Evaluation of a Preoperative Adverse Event Risk Index for Patients Undergoing Head and Neck Cancer Surgery

Importance

Patients 65 years or older are the most frequent users of operative resources and are also the most vulnerable to postoperative adverse events (AEs). Frailty indices are increasingly being used for preoperative risk stratification within head and neck cancer surgery, but most models lack a multifactorial basis and cannot be directly applied to clinical practice. A practical risk index is needed for clinicians to gauge risk factors preoperatively.

Objective

To develop a preoperative risk index of short-term major postoperative AEs for patients undergoing head and neck cancer surgery.

Design

Cohort analysis of patients from multiple medical centers undergoing inpatient ablative or reconstructive head and neck cancer surgery and registered in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) from 2006 to 2016.

Exposures

Inpatient ablative or reconstructive head and neck cancer surgery.

Main Outcomes and Measures

Sociodemographic, frailty-related, and surgical factors in the derivation cohort were evaluated using simple and multiple logistic regression. Risk factors were subsequently integrated into a preoperative head and neck surgery risk index (HNSRI) and compared with existing models using the validation cohort. A composite variable of major postoperative AEs was used, including death within 30 days of surgery.

Results

A total of 43 968 operations were found using the ACS NSQIP database. Of these, 12 569 cases were excluded as non-head and neck cancer or emergency surgery. Of the included 31 399 operations reviewed, the mean (SD) patient age was 56.9 (15.4) years, and 16 994 of the patients were women (54.1%). A total of 4556 (14.5%) patients had a major postoperative AE, and 209 (0.7%) died. Older age, male sex, smoking, anticoagulation, recent weight loss, functional dependence, free-tissue transfer, tracheotomy, duration of surgery, wound classification, anemia, leukocytosis, and hypoalbuminemia were independently associated with major AEs or death on multiple regression analysis (C statistic, 0.83). The area under the curve of the HNSRI to predict major AEs including death using the validation cohort (n = 15 699) was 0.84 (95% CI, 0.83-0.85) with a sensitivity of 80.1% (95% CI, 79.4%-80.8%) and specificity, 72.3% (95% CI, 70.3%-74.2%). The HNSRI outperformed existing risk models for prediction of AEs: delta C index of the HNSRI to the modified frailty index 11, 0.23 (95% CI, 0.22-0.25); the American Society of Anesthesiologists classification, 0.14 (95% CI, 0.13-0.16); and the ACS risk calculator, 0.02 (95% CI, 0.01-0.03).

Conclusions and Relevance

The proposed HNSRI demonstrated a high sensitivity and specificity for major postoperative AEs and death in the studied population. This risk index can be used to counsel patients awaiting head and neck cancer surgery.

Treatment de-escalation for HPV-associated oropharyngeal squamous cell carcinoma with radiotherapy vs. trans-oral surgery (ORATOR2): study protocol for a randomized phase II trial

Background

Patients with human papillomavirus-positive (HPV+) oropharyngeal squamous cell carcinoma (OPC) have substantially better treatment response and overall survival (OS) than patients with HPV-negative disease. Treatment options for HPV+ OPC can involve either a primary radiotherapy (RT) approach (± concomitant chemotherapy) or a primary surgical approach (± adjuvant radiation) with transoral surgery (TOS). These two treatment paradigms have different spectrums of toxicity. The goals of this study are to assess the OS of two de-escalation approaches (primary radiotherapy and primary TOS) compared to historical control, and to compare survival, toxicity and quality of life (QOL) profiles between the two approaches.

Methods

This is a multicenter phase II study randomizing one hundred and forty patients with T1–2 N0–2 HPV+ OPC in a 1:1 ratio between de-escalated primary radiotherapy (60 Gy) ± concomitant chemotherapy and TOS ± de-escalated adjuvant radiotherapy (50–60 Gy based on risk factors). Patients will be stratified based on smoking status (< 10 vs. ≥ 10 pack-years). The primary endpoint is OS of each arm compared to historical control; we hypothesize that a 2-year OS of 85% or greater will be achieved. Secondary endpoints include progression free survival, QOL and toxicity.

Discussion

This study will provide an assessment of two de-escalation approaches to the treatment of HPV+ OPC on oncologic outcomes, QOL and toxicity. Results will inform the design of future definitive phase III trials.

Trial Registration

Clinicaltrials.gov identifier: NCT03210103. Date of registration: July 6, 2017, Current version: 1.3 on March 15, 2019.

Radiotherapy versus transoral robotic surgery and neck dissection for oropharyngeal squamous cell carcinoma (ORATOR): an open-label, phase 2, randomised trial

BACKGROUND

Transoral robotic surgery (TORS) with concurrent neck dissection has supplanted radiotherapy in the USA as the most common treatment for oropharyngeal squamous cell carcinoma (OPSCC), yet no randomised trials have compared these modalities. We aimed to evaluate differences in quality of life (QOL) 1 year after treatment.

METHODS

The ORATOR trial was an investigator-initiated, multicentre, international, open-label, parallel-group, phase 2, randomised study. Patients were enrolled at six hospitals in Canada and Australia. We randomly assigned (1:1) patients aged 18 years or older, with Eastern Cooperative Oncology Group scores of 0-2, and with T1-T2, N0-2 (≤4 cm) OPSCC tumour types to radiotherapy (70 Gy, with chemotherapy if N1-2) or TORS plus neck dissection (with or without adjuvant chemoradiotherapy, based on pathology). Following stratification by p16 status, patients were randomly assigned using a computer-generated randomisation list with permuted blocks of four. The primary endpoint was swallowing-related QOL at 1 year as established using the MD Anderson Dysphagia Inventory (MDADI) score, powered to detect a 10-point improvement (a clinically meaningful change) in the TORS plus neck dissection group. All analyses were done by intention to treat. This study is registered with ClinicalTrials.gov (NCT01590355) and is active, but not currently recruiting.

FINDINGS

68 patients were randomly assigned (34 per group) between Aug 10, 2012, and June 9, 2017. Median follow-up was 25 months (IQR 20-33) for the radiotherapy group and 29 months (23-43) for the TORS plus neck dissection group. MDADI total scores at 1 year were mean 86·9 (SD 11·4) in the radiotherapy group versus 80·1 (13·0) in the TORS plus neck dissection group (p=0·042). There were more cases of neutropenia (six [18%] of 34 patients vs none of 34), hearing loss (13 [38%] vs five [15%]), and tinnitus (12 [35%] vs two [6%]) reported in the radiotherapy group than in the TORS plus neck dissection group, and more cases of trismus in the TORS plus neck dissection group (nine [26%] vs one [3%]). The most common adverse events in the radiotherapy group were dysphagia (n=6), hearing loss (n=6), and mucositis (n=4), all grade 3, and in the TORS plus neck dissection group, dysphagia (n=9, all grade 3) and there was one death caused by bleeding after TORS.

INTERPRETATION

Patients treated with radiotherapy showed superior swallowing-related QOL scores 1 year after treatment, although the difference did not represent a clinically meaningful change. Toxicity patterns differed between the groups. Patients with OPSCC should be informed about both treatment options.

FUNDING

Canadian Cancer Society Research Institute Grant (#701842), Ontario Institute for Cancer Research Clinician-Scientist research grant, and the Wolfe Surgical Research Professorship in the Biology of Head and Neck Cancers grant.

Contextual and historical factors for increased levels of anxiety and depression in patients with head and neck cancer: A prospective longitudinal study

BACKGROUND

This study aimed at examining predictors of clinical anxiety and depressive symptoms in patients with head and neck cancer (HNC) at 3, 6, and 12 months post-diagnosis, with a particular interest in contextual and historical factors.

METHODS

Prospective longitudinal study of 219 consecutive patients newly diagnosed with a first occurrence of primary HNC, including psychometric measures, Structured Clinical Interview for DSM-IV Diagnoses (SCID), and medical chart reviews.

RESULTS

Point prevalence of clinical anxiety symptoms (Hospital Anxiety and Depression Scale-Anxiety subscale) was 32.0%, 21.9%, 12.1%, and 12.6% at baseline, 3, 6, and 12 months; and clinical depressive symptoms on the Depression Subscale was 19.4%, 21.9%, 13.5%, and 9.2%, respectively. Predictors of anxiety and depressive symptoms included upon diagnosis SCID major depressive or anxiety disorder, stressful life events in previous year, neuroticism, and levels of anxiety and depressive symptoms upon cancer diagnosis.

CONCLUSIONS

This study emphasizes the predictive contribution of broader personal contextual and historical factors that increase psychological vulnerability in HNC and merit consideration.

Looking beyond Disfigurement: The experience of Patients with Head and Neck Cancer

Despite the frequent occurrence of head and neck cancer (HNC) disfigurement, little is known about its psychosocial impact on patients. This study aimed to understand the lived experience of disfigurement in HNC and explore what patients considered to be its influences. Fourteen disfigured HNC patients participated in a 45-to-120-minute in-depth, semi-structured interview, which was analyzed qualitatively using interpretive phenomenology. A majority of participants (64 percent) were considered to be at an advanced cancer stage (stage III or stage IV). Patients’ experiences revolved around the concept of a ruptured self-image (a discontinuity in sense of self). Forces triggering this ruptured self-image created a sense of “embodied angst”, in which disfigurement served as a constant reminder of the patient's cancer and associated foundational malaise. Other influences fostered a sense of normalcy, balance, and acceptance. Participants oscillated between these two states as they grew to accept their disfigurement. This study's findings could guide supportive interventions aimed at helping patients face head and neck surgery.

Contribution of psychiatric diagnoses to extent of opioid prescription in the first year post-head and neck cancer diagnosis: A longitudinal study

PURPOSE

The purpose of this study was to determine, within the first-year post-head and neck cancer (HNC) diagnosis, the contribution of past and upon HNC psychiatric diagnoses (ie, substance use disorder, major depressive disorder, and anxiety disorder) to the extent (ie, cumulated dose) of opioid prescription.

METHODS

Prospective longitudinal study of 223 consecutive adults (on 313 approached; 72% participation) newly diagnosed (<2 weeks) with a first occurrence of primary HNC, including Structured Clinical Interviews for DSM-IV disorders, validated psychometric measures, and medical chart reviews. Opioid doses were translated into standardized morphine milligram equivalents (MME) using CDC guidelines. A model of variables was tested using multiple linear regression.

RESULTS

Fifty-five percent (123/223) of patients received opioids at some point during the first 12 months post-HNC diagnosis, 37.7% (84/223) upon HNC diagnosis (pre-treatment), 40.8% (91/223) during treatments, and 31.4% (70/223) post-treatment. The multiple linear regression indicated that an AD (P = 0.04) upon HNC diagnosis in early stage contributes to cumulated MME dose in the first year post-HNC diagnosis.

CONCLUSION

This study underlines how anxiety has important repercussions on the management of pain and illustrates the importance of screening for AD upon HNC diagnosis to allow for early prophylactic treatment and support.

Development and validation of the McGill body image concerns scale for use in head and neck oncology (MBIS-HNC): A mixed-methods approach

OBJECTIVE

The aim of this study was to develop and validate a patient-reported outcome measure to evaluate body image concerns in head and neck cancer (HNC) patients.

METHODS

Items were created using a combination of deductive (eg, US Food and Drug Administration Qualification of Clinical Outcome Assessments, literature review) and inductive approaches (eg, subject matter experts, HNC patients). Items were translated for use in both Canadian English and Canadian French using back-translation. A two-step empirical validation process using the Classical Test Theory (CTT) and Rasch Measurement Theory (RMT) was conducted with 224 and 258 HNC patients, respectively, having undergone disfiguring surgery within the past 3 years.

RESULTS

Analyses suggest two subscales for MBIS-HNC: social discomfort (10 items) and negative self-image (11 items). The McGill Body Image Concerns Scale-Head and Neck Cancer (MBIS-HNC) is reliable with high internal consistency (0.98), high test-retest reliability over a two-week period (ICC = 0.88), moderate to high convergent validity (range r = 0.43-0.81), and divergent validity (range r = 0.12-0.15). RMT was used in addition to CTT. Disordered thresholds led to the modification of the number of response options, and items were deleted based on differential item functioning and high local dependency. Unidimensionality of both subscales and supporting a total score was confirmed. The measure was however characterized by the presence of an important floor effect, confirmed with poor targeting as demonstrated by the person-item threshold distribution.

CONCLUSION

Evidence gathered from our theory-driven validation study using CTT and RMT provides practitioners and researchers with a useful and easy to use self-report measure.

Local Failure Rate in Oropharyngeal Carcinoma Patients Treated with Intensity-modulated Radiotherapy Without High-dose Clinical Target Volume

Purpose: Our purpose was to evaluate whether omitting high-dose clinical target volume radiation (CTV-HD) around the gross tumor volume (GTV) in patients with oropharyngeal squamous cell carcinoma (OSCC) treated with intensity-modulated radiotherapy (IMRT) was associated with increased local failure.

Methods and materials: Patients diagnosed with stage I to stage IV OSCC between December 2004 and April 2017 were retrospectively reviewed. All patients were treated with radical radiotherapy using IMRT, with or without neoadjuvant or concurrent chemotherapy. In accordance with institution guidelines, CTV-HD was not used. Local failure was defined as disease persistence or reappearance at the primary tumor site. When primary failure was documented, the computed tomography/positron emission tomography (CT/PET) scan that showed primary failure was fused with the original treatment scan. Each recurrent tumor was contoured to evaluate the pattern of recurrence. Recurrences were categorized as in-field, marginal, or out-of-field if >95%, 20%-95%, or <20% of the recurrent tumor volume, respectively, was encompassed by the 95% high-dose prescription isodose line of the original treatment plan. We then determined whether omitting CTV-HD was associated with increased locoregional failure.

Results: A total of 272 patients with OSCC were assessed. The median follow-up from initial treatment was 43 months (range: 3-194 months). Seven patients were lost to follow-up. The overall five-year survival rate was 87%. The three- and five-year disease-free survival rates were 86% and 83%, respectively. Forty-one patients had 53 treatment failures (16 were local, eight were regional, and 29 were distant; some patients had treatment failures in multiple locations). Fourteen (87.5%) of the local recurrences were in-field, one (6.25%) was marginal, and one (6.25%) was out-of-field.

Conclusion: Our analysis of patients with oropharyngeal cancer suggests that local failure is mostly in-field and potentially due to radioresistance, rather than a marginal miss of the tumor. It suggests that omitting CTV-HD is feasible and safe.

Prevalence and Risk Factors of Suicidal Ideation among Patients with Head and Neck Cancer: Longitudinal Study

OBJECTIVES

(1) Determine 1-year period prevalence of suicidal ideation, suicide attempt, and completed suicide among patients newly diagnosed with a first occurrence of head and neck cancer (HNC). (2) Characterize stability and trajectory of suicidal ideation over the year following cancer diagnosis. (3) Identify patients at risk of suicidal ideation.

STUDY DESIGN

Prospective longitudinal study with 1-year follow-up.

SETTING

Three university-affiliated outpatient departments of otolaryngology-head and neck surgery.

SUBJECTS AND METHODS

The study comprised a representative sample of 223 consecutive patients who were newly diagnosed (<2 weeks) with a first occurrence of primary HNC, were ≥18 years old and able to consent, and had a Karnofsky Performance Scale score ≥60. Patients completed the Beck Scale for Suicidal Ideation and Structured Clinical Interview for DSM-IV-TR Axis I Disorders.

RESULTS

Sixteen percent (15.7%) of patients with HNC were suicidal <1 year from diagnosis, with point prevalences of 8.1% <2 weeks, 14.8% at 3 months, 9.4% at 6 months, and 10.4% at 12 months; 0.4% committed suicide within 3 months, and 0.9% attempted suicide. An a priori comprehensive conceptual model revealed 2 predictors of 1-year period prevalence of suicidal ideation in HNC: psychiatric history ( P = .017, β = 2.1, 95% CI = 0.4-3.8) and coping with the diagnosis by using substances (alcohol/drugs; P = .008, β = 0.61, 95% CI = 0.16-1.06). All other predictors, including medical predictors, were nonsignificant. A clinical suicide risk assessment revealed low risk among 71.4% and medium to high risk among 28.6%.

CONCLUSION

Suicide prevention strategies are clearly needed as part of routine clinical care in head and neck oncology, as well as their integration into clinical practice guidelines for HNC.

Three-dimensionally printed polyetherketoneketone scaffolds with mesenchymal stem cells for the reconstruction of critical-sized mandibular defects

OBJECTIVE

Additive manufacturing offers a tailored approach to tissue engineering by providing anatomically precise scaffolds onto which stem cells and growth factors can be supplied. Polyetherketoneketone (PEKK), an ideal candidate biomaterial, is limited by a poor implant-bone interface but can be functionalized with adipose-derived stem cells (ADSC) to promote integration. This in vivo study examined the interaction of a three-dimensional printed PEKK/ADSC implant within the critical-sized mandibular defect in a rabbit model.

STUDY DESIGN/METHODS

Trapezoidal porous scaffolds with dimensions of 1.5 × 1.0 × 0.5 cm were printed using selective laser sintering. ADSCs were seeded on the scaffolds that were then implanted in marginal defects created in New Zealand rabbits. Rabbits were euthanized at 10- and 20-week intervals. Microcomputed tomography was used to characterize bone ingrowth and was correlated with histological analysis. Stress testing was performed on the scaffolds before and after implantation.

RESULTS

All scaffolds were well integrated into adjacent bone. Bone-to-tissue volume increased from 30.34% ( ± 12.46) to 61.27% ( ± 8.24), and trabecular thickness increased from 0.178 mm ( ± 0.069) to 0.331 mm ( ± 0.0306) in the 10- and 20-week groups, respectively, compared to no bone regrowth on the control side (P < 0.05). Histology confirmed integration at the bone-implant interface. Biomechanical testing revealed a compressive resistance 15 times that of bone alone (P < 0.05) CONCLUSION: 3D-printed PEKK scaffolds combined with ADSCs present a promising solution to improve the bone-implant interface and increase the resistance to forces of mastication after mandibular reconstruction.

LEVEL OF EVIDENCE

NA. Laryngoscope, 127:E392-E398, 2017.

Meta-analysis of microRNAs expression in head and neck cancer: uncovering association with outcome and mechanisms

Head and neck squamous cell carcinoma (HNSCC) is often diagnosed at advanced stages, incurring significant high mortality and morbidity. This review explored the risk stratification of miRNAs, and investigated the impact of miRNA networking in HNSCC prognostication. We performed a meta-analysis and a systematic literature search on online databases for papers published prior to December 1, 2016. The list of miRNAs was uploaded to MetacoreTM to construct a protein-protein interaction network, which was used to identify targets of the miRNAs and potential drugs. In addition, a representative network was further validated by immunohistochemistry in a cohort of 100 patients. We found 116 studies that included 8,194 subjects, in which the relationship between miRNA expression and prognosis of HNSCC were analyzed. Significant elevated expressions of 27 miRNAs and decreased expression of 26 miRNAs were associated with poor outcome. After excluding the studies causing heterogeneity, a fixed model was applied, which showed a statistically significant association between increased expression of miR-21 and poor survival (Pooled HR = 1.81,95% CI = 0.66-2.95, P < 0.005). We identified four networks affected by the miRNAs expression and enriched in genes related to metabolic processes and regulation of cell mitogenesis in response to extracellular stimuli. One network point out to 16 miRNAs directly or indirectly involved in the regulation of androgen-receptor (AR). Evaluation of AR protein expression in our cohort revealed that patients with upregulation of AR had poor survival rates (log-rank test, P < 0.005). This study showed that miRNAs have potential prognostic value to serve as screening tool for HNSCC during the follow-up. In addition, the implementation of a network-based analysis may reveal proteins with potential to be used as a biomarker.

The role of repeat fine needle aspiration in the management of indeterminate thyroid nodules

Background

Management decisions are not straightforward when the Ultrasound Guided Fine Needle Aspiration (USFNA) demonstrates a Bethesda score of either category III or IV, and a diagnostic hemi-thyroidectomy or a repeat USFNA (r-USFNA) could be performed. The aim of this study is to assess the effectiveness of r-USFNA in the management of indeterminate thyroid nodules by evaluating the likelihood of obtaining a definite diagnosis.

Methods

We reviewed the medical records of all patients with thyroid nodules between 2011 and 2015 at the Jewish General Hospital (Montreal, Canada). Three hundred fifty-one patients who had undergone a surgical procedure (hemi or total thyroidectomy) and a diagnosis of B3 or B4 on the primary USFNA (p-USFNA) were included in the study. Ninety-six of the included patients also had a repeat USFNA prior to the surgery. Demographic data, type of procedure, and McGill Thyroid Nodule Score (MTNS) were obtained from the medical records. Malignancy rates were calculated based on the final surgical histopathology report.

Results

Upon r-USFNA, an average 76 % of patients did not change Bethesda categories, 7.4 % downgraded to a benign category. The results showed that, on an average 17.3 % of patients with p-USFNA of B3 and 20 % of patients with p-USFNA of B4, upgraded to a malignant or suspicious for malignancy category, thus changing the clinical management to total thyroidectomy. Our data demonstrates that r-USFNA facilitates choosing the correct surgery of total thyroidectomy in about 20 % of nodules that have upgraded from B3/B4 to a more definite malignant category.

Conclusions

r-USFNA in patients with indeterminate diagnoses (B3 or B4) increases categorization into more definite categories. Approximately 20 % of patients are found to have malignant thyroid nodules and suspicious for malignancy thyroid nodules upon repeating the biopsy, hence a diagnostic hemi-thyroidectomy was avoided and a more definitive surgery could be performed. Furthermore, repeat USFNA results in a fewer number of hemi-thyroidectomy and completion thyroidectomy procedures.

Survival outcomes in patients with oropharyngeal cancer treated with carboplatin/paclitaxel and concurrent radiotherapy

Background

A commonly employed treatment for advanced staged oropharyngeal squamous cell carcinoma (OPSCC) is concurrent radiation and chemotherapy with cisplatin as the gold standard. Carboplatin is reported to have the same radiopotentiation properties and a superior side effect profile; however, its use in head and neck cancer has been limited due to the paucity of data and reported hematologic side effects. In this study, we describe our institution’s experience with carboplatin, paclitaxel and radiation in the treatment of oropharyngeal squamous cell carcinoma over a 10 year period.

Methods

A retrospective chart review of patients aged 18 to 80 years old with stage III-IV OPSCC treated with weekly carboplatin, paclitaxel and intensity modulated radiotherapy (IMRT) was performed. Data collected included patient demographics, tumor location and stage and survival outcomes. In addition, we noted treatment morbidities according to the Radiation Therapy Oncology Group (RTOG) scoring criteria scale. The data was analyzed using the student’s t-test and analysis of variables.

Results

Over a 10 year period, 160 patients received chemoradiation with carboplatin and paclitaxel for OPSCC. One-hundred-four and 65 patients were followed for at least 3 and 5 years, respectively. Overall survival for all patients was 81.7 and 70.7 % at 3 and 5 years, respectively. Disease free survival and locoregional recurrence-free survival at 5 years was 64.6 and 89.2 %, respectively. There was no association of survival with stage, regional nodal status or subsite. The most common side effect attributed to treatment was acute dysphagia (75.25 %) followed by odynophagia, xerostomia and hypogeusia. Hospitalizations and non-hospitalization emergency department visits attributed to treatment totalled 33 and 11, respectively. Hematologic toxicities greater than grade II were: 11.9 % neutropenia, 6.3 % anemia, 1.8 % thrombocytopenia. The incidence of febrile neutropenia was 5.0 % (8/160).

Conclusion

In conclusion, the overall, disease-free and locoregional recurrence-free survival of patients treated with carboplatin and radiotherapy for advanced stage OPSCC parallels what has been described in the literature for cisplatin, with an acceptable side effect profile.

Predominant Rab-GTPase amplicons contributing to oral squamous cell carcinoma progression to metastasis

Metastatic oral squamous cell carcinoma (OSCC) is frequently associated with recurrent gene abnormalities at specific chromosomal loci. Here, we utilized array comparative genomic hybridization and genome-wide screening of metastatic and non-metastatic tongue tumors to investigate genes potentially contributing to OSCC progression to metastasis. We identified predominant amplifications of chromosomal regions that encompass the RAB5, RAB7 and RAB11 genes (3p24-p22, 3q21.3 and 8p11-12, respectively) in metastatic OSCC. The expression of these Rab GTPases was confirmed by immunohistochemistry in OSCC tissues from a cohort of patients with a follow-up of 10 years. A significant overexpression of Rab5, Rab7 and Rab11 was observed in advanced OSCC cases and co-overexpression of these Rabs was predictive of poor survival (log-rank test, P = 0.006). We generated a Rab interaction network and identified central Rab interactions of relevance to metastasis signaling, including focal adhesion proteins. In preclinical models, mRNA and protein expression levels of these Rab members were elevated in a panel of invasive OSCC cell lines, and their down-regulation prevented cell invasion at least in part via inhibition of focal adhesion disassembly. In summary, our results provide insights into the cooperative role of Rab gene amplifications in OSCC progression and support their potential utility as prognostic markers and therapeutic approach for advanced OSCC.

Can preoperative thyroglobulin antibody levels be used as a marker for well differentiated thyroid cancer?

Background

It has been reported that thyroglobulin antibody are more frequently elevated in patients with thyroid cancercompared to general population. This study aims at evaluating whether preoperative thyroglobulin antibody (TgAb) levels increase the likelihood that a thyroid nodule is malignant.

Methods

A retrospective review of 586 patients who underwent thyroidectomy was conducted. Demographic data, TgAb levels, and final histopathology were recorded. Patients were divided into two groups: TgAb positive (defined as TgAb ≥ 30 IU/ml) and TgAb low/negative (defined as TgAb < 30).

Results

Preoperative TgAb levels were available in 405 patients. There were 353 (87 %) patients in the TgAblow/negative group (malignancy rate: 50.42 %) and 52 (13 %) patients in the TgAb positive group (malignancy rate: 65.38 %). The sensitivity, specificity, positive predictive value and negative predictive value of TgAb ≥ 30 IU/ml for thyroid malignancy were 16.04 %, 90.67 %, 65.38 % and 49.58 %, respectively. The relative risk of having a malignant thyroid nodule when the TgAb titers were≥30 IU/ml was 1.30 (CI1.04-1.62) and the odds ratio was 1.86 (CI 1.01-3.41). Both the Pearson chi-square test (p = 0.024) and Fisher’s exact test (p = 0.017) yielded statistical significance between the two groups.

Conclusions

In this study, patients with preoperative TgAb ≥ 30 IU/ml had a higher rate of malignancy when compared topatients with TgAb < 30 IU/ml. This suggests that an elevated TgAb level may indicate that a thyroid nodule is at an increased risk for malignancy.

Improving PEEK bioactivity for craniofacial reconstruction using a 3D printed scaffold embedded with mesenchymal stem cells

Objective

Polyetheretherketone (PEEK) is a bioinert thermoplastic that has been investigated for its potential use in craniofacial reconstruction; however, its use in clinical practice is limited by a poor integration with adjacent bone upon implantation. To improve the bone–implant interface, two strategies have been employed: to modify its surface or to impregnate PEEK with bioactive materials. This study attempts to combine and improve upon the two approaches by modifying the internal structure into a trabecular network and to impregnate PEEK with mesenchymal stem cells. Furthermore, we compare the newly designed PEEK scaffolds' interactions with both bone-derived (BMSC) and adipose (ADSC) stem cells.

Design

Customized PEEK scaffolds were designed to incorporate a trabecular microstructure using a computer-aided design program and then printed via selective laser sintering (SLS), a 3D-printing process with exceptional accuracy. The scaffold structure was evaluated using microCT. Scanning electron microscopy (SEM) was used to evaluate scaffold morphology with and without mesenchymal stem cells (MSCs). Adipose and bone marrow mesenchymal cells were isolated from rats and cultured on scaffolds. Cell proliferation and differentiation were assessed using alamarBlue and alkaline phosphatase assays, respectively. Cell morphology after one week of co-culturing cells with PEEK scaffolds was evaluated using SEM.

Results

SLS 3D printing fabricated scaffolds with a porosity of 36.38% ± 6.66 and density of 1.309 g/cm2. Cell morphology resembled viable fibroblasts attaching to the surface and micropores of the scaffold. PEEK scaffolds maintained the viability of both ADSCs and BMSCs; however, ADSCs demonstrated higher osteodifferentiation than BMSCs ( p < 0.05).

Conclusions

This study demonstrates for the first time that SLS 3D printing can be used to fabricate customized porous PEEK scaffolds that maintain the viability of adipose and bone marrow-derived MSCs and induce the osteodifferentiation of the adipose-derived MSCs. The combination of 3D printed PEEK scaffolds with MSCs could overcome some of the limitations using PEEK biopolymers for load-bearing bone regeneration in craniofacial reconstruction.

3-phase dual-energy CT scan as a feasible salvage imaging modality for the identification of non-localizing parathyroid adenomas: a prospective study

Objectives

Accurate pre-operative imaging of parathyroid adenomas (PAs) is essential for successful minimally invasive surgery; however, rates of non-localizing PAs can be as high as 18 %. Multiphasic dual-energy CT (DECT) has the potential to increase accuracy of PA detection by enabling creation of paired material maps and spectral tissue characterization. This study prospectively evaluated the utility of 3-phase DECT for PA identification in patients with failed localizatio n via standard imaging.

Methods

Patients with primary hyperparathyroidism and non-localizing PAs underwent a 3 phase post-contrast DECT scan acquired at 25, 55, and 85 s. The scans were prospectively evaluated by two head and neck radiologists. Pre-operative localization was compared to intraoperative localization and final histopathology. A post-hoc DECT spectral density characterization was performed on pathologically-proven PAs.

Results

Out of 29 patients with primary hyperparathyroidism and non-localized PAs, DECT identified candidates in 26. Of the 23 patients who underwent parathyroidectomy, DECT provided precise anatomic localization in 20 patients (PPV = 87.0 %), one with multi-gland disease. The virtual unenhanced images were not found to be useful for diagnosis but successful diagnosis was made without an unenhanced phase regardless. Spectral analysis demonstrated a distinct spectral Hounsfield attenuation curve for PAs compared to lymph nodes on arterial phase images.

Conclusion

3-phase DECT without an unenhanced phase is a feasible salvage imaging modality for previously non-localizing parathyroid adenomas. Optimal interpretation is achieved based on a combination of perfusion characteristics and other morphologic features. Advanced spectral DECT analysis has the potential for further increasing accuracy of PA identification in the future.

Intraoperative localization of the marginal mandibular nerve: a landmark study

Background

Identification and preservation of the marginal mandibular nerve (MMN) remains an important step in otolaryngology procedures. Current publications place the MMN at least 1 cm below the mandible. This study will evaluate the accuracy of the method of determining the surgical location of this branch of the facial nerve in vivo.

Methods

MMN were examined in 52 consecutive otolaryngology patients. Using a validated landmarking scheme, distances were measured from the inferior edge of the mandible and the lowest point of the nerve. A comparison of 33 nerves pairs was undertaken. Effect of patient’s age was analysed.

Results

Eighty five nerves were landmarked. The mean position of the nerve was 0.2–3.4 mm higher than the margin of the mandible. There were no significant difference in position with respect to age and left versus right comparisons.

Conclusion

The marginal mandibular nerve (MMN) is significantly higher than previously published. The location of the nerve on the right does not correlate with the left. Location of the nerve does not correlate with patient’s age.

Silver nitrate mimicking a foreign body in the pharyngeal mucosal space

Silver nitrate is sometimes used as a means of chemical cauterization for control of minor bleeding and management of hypergranulation tissue following bedside head and neck procedures. There are only few reports available on the imaging appearance of silver nitrate and its potential to mimic a foreign body. We report a case of a patient presenting with dysphagia, odynophagia, and fever following dental work who had a peritonsillar incision and drainage for treatment of a deep neck space infection. During the procedure, silver nitrate was applied to halt the bleeding. Patient was subsequently transferred to another institution. Since the patient was not showing significant clinical improvement on antibiotic therapy, a computed tomography (CT) scan was performed demonstrating a hyperdense structure lodged in the pharyngeal mucosal space in the oropharynx and soft palate that was mistaken for a foreign body such as bone. Silver nitrate can have density similar to bone but does not have the normal architecture of bone with cortex and marrow on CT. Familiarity with the appearance of silver nitrate on CT, lack of bone architecture, and proper documentation and communication of the use of silver nitrate to the consultant radiologist and medical personnel could help avoid misdiagnosis and potentially unnecessary surgical exploration.

The Mcgill thyroid nodule score - does it help with indeterminate thyroid nodules?

BACKGROUND

Ultrasound guided fine-needle aspiration (USFNA) biopsy of thyroid nodules often gives a result of indeterminate pathology, placing thyroid specialists in difficult management situations. The aim of this study is to evaluate the incidence of malignancy in patients undergoing surgery and to correlate these results with the McGill Thyroid Nodule Score (MTNS).

METHODS

We performed a retrospective study comparing USFNA results, MTNS and histopathology of patients undergoing thyroid surgery between 2010 and 2012. Pre-operative USFNA results were divided into three subgroups: benign, indeterminate and suspicious for/malignant. The indeterminate USFNA subgroup comprised of Bethesda type III (atypia of undetermined significance) and Bethesda type IV (follicular neoplasms, including Hurthle cell neoplasms) lesions. Post-operative histopathology was divided into benign or malignant groups.

RESULTS

Of the 437 patient charts reviewed, 57.0% had an indeterminate USFNA biopsy. Within the indeterminate group, the malignancy rate was 39.8%. For indeterminate USFNA, the median MTNS was 7 (32% risk of malignancy) for benign nodules and 9 (63% risk of malignancy) for malignant nodules on post-operative histopathology (p < 0.05).

CONCLUSION

The rate of malignancy in operated patients with an indeterminate USFNA result was 39.8%. The MTNS can be of value to thyroid specialists in pre-operative decision-making when dealing with an indeterminate result of a thyroid nodule on USFNA.