Abstract
Advanced/Recurrent Pediatric Differentiated Thyroid Cancer: Beyond the Guidelines
Ken Kazahaya, MD, MBA (moderator); Andrew J. Bauer, MD; Lourdes Quintanilla-Dieck, MD; Fernando Escobar, MD
Session Description:
With the first guidelines for the management of pediatric thyroid nodules and differentiation of thyroid cancer from the American Thyroid Association in 2015 and the recent Association of Clinical Endocrinology/American Head and Neck Society consensus statement on pediatric benign and malignant thyroid surgery released in 2020, there is increasing guidance for the management of thyroid nodules and cancer in children. However, the recommendations are aimed more at the initial evaluation and management of nodules and radioactive iodine (RAI)-responsive differentiated thyroid cancer. There is a paucity of information and guidance for the management of pediatric patients who present with morbidly advanced disease or who develop progressive, RAI-refractory thyroid cancer. In a July 2020 article published in JAMA Otolaryngology–Head & Neck Surgery, a recommendation was made to consider a paradigm shift in the care for these patients using oral, systemic chemotherapy, either tyrosine kinase inhibitors and/or oncogene-specific targeted therapy, in an effort to reduce surgical and medical morbidity and improve outcome. This panel will discuss the management of advanced or recurrent thyroid cancer. The use of systemic therapy as well as surgical and nonsurgical modalities for invasive thyroid cancer in children and adolescents will be presented.
Outcome Objectives:
(1) Recognize and ensure complete evaluation of advanced thyroid cancer in children and adolescents. (2) Understand targets of action and clinical application of systemic, oral chemotherapy for advanced, progressive thyroid cancer and to define their clinical indication for use. (3) Compare surgical and nonsurgical management of persistent or recurrent disease in the neck and formulate a plan to optimize outcome and reduce treatment associated morbidity.
Controversies in Parotid Surgery: Is There Evidence? Part I
Samir Khariwala, MD (moderator); Richard V. Smith, MD; Bevan Yueh, MD, MPH; Derrick T. Lin, MD
Session Description:
This miniseminar addresses controversial, but commonly encountered, issues in the management of benign and malignant parotid disease. We will review the data regarding (1) capsular dissection for pleomorphic adenoma and other benign salivary tumors, (2) superficial vs total parotidectomy for both primary malignancy and cutaneous metastases, (3) indications for neck dissection with primary parotid malignancy, (4) management of the facial nerve in the setting of malignancy, and (5) complication rates and management. This session will allow for audience interaction and appeal to general otolaryngologists, academicians, and trainees, in addition to the head and neck oncological surgeon. It will cover the topics above using a combination of didactics, audience response queries, and case-based examples.
Outcome Objectives:
(1) Use an evidence-based framework to determine appropriate use of capsular dissection in benign parotid disease. (2) Understand indications for superficial vs total parotidectomy as well as the use of neck dissection in parotid malignancy. (3) Understand the data-based approach for facial nerve management in malignancy and prevention/management of complications.
Controversies in Parotid Surgery: Is There Evidence? Part II
Richard V. Smith, MD (moderator); Samir Khariwala, MD; Carol R. Bradford, MD, MS; Michael G. Moore, MD
Session Description:
This miniseminar addresses controversial, but commonly encountered, issues in the management of benign and malignant parotid disease. We will review the data regarding (1) capsular dissection for pleomorphic adenoma and other benign salivary tumors, (2) superficial vs total parotidectomy for both primary malignancy and cutaneous metastases, (3) indications for neck dissection with primary parotid malignancy, (4) management of the facial nerve in the setting of malignancy, and (5) complication rates and management. This session will allow for audience interaction and appeal to general otolaryngologists, academicians, and trainees, in addition to the head and neck oncological surgeon. It will cover the topics above using a combination of didactics, audience response queries, and case-based examples.
Outcome Objectives:
(1) Use an evidence-based framework to determine appropriate use of capsular dissection in benign parotid disease. (2) Understand indications for superficial vs total parotidectomy as well as the use of neck dissection in parotid malignancy. (3) Understand the data-based approach for facial nerve management in malignancy and prevention/management of complications.
Controversies in Skull Base Surgery: A Multidisciplinary Discussion
Zain H. Rizvi, MD (moderator); Adam M. Zanation, MD; Martin J. Citardi, MD; Shirley Y. Su, MBBS, FRACS
Session Description:
Treatment of skull base tumors requires making challenging decisions affecting critical structures that can have a lasting effect on function. Quality of life, oncologic outcomes, and treatment sequelae must all be taken into consideration. Through debate and discussion, this multisubspecialty panel aims to shed light and achieve a consensus on topics such as induction therapy, margin control, management of the functional eye, decision making for reconstruction, smell preservation, and other controversial areas in the field.
Outcome Objectives:
(1) Recognize areas in which decision making in skull base surgery is not clear and considerations for oncologic outcome and quality of life may be at odds. (2) Understand and compare practices and management of skull base tumors. (3) Implement the management strategies outlined during the discussion into practice.
Elderly H&N Cancer Patients: To Operate or Not? Part I
Sidharth V. Puram, MD, PhD (moderator); Nicole C. Schmitt, MD; Neal D. Futran, MD, DMD; Jonas T. Johnson, MD
Session Description:
As the average age of individuals across the world continues to rise, the elderly represent an increasing proportion of patients with head and neck cancer. Comorbid conditions, restricted life expectancy, and other factors must be carefully considered when exploring treatment options for these patients, including traditional modalities of therapy (surgery, radiation, and systemic therapy) and palliative options. However, these patients also pose unique challenges when undergoing treatment, as elderly patients are more likely to experience complications and treatment interruptions. In this seminar, we will provide an interactive but didactic introduction to the management of elderly patients with head and neck cancer followed by a tumor board-based panel. The didactic portion will provide an evidence-based summary of the options (including reconstructive techniques), challenges, outcomes, and complications associated with treating elderly head and neck cancer patients. Patient indices other than age, which can be helpful in the medical decision-making process, will also be discussed, along with palliative care and the surgeon’s role in facilitating palliation. The tumor board discussion will provide a rich foundation of 6 patient cases, with discussion and debate by widely renowned panelists. Audience participation and feedback via live, interactive polling throughout the cases will be integrated to help shed further insight into practice patterns, audience preferences, and changes in opinion as the seminar progresses. Given the challenges posed by this unique set of patients, this topic should be of value to otolaryngologists across diverse practice settings.
Outcome Objectives:
(1) Describe options, outcomes, and complications of surgically treated, elderly patients with head and neck cancer. (2) Incorporate measures other than age (eg, frailty) in the treatment selection process. (3) Define the role of the head and neck surgeon in end-of-life discussions and palliative care.
Equitable HNC Care: Improving Access, Decreasing Delays, and Addressing Disparities
Carol M. Lewis, MD (moderator); Evan M. Graboyes, MD, MPH; John D. Cramer, MD; Chanita Hughes-Halbert, PhD
Session Description:
Two of the National Academy of Medicine’s pillars of health care quality include the delivery of timely care and the delivery of equitable care. However, for patients with head and neck cancer (HNC), treatment delays across the cancer continuum from initial presentation and diagnosis through treatment initiation and completion of adjuvant therapy are highly prevalent and strongly associated with poor oncologic outcomes. Inadequate access to care and subsequent treatment delays among patients with HNC also drive profound racial disparities in HNC-related outcomes and mortality. In this panel, we highlight the oncologic and moral imperative to delivery of timely and equitable HNC care. We also synthesize existing data about the prevalence of treatment delays and their contribution to observed disparities in outcomes. We will then discuss strategies to address disparities and improve access to timely HNC care. Finally, we situate the issues of racial disparities in access to care and treatment delay among patients within HNC within the broader context of cancer disparities in the United States. This interactive forum focuses on enhancement of knowledge and delivery of practical, action-oriented information. Goals of the miniseminar include (1) characterizing how inadequate access to care and treatment delays across the head and neck continuum contribute to racial disparities in HNC outcomes, (2) enhancing ongoing efforts by American Academy of Otolaryngology–Head and Neck Surgery members to address racial disparities within head and neck oncology by providing them with the knowledge and tools to begin to effect change in their clinical practices and/or health systems, and (3) providing a framework for understanding how issues of inadequate access and treatment delays within head and neck oncology fit within the larger framework of disparities in oncology care and outcomes in the United States.
Outcome Objectives:
(1) Recognize that treatment delays are highly prevalent across the head and neck treatment continuum, disproportionately burden racial minorities, and contribute to racial disparities in outcomes. (2) Examine the drivers of disparities in HNC outcomes and how quality improvement-based methodologies may improve timely access to HNC care across a broad range of clinical practice types. (3) Explain how racial disparities in access to care and timely care within head and neck oncology fit within the broader context of racial disparities in access to oncology care.
Head and Neck in a Pandemic: Lessons Learned From COVID-19
Caitlin P. McMullen, MD (moderator); Vikas Mehta, MD; Evan M. Graboyes, MD, MPH; Andrew G. Shuman, MD, FACS
Session Description:
The COVID-19 pandemic brought many otolaryngology and head and neck practices into sharp focus. Critical resources were diverted to acute care specialties on the front lines. Head and neck cancer care was upended, and surgeons witnessed treatment delays resulting in worse oncologic outcomes and the exacerbation of existing health care disparities. Caring for patients with head and neck cancer under severe acute resource constraint and infection risk of COVID-19 required health care systems and clinicians to develop innovative care delivery strategies to optimize timely, equitable, head and neck cancer care delivery. As a result, several approaches emerged to minimize treatment delays, develop ethical frameworks for prioritization of care and resources, enhance access, and minimize viral transmission; these important innovations are likely to persist into the foreseeable future. Lessons learned during this experience will prepare head and neck surgeons for potential subsequent events that may similarly strain health care resources. The goal of this interactive panel presentation is to understand important lessons learned about cancer care delivery and outcomes during the COVID-19 pandemic in various jurisdictions. These expert panelists will discuss the ethical considerations of surgical prioritization and the clinical practice changes that were implemented. The panelists will provide a framework for ongoing decision making with the goal of minimizing health care disparities and optimizing oncologic outcomes while resources are restricted.
Outcome Objectives:
(1) Understand the effects of the COVID-19 pandemic on head and neck cancer patients in various health care systems and regions. (2) Recognize the components of attendees’ health care systems that may contribute to inequities and demonstrate knowledge of the ethical considerations when caring for cancer patients during a pandemic. (3) Apply the lessons learned to address disparities and care gaps even after the resolution of the COVID-19 pandemic and in possible future disaster situations.
Immunotherapy for Cancer Treatment: 101
Larissa Sweeny, MD (moderator); Clint T. Allen, MD; Arun Sharma, MD, MS; Cherie-Ann O. Nathan, MD
Session Description:
Head and neck cancer (HNC) is a heterogeneous disease, with advanced/recurrent disease having a poor prognosis with low survival rates. In recent years, immunotherapy has shown promise as a new therapeutic pathway, and pembrolizumab has been approved as a first-line agent in the treatment of recurrent or metastatic head and neck squamous cell carcinoma. Targeted therapies, such as those for immune checkpoints of programmed cell death 1 and programmed cell death ligand 1, have been the agents with the greatest therapeutic potential. Patients newly diagnosed with squamous cell carcinoma of the head and neck, whether by general otolaryngologists or head and neck surgeons, are also inquiring about immunotherapy with increasing frequency. Having a fundamental understanding of immunotherapy, its current indications, and it future possibilities can be useful for counseling patients. This panel, geared toward general otolaryngologist, head and neck surgeons, and trainees, will provide an overview of basic immunotherapy principals, followed by more in-depth review of immunotherapy agents for the treatment of mucosal and cutaneous malignancies of the head and neck.
Outcome Objectives:
(1) Understand the basic principles of cancer immunotherapy. (2) Describe immunotherapies currently being used for the treatment of mucosal HNC. (3) Identify immunotherapies currently being used for the treatment of cutaneous HNC.
Immunotherapy for Cancer Treatment: 102
Larissa Sweeny, MD (moderator); Nicole C. Schmitt, MD; Eleni M. Rettig, MD; Daniel L. Faden, MD
Session Description:
This is the second part of the popular course, Immunotherapy for Cancer: What the Otolaryngologist Needs to Know. In recent years, immunotherapy has shown promise as a new therapeutic pathway for the treatment of head and neck cancer. This second part of the course will focus on emerging biomarkers in oncology, ongoing clinical trials, and exciting future directions for the field. Understanding the current state and future directions of immunotherapy is valuable for counseling patients. This panel, geared toward general otolaryngologist, head and neck surgeons, and trainees, will provide an in-depth review of biomarkers, ongoing clinical trials, and potential future agents.
Outcome Objectives:
(1) Understand new and emerging biomarkers for head and neck cancer (HNC). (2) Identify ongoing clinical trials evaluating immunotherapies for treatment of HNC. (3) Understand new and emerging immunotherapies for HNC.
Integrative Approaches for Healthy Survivorship in Head and Neck Cancer
Marilene B. Wang, MD (moderator); Cherie-Ann O. Nathan, MD; Chau T. Nguyen, MD; Malcolm B. Taw, MD
Session Description:
Survivorship in head and neck cancer patients requires a multidisciplinary approach to address the sequelae of the intense treatment regimens of surgery, radiation, and chemotherapy. Although the cancer has been eradicated, patients must deal with the treatment’s significant impact on their physical and emotional health. It is important for physicians to recognize the importance of maintaining well-being and quality of life for head and neck cancer survivors. In this expert panel, we will discuss integrative approaches to optimize both oncologic outcomes and quality of life for head and neck cancer survivors. Integrative treatments, including herbal therapies, dietary supplements, nutritional strategies, exercise, acupuncture, and mind–body techniques will be discussed. The rationale for incorporating integrative approaches for cancer survivors will be presented, with an emphasis on understanding the evidence for their potential harm and benefits.
Outcome Objectives:
(1) Discuss issues faced by head and neck cancer survivors, including physical and emotional sequelae of treatment. (2) Discuss integrative treatments for head and neck cancer patients, including herbal and dietary supplements, nutritional strategies, and mind–body techniques, evidence, risks, and benefits. (3) Analyze the integrative approach to the care of the cancer survivor and its role in improving oncologic outcomes and quality of life.
Is Bigger Really Better? The State of Surgical Margin Assessment
Daniel L. Faden, MD (moderator); Mark A. Varvares, MD; Jeremy D. Richmon, MD; Eben L. Rosenthal, MD
Session Description:
The status of surgical margins in head and neck cancer is a key component driving outcomes and adjuvant treatment choices. Despite this, there is no consensus on many basic questions: What is considered a positive margin or close margin? When should a patient with close margins receive adjuvant therapy? Should margin sizes be the same in different subsites? In this panel presentation we will (1) review the evidence surrounding margin assessment in the oral cavity and decision making for adjuvant treatment, giving practical recommendations while highlighting areas of controversy and (2) review the emerging literature dealing with margin assessment in the oropharynx, with an emphasis on transoral robotic surgery and need for adjuvant therapy based on margins. Lastly, the field of surgical margin assessment is rapidly evolving with new technologies on the horizon. Here, we will discuss emerging technologies for assessment of margins, including light-guided surgery using fluorescent markers and intraoperative tongue ultrasound. The overarching purpose of this presentation is to present practical guidelines for margin assessment and utilization of this information for treatment choices in clinical practice, based on existing literature.
Outcome Objectives:
(1) Summarize the literature surrounding appropriate margins in the oral cavity, use of adjuvant treatment, and areas of controversy. (2) Discuss how and why margins may differ between different anatomic sites, such as in the oropharynx vs oral cavity. (3) Recognize the emerging technologies in surgical margin assessment.
p16+ (HPV+) OPSCC: A Surgical Approach to Management
Sidharth V. Puram, MD, PhD (moderator); Jose P. Zevallos, MD; Ryan S. Jackson, MD; Wade L. Thorstad, MD
Session Description:
With the increasing use of transoral robotic surgery, p16+ (human papillomavirus [HPV]+) oropharynx squamous cell carcinoma (OPSCC) is increasingly being managed surgically. However, the widespread adoption of transoral robotic surgery does not relinquish the general otolaryngologist or head and neck surgeon from following evidence-based medicine and demands even greater attention to disease attributes, institutional capabilities, and patient goals. Importantly, a clear understanding of the role for adjuvant therapy in the context of a more surgically focused management paradigm is critical to improve communication with patients and set appropriate expectations. This multidisciplinary panel will discuss a surgically focused approach to HPV+ OPSCC, including treatment options for HPV+ OPSCC as well as criteria for identifying ideal surgical candidates. Discussion will be presented in a tumor-board style and, when applicable, include images and videos from surgical cases performed. An emphasis will be placed on evidence and previously published studies, as well as ongoing clinical trials (eg, Eastern Cooperative Oncology Group 3311). Our discussion will importantly extend to our institutional focus on surgical management and the rationale and patient management considerations that accompany this approach. In particular, we will focus on the options for adjuvant therapy and factors that determine the sites and dosage of radiation received. This important topic will be approached through case-based discussion, including live polling of the audience to help shed insight into state-of-the-art practice patterns, while incorporating the input of experts in head and neck oncology.
Outcome Objectives:
(1) Understand the treatment options based on the National Comprehensive Cancer Network guidelines for p16+ OPSCC. (2) Describe the rationale and approach for surgically focused management of p16+ OPSCC. (3) Appreciate the major do’s and don’ts of p16+ OPSCC treatment, including the role of adjuvant therapy.
Preventing and Treating Osteoradionecrosis: A Stepwise Approach With the Experts
Alice L. Tang, MD (moderator); Chad A. Zender, MD; Matthew O. Old, MD; Marita S. Teng, MD
Session Description:
Osteoradionecrosis (ORN) and soft-tissue necrosis are causes of significant morbidity in head and neck cancer survivors. An evidence-based approach of the treatment of ORN continues to evolve with both surgical and nonsurgical management. For advanced ORN, the gold-standard treatment is surgical resection of the hypoxic and hypovascular necrotic bone with immediate reconstruction with vascularized tissue into the irradiated fields. However, there are special considerations for this type of intervention given that previously irradiated and/or operated environments offer unique challenges. Similarly, soft-tissue necrosis after radiation can be a diagnostic challenge, as tumor recurrence is always a consideration. Recognizing when to treat can also be problematic as it is difficult to determine if and when these ulcers will heal without surgical intervention with vascularized tissue. Experts will review the evidence and share their personal experiences of operating in these distinct conditions. In addition, this session will also analyze the conservative management options and review recently published protocols for early ORN.
Outcome Objectives:
(1) Understand diagnosing ORN and soft-tissue necrosis in head and neck cancer survivors. (2) Understand conservative management for ORN and how to implement up-to-date protocols appropriately. (3) Understand the unique challenges in performing reconstructive surgery in the setting of ORN and soft tissue necrosis.
Reconstructive Showdown 2021
Blake Golden, MD (moderator); Kelly Michele Malloy, MD; Gina D. Jefferson, MD; Eben L. Rosenthal, MD
Session Description:
Come join us for the 2021 Reconstructive Showdown! Here we will debate the best reconstructive techniques for common cutaneous, mucosal, soft tissue, and traumatic defects. Cases will be presented in entertaining debate-style format by our expert reconstructive surgeons. The audience will ultimately decide which presenter is most convincing through audience polling. Participants will leave able to recognize which local, regional, or free flap works best for a variety of common facial, parotidectomy, and oral cavity defects. Additional perspective will be provided on what criteria should be used to drive intraoperative decision making. New this year will be a greater focus on best techniques to manage and indeed mitigate perioperative complications in reconstructive surgery. With panelists of diverse backgrounds and training, our session will provide insight into the various approaches to these reconstructive challenges and how to plan appropriately to optimize the chance of long-term success. Join us for this lively discussion to learn from our team and share your experiences as well.
Outcome Objectives:
(1) Compare and contrast various local and regional flap options for common cutaneous, mucosal, and soft tissue defects. (2) Recognize when free tissue transfer/advanced reconstructive care may be necessary for more extensive head and neck defects, both from malignancy and secondary to trauma. (3) Manage early and late perioperative complications of common cutaneous and mucosal reconstructions.