To Örebro University

INTRODUCTION: The free fibula flap is a workhorse flap for bony reconstruction of the craniofacial skeleton. The aim of the study was to conduct a systematic review to investigate the postoperative donor site complications and functional outcomes, specifically ankle instability (AI) and gait disturbances (GD), for patients who have received a free fibula flap (FFF) for head and neck cancer reconstruction.

METHODS: We designed a PRISMA-compliant systematic review, which was registered prospectively in PROSPERO. Searches were designed with a health science librarian and included MEDLINE, EMBASE, CINAHL and PEDro. Risk of bias assessment was conducted for each included study, with an assessment of quality using GRADE.

RESULTS: Following exclusion of duplicate entries, a total of 1940 abstracts were identified. After parallel blinded eligibility assessment, 32 studies were included in the analysis. The total number of included participants was 1163, with the total number of FFF being 955. The mean time for functional assessment was 35 months postoperatively (range 8-81 months). The subjective and objective assessment modalities varied considerably. The primary result for AI were 3.3 % and 5.5 % for GD. The results demonstrate heterogeneity in the literature regarding the reporting of AI and GD following FFF.

CONCLUSION: According to this review, the risk of developing these complications appears to be limited but underreporting may be a limitation. Consensus on methods for standardized outcomes assessment of FFF-reconstruction is needed to establish the impact of free fibula flap on AS and GD.

OBJECTIVES: HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) and head and neck carcinoma of unknown primary (HNCUP) are increasing. Despite good prognosis, recurrence rates range from 10% to 25%. Surveillance with clinical controls and imaging is not always reliable. Circulating tumour human papillomavirus DNA (ctHPV-DNA) has emerged as a potential biomarker for treatment evaluation and detection of recurrence. We aimed to investigate the correlation between ctHPV-DNA in HPV+ OPSCC/HNCUP and radiologic tumour burden. Additionally, we sought to assess whether ctHPV-DNA could serve as a tool in treatment evaluation.

DESIGN: A prospective observational cohort study.

SETTING: This multicenter study involved three otolaryngology units located in central Sweden. We utilised HPV genotype-specific assays for droplet digital PCR (ddPCR) to detect ctHPV-DNA in plasma at diagnosis and follow-up. ctHPV-DNA levels were correlated to radiological tumour burden and radiological response using the Kendall Rank correlation coefficient and the Kruskal-Wallis test.

PARTICIPANTS: Patients with HPV+ OPSCC/HNCUP undergoing definitive (chemo)radiotherapy and enrolled in the CIRCOS study. RESULTS: Out of 54 patients, 51 were eligible for analyses. At baseline, ctHPV-DNA was detectable in 88%. A majority of patients with a favourable radiological evaluation according to RECIST had a corresponding undetectable ctHPV-DNA at follow-up. The levels of ctHPV-DNA at baseline correlated with total tumour volume and nodal volume (rτ = 0.39, p < 0.01, respectively rτ = 0.26, p < 0.01).

CONCLUSION: ctHPV-DNA shows correlation with tumour burden. This study strengthens the role of ctHPV-DNA as a promising biomarker for treatment evaluation in HPV-related OPC/HNCUP. With further research on serial plasma sampling, ctHPV-DNA could complement radiological treatment evaluation in HPV+ OPSCC/HNCUP.

TRIAL REGISTRATION: NCT05904327 [ClinicalTrials.gov].

Generative artificial intelligence (AI) large language models are an emerging technology, with ChatGPT and Gemini being 2 well-known examples. The current literature discusses clinical applications and limitations of AI, but its role in research has not yet been extensively evaluated. This study aimed to assess the role of ChatGPT and Gemini in developing novel and clinically relevant research ideas (RIs) for systematic reviews (SRs) in head and neck reconstruction. ChatGPT and Gemini were prompted to provide 10 novel and clinically relevant RIs for SRs in the following domains: head and neck reconstruction in general, microsurgery, and complications in reconstructive head and neck procedures. A comprehensive search was then performed for SRs in MEDLINE, Cochrane Library, and Embase to determine the novelty of the RIs generated. A total of 60 RIs were generated, with half created by ChatGPT and the other half by Gemini. Overall, 3613 entries were found through the literature search. After deduplication and screening, a total of 50 studies that partially addressed the AI-generated RIs were identified and were included in the present review. Out of the 60 AI-generated RIs, 42 had not been previously studied and were therefore considered novel. No statistically significant differences were found between the outputs generated by Gemini and ChatGPT. Both ChatGPT and Gemini were able to effectively generate novel and clinically relevant RIs for SRs, although their suggestions were generally broad. This study demonstrated that AI could potentially aid in the process of conducting novel SRs.

BACKGROUND: Head and neck cancer (HNC) is the seventh most prevalent cancer worldwide, usually requiring a multidisciplinary approach. The National Surgical Quality Improvement Program (NSQIP) risk calculator is a tool for predicting postoperative complications that possibly can help in decision-making, support patient education, and guide the choice between surgical and nonsurgical treatment options. The aim of this study was to assess the reliability of the NSQIP risk calculator as a predictor of postoperative complications following head and neck surgery with microvascular reconstruction.

METHODS: This retrospective study included 99 patients diagnosed with HNC who underwent microvascular reconstruction from January 2016 to February 2021. The observed complications were compared with those predicted by the NSQIP calculator. To assess the discriminatory power of the NSQIP estimates, receiver operating characteristic statistics, logistic regression, and the overall Brier score were used.

RESULTS: Forty-four percent of the patients experienced at least 1 postoperative complication, and 27.2% developed serious complications. The receiver operating characteristic analysis for any complications revealed an area under the curve (AUC) of 0.62 (95% confidence interval 0.51-0.73, P = 0.046). For serious complications, the AUC was 0.65 (95% confidence interval, 0.52-0.79, P = 0.021). Both AUC values fell short of the threshold for "acceptable discrimination" (0.7-0.8). The overall Brier score was 0.32, with scores less than 0.09 considered to have good accuracy.

CONCLUSIONS: The results suggest that the NSQIP risk calculator tends to underestimate the likelihood of postoperative complications in patients who are undergoing resection for HNC accompanied by microvascular reconstruction.

Diagnostic mediastinoscopy is a procedure with well-known serious complications: Hemorrhage, mediastinitis, pneumothorax and recurrent nerve damage. Esophageal perforation is a less known potentially life-threatening complication. Here the case of a young man with an iatrogenic esophageal perforation following a diagnostic mediastinoscopy is presented with a literary review of previously published cases.

BACKGROUND: In oral cancers, tumour borders are typically defined by white light (WL). Narrow-band imaging (NBI) is an optical endoscopic technique commonly used for the larynx and for cancers of unknown primary. However, evidence for using NBI in oral cancers is insufficient.

AIMS/OBJECTIVES: We investigated whether NBI is a better predictor of the true mucosal tumour borders than WL in oral cancers. Additionally, we examined the agreement between NBI-based Takano intrapapillary capillary loop classifications and pathology reports.

MATERIALS AND METHODS: In this prospective study, the tumour borders were assessed by both NBI and WL at the time of surgical resection and then compared. Pathology reports of the examined areas were used as gold standard.

RESULTS: Forty-nine participants were included. After exclusion of 15 patients due to missing data, 34 were included in analyses. In 26.5% of the assessments, the tumour borders defined by NBI were outside the borders defined by WL. However, 55.5% of these were false-positives.

CONCLUSIONS AND SIGNIFICANCE: The delineation of mucosal tumour borders in oral cancers by NBI was not better than that by WL in this study. Several methodological challenges may have influenced the findings of this study, similar to the limitations reported in previous studies.

Surgery is the first line of treatment in gingival cancers of the mandible, and bone resection is necessary in the majority of cases. In the less extensive surgical option, marginal mandibulectomy (MM), the mandibular base is preserved. In contrast, in a segmental mandibulectomy (SM) the mandible is divided and the continuity is not preserved. If MM can be performed with comparable oncological results to SM, it is the preferred method. The aim of the present study was to identify preoperative predictors for local recurrence (LR), to support the selection of candidates for MM. Outcome measures were local recurrence free survival (LRFS) and disease specific survival (DSS). 67 patients treated with MM between 2008 and 2021 were included. Cox regression analyses of LR with hazard ratios and adjustments for postoperative radiotherapy, pathological T-stage (pT) and soft tissue margins were performed. 5-years LRFS was 63% (95% CI 46.9-75.5) and DSS 80.6% (95% CI 64.7-89.9). In conclusion we found that edentulous patients, more advanced pT-stage and positive soft tissue margins had increased risk for LR. Future studies of the correlation between cT and pT would be important to provide more robust preoperative support in the selection between MM and SM.

Introduction: In Sweden, approximately 1700 patients are diagnosed with head and neck cancer (HNC) every year. HNC is relatively rare (2,6 % of all cancers). Risk factors for HNC are smoking, high consumption of alcohol, human papilloma virus (HPV) infection and inflammation 1. The Örebro head and neck cancer registry (ÖHNCR) was founded 1988 to register amount of HNC patients, treatment, reconstruction and overall survival.

Method: We performed a retrospective review of all microvascular and local/regional reconstructions in ÖHNCR from 1988 to 2023. It includes in total 4111 patients in the registry to present day.

Result: The majority, approximately 71.8% of the patients, were judged to be tumour-free at the last check-up. The five-year survival rate for all HNC patients has increased from 49.8% in 1988 to 55.1% in 2023, an increase of 5.3%. Overall survival varies between types of cancer within HNC. The number of both free and local/regional flaps has increased over the past two decades. Of all reported patients in ÖHHCR, approximately 44 patients (34%) have been reconstructed each year. The most common free flap for soft tissue reconstruction were, radial free flap (n=331, 49%) and osteocutaneous reconstruction was the fibula free flap (n=210, 31%). The most common local/regional flap were pectoralis major flap (n=242, 33%).

Discussion: The registry data trends correspond with the current literature, with increased incidence of number of cases with HNC and following reconstruction. We speculate that the increased number of reconstructions, permits an increased number of radical HNC resections followed by improved oncological- and functional outcomes.

BACKGROUND/AIM: Radioactive iodine (RAI) treatment is a cornerstone of treatment of differentiated thyroid carcinoma. Although serious RAI-related complications are uncommon, there have been reports of airway emergencies. Here, a life-threatening airway complication after RAI treatment is reported and previously reported cases are reviewed.

CASE REPORT: A 79-year old man with Hürthle cell carcinoma and a remnant thyroid lobe after surgery developed an edema compromising the airway two days after receiving radioactive iodine treatment. An emergency awake intubation and tracheostomy were performed. He could be successfully de-cannulated 17 days later with no long-term complications.

CONCLUSION: Although rare, life-threatening airway complications after radioactive iodine treatment, especially with high dose treatment in patients with remaining thyroid tissue, can occur and these patients should be supervised where these complications can be managed.

Endoscopic balloon dilation of tracheal stenosis is usually a safe procedure. However, there are life-threatening complications that physicians performing the procedure need to be aware of. A 43-year old woman with a multi-level tracheal stenosis following lengthy intubation and a tracheostomy was treated with endoscopic balloon dilation. This resulted in an almost total rupture of the posterior tracheal wall. Here a safe and successful conservative treatment approach is reported.