Supraclavicular Artery Island Flap for Head and Neck Oncologic Reconstruction: 15-year Experience, Past, Present, Future

Head and neck reconstruction poses unique challenges due to the complex structure of the region. Primary goals include soft-tissue coverage, adequate color and texture match, and minimal donor-site morbidity. Local and musculocutaneous regional flaps have largely been replaced with fasciocutaneous free flaps (FFF) over recent years. The supraclavicular artery island flap (SCAIF), a locoregional, fasciocutaneous, axially-based flap, has been shown to produce similar outcomes to FFF. We present our 15-year experience using the SCAIF for head and neck reconstruction, discuss its evolution, and provide case examples for its range of indications.

Methods

Retrospective chart review identified 128 patients who underwent reconstruction of the head and neck with the SCAIF between the years 2006-2021 at Tulane University Medical Center. Patient demographics, lengths of stay, operative times, surgical indications, and complications were recorded.

Results

The cohort mean age was 66.9 years. Mean lengths of stay and follow-up times were 6.9 days and 9.1 months, respectively. The most common indications for SCAIF reconstruction were recurrent radiated neck disease (n=27, 21.1%), pharyngeal wall defects (n=23, 18.0%), and parotidectomy defects (n=21, 16.4%). Overall complication rate was 17.2%. Partial thickness flap loss (5.5%), contained pharyngeal leak (3.2%), and distal tip necrosis (2.4%) were the most common complications. No functional donor site morbidity was encountered.

Conclusions

The SCAIF is a versatile, fasciocutaneous, axially-based flap able to produce similar outcomes to FFF in the reconstruction of the head and neck region while reducing costs, lengths of stay, operative times, and donor site morbidity.

Cervical Necrotizing Fasciitis, Diagnosis and Treatment of a Rare Life-Threatening Infection

IMPORTANCE

Necrotizing fasciitis is a relatively uncommon and potentially life-threatening soft tissue infection, with morbidity and mortality approaching 25% to 35%, even with optimal treatment. The challenge of diagnosis for necrotizing soft tissue infections (NSTIs) is their rarity, with the incidence of approximately 1000 cases annually in the United States. Given the rapid progression of disease and its similar presentation to more benign processes, early and definitive diagnosis is imperative.

FINDINGS

Signs and symptoms of NSTIs in the early stages are virtually indistinguishable from those seen with abscesses and cellulitis, making definitive diagnosis difficult. The clinical presentation will depend on the pathogen and its virulence factors which ultimately determine the area and depth of invasion into tissue. There are multiple laboratory value scoring systems that have been developed to support the diagnosis of an NSTI. The scoring system with the highest positive (92%) and negative (96%) predictive value is the laboratory risk indicator for necrotizing fasciitis (LRINEC). The score is determined by 6 serologic markers: C-reactive protein (CRP), total white blood cell (WBC) count, hemoglobin, sodium, creatinine, and glucose. A score ≥ 6 is a relatively specific indicator of necrotizing fasciitis (specificity 83.8%), but a score <6 is not sensitive (59.2%) enough to rule out necrotizing fasciitis. In terms of imaging, computed tomography (CT) imaging, while more sensitive (80%) than plain radiography in detecting abnormalities, is just as nonspecific. Computed tomography imaging of NSTIs demonstrates fascial thickening (with potential fat stranding), edema, subcutaneous gas, and abscess formation. Magnetic resonance imaging (MRI) has demonstrated sensitivity of 100% and specificity of 86%, though MRI may not show early cases of fascial involvement of necrotizing fasciitis.

CONCLUSIONS AND RELEVANCE

Necrotizing soft tissue infections are rapidly progressive and potentially fatal infections that require a high index of clinical suspicion to promptly diagnose and aggressive surgical debridement of affected tissue in order to ensure optimal outcomes.Prompt surgical and infectious disease consultation is necessary for the treatment and management of these patients. While imaging is useful for further characterization, it should not delay surgical consultation. Necrotizing soft tissue infection remains a clinical diagnosis, although plain radiography, CT imaging, and ultrasound can provide useful clues. In general, the management of these patients should include rapid diagnosis, using a combination of clinical suspicion, laboratory data (LRINEC score), and imaging (MRI being the recommended imaging modality), prompt infectious disease and surgical consultation, surgical debridement, and delayed reconstruction. Laboratory findings that can more strongly suggest a diagnosis of NSTI include elevated CRP, elevated WBC, low hemoglobin, decreased sodium, and increased creatinine. Imaging findings include fascial thickening (with potential fat stranding), edema, subcutaneous gas, and abscess formation. Broad-spectrum antibiotics should be started in all cases of suspected NSTI. Surgical debridement, however, remains the lynchpin for treatment of cervical necrotizing fasciitis.

The effect of race, socioeconomic status, and comorbidity on patients afflicted with COVID 19: A Local Perspective

PURPOSE

The aim of this study is to further examine the associations of race, socioeconomic factors, and comorbidity with COVID-19 health outcomes.

METHODS

This is a retrospective cohort study of 309 PCR confirmed COVID-19 positive adults who presented to Tulane Medical Center in New Orleans, LA, from March 9 to May 29, 2020. The primary outcomes investigated were need for invasive mechanical ventilation (IMV) and in-hospital mortality. A multivariate analysis was performed to determine socioeconomic and medical risk factors for IMV and in-hospital mortality.

RESULTS

Compared to white patients, Black patients were more likely to present younger, female, obese, unemployed, and underinsured. However, when controlled for common risk factors, Black and white patients had similar risk for IMV and mortality. Increased age (≥65 years), obesity, and increased comorbidity were associated with increased risk for IMV and mortality.

CONCLUSIONS

Race and socioeconomic factors may increase risk for COVID-19 infection but did not affect health outcomes within the hospital setting. Therefore, the higher rates of COVID-19 infection and mortality in vulnerable populations may be better explained by lower socioeconomic status, with subsequent higher comorbidity, in these populations. Community health initiatives should be prioritized in response to the COVID-19 pandemic.

Abstract CT101: Phase I clinical trial: results from the use of 4-demethyl-4 cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) plus radiation as treatment for cancers involving the CNS

Purpose: 4-Demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) is a poly-chlorinated pyridine cholesteryl carbonate with a MOA via bis-alkylation of DNA @ N7-guanine and N4-cytosine that has completed Phase I/II studies [AACR, #CT129, 2017] in adult subjects with cancers involving the CNS. Four (4) subjects in the Phase I/II trials required surgery for persistent CNS lesions following DM-CHOC-PEN therapy with 39-98.8 mg/m2 of drug. DM-CHOC-PEN was identified in samples from all 4-subjects - 90-212 ng/g tumor. Thus, the drug penetrates the CNS and tumors and is available to act as a radiosensitizer; the latter has been supported with in vitro studies [AACR, #4746, 2017]. The current presentation reviews the long term Phase I clinical data that supports safety, dose-tolerance and use of DM-CHOC-PEN plus radiation in subjects with cancers involving the CNS - IND 68,876. Patients & Methods: DM-CHOC-PEN was administered as a 3-hr IV infusion once to subjects with advanced cancer involving the CNS. A single dose (39 mg/m2 to 98.7 mg/m2 in escalating Phase I scheme) was administered once anywhere from 48 hours to 3-weeks prior to receiving stereotactic radiosurgery (SRS) or whole brain radiation therapy (WBRT). Radiation was administered in doses of 15-30 Gy depending on the size and number of lesions. Results: Nineteen (19) subjects with cancer involving the CNS have been treated to date with DM-CHOC-PEN (6-NSCLC, 1-breast, 1-melanoma, 5-GBM, 3-sarcomas, 1-astrocytoma & 2-renal cell carcinomas). Subjects received 39, 50, 70, 86.8 or 98.7 mg/m2 of DM-CHOC-PEN. Five subjects received WBRT (30 Gy) and 14 subjects received SRS (15-24 Gy. One (1) subject with NSCLC did develop vasogenic edema and tumor necrosis which resolved and the subject is in complete remission 55+ mos. A second subject with a recurrent GBM developed Gr-3 confusion secondary to an enlarging lesion which was removed. Drug was present in ng/g of tumor conc.; confusion resolved. Ten (10) of the thirteen (13) subjects have had objective results (OS 8-58 mos.) Bioavailability for DM-CHOC-PEN revealed a rebound phenomenon @ ~ 50 hours post-infusion with a T-release of 26.7 h. and drug in the plasma (Cmax=17.5 µg/mL) until day 15 . The AUC was linear for all doses. Pre-clinical radiosensitization in vitro studies [AACR #1917, 2017] supported the present trial. Photon induced charge transfer reactions with DM-CHOC-PEN will be discussed as a MOA. Conclusion: Data is presented that documents effectiveness and safety of DM-CHOC-PEN plus radiation as therapy for subjects with cancers involving the CNS. Observations during this trial supported the drug's ability to penetrate human tumors involving the CNS and acceptability as a method to improving responses to radiation. Complete data on subject responses and observed toxicities will be presented. Supported by - NCI/SBIR grants - R43 CA213545-02 and NIH NIGMS 1 U54 GM104940 - the latter funds the Louisiana Clinical and Translational Science Center.

Citation Format: Steven J. DiBiase, Roy S. Weiner, Tallat Mahmood, Kendra Harris, Ronald Kawauchi, Kiran Devisetty, James Herman, Manish Bhandari, Marcus Ware, Paul Friedlander, Lee R. Morgan, Ali Baghian. Phase I clinical trial: results from the use of 4-demethyl-4 cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) plus radiation as treatment for cancers involving the CNS [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT101.

Tumor necrosis factor-α triggers opposing signals in head and neck squamous cell carcinoma and induces apoptosis via mitochondrial- and non-mitochondrial-dependent pathways

Head and neck squamous cell carcinoma (HNSCC) remains one of the most common malignancies worldwide. Although the treatment outcomes of HNSCC have improved in recent years, the prognosis of patients with advanced-stage disease remains poor. Current treatment strategies for HNSCC include surgery as a primary therapy, while radio-, chemo-, and biotherapeutics can be applied as second-line therapy. Although tumor necrosis factor-α (TNF-α) is a potent tumor suppressor cytokine, the stimulation of opposing signals impairs its clinical utility as an anticancer agent. The aim of this study was to elucidate the mechanisms regulating TNF-α‑induced opposing signals and their biological consequences in HNSCC cell lines. We determined the molecular mechanisms of TNF-α-induced opposing signals in HNSCC cells. Our in vitro analysis indicated that one of these signals triggers apoptosis, while the other induces both apoptosis and cell survival. The TNF-α-induced survival of HNSCC cells is mediated by the TNF receptor-associated factor 2 (TRAF2)/nuclear factor (NF)-κB-dependent pathway, while TNF-α-induced apoptosis is mediated by mitochondrial and non-mitochondrial-dependent mechanisms through FADD-caspase-8-caspase-3 and ASK-JNK-p53-Noxa pathways. The localization of Noxa protein to both the mitochondria and endoplasmic reticulum (ER) was found to cause mitochondrial dysregulation and ER stress, respectively. Using inhibitory experiments, we demonstrated that the FADD‑caspase-8‑caspase-3 pathway, together with mitochondrial dysregulation and ER stress-dependent pathways, are essential for the modulation of apoptosis, and the NF-κB pathway is essential for the modulation of anti-apoptotic effects/cell survival during the exposure of HNSCC cells to TNF-α. Our data provide insight into the mechanisms of TNF-α-induced opposing signals in HNSCC cells and may further help in the development of novel therapeutic approaches with which to minimize the systemic toxicity of TNF-α.

Abstract CT065: A Phase I clinical trial: Use of 4-demethyl-4-cholesteryl- oxycarbonyl-penclomedine (DM-CHOC-PEN) plus radiation as treatments for cancers involving the CNS

Purpose: 4-Demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) is a poly-chlorinated pyridine cholesteryl carbonate with a MOA via bis-alkylation of DNA @ N7-guanine and N4-cytosine that has completed Phase II studies [AACR, #CT129, 2017] in subjects with cancers involving the CNS. Four (4) subjects in the Phase I/II trials required surgery for persistent CNS lesions following DM-CHOC-PEN therapy with 39-98.8 mg/m2 of drug. DM-CHOC-PEN was identified in samples from all 4-subjects - 90-212 ng/g tumor. Thus, the drug penetrates the CNS and tumors and is available to act as a radiosensitizer; the latter has been supported with in vitro studies [AACR, #4746, 2017]. The current presentation reviews Phase I clinical data that supports the safety, dose-tolerance and use for DM-CHOC-PEN plus radiation in subjects with cancers involving the CNS - IND 68,876.

Patients & Methods: DM-CHOC-PEN was administered as a 3-hr IV infusion once to subjects with advanced cancer involving the CNS. A single dose (39 mg/m2 to 98.7 mg/m2 in escalating Phase I scheme) was administered once 3-weeks prior to receiving stereotaxic radio-surgery (SRS), gamma knife or whole brain irradiation (WBRT) therapy. Radiation was administered in doses of 15-30 Gy depending on the size and number of lesions.

Results: Thirteen (13) subjects with cancer involving the CNS have been treated to date with DM-CHOC-PEN (6-NSCLC, 1-breast, 1-melanoma, 2-GBM & 3-sarcomas). Subjects received 39, 50, 70, 86.8 or 98.7 mg/m2 and 15-30 Gy of radiation. The drug/radiation combination was well tolerated. One (1) subject with NSCLC did develop vasogenic edema and tumor necrosis which resolved and the subject is in complete remission 42+ mos. A second subject with a recurrent GBM with confusion progressed - Gr-3. Ten (10) of the thirteen (13) subjects have had objective results (OS 8-54+ mos.) Bioavailability for DM-CHOC-PEN revealed a rebound phenomenon @ ~ 50 hours post-infusion with a T-release of 26.7 h. The same phenomenon was observed with RBCs (estimation using Monolix 3.2). DM-CHOC-PEN was detected bound to RBCs for 3-days (after 70 mg/m2) and was also detected in the urine (Cmax=17.5 µg/mL) until day 15. The AUC was linear for all doses. Pre-clinical radiosensitization in vitro studies [AACR #1917, 2017] support the present trial study result. Photon induced charge transfer reactions with DM-CHOC-PEN will be discussed as a MOA.

Conclusion: Data is presented that documents effectiveness and safety of DM-CHOC-PEN plus radiation as therapy for subjects with cancers involving the CNS. Observations during Phase I/II clinical trials with DM-CHOC-PEN alone supported the drug’s persistent presence in human tumors after systemic administration and possible positive effects on response to subsequent radiation. Complete data on subject responses and observed toxicities will be presented. Supported by - NCI/SBIR grants - R43 CA213545-02 and NIH NIGMS 1 U54 GM104940 - the latter funds the Louisiana Clinical and Translational Science Center.

Citation Format: RS Weiner, T Mahmood, Lee Roy Morgan, K. Harris, A. Baghian, SJ DiBiase, P. Friedlander, ML Ware, R. Kawauchi, J. Herman, M. Bhandari. A Phase I clinical trial: Use of 4-demethyl-4-cholesteryl- oxycarbonyl-penclomedine (DM-CHOC-PEN) plus radiation as treatments for cancers involving the CNS [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT065.

Abstract CT119: Early phase I clinical trial results for 4-demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) plus radiation in cancers involving the CNS

Purpose:4-Demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) is a poly-chlorinated pyridine cholesteryl carbonate with a mechanism of action (MOA) via bis-alkylation of DNA @ N7-guanine and N4-cytosine that has completed Phase I/II studies [AACR, 58, #CT129, 2017] in subjects with cancers involving the CNS. Four (4) subjects in the Phase I/II trials required surgery for persistent CNS lesions following DM-CHOC-PEN therapy and DM-CHOC-PEN was identified in samples from all 4-subjects - 90-212 ng/g tumor [subjects had been treated with 39-98.8 mg/m2 of drug]. Thus, the drug penetrates the CNS and concentrates in tumors. It is available, therefore, to act as a radiosensitizer as demonstrated in in vitro studies [AACR, 58, #4746, 2017]. The current presentation reviews Phase I clinical data that supports the safety, dose-tolerance, and use of DM-CHOC-PEN with radiation in subjects with cancers involving the CNS - IND 68,876.

Patients & Methods: DM-CHOC-PEN was administered as a 3-hr IV infusion once every 21 days to subjects with advanced cancer involving the CNS. A single dose was administered prior to standard radiation therapy. The dose was escalated from 39 mg/m2 to 98.7 mg/m2 I.X1, then 3-weeks later the subject received stereotaxic radio-surgery (SRS) or whole brain irradiation (WBRT). Total radiation administered was 15-30 Gy depending on the size and number of lesions.

Results: Nine (9) subjects with cancer involving the CNS have been treated to date - (6-NSCLC, 1-breast, 1-melanoma & 1-sarcoma). Subjects received 39, 55, 70, 86.8 or 98.7 mg/m2 followed by 15-30 Gy of radiation. The drug/radiation combination was well tolerated. One (1) subject with NSCLC developed vasogenic edema and tumor necrosis which resolved; that subject is in complete remission 31+ mos. Six out of nine subjects have had objective responses (OS 4 - 42+ mos.) Bioavailability for DM-CHOC-PEN revealed a rebound phenomenon @ ~ 50 hours post-infusion with a T-release of 26.7 h. The same phenomenon was observed with RBCs (estimation using Monolix 3.2). DM-CHOC-PEN was detected bound to RBCs for 3-days (after 70 mg/m2); DM-CHOC-PEN was also detected in the urine (Cmax=17.5 µg/mL) until day 15. The AUC was linear for all doses. Pre-clinical in vitro studies supported the clinical data: NSCLC cells treated with DM-CHOC-PEN (0.1 -1.0 µg/mL) demonstrated 50 & 100% cytotoxicity @ 0.4 & 1.0 µg/mL. For radiation alone (6, 9 &12 Gy) - cell kill was 20 & 65% @ 6 & 12 Gy [100% kill was not observed at this dose range]; for DM-CHOC-PEN (0.25 µg/mL) plus radiation (6-12 Gy) - cell kill was 80 & 100% @ 6 & 12 Gy. Photon induced charge transfer reactions with DM-CHOC-PEN will be discussed.

Conclusion: Preliminary data is presented that supports enhanced cytotoxicity and safety of DM-CHOC-PEN plus radiation as therapy for subjects with cancers involving the CNS. Observations during Phase I/II clinical trials with DM-CHOC-PEN alone support the drug's persistent presence in human tumors after systemic administration and possible positive effects on response to subsequent radiation. Complete data on subject responses and observed toxicities will be presented. Supported by - NCI/SBIR grants - R43 CA213545-01 and NIH NIGMS 1 U54 GM104940 - the latter funds the Louisiana Clinical and Translational Science Center.

Citation Format: LR Morgan, T Mahmood, R S. Weiner, R Kawauchi, M Bhandari, K Devisitty, J Herman, R Summe, ML Ware, P Friedlander, AH Rodgers. Early phase I clinical trial results for 4-demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) plus radiation in cancers involving the CNS [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT119.

Bortezomib sensitizes thyroid cancer to BRAF inhibitor in vitro and in vivo

Although overall survival rate for patients with thyroid cancer (TC) is high, there is an alarming 10-year recurrence rate of up to 30% conferring a ~50% survival among these high-risk patients. The BRAF^V600E mutation is estimated to be present in over 50% of papillary thyroid cancer (PTC) cases besides being associated with carcinogenesis and poor prognosis. We assessed the status of NF-κB, Ki-67, cyclin D1 and BRAF^V600E in TC tissues and TC cell lines using immunohistochemistry and Western blot analysis. Concurrently, we evaluated the outcomes of combined targeting of the proteasome pathway in addition to selective BRAF inhibitors in cases of PTC. In this study, BRAF^V600E-bearing TC cells were treated with BRAF^V600E inhibitor, Vemurafenib alone or in combination with the proteasome inhibitor, Bortezomib. The combination of both drugs showed synergistic effects as evidenced by cell growth inhibition (P < 0.05), increased G2-phase cell cycle arrest and induced apoptosis (P < 0.05). In our TC xenograft model, the combination of Vemurafenib and Bortezomib significantly reduced tumor size (P < 0.05) and expression of the markers of cell growth and proliferation, Ki-67 and cyclin D1 (P < 0.001), when compared to monotherapy. Further analysis demonstrated that treatment with Bortezomib sensitized TC cells to Vemurafenib via mitochondrial dysregulation and apoptosis of TC cells, as evidenced by the increase in the expression of p53, Noxa protein, the loss of mitochondrial membrane potential, cytochrome c release and Poly (ADP-ribose) polymerase cleavage. Our results demonstrate a strong clinical potential for the combination of the Bortezomib and the BRAF inhibitor Vemurafenib as an efficient therapeutic approach for the treatment of TC.

Liver transplantation in New Orleans: parity in a world of disparity?

BACKGROUND

Racial disparity in access to liver transplantation among African Americans (AA) compared to Caucasians (CA) has been well described. The aim of this investigation was to examine the presentation of AA liver transplant recipients in a socioeconomically challenged region.

METHODS

680 adult liver transplant candidates and 233 resultant recipients between 2007 and 2015 were analyzed using univariate and multivariate analyses to evaluate factors significant for transplantation.

RESULTS

Percentages of wait list patients transplanted were similar between CA and AA (34.9% vs. 32.2%, p = 0.5205). AA were younger (50.4 ± 1.8 vs. 56.3 ± 0.7 yrs, p = 0.0003) with higher average MELD scores (22.9 ± 1.6 vs. 19.4 ± 0.7, p = 0.0230). Overall patient mortality was similar (AA 22.7% vs. CA 26.3%, p = 0.5931). A multiple linear regression showed that male gender was strongly associated with transplantation.

CONCLUSIONS

Equal access to liver transplantation remains challenging for racial minorities. At our institution, AA were accepted and transplanted at an equivalent rate as CA despite a higher AA population, HCV rate and diagnosed HCC. AA were younger and sicker at the time of transplant, but overall had similar outcomes compared to CA. Our study highlights the need for studies to delineate the underpinnings of disparity in transplantation access.

A National Perspective of the Risk, Presentation, and Outcomes of Pediatric Thyroid Cancer

IMPORTANCE

Thyroid cancer is the most common endocrine malignant neoplasm in children and adolescents. Despite a more advanced presentation of thyroid cancer, younger patients tend to have a more favorable prognosis and a lower mortality rate than adults with thyroid cancer.

OBJECTIVE

To examine the presentation and outcomes of thyroid cancer in pediatric patients.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional weighted analysis was performed using data from the Nationwide Inpatient Sample from January 1, 2003, to December 31, 2010. Patient data were derived from a sample of 20% of community hospitals in the United States. Six hundred forty-four children and adolescents (age, <18 years; hereinafter referred to as children) with thyroid cancer were compared with 43 536 adults (age, ≥18 years) with thyroid cancer. Data were analyzed from December 7, 2014, to November 19, 2015.

EXPOSURES

Thyroid cancer and thyroidectomy.

MAIN OUTCOMES AND MEASURES

Presentation and management characteristics of thyroid cancer and thyroidectomy outcomes in relation to surgeon volume and specialty.

RESULTS

A total of 644 cases of pediatric thyroid cancer were included (female, 77.3%; mean [SEM] age, 13.8 [0.2] years), corresponding to a weighted sample of 32 563. Compared with adults with thyroid cancer, children were more likely to present with cervical lymph node involvement (31.5% vs 14.7%; odds ratio [OR], 2.29; 95% CI, 1.76-2.97; P < .001) and lung metastases (5.7% vs 2.2%; OR, 2.79; 95% CI, 1.82-4.28; P < .001), whereas bone metastases were more frequent in adults (0.3% vs 1.1%; OR, 0.23; 95% CI, 0.06-0.90; P = .04). Children were more likely to be treated by a low-volume surgeon (26.9% vs 16.0%; OR, 2.09; 95% CI, 1.26-3.48; P = .005) or a pediatric surgeon (14.5% vs 9.6%; OR, 1.66; 95% CI, 1.04-2.67; P = .04) and in a low-volume hospital (20.5% vs 15.2%; OR, 2.97; 95% CI, 1.60-5.54; P < .001) or a teaching hospital (81.7% vs 63.1%; OR, 3.61; 95% CI, 2.33-5.60; P < .001). Compared with those treated by low-volume surgeons, children treated by high-volume surgeons were less likely to experience postoperative complications (14.3% vs 35.9%; OR, 0.16; 95% CI, 0.05-0.51; P = .002) or a hospital stay of more than 1 day (49.8% vs 67.9%; OR, 0.36; 95% CI, 0.15-0.90; P = .03). Management by pediatric surgeons did not significantly alter the risk for postoperative complications compared with other specialties (21.3% vs 18.5%; OR, 1.71; 95% CI, 0.64-4.53, P = .28). Management of thyroid cancer in children was significantly more costly (>$10 067.08/case) compared with adults (P = .04).

CONCLUSIONS AND RELEVANCE

Compared with thyroid cancer in adults, pediatric thyroid cancer is more likely to present as advanced disease and to be managed by low-volume or pediatric surgeons. In addition, within the United States, surgeon volume appears to be more crucial in determining thyroidectomy outcomes than the surgeon's field of specialization.

Rare primary mucosal melanoma of the larynx

Few cases of primary mucosal melanoma of the larynx have been documented in the literature, so only a limited amount of data exists regarding its diagnosis and treatment. The prognosis is poor, as patients often present at a late stage with regional or distant metastases. We describe the case of a 66-year-old man who presented with hoarseness and dysphagia. Laryngoscopy identified a dark discoloration of the supraglottic larynx and incomplete mobility of the right vocal fold; an excisional biopsy confirmed the diagnosis. We discuss the epidemiology, clinical features, diagnosis, interpretation of imaging findings, and management of this rare malignant melanoma.

Initial Experience of a Patient Navigation Model for Head and Neck Cancer

IMPORTANCE

Specific temporal goals for treatment of head and neck cancer (HNC) are common in Europe but not in the United States. We implemented a patient-centric navigation model with an aspirational goal that all patients will receive treatment recommendations within 2 weeks of presentation as a means to improve outcomes in our patients with HNC.

OBJECTIVE

To assess the temporal impact of using an aspirational goal in a patient-centric navigation system on the time from presentation to formulation of treatment planning for patients with HNC.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective review of 100 consecutive patients treated for squamous cell carcinoma of the head and neck at a tertiary referral center between 2011 and 2014. Patients were assessed to determine the efficiency of a patient-centric navigational model in delivering cancer treatment recommendations. This model was designed with an aspirational goal of providing treatment recommendations within a 2-week period.

EXPOSURE

Starting in 2011, patient-centric navigation model including the assignment of a nurse who acts as a patient navigator.

MAIN OUTCOMES AND MEASURES

The time interval between presentation to clinic and definitive treatment recommendations, as well as factors associated with delay.

RESULTS

Of the 93 patients who met inclusion requirements, most were white (81 [87%]) males (74 [80%]) with a mean (SD) age of 63.4 (10.8) years insured by Medicare or Medicaid (64 [69%]). Forty-seven (51%) received treatment recommendations within the 2-week period, with median and mode values of 15 and 14 days, respectively. The mean (SD) interval was 18.8 (18.6) days. Outliers included 2 patients with synchronous lung nodules (72 and 85 days) and 2 patients with psychosocial barriers (107 and 86 days). There were no significant differences seen for the mean (SD) time interval with respect to patient race (blacks, 17.6 [15.7] vs whites, 22.5 [30.0]; P = .20), sex (males, 18.3 [18.1] vs females, 20.4 [19.7]; P = .13), insurance status (insured, 16.3 [10.2] vs uninsured, 19.8 [21.0]; P = .24), and stage at presentation (stage I, 14.4 [17.0] vs stage II, 11.0 [5.3] vs stage III, 14.7 [8.6] vs stage IV, 21.2 [20.2]; P = .40).

CONCLUSIONS AND RELEVANCE

The goal of treatment recommendations for HNC within 2 weeks was shown to be reasonable and attainable. Further research should address the delays encountered by patients with psychosocial barriers and those with synchronous lung nodules.

The utility of molecular markers in pre-operative assessment of thyroid nodules

The pre-operative diagnosis of thyroid tumors is determined by gold standard fine needle aspiration (FNA) biopsy. This has been widely accepted and offers the most cost-effective approach for evaluation of thyroid nodules. However, its diagnostic accuracy can pose a challenging scenario to surgeons. These diagnostic difficulties may subject patients to unnecessary thyroidectomies for benign thyroid nodules. Thus, additional molecular tests are needed to improve the sensitivity and specificity of FNA. The role of molecular markers is being proposed to predict the type and risk of malignancy to abate the need for diagnostic thyroidectomies. This review discusses their utility and validity in pre-operative diagnosis of thyroid nodules and how these markers can enhance the accuracy of FNA cytology.

Abstract CT218: Results from the early cancer clinical trials for 4-demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN)

Purpose: 4-Demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN), is a poly-chlorinated pyridine cholesteryl carbonate whose MOA is via alkylation of DNA @ N7 - guanine and N6 - cytosine and via oxidative stress. DM-CHOC-PEN underwent a phase I study in patients with advanced cancer +/- CNS involvement and is being evaluated in a phase II trial in patients with primary brain cancer and brain metastases from melanoma, breast, and lung cancers. The aims are to assess clinical responses when DM-CHOC-PEN is administered I.V, at maximum tolerated dose (MTD) and to monitor safety/toxicities, pharmacokinetics, and cardiac functions - IND 68,876.

Patients & Methods: In phase I, DM-CHOC-PEN was administered as a 3-hr IV infusion once every 21-days to patients with advanced cancer - melanoma (n = 3), colorectal CA (n = 4), breast (n = 3), lung (n = 8) and glioblastoma multiforme (GBM) (n = 9) - the most common tumor treated. Cohorts were treated with escalating doses from 39 to 111 mg/m2. The phase II dose schedule is 2-tiered: 85.8 mg/m2 for patients with liver involvement and 98.7 mg/m2 for patients with normal livers.

Results: Forty (40) patients have been treated to date - 27 in phase I and 13 in phase II. The drug was well tolerated; the most common adverse effects were fatigue (n = 2), liver dysfunction - elevated bilirubin (Gr-3, n = 3; Gr-2, n = 1), ALT/AST (Gr-2, n = 3), alk phos (Gr-2, n = 3), nausea (Gr-1/2, n = 5) and an allergic reaction (Gr-2, n = 1). Three (3) patients with liver metastasis had hyperbilirubinemia (Gr-3 SLT) - two (2) at 98.7 mg/m2 and one (1) at 111 mg/m2 levels. No neuro/psychological, hematological, cardiac or renal toxicities were observed. PK studies revealed the following profile for DM-CHOC-PEN 98.7 mg/m2: AUC o-t = 1850 mg.h/L, CL - 3.0 L/h, T1/2 α - 3.3 h & Tβ - 79.1 h. DM-CHOC PEN and DM-PEN (metabolite) showed a rebound phenomenon at ∼50 hours post-infusion with a T release of 26.7 h for plasma and rbcs. DM-CHOC-PEN and DM-PEN were detected 3 and 15 days bound to RBCs (70 - 111 mg/m2); DM-CHOC-PEN was also detected in the urine (Cmax = 17.5 μg/mL) until day 21. The AUC was linear for all doses. DM-CHOC-PEN was detected in spinal sarcoma and in lung cancer tissues (75 & 190 ng/g, resp.) surgically obtained from patients 21-days post single injection of 39 & 98.7 mg/m2, resp. Patients receiving dexamethasone demonstrated lower blood levels of DM-CHOC-PEN along with induction of steroid esterase activities. After multiple doses, DM-CHOC-PEN also induced steroid esterase levels, which reversed within 4 weeks. Steroid esterase assays may be a valuable companion assay.

Conclusion: DM-CHOC-PEN is safe at the presented dose levels and shows a favorable PK profile. To date, 15 patients have had responses with significant PFS/OS, including 10 with CNS involvement. DM-CHOC-PEN is well tolerated with manageable toxicities. Complete patient responses/toxicities will be presented. Supported by NCI/SBIR grant - R43/44CA132257

Citation Format: Roy S. Weiner, P Friedlander, T Mahmood, Adilia Hormigo, C Gordon, Y Saenger, ML Ware, VK Thirukonda, VM Patel, TJ Cosgriff, AH Rodgers, LR Morgan, G Bastian. Results from the early cancer clinical trials for 4-demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN). [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr CT218. doi:10.1158/1538-7445.AM2015-CT218