Contemporary use of sentinel lymph node biopsy in the head and neck

Sentinel lymph node biopsy has become a well-established and commonplace practice in many oncologic disease sites as a means to stage the regional lymphatics, avoid unnecessary surgery and decrease patient morbidity. In the head and neck, its role is well established for cutaneous melanoma with proven fidelity and survival benefit. Its role in use for other sites such as oral cavity carcinoma continues to develop with promising results from several recent trials. Although not widely adopted, the potential benefits of sentinel lymph node biopsy in the management of oral cavity carcinoma are apparent. Refinements in technology and protocols including development of novel radiopharmaceutical tracers, routine incorporation of detailed anatomic imaging, increasing surgeon experience and development of new intraoperative identification aids will likely lead to improvements in the use and accuracy of this technique. Keywords: Oral cavity cancer, Sentinel lymph node, Head and neck cancer, Squamous cell carcinoma, Lymphoscintigraph

Transformation of facial basal cell carcinoma to squamous cell carcinoma following vismodegib

Objective(s): Vismodegib, a unique hedgehog pathway inhibitor, has been demonstrated to be effective in the treatment of non-operable and metastatic basal cell carcinoma (BCC). While effective, concerns regarding its role in the development of cutaneous squamous cell carcinoma (CSCC) remain. The primary objective is to describe a unique case of locally advanced BCC of the face and subsequent transformation to CSCC following treatment with vismodegib. Methods: Case report. Results: A 64-year-old Caucasian female presented with a 3-year history of a progressive and erosive lesion involving the entirety of her forehead with involvement of the left medial canthus and upper eyelid. Biopsies performed at the periphery of the lesion demonstrated superficial and nodular BCC. As surgical management would result in significant morbidity, the patient elected for treatment with oral vismodegib, 150 mg daily, with curative intent. Dramatic tumor response was experienced over an 18-month period; however, surveillance MRI demonstrated concern for tumor progression at the periphery of the mass without evidence of intracranial extension or metastases. Subsequent biopsies at the superior and left supraorbital margins demonstrated invasive SCC. Following immunohistochemistry analysis, intravenous nivolumab, 480 mg monthly was initiated; the patient remains progression-free after 18 months of therapy. Conclusion: This case highlights the importance of close surveillance in patients treated with vismodegib for non-operable BCC. Serial biopsies of new or suspicious appearing tumors should be performed given the potential for CSCC transformation

Expanding use of osseointegrated implantation using 3-dimensional surgical planning: a paradigm shift in dental reconstruction

Medical modeling and 3-dimensional (3D) virtual surgical planning represent a rapidly expanding, technological advancement especially useful in complex mandibular or maxillary defects in head and neck reconstruction. With utilization of 3D surgical planning, the reconstructive surgeon can initiate dental rehabilitation during the primary surgery with osseointegrated implants (OI), streamlining a typically lengthy process to full oral rehabilitation. Careful patient selection is important to optimize outcomes with immediate OI, and factors to consider during the evaluation process include pathology, prognosis, anticipated defect, dental status, donor site availability, and patient motivation and resources. Synthesizing this information and developing a reconstructive plan with a multidisciplinary team approach is critical to expedite dental rehabilitation for select patients. A review of relevant literature and our surgical planning algorithm for selecting candidates for immediate OI is provided, along with our experience using this decision algorithm in a uniquely complex clinical case

Anterior skull base reconstruction: a contemporary review

Anterior skull base (ASB) defects present a significant challenge in head and neck reconstructive surgery. The main goal of skull base reconstruction is to create a watertight separation between the intracranial cavity and aerodigestive tract. Successful reconstruction aims to prevent cerebrospinal fluid (CSF) leak, pneumocephalus, and a range of infectious manifestations. Functional outcomes and cosmesis are also critical considerations when developing a reconstructive plan. Advancements with endoscopic endonasal approaches have revolutionized skull base surgery but also have created new reconstructive challenges due to the narrow operative corridor, especially for extensive defects or salvage cases where microvascular free tissue transfer is required. Though a variety of techniques including local, regional, and free flaps have been described, ASB reconstruction remains a difficult undertaking due to the complex anatomy and high risk for post-operative complications. This review provides a comprehensive discussion of available reconstructive techniques that can be used after both open and endoscopic ASB resections to help determine the optimal reconstruction for a variety of defects

Risk of COVID-19 after natural infection or vaccinationResearch in context

Background: While vaccines have established utility against COVID-19, phase 3 efficacy studies have generally not comprehensively evaluated protection provided by previous infection or hybrid immunity (previous infection plus vaccination). Individual patient data from US government-supported harmonized vaccine trials provide an unprecedented sample population to address this issue. We characterized the protective efficacy of previous SARS-CoV-2 infection and hybrid immunity against COVID-19 early in the pandemic over three-to six-month follow-up and compared with vaccine-associated protection. Methods: In this post-hoc cross-protocol analysis of the Moderna, AstraZeneca, Janssen, and Novavax COVID-19 vaccine clinical trials, we allocated participants into four groups based on previous-infection status at enrolment and treatment: no previous infection/placebo; previous infection/placebo; no previous infection/vaccine; and previous infection/vaccine. The main outcome was RT-PCR-confirmed COVID-19 >7–15 days (per original protocols) after final study injection. We calculated crude and adjusted efficacy measures. Findings: Previous infection/placebo participants had a 92% decreased risk of future COVID-19 compared to no previous infection/placebo participants (overall hazard ratio [HR] ratio: 0.08; 95% CI: 0.05–0.13). Among single-dose Janssen participants, hybrid immunity conferred greater protection than vaccine alone (HR: 0.03; 95% CI: 0.01–0.10). Too few infections were observed to draw statistical inferences comparing hybrid immunity to vaccine alone for other trials. Vaccination, previous infection, and hybrid immunity all provided near-complete protection against severe disease. Interpretation: Previous infection, any hybrid immunity, and two-dose vaccination all provided substantial protection against symptomatic and severe COVID-19 through the early Delta period. Thus, as a surrogate for natural infection, vaccination remains the safest approach to protection. Funding: National Institutes of Health

Risk of COVID-19 after natural infection or vaccinationResearch in context

Summary: Background: While vaccines have established utility against COVID-19, phase 3 efficacy studies have generally not comprehensively evaluated protection provided by previous infection or hybrid immunity (previous infection plus vaccination). Individual patient data from US government-supported harmonized vaccine trials provide an unprecedented sample population to address this issue. We characterized the protective efficacy of previous SARS-CoV-2 infection and hybrid immunity against COVID-19 early in the pandemic over three-to six-month follow-up and compared with vaccine-associated protection. Methods: In this post-hoc cross-protocol analysis of the Moderna, AstraZeneca, Janssen, and Novavax COVID-19 vaccine clinical trials, we allocated participants into four groups based on previous-infection status at enrolment and treatment: no previous infection/placebo; previous infection/placebo; no previous infection/vaccine; and previous infection/vaccine. The main outcome was RT-PCR-confirmed COVID-19 >7–15 days (per original protocols) after final study injection. We calculated crude and adjusted efficacy measures. Findings: Previous infection/placebo participants had a 92% decreased risk of future COVID-19 compared to no previous infection/placebo participants (overall hazard ratio [HR] ratio: 0.08; 95% CI: 0.05–0.13). Among single-dose Janssen participants, hybrid immunity conferred greater protection than vaccine alone (HR: 0.03; 95% CI: 0.01–0.10). Too few infections were observed to draw statistical inferences comparing hybrid immunity to vaccine alone for other trials. Vaccination, previous infection, and hybrid immunity all provided near-complete protection against severe disease. Interpretation: Previous infection, any hybrid immunity, and two-dose vaccination all provided substantial protection against symptomatic and severe COVID-19 through the early Delta period. Thus, as a surrogate for natural infection, vaccination remains the safest approach to protection. Funding: National Institutes of Health