AMA Publishing Group: Surgery Topic Collection

An Oral Cavity Carcinoma Nomogram to Predict Benefit of Adjuvant Radiotherapy Oral Cavity Adjuvant Radiotherapy Prediction Model

Wang SJ, Patel SG, Shah JP, et al. — Thu, 16 May 2013 00:00:00 GMT

Importance

After surgical resection for oral cavity squamous cell carcinoma, adjuvant radiotherapy may be recommended for patients at higher risk for locoregional recurrence, but it can be difficult to predict whether a particular patient will benefit.

Objective

To construct a model to predict which patients with oral cavity squamous cell carcinoma would benefit from adjuvant radiotherapy.

Design and Setting

We constructed several types of survival models using a set of 979 patients with oral cavity squamous cell carcinoma. Covariates were age, sex, tobacco use, stage, grade, margins, and subsite. The best performing model was externally validated on a set of 431 patients.

Participants

The model was based on a set of 979 patients with oral cavity squamous cell carcinoma, including 563 from Memorial Sloan Kettering Cancer Center, New York, New York, and 416 from the Hospital AC Camargo, São Paulo, Brazil. The validation set consisted of 431 patients from Princess Margaret Hospital, Toronto, Ontario, Canada.

Main Outcome and Measure

The primary outcome measure of interest was locoregional recurrence-free survival.

Results

The lognormal model showed the best performance per the Akaike information criterion. An online nomogram was built from this model that estimates locoregional failure-free survival with and without postoperative radiotherapy.

Conclusions and Relevance

A web-based nomogram can be used as a decision aid for adjuvant treatment decisions for patients with oral cavity squamous cell carcinoma.

Learning Curve for Transoral Robotic Surgery A 4-Year Analysis Learning Curve for Transoral Robotic Surgery

White HN, Frederick J, Zimmerman T, et al. — Thu, 16 May 2013 00:00:00 GMT

Importance

As new institutions incorporate transoral robotic surgery (TORS) into their everyday practice, it is helpful to have a timeline reference of expected goals to follow as their experience increases. This article evaluates a single tertiary care academic institution's experience with TORS for head and neck tumors and reports its 4-year learning curve.

Objective

To evaluate a single institution's experience with TORS over a 4-year period and report treatment trends and clinical outcomes.

Design

Prospective case study.

Setting

A single tertiary care academic institution.

Participants

A total of 168 patients underwent TORS for tumors of the head and neck at University of Alabama at Birmingham between March 2007 and September 2011. The total group was subdivided into 4 consecutive groups (42 patients each). Patients were monitored throughout their hospital stay and up to 4.5 years postoperatively (mean follow-up duration, 14 months).

Intervention

Transoral robotic surgery.

Main Outcomes and Measures

Data points were collected and compared over time, including feasibility, operative time, tumor type, stage, subsite, length of intubation, need for tracheostomy, feeding tube use, hospital stay, margin status, neck dissection performed, and postoperative complications.

Results

Significant decreases in operative time, length of intubation, and hospital stay were seen as TORS experience increased. Overall, the mean operative time decreased by 47% (group 4, 86 minutes; group 1, 183 minutes). Total mean intubation time decreased by 87% (group 1, 12.9 hours; group 4, 1.7 hours) and mean hospital stay decreased from 3.0 days to 1.4 days. There was not a significant difference between groups in number of cases unable to be performed robotically (7-9 per group), tumor stage (majority T1/T2), tumor subsite (majority oropharynx), positive margin status (2-5 per group), number of salvage cases performed (7-9 per group), and number of tracheostomies (2-4 per group) or feeding tubes (22-25 per group) required.

Conclusions and Relevance

This is the first multiyear prospective study to document a single institution's TORS experience over time and demonstrate particular areas of expected improvement as case number increases.

Treatment Outcomes of Saddle Nose Correction Saddle Nose Correction

Hyun S, Jang Y. — Thu, 16 May 2013 00:00:00 GMT

Importance

Many valuable classification schemes for saddle nose have been suggested that integrate clinical deformity and treatment; however, there is no consensus regarding the most suitable classification and surgical method for saddle nose correction.

Objectives

To present clinical characteristics and treatment outcome of saddle nose deformity and to propose a modified classification system to better characterize the variety of different saddle nose deformities.

Design, Setting, and Participants

The retrospective study included 91 patients who underwent rhinoplasty for correction of saddle nose from April 1, 2003, through December 31, 2011, with a minimum follow-up of 8 months. Saddle nose was classified into 4 types according to a modified classification.

Main Outcome and Measure

Aesthetic outcomes were classified as excellent, good, fair, or poor.

Results

Patients underwent minor cosmetic concealment by dorsal augmentation (n = 8) or major septal reconstruction combined with dorsal augmentation (n = 83). Autologous costal cartilages were used in 40 patients (44%), and homologous costal cartilages were used in 5 patients (6%). According to postoperative assessment, 29 patients had excellent, 42 patients had good, 18 patients had fair, and 2 patients had poor aesthetic outcomes. No statistical difference in surgical outcome according to saddle nose classification was observed. Eight patients underwent revision rhinoplasty, owing to recurrence of saddle, wound infection, or warping of the costal cartilage for dorsal augmentation.

Conclusions

We introduce a modified saddle nose classification scheme that is simpler and better able to characterize different deformities. Among 91 patients with saddle nose, 20 (22%) had unsuccessful outcomes (fair or poor) and 8 (9%) underwent subsequent revision rhinoplasty. Thus, management of saddle nose deformities remains challenging.

Association of Ocular and Oculodermal Melanocytosis With the Rate of Uveal Melanoma Metastasis Analysis of 7872 Consecutive Eyes Oculo(dermal) Melanocytosis and Uveal Melanoma

Shields CL, Kaliki S, Livesey M, et al. — Thu, 16 May 2013 00:00:00 GMT

Importance

Ocular/oculodermal (oculo[dermal]) melanocytosis is a congenital periocular pigmentary condition that can lead to the development of uveal melanoma, estimated at 1 in 400 affected patients. In this study, patients with melanocytosis who developed uveal melanoma were found to have double the risk for metastasis compared with those without melanocytosis.

Objective

To determine the relationship of oculo(dermal) melanocytosis to the prognosis of patients with uveal melanoma.

Design, Setting, and Patients

Retrospective chart review of 7872 patients with uveal melanoma treated at the Ocular Oncology Service, Wills Eye Institute, from August 25, 1970, through August 27, 2008.

Exposures

Enucleation, plaque radiotherapy, local resection, or thermotherapy.

Main Outcomes and Measures

Metastasis and death.

Results

Of 7872 patients with uveal melanoma, oculo(dermal) melanocytosis was present in 230 (3%). The melanocytosis involved the sclera (92%), iris (17%), choroid (12%), eyelid (8%), and temporal fossa (1%). Eyes with melanoma and oculo(dermal) melanocytosis had a relative risk for metastasis 1.6 times greater compared with those with no melanocytosis (P < .001). Metastasis of uveal melanoma was 2.8 times higher in patients with iris melanocytosis (P < .001), 2.6 times higher with choroidal melanocytosis (P = .02), and 1.9 times higher with scleral melanocytosis (P < .001). By Kaplan-Meier estimates, metastasis in patients with oculo(dermal) melanocytosis vs no melanocytosis was 2% vs 1.8% at 1 year, 27% vs 15% at 5 years, and 48% vs 24% at 10 years (P < .001). By multivariable analysis, the factors predictive of metastasis in patients harboring uveal melanoma associated with oculo(dermal) melanocytosis were increased tumor thickness (P = .001) and the presence of subretinal fluid (P = .05), and the only factor predictive of death was increased tumor thickness (P = .009).

Conclusions and Relevance

Patients with uveal melanoma associated with oculo(dermal) melanocytosis have double the risk for metastasis compared with those with no melanocytosis. All patients with oculo(dermal) melanocytosis should undergo ophthalmic examination and imaging on a twice-yearly basis because this could help with the early detection of melanoma.

A Novel Technique of Modified Continuous Blanket Suture for Amniotic Membrane Fixation in Severe Ocular Surface Diseases Modified Continuous Blanket Suture

Zhang Z, Ma H, Chen D, et al. — Thu, 16 May 2013 00:00:00 GMT

The purpose of this article is to demonstrate a novel technique using modified continuous blanket suture (MCBS) to fix the amniotic membrane (AM) in different severe ocular surface disease lesions. The MCBS techniques were used to fix the AMs of 5 representative patients with different ocular surface lesions related to severe ocular surface diseases. In all cases, stable adherence of the AM was maintained until the epithelialization of the ocular surface was completed. No early detachment, dissolution, or dislocation of the AM patch was observed. During follow-up, all patients acquired a smooth and acceptable ocular surface without any persistent epithelial defect, infection, or ulceration. The MCBS method achieved good AM fixation on the ocular surface in cases of severe ocular surface lesions and could prevent the early detachment of the AM and promote the epithelialization of the ocular surface.

Paul A. Cibis, MD A Pioneer of Modern Vitreoretinal Surgery Paul A. Cibis, MD

Feibel RM, Blodi CF. — Thu, 16 May 2013 00:00:00 GMT

Paul Anton Cibis (1911-1965) was one of the pioneers of modern vitreoretinal surgery. He reasoned that the pathology of complex retinal detachments was intravitreal fibrosis and concluded that the optimum surgery was the injection of liquid silicone oil into the vitreous cavity to dissect fibrous membranes from the retinal surface and use the silicone for retinal tamponade. Prior to the invention of pars plana vitrectomy, such surgery was innovative, even daring. These surgical techniques were an important advance in directly operating on the vitreous in retinal detachment surgery. However, Cibis' contributions to vitreoretinal surgery only occupied the last 10 years of his tragically short life. Prior to his practice in retinal surgery, he made contributions to basic research in physiologic optics, local retinal adaptation, and the effect of ionizing radiation and atomic energy on the globe.