American Head & Neck Society

Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.

Published on by AHNS Webmaster

Myers’ Family Summer Travel Fellowship in Otolaryngology Application is Open

Diversity Summer Travel Fellowship in Otolaryngology for under-represented minority medical students 

This program is sponsored by the American Head and Neck Society Research and Education Foundation, thanks to the very generous contributions of Dr. Eugene Myers and Dr. Jeffrey Myers, as well as other AHNS donors.  It is intended to expose an under-represented minority medical student to the field of Head and Neck surgery specifically and Otolaryngology in general. Please click the link here to watch the RFA video to disseminate to your URM M1 and M2 candidates of the AHNS Myers’ Family Summer Travel Fellowship in Otolaryngology.

 

A grant of $5,000 will be awarded to a medical student to cover travel, lodging and food expenses for the summer experience.  This summer program offers the interested candidate the opportunity to work in a Department of Academic Excellence in Head and Neck Surgical Oncology that has an approved Fellowship Training Program from the Advanced Training Council of the AHNS.  Participants will be assigned to a clinical faculty mentor and will rotate on his or her clinical service and have the chance to participate in the care of Head and Neck Cancer patients in the outpatient setting, inpatient environment, as well as the operating room.  Summer fellows will also have the opportunity to perform basic, translational, clinical, or population based research under the guidance of a chosen/assigned research mentor.

 

The grant of $5,000 includes the recipients roundtrip airfare, cost to travel to the meeting, transportation to and from, food and hotel stay expenses at the AHNS Annual/International Meetings. At the AHNS Annual/International Meeting the student will share their Summer experience via PowerPoint presentation and can network with AHNS members.

 

Ideally the candidate is between year 1 and 2 of medical school. Some applicants between year 2 and 3 may have the ability to participate as a fellow award winner but this depends upon their medical school year academic calendar. Our Myers’ Family Summer Travel Fellowship in Otolaryngology FAQ page can be found by clicking here.

Published on by AHNS Webmaster

New Grant Opportunity from SU2C in Head and Neck Cancer: LOI Deadline March 22, 2021

Head and neck cancer is a blanket term used to describe several different types of cancers.
About 65,000 new cases, not counting thyroid cancer, are diagnosed in the U.S. every year.
A number of causes of these cancers have been identified, potentially offering new
opportunities to screen for the cancers and create new treatments for patients.

For example, the incidence of head and neck squamous cell carcinoma in people with
Fanconi anemia is 500- to 700-fold higher than in the general population. Additionally up to
70% of certain head and neck cancers are caused by human papillomavirus (HPV) infection.
Genetic defects that cause Fanconi anemia, as well as genetic changes resulting from HPV
infection, both adversely affect DNA repair systems, which can lead to cancer. This similarity
provides investigators with different perspectives on a common problem and the opportunity
to collaborate in new and innovative ways.

Head and neck cancers can appear in the nasal cavity, sinuses, lips, mouth, salivary glands,
thyroid gland, throat or larynx. Experts estimate there are about 550,000 cases of various
kinds of head and neck cancer diagnosed around the world each year, with 300,000 annual
deaths due to the cancers. Research has also shown that Black people have higher
incidence of head and neck cancer and a lower 5-year survival rate compared to white
people. Black patients are also typically diagnosed with more advanced head and neck
cancer.

To unlock potential new treatments, Stand Up To Cancer, with the generous support of the
Fanconi Anemia Research Fund, the Farrah Fawcett Foundation, the American Head and
Neck Society, and the Head and Neck Cancer Alliance, is offering up to $3.25 million in
grants to fund research to find new treatments for head and neck cancer. The team will have
a special focus on head and neck cancers associated with Fanconi anemia and HPV. Applicants will need to ensure that people from medically disadvantaged backgrounds are included in all phases of their proposed research.

Further information and a link to the application

visit StandUpToCancer.org/HeadandNeck.

 

Published on by Daniel Clayburgh

When should sentinel node biopsy be used for cutaneous squamous cell carcinoma?

Problem:
Cutaneous squamous cell carcinoma (cSCC) is a common malignancy, accounting for 20% of all skin malignancies1; furthermore, 80-90% of cSCC are located on thehead or neck2.  With surgical excision most localized cSCC has an excellent prognosis, with 5 year cure rates >90%3.  However, cSCC does have metastatic potential; in the 4% of cases that metastasize4 to regional lymphatics, the 5-year survival rate drops to 50-60%5.  Thus, risk-stratification and identification of patients with potential metastatic spread is important to optimize treatment.  While the majority of cSCC are easily treated with surgical excision and do not require nodal evaluation, the risk of metastatic spread may be as high as 47% in some high-risk populations (Table 1)6.  Sentinel lymph node biopsy (SLNB) is a method of evaluating the draining nodal basin of a primary cancer for occult disease that is widely used in melanoma, breast cancer, and other malignancies.  SLNB increases staging and prognosis accuracy and aids in local disease control6, although recent trials have not demonstrated overall survival benefit with SLNB7.  This technique has intermittently been applied to cSCC for many years, but the optimal use of SLNB in cSCC has not yet been defined.

Evidence
There are currently no large-scale, prospective, randomized clinical trials examining the use of SLNB in cSCC.  There are many prospective observational, retrospective, and meta-analysis studies examining this question, which are generally small (<200 patients) and limited to single-institution studies.  These studies demonstrate significant heterogeneity in patient inclusion criteria, methodology, and outcome measurements.  SLN positivity rates range from 0-66% across studies8, while meta-analyses of multiple studies have found positivity rates of 8%, 12%, and 14%.9,10,11  One literature review reported the sensitivity of SLNB to be 79%, specificity of 100%, and negative predictive value of 96%.12  A significant source of heterogeneity in these studies is the number and type of high risk features of the patients within each study.  While there is generally consensus regarding what constitutes high-risk features of cSCC (Table 1), it is not clear which of these features may provide the strongest indication for SLNB.

There is some data to support SLNB as a prognostic test in cSCC.  One study13 of 62 patients found a 100% 3-year survival in patient with negative SLNB, and a 20.8% 3 year survival in those with a positive SLNB.  Similarly, a second prospective study14 of 57 patients found a significant difference in disease-specific survival between SLNB positive and negative patients. In addition, other studies have shown that locoregional and distant recurrence is more likely in patient with positive SLNB.  In all studies, patients with positive SLNB were treated with additional surgery, radiation, or both.  Only one retrospective study compared SLNB patients to an observation arm; in this study of 720 patients, there were slightly more cSCC-related deaths in the SLNB arm (7.14% vs 4.74% in the observation arm) although this was not statistically significant.15  Thus, it remains unclear if SLNB and directed adjuvant therapy may improve survival in patients with cSCC.

Current guidelines on SLNB
Management of high-risk cSCC can be complex, and multiple guidelines exist to guide treatment decisions in these patients.  Most guidelines currently available discuss SLNB and conclude the data surrounding SLNB is limited, and few definitive statements are available.  Canadian guidelines16 provide a weak recommendation to consider SLNB as an optional procedure in certain high-risk patients; alternatively, European guidelines17 state that SLNB cannot be recommended outside of a clinical trial.  SLNB is not incorporated into any National Comprehensive Cancer Network treatment algorithms for cSCC; it contains a statement that “it is unclear whether SLNB followed by completion lymph node dissection or adjuvant RT will improve patient outcomes.  The criteria for selecting patients for SLNB are also unclear.”18

Bottom line:
SLNB likely provides some prognostic information in cSCC, but to date it is unclear which patients may benefit from this procedure, or its effect on the overall disease course.  Large-scale, well-controlled clinical trials are needed to define when SLNB is most useful in the management of cSCC.  While no clear recommendations currently exist, it does appear reasonable to consider SLNB in certain high-risk cases of cSCC; for example, patients with two or more high-risk features or after collaborative decision-making in a multidisciplinary treatment setting.

References

  1. Green AC, Olsen CM. Cutaneous squamous cell carcinoma: an epidemiological review. Br J Dermatol 2017;177:373e81.
  2. Alam M, Ratner D. Cutaneous squamous-cell carcinoma. N Engl J Med 2001;344:975e83.
  3. Bougham ND, Dennett ER, Cameron R, Tan ST. The incidence of metastasis from cutaneous squamous cell carcinoma and the impact of its risk factors. J Surg Oncol 2012;106:811e5.
  4. Brantsch KD, Meisner C, Schonfisch B, Trilling B, Wehner-Caroli J, Rocken M, et al. Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study. Lancet Oncol 2008;9:713e20.
  5. Robsahm TE, Helsing P, Veierod MB. Cutaneous squamous cell carcinoma in Norway 1963-2011: increasing incidence and stable mortality. Cancer Med 2015;4:472e80.
  6. Rowe DE, Carroll RJ, Day CL Jr. Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip: implications for treatment modality selection. J Am Acad Dermatol. 1992;26:976–90.
  7. Faries MB, Thompson JF, Cochran AJ, et al. Completion dissection or observation for sentinel-node metastasis in melanoma. N Engl J Med. 2017;376:2211–22.
  8. Mooney CP, et al. Sentinel Node Biopsy in 105 High-Risk Cutaneous SCCs of the Head and Neck: Results of a Multicenter Prospective Study. Ann Surg Oncol 2019; 26:4481-4488
  9. Navarrete-Dechent C, Veness MJ, Droppelmann N, Uribe P. High-risk cutaneous squamous cell carcinoma and the emerging role of sentinel lymph node biopsy: A literature review. J Am Acad Dermatol 2015;73:127e37.
  10. Tejera-Vaquerizo A, Garcia-Doval I, Llombart B, Canueto J, Martorell-Calatayud A, Descalzo-Gallego MA, et al. Systematic review of the prevalence of nodal metastases and the prognostic utility of sentinel lymph node biopsy in cutaneous squamous cell carcinoma. J Dermatol 2018;45:781e90.
  11. Schmitt AR, Brewer JD, Bordeaux JS, Baum CL. Staging for cutaneous squamous cell carcinoma as a predictor of sentinel lymph node biopsy results: meta-analysis of American Joint Committee on Cancer criteria and a proposed alternative system. JAMA Dermatol 2014;150:19e24.
  12. Allen JE, Stolle LB. Utility of sentinel node biopsy in patients with high-risk cutaneous squamous cell carcinoma. Eur J Surg Oncol 2015;41:197e200.
  13. Takahashi A, Imafuku S, Nakayama J, Nakaura J, Ito K, Shibayama Y. Sentinel node biopsy for high-risk cutaneous squamous cell carcinoma. Eur J Surg Oncol. 2014;40:1256-1262.
  14. Gore SM, Shaw D, Martin RC, Kelder W, Roth K, Uren R, Gao K, Davies S, Ashford BG, Ngo Q, Shannon K, Clark JR. Prospective study of sentinel node biopsy for high-risk cutaneous squamous cell carcinoma of the head and neck. Head Neck 38: E884–E889, 2016
  15. Kofler L, Kofler K, Schulz C, Breuninger H, Hafner HM, Sentinel lymph node biopsy for high-thickness cutaneous squamous cell carcinoma. Arch Dermatol Res. 2021 Mar;313(2):119-126
  16. Sapijaszko M, Zloty D, Bourcier M, Poulin Y, Janiszewski P, Ashkenas J. Non-melanoma skin cancer in Canada chapter 5: management of squamous cell carcinoma. J Cutan Med Surg 2015; 19: 249–259
  17. Stratigos AJ, Garbe C, Dessinioti C, et al. European interdisciplinary guideline on invasive squamous cell carcinoma of the skin: Part 1. Epidemiology, diagnostics, and prevention. European Journal of Cancer 128 (2020) 60-82
  18. National Comprehensive Cancer Network (NCCN) Clinical Practice Guideline for Squamous Cell Skin Cancer. Version 2.2020, 7/14/20. Accessed 1/29/2021.
Daniel Clayburgh

Daniel Clayburgh

Daniel Clayburgh is an associate professor of Otolaryngology-Head and Neck Surgery at Oregon Health Sciences University and the Chief of Surgery at the Portland Veterans Affairs Medical Center. He completed medical and graduate school at the University of Chicago, otolaryngology residency at Oregon Health Sciences University, and head and neck fellowship at the University of Pittsburgh. His research interests primarily focus on perioperative optimization of head and surgical outcomes and developing novel prognostic factors in head and neck cancer patients.
Daniel Clayburgh

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Published on by AHNS Webmaster

AHNS Virtual Education Series

To Reconstruct or Not: Early Stage Oral Cavity Cancers

AHNS Virtual Education Series: To Reconstruct or Not: Early Stage Oral Cavity Cancers

The AHNS gratefully acknowledges support of this webinar from KLS Martin.

Date: Tuesday, February 23, 2021

Time: 4:00 PM Pacific /6:00 PM Central / 7:00 PM Eastern

This session is an hour long

Complimentary to all attendees

Register Here

Faculty:

Host: Urjeet Patel, MD, FACS, Cook County Hospital Stroger

Moderator: Matthew Old, MD, FACS, Wexner Medical Center, The Ohio State University

Panelists:
Alice Lin, MD, FACS, Kaiser Permanente – Los Angeles Medical Center
Larissa Sweeny, MD, Louisiana State University at New Orleans
Neal Futran, MD, Univ of Washington Med Center
Stephan Kang, MD, The Ohio State University
Rizwan Aslam, MD, Tulane University
Rodrigo Bayon, MD, FACS, University of Iowa Hospitals & Clinics
Arnaud Bewley, MD, University of California – Davis Medical Center
Steven Chinn, MD MPH FACS, University of Michigan
Michael Moore, MD, Indiana University School of Medicine
Jason Rich, MD, Washington University School of Medicine
Chad Zender, MD, FACS, University of Cincinnati College of Medicine

Published on by Aviram Mizrachi

Cutaneous Malignancies in the Organ Transplant Population

Case

A 68 y/o man with a history of kidney transplantation on Tacrolimus and prednisone treatment.

Several months prior to his presentation he underwent excision of a Rt temple skin lesion by a plastic surgeon. Pathology revealed a 4 mm SCC with evidence of PNI and free surgical margins. No further treatment or follow-up was recommended.

The patient presents now after noticing a weakness of Rt eyebrow for the last two months. He was seen at the Ophthalmology clinic and diagnosed with complete paralysis of the Rt temporal branch of CN-VII. In addition, there was a 2 cm firm subcutaneous painless mass on the Rt temple, deep to the surgical scar. Biopsy of the Rt temple lesion showed SCC. The patient was then referred to the head and neck clinic for further evaluation and treatment. There were no additional findings on physical examination and imaging studies did not show evidence of regional or distant disease (Figures 1, 2).

Figure 1
Figure 2: PET-CT

 

 

 

 

 

 

Risk of recurrence or metastases

The above case depicts a patient with a high risk for disease recurrence and/or metastases due to chronic immunosuppression. A recent review summarizes the role of the immune system in cutaneous SCC (Figure 3). In this paper the authors illustrate the effect of immunosuppressive drugs on several carcinogenic mechanisms including DNA repair, synergism with UV-related DNA damage, angiogenesis and invasiveness.  The NCCN guidelines address the group of high-risk patients with skin SCC and specify the risk factors that warrant close follow-up. Pay attention to “Area H” that includes the “Mask areas” of the face and is considered a high-risk feature (Figure 4).

Management

Every attempt should be made to achieve complete excision of the primary lesion with negative margins. Modification or reduction of immunosuppression should be considered and consulting the appropriate discipline (nephrologist, hepatologist etc.) is strongly encouraged. Adjuvant radiation may be recommended in cases of perineural involvement of large nerves. However, it should be noted that the definition of large nerves by AJCC 8th edition for skin SCC of the head and neck is above 0.1 mm and most nerves deep to the dermis are above 0.1 mm. Moreover, the survival benefit of adjuvant radiation following complete resection of the primary lesion remains unclear (Figure 5).

Outcomes

Several studies addressed the differences in survival outcomes between immunosuppressed and immunocompetent patients with skin SCC. A recent multi-center study reported on 67 immunosuppressed patients, most of them solid organ recipients, and compared them with 138 immunocompetent patients (Figure 8). They found better progression free survival and locoregional control in the immunocompetent patients group. However, no difference in overall survival between the two groups was noted. Another study by Ritter et al. compared 177 solid organ recipients with 177 immunocompetent patients with skin SCC. They found a significantly higher recurrence rate and worse overall survival in the solid organ recipients group (Figure 6).

Checkpoint inhibitors 

Immunocompromised patients have been traditionally excluded from the major clinical trials on checkpoint inhibitors. Solid organ recipients and patients with chronic viral infections (HIV, HBV, HCV) are considered poor candidates for checkpoint inhibitors due to the risk of allograft rejection and disease flare-up respectively. A multi-center European study reported on 46 patients treated with anti-PD-1/PD-L1 agents. Of them 6 were solid organ recipients and the remaining had chronic viral infections. They concluded that while patients with chronic viral infection may be safely treated with anti-PD-1/PD-L1 drugs, in solid organ recipients the risk of allograft rejection needs to be carefully weighed against the benefit of immunotherapy (Figure 7).

 

“CONCLUSION: Patients with HIV or hepatitus B/C infection treated with anti-PD-1/PD-L1 immunotherapy may respond to treatment without increased toxicity. Given the risk of graft rejection in solid organ transplant patients and also the potential for response, the role of anti-PD-1/PD-L1 immunotherapy needs to be carefully considered.”

 

Another study from MD Anderson Cancer Center reported on 37 solid organ recipients treated with checkpoint inhibitors. They found that 41% of patients experienced allograft rejection with a median time to rejection of 21 days from the initiation of immunotherapy. Furthermore, patients with allograft rejection had a significantly worse overall survival (Figure 8).

There is certainly a need for prospective trials in order to optimize the use of checkpoint inhibitors in immunosuppressed patients. A recently opened trial is enrolling kidney transplant recipients with advanced cancers, with an aim to treat them with Tacrolimus, Nivolumab and Ipilimumab. Additional details on this topic and the trial can be found in the following link:

https://ascopost.com/issues/march-10-2020/immune-checkpoint-inhibitors-in-solid-organ-transplant-recipients/

References

  • Bottomley MJ, Thomson J, Harwood C, Leigh I. The Role of the Immune System in Cutaneous Squamous Cell Carcinoma. Int J Mol Sci. 2019 Apr 24;20(8):2009. doi: 10.3390/ijms20082009. PMID: 31022866; PMCID: PMC6515307.
  • National Comprehensive Cancer Network. Squamous Cell Skin Cancer (Version 2.2020). https://www.nccn.org/professionals/physician_gls/pdf/squamous.pdf
  • Manyam BV, Garsa AA, Chin RI, Reddy CA, Gastman B, Thorstad W, Yom SS, Nussenbaum B, Wang SJ, Vidimos AT, Koyfman SA. A multi-institutional comparison of outcomes of immunosuppressed and immunocompetent patients treated with surgery and radiation therapy for cutaneous squamous cell carcinoma of the head and neck. Cancer. 2017 Jun 1;123(11):2054-2060. doi: 10.1002/cncr.30601. Epub 2017 Feb 7. PMID: 28171708.
  • Ritter A, Badir S, Mansour M, Segal Z, Ad-El D, Bachar G, Shpitzer T, Popovtzer A, Mizrachi A. Solid organ transplantation worsens the prognosis of patients with cutaneous squamous cell carcinoma of the head and neck region-Comparison between solid organ transplant recipients and immunocompetent patients. Head Neck. 2020 Nov 27. doi: 10.1002/hed.26546. Epub ahead of print. PMID: 33247523.
  • Tio M, Rai R, Ezeoke OM, McQuade JL, Zimmer L, Khoo C, Park JJ, Spain L, Turajlic S, Ardolino L, Yip D, Goldinger SM, Cohen JV, Millward M, Atkinson V, Kane AY, Ascierto PA, Garbe C, Gutzmer R, Johnson DB, Rizvi HA, Joshua AM, Hellmann MD, Long GV, Menzies AM. Anti-PD-1/PD-L1 immunotherapy in patients with solid organ transplant, HIV or hepatitis B/C infection. Eur J Cancer. 2018 Nov;104:137-144. doi: 10.1016/j.ejca.2018.09.017. Epub 2018 Oct 20. PMID: 30347289.
  • Abdel-Wahab N, Safa H, Abudayyeh A, Johnson DH, Trinh VA, Zobniw CM, Lin H, Wong MK, Abdelrahim M, Gaber AO, Suarez-Almazor ME, Diab A. Checkpoint inhibitor therapy for cancer in solid organ transplantation recipients: an institutional experience and a systematic review of the literature. J Immunother Cancer. 2019 Apr 16;7(1):106. doi: 10.1186/s40425-019-0585-1. Erratum in: J Immunother Cancer. 2019 Jun 24;7(1):158. PMID: 30992053; PMCID: PMC6469201.
Aviram Mizrachi

Aviram Mizrachi

Dr. Aviram Mizrachi is a surgeon-scientist at the Department of Otolaryngology – Head and Neck Surgery of Rabin Medical Center in Israel. He has an active research laboratory focusing on tumor and radiation biology in head and neck cancer as well as targeted drug delivery. Furthermore, he investigates both radiation and chemotherapy mechanisms of action and their effect on tumor and normal tissue including the utility of novel radio-sensitizing and radio-protective agents. In addition, Dr. Mizrachi conducts clinical research on outcomes in head and neck, skin and thyroid cancers.