scholarly journals Reconstruction of Pharyngeal Defects

2020 ◽  
Author(s):  
Takako Yabe ◽  
Bruce Ashford
Keyword(s):  
Local Control ◽  
Organ Preservation ◽  
Patient Management ◽  
Nonsurgical Treatment ◽  
Tissue Loss ◽  
Department Of Veterans Affairs ◽  
Related Factors ◽  
Cancer Study ◽  
Challenging Tasks ◽  
Pharyngeal Reconstruction

The management of pharyngeal defects is one of the most challenging tasks for reconstructive surgeons. The reconstructive method is driven by the amount of tissue loss as well as patient-related factors. Since the advent of organ preservation strategies in the 1990s as described by the Department of Veterans Affairs Laryngeal Cancer Study, salvage surgery has become a common pharyngeal procedure to obtain local control when nonsurgical treatment fails. This chapter is divided into preoperative, intraoperative, and postoperative phases of patient management. Each section will focus on particular aspects of management that are essential to achieve the best therapeutic outcome for patients who need pharyngeal reconstruction.

scholarly journals Building cohesion in distributed telemedicine teams: Findings from the Department of Veterans Affairs National Telestroke Program

2020 ◽  
Author(s):  
Himalaya Patel ◽  
Teresa M. Damush ◽  
Edward J. Miech ◽  
Nicholas A. Rattray ◽  
Holly A. Martin ◽  
...  
Keyword(s):  
Clinical Evidence ◽  
Veterans Affairs ◽  
Team Cohesion ◽  
Case Conference ◽  
Department Of Veterans Affairs ◽  
Related Factors ◽  
Shared Identity ◽  
Assessment And Treatment ◽  
National Infrastructure ◽  
Interview Transcript

Abstract Background: As telemedicine adoption increases, so does the importance of building cohesion among physicians in telemedicine teams. For example, in acute telestroke services, stroke specialists provide rapid remote stroke assessment and treatment to patients at hospitals without stroke specialty care. In the National Telestroke Program (NTSP) of the U.S. Department of Veterans Affairs, a virtual (distributed) hub of stroke specialists throughout the country provides 24/7 consultations nationwide. We examined how these specialists adapted to distributed teamwork, and we identified cohesion-related factors in program development and support. Methods: We studied the virtual hub of stroke specialists employed by the NTSP. Semi-structured, confidential interviews with stroke specialists in the virtual hub were recorded and transcribed. We explored the extent to which these specialists had developed a sense of shared identity and team cohesion, and we identified factors in this development. Using a qualitative approach with constant comparison methods, two researchers coded each interview transcript independently using a shared codebook. We used matrix displays to identify themes, with special attention to team cohesion, communication, trust, and satisfaction. Results: Of 13 specialists with at least 8 months of NTSP practice, 12 completed interviews; 7 had previously practiced in telestroke programs in other healthcare systems. Interviewees reported high levels of trust and team cohesion, sometimes even more with their virtual colleagues than with co-located colleagues. Factors facilitating perceived team cohesion included a weekly case conference call, a sense of transparency in discussing challenges, engagement in NTSP development tasks, and support from the NTSP leadership. Although lack of in-person contact was associated with lower cohesion, annual in-person NTSP meetings helped mitigate this issue. Despite technical challenges in establishing a new telehealth system within existing national infrastructure, providers reported high levels of satisfaction with the NTSP. Conclusion: A virtual telestroke hub can provide a sense of team cohesion among stroke specialists at a level comparable with a standard co-located practice. Engaging in transparent discussion of challenging cases, reviewing new clinical evidence, and contributing to program improvements may promote cohesion in distributed telemedicine teams.

Association of tumor volume and outcomes in T3 larynx cancer with organ preservation approach.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e18044-e18044
Author(s):  
Nauman Malik ◽  
Nicolin Hainc ◽  
Gia Gill ◽  
Steven Nakoneshny ◽  
Paul Kerr ◽  
...  
Keyword(s):  
Overall Survival ◽  
Cohort Study ◽  
Local Control ◽  
Systemic Therapy ◽  
Retrospective Cohort Study ◽  
Organ Preservation ◽  
Retrospective Cohort ◽  
Tumor Volume ◽  
Local Failure ◽  
Larynx Cancer

e18044 Background: Organ preservation approaches to treatment of locally advanced larynx cancers are widely used and consist of radiotherapy (RT) with or without concurrent systemic therapy (CRT). Analyses of the National Cancer Database point to decreasing survival as CRT became widely adopted in place of total laryngectomy (TL). Tumor volume in T3 laryngeal tumors has been postulated as one variable to explain this finding, with higher volume associated with lower local control based on small sample size studies largely in pre-intensity modulated radiotherapy (IMRT) era, and low volume T3 tumors being associated with improved local control with CRT. We sought to validate these findings in a contemporary cohort of T3 larynx patients treated with IMRT. Methods: This was a national, multicentre retrospective cohort study of patients diagnosed with American Joint Committee on Cancer (AJCC) T3 N0-3 M0 glottic and supraglottic cancers who underwent curative intent IMRT with or without systemic treatment from 2002-2018. Tumor volumes were calculated using a validated standardized approach by a Neuroradiologist. Primary predictor was tumor volume, primary outcome was local control (LC), and secondary outcomes included overall survival (OS), as well as late grade 3+ toxicities. Kaplan Meier estimates and log-rank tests were used for survival analyses, with Cox proportional hazards used for univariable analyses. Results: 246 patients met inclusion criteria, 147 glottic and 99 supraglottic cancers. At baseline, glottic patients were more likely to be male (p < 0.01), have a fixed vocal cord (p < 0.01), not have pre-epiglottic space invasion ( < 0.01), be cN0 (p < 0.01), and have lower grade tumors (p < 0.01). Mean tumor volumes for glottic and supraglottic tumors were 5.0 (4.2-5.8) cc and 13.0 (10.3–15.6) cc respectively. Univariable analysis showed systemic therapy was associated with improved local failure (HR 0.49, 95%CI 0.24 – 0.99, p = 0.05). Within the glottic cohort, tumor volume was not associated with local failure (HR 1.09, 95%CI 0.71 – 1.67, p = 0.38), however having a local failure event was associated with increased feeding tube dependence (HR 2.52, 95%CI 1.05 – 6.02, p = 0.04). Median local failure free survival in the overall cohort was 28.5 months, with median OS 23.2 months. There was a trend towards improved local control in the supraglottic cohort compared to glottic patients (log-rank p = 0.08), but the supraglottic cohort had significantly worse overall survival (log-rank p = 0.02). Conclusions: In this retrospective cohort study, there were baseline and outcome differences between patients with T3 glottic and supraglottic larynx cancer, with worse overall survival in supraglottic patients. Tumor volume was not associated with local control in the glottic cohort. These findings are pending further validation in a larger cohort and will be analyzed separately for supraglottic tumors.

Organ preservation with daily concurrent chemoradiotherapy using retrograde superselective intra-arterial infusion for stage III, IV oral cancer: Analysis of therapeutic results in 112 cases.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. 6060-6060
Author(s):  
Kenji Mitsudo ◽  
Toshiyuki Koizumi ◽  
Toshinori Iwai ◽  
Hideyuki Nakashima ◽  
Senri Oguri ◽  
...  
Keyword(s):  
Oral Cancer ◽  
Local Control ◽  
Organ Preservation ◽  
Concurrent Chemoradiotherapy ◽  
Chemotherapeutic Agents ◽  
Stage Iii ◽  
Concurrent Radiotherapy ◽  
Therapeutic Results ◽  
Grade 3

6060 Background: Retrograde superselective intra-arterial chemotherapy for oral cancer has the advantage of delivering a high concentration of the chemotherapeutic agents to the tumor bed, it can be used to provide daily concurrent chemoradiotherapy for patients with advanced oral cancer. The purpose of this study was to evaluate the therapeutic results and rate of organ preservation in 112 patients of stage III or IV (M0) oral cancer treated with retrograde superselective intra-arterial chemotherapy and daily concurrent radiotherapy. Methods: Between August 2006 and July 2011, 112 patients with stage III or IV oral squamous cell carcinoma underwent intra-arterial chemoradiotherapy. Catheterization from the superficial temporal and occipital arteries was performed. And treatment consisted of superselective intra-arterial chemotherapy (docetaxel, total 60 mg/m2, cisplatin, total 150 mg/m2) and daily concurrent radiotherapy (total 60 Gy) for 6 weeks. Results: The median follow-up for all patients was 46.2 months (range, 10–90 months). The median follow-up for living patients was 49.7 months (range, 36–90 months). After intra-arterial chemoradiotherapy, primary site complete response was achieved in 98 (87.5%) of 112 cases. Thirty patients (26.8%) died. Using the Kaplan-Meier method, 3-year, and 5-year survival rates were 74.6% and 71.3%, respectively, while 3-year, and 5-year local control rates were both 79.3%. Grade 3 or 4 toxicities included mucositis in 92.0%, neutropenia in 30.4%, dermatitis in 28.6%, anemia in 26.8%, and thrombocytopenia in 7.1%. Grade 3 toxicities included dysphagia in 72.3%, nausea/vomiting in 21.4%, fever in 8.0%, and renal failure occurred in 0.9%, no patients died as a result of treatment toxicity. Conclusions: Retrograde superselective intra-arterial chemotherapy and daily concurrent radiotherapy for Stage III, IV oral cancer provided good overall survival and local control rates, thus preserving organs and contributing to patients’ QOL.

scholarly journals T1b Glottic Tumor and Anterior Commissure Involvement: Is the Transoral CO2 Laser Microsurgery a Safe Option?

2020 ◽  
Vol 100 (1_suppl) ◽  
pp. 68S-72S
Author(s):  
Juan Antonio Cabrera-Sarmiento ◽  
Juan Carlos Vázquez-Barro ◽  
Jesús Herranz González-Botas ◽  
Carlos Chiesa-Estomba ◽  
Miguel Mayo-Yáñez
Keyword(s):  
Laser Therapy ◽  
Local Control ◽  
Organ Preservation ◽  
Randomized Trials ◽  
Early Stage ◽  
Anterior Commissure ◽  
Local Recurrences ◽  
Laryngeal Tumors

Objectives: Transoral CO2 laser therapy represents the treatment of choice for early-stage laryngeal tumors. The anterior commissure involvement (ACI) is related to a worse local control and a lower rates of organ preservation. The objective of this study is to analyze the differences in survival, local control, and organ preservation in T1b glottic patients according to the presence of ACI. Methods: Observational prospective study in pT1b treated with transoral CO2 laser between 2009 and 2014. Results: Forty patients (37 male and 3 female) with a mean age of 66.43 ± 8.16 years were recruited. Anterior commissure involvement was present in 70% of the patients. The 5-year specific cause survival was 91.66%, with 32.50% of local recurrences. Laryngeal preservation was 80%, being lower in the group with local recurrence ( P < .000). The involvement of the anterior commissure does not influence the organ preservation ( P = .548), the appearance of local recurrences ( P = .391), or the survival ( P = .33). Conclusions: Transoral CO2 laser therapy is an effective and reproducible treatment for early-stage laryngeal tumors. The results obtained are similar to previous studies, although they present discrepancies in relation to the role of the ACI. Prospective randomized trials are required focusing also on the patients’ quality of life and functional outcome in order to clarify the role of the ACI and the need to implement changes in its evaluation, staging, and evolution.

scholarly journals Building cohesion in distributed telemedicine teams: findings from the Department of Veterans Affairs National Telestroke Program

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Himalaya Patel ◽  
Teresa M. Damush ◽  
Edward J. Miech ◽  
Nicholas A. Rattray ◽  
Holly A. Martin ◽  
...  
Keyword(s):  
Clinical Evidence ◽  
Veterans Affairs ◽  
Team Cohesion ◽  
Case Conference ◽  
Department Of Veterans Affairs ◽  
Related Factors ◽  
Shared Identity ◽  
Assessment And Treatment ◽  
National Infrastructure ◽  
Interview Transcript

Abstract Background As telemedicine adoption increases, so does the importance of building cohesion among physicians in telemedicine teams. For example, in acute telestroke services, stroke specialists provide rapid remote stroke assessment and treatment to patients at hospitals without stroke specialty care. In the National Telestroke Program (NTSP) of the U.S. Department of Veterans Affairs, a virtual (distributed) hub of stroke specialists throughout the country provides 24/7 consultations nationwide. We examined how these specialists adapted to distributed teamwork, and we identified cohesion-related factors in program development and support. Methods We studied the virtual hub of stroke specialists employed by the NTSP. Semi-structured, confidential interviews with stroke specialists in the virtual hub were recorded and transcribed. We explored the extent to which these specialists had developed a sense of shared identity and team cohesion, and we identified factors in this development. Using a qualitative approach with constant comparison methods, two researchers coded each interview transcript independently using a shared codebook. We used matrix displays to identify themes, with special attention to team cohesion, communication, trust, and satisfaction. Results Of 13 specialists with at least 8 months of NTSP practice, 12 completed interviews; 7 had previously practiced in telestroke programs in other healthcare systems. Interviewees reported high levels of trust and team cohesion, sometimes even more with their virtual colleagues than with co-located colleagues. Factors facilitating perceived team cohesion included a weekly case conference call, a sense of transparency in discussing challenges, engagement in NTSP development tasks, and support from the NTSP leadership. Although lack of in-person contact was associated with lower cohesion, annual in-person NTSP meetings helped mitigate this issue. Despite technical challenges in establishing a new telehealth system within existing national infrastructure, providers reported high levels of satisfaction with the NTSP. Conclusion A virtual telestroke hub can provide a sense of team cohesion among stroke specialists at a level comparable with a standard co-located practice. Engaging in transparent discussion of challenging cases, reviewing new clinical evidence, and contributing to program improvements may promote cohesion in distributed telemedicine teams.

Oncological management of head and neck cancer I

2018 ◽  
Author(s):  
Liam Masterson
Keyword(s):  
Head And Neck Cancer ◽  
Head And Neck ◽  
Outcome Measures ◽  
Laryngeal Cancer ◽  
Neck Cancer ◽  
Veterans Affairs ◽  
Department Of Veterans Affairs ◽  
Cancer Study

This chapter discusses Department of Veterans Affairs Laryngeal Cancer Study Group’s paper on oncological management of head and neck cancer including the design of the study (outcome measures, results, conclusions, and a critique).

Maximizing Local Control and Organ Preservation in Stage IV Squamous Cell Head and Neck Cancer With Hyperfractionated Radiation and Concurrent Chemotherapy

2002 ◽  
Vol 20 (5) ◽  
pp. 1405-1410 ◽  
Author(s):  
David J. Adelstein ◽  
Jerrold P. Saxton ◽  
Pierre Lavertu ◽  
Lisa A. Rybicki ◽  
Ramon M. Esclamado ◽  
...  
Keyword(s):  
Head And Neck Cancer ◽  
Head And Neck ◽  
Local Control ◽  
Neck Cancer ◽  
Squamous Cell ◽  
Organ Preservation ◽  
Stage Iv ◽  
Distant Metastases ◽  
Concurrent Chemotherapy ◽  
Primary Site

PURPOSE: Results are reported from an aggressive chemoradiotherapy protocol for advanced squamous cell head and neck cancer. PATIENTS AND METHODS: Patients with advanced squamous cell head and neck cancer were treated with hyperfractionated radiation therapy (72 Gy at 1.2 Gy twice per day) and two courses of concurrent chemotherapy with fluorouracil (1,000 mg/m2/d) and cisplatin (20 mg/m2/d), both given as 96-hour continuous intravenous infusions during weeks 1 and 4 of radiation therapy. Primary-site resection was reserved for residual or recurrent primary-site disease after chemoradiotherapy. Neck dissection was considered for N2 or greater disease, irrespective of clinical response, and for residual or recurrent neck disease after nonoperative treatment. RESULTS: Forty-one patients with stage IV disease were treated. Toxicity was significant, with grade 3 to 4 mucositis in 98%, dysphagia in 88%, and skin reaction in 85%. Neutropenic fever requiring hospitalization occurred in 51%. Despite feeding tube placement in 35 patients (85%), the mean weight loss during chemoradiotherapy was 13.3% of initial body weight. One patient died during treatment as a result of a pulmonary embolus. At a median follow-up period of 30 months, the 3-year Kaplan-Meier projected overall survival was 59%, disease-specific survival 69%, likelihood of local control without surgical resection 91%, and local control with surgical resection 97%. The likelihood of distant disease control at 3 years was 74%, and distant metastases were present in eight of 13 patients who died. CONCLUSION: This chemoradiotherapy schedule produces considerable but manageable toxicity. Survival and organ preservation are excellent for this poor-prognosis patient cohort. Distant metastases are the most common cause of treatment failure.

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