worse DSS, regardless of stage, tumor location within the larynx (glottis/supraglottis; p < .001), or treatment received (p ≤ .052). Conclusion Analysis of the largest laryngeal BSCC series to date (n = 145) demonstrates that BSCC carries a worse prognosis than conventional SCC of the larynx. © 2013 Wiley Periodicals, Inc. Head Neck 36: 164–170, 2014

Background Liposarcomas are rare in the head and neck. We analyzed a large series of head and neck liposarcomas to determine features unique to the head and neck. Methods Three hundred eighteen liposarcomas of the head and neck were contrasted with 9485 liposarcomas of other regions using the Surveillance, Epidemiology, and End Results (SEER) database. Results Head and neck liposarcomas were most commonly subcutaneous (81.%), low grade (70.1%; p < .001), and early stage (p < .001). They were more likely to be treated with surgery alone, whereas conventional liposarcomas were more likely to receive adjuvant radiation (p < .001). Treatment that included surgery had better survival than radiation therapy alone (p = .008). Overall, liposarcomas of the head and neck had significantly higher disease-specific survival (DSS) and overall survival (OS) than conventional liposarcomas (p < .001). Conclusion Liposarcomas of the head and neck are usually early stage, low grade, and with fewer nodal metastases than conventional liposarcomas. DSS and OS were significantly greater for liposarcomas of the head and neck. © 2013 Wiley Periodicals, Inc. Head Neck 36: 393–400, 2014