Percutaneous Management of Recurrent Head and Neck Cancer: Current Role and Evolving Principles in the Multidisciplinary Setting

PURPOSE OF REVIEW

In this review, we will outline the role of percutaneous interventional radiological management of recurrent head and neck (H&N) cancer in the context of a multidisciplinary setting which consists of surgery, radiation therapy, as well as established and evolving systemic therapies that may impact current practice.

RECENT FINDINGS

Management of recurrent H&N cancer is complex, with attention to the preservation of function and minimal treatment-related morbidity. The favored treatment modalities in local recurrence previously treated with radiotherapy are surgical resection, and if unresectable, for chemotherapy as definitive treatment, or as a prelude to resection if there is good tumor response. Unfortunately, some of these patients are too frail for major surgery or to withstand the toxicity of chemotherapy. There is a gap for effective local therapy without the morbidity of surgery, toxicity of re-irradiation, and systemic side effects of chemotherapy. Percutaneous interventions have the potential to bridge that gap as well as provide palliative symptomatic treatment for patients that have exhausted all treatment options. In the multidisciplinary setting involving the treatment of complex recurrent H&N cancer, percutaneous management now plays a viable and effective role with a foothold in this team-based approach.

Impact of COVID-19 on a Tertiary Otolaryngology Practice in Singapore

The COVID-19 pandemic has had a major impact in healthcare systems across the world, with many hospitals having to come up with protocols and measures to contain the spread of the virus. This affects various specialties' clinical practices in many ways. Since early 2020 in Singapore, the Department of Otorhinolaryngology at Tan Tock Seng Hospital had to rapidly adapt to this pandemic as we provided services to the main healthcare facility combating the virus in our country. We had to design new workflows and also remain flexible in view of the ever-changing situation. There are 6 important domains for an otolaryngology department or any clinical department in general to consider when making adjustments to their practices in an outbreak: (1) clinical work, (2) education, (3) research, (4) safety of patients and staff, (5) morale of medical staff and (6) pandemic frontline work. We hope that the sharing of our experiences and the lessons learnt will be useful for both our local and international colleagues.

Olfactory taste disorder as a presenting symptom of COVID-19: a large single-center Singapore study

Purpose

To investigate the prevalence and epidemiological risk factors of olfactory and/or taste disorder (OTD), in particular isolated OTD, in patients with laboratory-confirmed COVID-19 infection.

Methods

We conducted a retrospective and cross-sectional study. Patients with laboratory-confirmed COVID-19 infection were recruited from the National Centre for Infectious Diseases (NCID) Singapore between 24 March 2020 and 16 April 2020. The electronic health records of these patients were accessed, and demographic data and symptoms reported (respiratory, self-reported OTD and other symptoms such as headache, myalgia and lethargy) were collected.

Results

A total of 1065 patients with laboratory-confirmed COVID-19 were recruited. Overall, the prevalence of OTD was 12.6%. Twelve patients (1.1%) had isolated OTD. The top three symptoms associated with OTD were cough, fever and sore throat. The symptoms of runny nose and blocked nose were experienced by only 29.8 and 19.3% of patients, respectively. Multivariate analysis demonstrated that the female gender, presence of blocked nose and absence of fever were significantly associated with OTD (adjusted relative risks 1.77, 3.31, 0.42, respectively). All these factors were statistically significant.

Conclusion

Patients with COVID-19 infection can present with OTD, either in isolation or in combination with other general symptoms. Certain demographic profile, such as being female, and symptomatology such as the presence of blocked nose and absence of fever, were more likely to have OTD when infected by COVID-19. Further studies to elucidate the pathophysiology of OTD in these patients will be beneficial.

Laryngeal gout mimicking chondrosarcoma with concurrent longus colli tendinitis

A 42-year-old man with multiple comorbidities, including gout, presented to the emergency department with severe odynophagia for 4 days with intermittent dysphagia for 1-2 months. A CT scan of the neck showed right longus colli tendinitis and partially calcified excrescences from the right thyroid cartilage which raised suspicion of a cartilaginous tumour. He underwent an MRI scan of the neck to better evaluate the thyroid cartilage findings, which showed a heterogeneous mass suspicious for a chondroid tumour. He then underwent a positron-emission tomography-CT scan which showed a fluorodeoxyglucose-avid mass containing foci of calcification involving the right thyroid cartilage and adjacent strap muscle, with high standardised uptake value of 7.7. He subsequently underwent a CT-guided biopsy and an open biopsy of the right thyroid cartilage, and the results revealed gouty tophi. To our knowledge, this is the first reported case of laryngeal gout with longus coli tendinitis, both of which are rare conditions.

Risk stratification of fine-needle aspiration cytology of parotid neoplasms based on the Milan system-Experience from a tertiary center in Asia

BACKGROUND

The recently described Milan system provides a unified way of categorizing salivary gland fine-needle aspiration (FNA) cytology. We aim to use this system to stratify risk of malignancy in parotid FNAs.

METHODS

In this retrospective case series, 376 FNAs were preoperatively performed for 573 parotidectomies over 14 years.

RESULTS

Risk of malignancy on FNA is as follows: nondiagnostic 14.5%, non-neoplastic 26.7%, atypia of undetermined significance 29.3%, benign neoplasm 2.7%, neoplasm of uncertain malignant potential 19.1%, suspicious for malignancy 87.5%, and malignant 100%. The specific diagnoses of pleomorphic adenoma and Warthin tumor on FNA have high positive predictive value of 97.5% and 96.6%, respectively. Multivariate regression associates smaller size of lesion with a nondiagnostic or indeterminate result. Seniority of operator is associated with a lower likelihood of a nondiagnostic result.

CONCLUSIONS

This large Asian series validates the Milan system as a valuable tool in stratifying malignancy risk of parotid FNAs.

Enhancing the immune stimulatory effects of cetuximab therapy through TLR3 signalling in Epstein-Barr virus (EBV) positive nasopharyngeal carcinoma

Cetuximab immunotherapy targeting the epidermal growth factor receptor (EGFR) has been used to treat nasopharyngeal cancer (NPC) with some success. Therefore, combining an immune adjuvant to boost the immune microenvironment may improve its clinical efficacy. Herein, we investigate the immune-stimulatory effects of Poly-ICLC (a TLR3 agonist) in enhancing cetuximab-based immunotherapy and correlate these responses with FcɣRIIIa (V158F) or TLR3 single nucleotide polymorphisms (SNPs- L412F and C829T) expressed on immune effector cells. We observed high levels of TLR3 mRNA in NPC cells; and both TLR3 and EGFR expression were unaffected by Poly-ICLC treatment. Cetuximab plus Poly-ICLC significantly enhanced NK-mediated ADCC through up-regulation of CD107a and Granzyme B expression. This effect was independent of FcɣRIIIa-V158F and TLR3-L412F or TLR3-C829T polymorphisms expressed on NK cells. Additionally, IFN-ɣ expression and secretion were doubled following cetuximab plus poly-ICLC treatment; compared to either treatment alone. This effect was independent of TLR3 polymorphisms. Consequentially, adaptive immune responses were also seen with increased DC maturation (CD83), co-stimulatory molecules expression (CD80 and CD86) and increased frequency of EGFR-specific CD8 + T cells following Poly-ICLC treatment. The percentage of CD80+ CD83+ and CD83+ CD86+ DC was highest in the Poly-ICLC plus cetuximab group, compared to either treatment alone. These results demonstrate the effectiveness of Poly-ICLC in enhancing both cetuximab-mediated innate and adaptive anti-tumor immunity against NPC, which is independent of FcɣRIIIa-158, TLR3-L412F or TLR3-C829T polymorphisms. Additionally, Poly-ICLC does not downregulate EGFR expression on NPC cells and hence, will not dampen cetuximab anti-tumor activity.

Vitamin D Binding Protein and Vitamin D Levels in Multi-Ethnic Population

INTRODUCTION

Low levels of 25-hydroxyvitamin D (25(OH)D) has been associated with many negative health outcomes including falls and fractures. 25(OH)D is largely bound to vitamin D binding protein (VDBP). There is increasing evidence that free or bioavailable 25(OH)D may be a better measure of vitamin D deficiency.

OBJECTIVE

To determine the prevalence of 25(OH)D deficiency and VDBP levels in multi-ethnic population, and its impact on muscle strength.

DESIGN AND METHODS

Cross-sectional study of older adults in Western region of Singapore. 295 participants from three ethnic groups were selected from the Healthy Older People Everyday (HOPE) cohort for measurements of total 25(OH)D and VDBP levels. Total 25(OH)D, VDBP, frailty status, Timed-Up-and-Go (TUG) and grip strength (GS) were assessed. Albumin, free and bioavailable 25(OH)D were only available for 256 participants.

RESULTS

53% of Malay and 55% of Indians were deficient in 25(OH)D compared with 18.2% of ethnic Chinese participants. Chinese also had higher total 25(OH)D concentrations with a mean of 29.1 ug/l, (p = <0.001). Chinese had the lowest level of VDBP (169.6ug/ml) followed by Malay (188.8 ug/ml) and Indian having the highest (220.1 ug/ml). Calculated bioavailable and free 25(OH)D levels were significantly higher in Chinese, followed by Malays and Indians, which also correlated with better grip strength measures amongst the Chinese.

CONCLUSION

The Malays and Indians had overall lower free, bioavailable and total 25(OH)D compared with ethnic Chinese. Chinese ethnic group also had the lowest VDBP and better overall grip strength.

Hearing Loss amongst the Elderly in a Southeast Asian Population - A Community-based Study

INTRODUCTION

The aim of this study was to determine the prevalence of hearing loss amongst the elderly population attending community services in Singapore. The usefulness of the Hearing Handicap Inventory for the Elderly Screening version (HHIE-S) in detecting hearing loss was also investigated.

MATERIALS AND METHODS

Pure-tone audiometry was carried out on a randomly recruited cohort of people (n = 338) over 60 years old and who were attending rehabilitation and social day care services for senior citizens at St Luke's Elder Care centres located throughout the city. Prior to the hearing test, subjects were administered the HHIE-S questionnaire, which was translated into the language they were most conversant in.

RESULTS

The study cohort showed mean pure-tone average at speech frequencies (0.5, 1, 2 and 4 kHz; 4-frequency average hearing level [4FA HL]) of the subjects' better hearing ear that has worsened with age. The percentage of the elderly with disabling hearing impairment (4FA >40 dB HL) was 9.1% (60 to 69 years old), 22.0% (70 to 79 years old), 35.7% (80 years old and above). Across all age groups, males had significantly poorer thresholds at 4 kHz than females. When adjusted for the demographic profile of the country, the prevalence of hearing loss (4FA >25 dB HL) and disabling hearing impairment (4FA >40 dB HL) amongst the elderly in Singapore was 63.7% and 16.2%, respectively. We estimate that there are currently 422,000 elderly with hearing loss greater than 25dB HL and over 100,000 elderly with disabling hearing loss of over 40 dB HL. Of subjects with a disabling hearing impairment, only 7.5% used hearing aids. The use of self-reporting HHIE-S showed poor sensitivity in detecting hearing loss of various severities amongst the elderly.

CONCLUSION

These data provide estimates of the prevalence and severity of hearing loss in older persons in Singapore and suggest that more can be done to help the elderly recognise, acknowledge and address hearing loss in the country.

Thrombin generation and cell-dependent hypercoagulability in sickle cell disease

Essentials Sickle cell disease is increasingly being recognized as a chronic hypercoagulable state. Thrombin generation is elevated in the whole blood, but not the plasma of sickle cell patients. Whole blood thrombin generation inversely correlates to erythrocyte phosphatidylserine exposure. Acquired protein S deficiency is likely explained by binding of protein S to sickle red cells. Click to hear Dr Hillery discuss coagulation and vascular pathologies in mouse models of sickle cell disease.

SUMMARY

Introduction Sickle cell disease (SCD) is a hypercoagulable state with chronic activation of coagulation and an increased incidence of thromboembolic events. However, although plasma pre-thrombotic markers such as thrombin-anithrombin complexes and D-dimer are elevated, there is no consensus on whether global assays of thrombin generation in plasma are abnormal in patients with SCD. Based on our recent observation that normal red blood cells (RBCs) contribute to thrombin generation in whole blood, we hypothesized that the cellular components in blood (notably phosphatidylserine-expressing erythrocytes) contribute to enhanced thrombin generation in SCD. Methods Whole blood and plasma thrombin generation assays were performed on blood samples from 25 SCD patients in a non-crisis 'steady state' and 25 healthy race-matched controls. Results Whole blood thrombin generation was significantly elevated in SCD, whereas plasma thrombin generation was paradoxically reduced compared with controls. Surprisingly, whole blood and plasma thrombin generation were both negatively correlated with phosphatidylserine exposure on RBCs. Plasma thrombin generation in the presence of exogenous activated protein C or soluble thrombomodulin revealed deficiencies in the protein C/S anticoagulant pathway in SCD. These global changes were associated with significantly lower plasma protein S activity in SCD that correlated inversely with RBC phosphatidylserine exposure. Conclusion Increased RBC phosphatidylserine exposure in SCD is associated with acquired protein S deficiency. In addition, these data suggest a cellular contribution to thrombin generation in SCD (other than RBC phosphatidylserine exposure) that explains the elevated thrombin generation in whole blood.

Proposed Staging System for Patients With HPV-Related Oropharyngeal Cancer Based on Nasopharyngeal Cancer N Categories

PURPOSE

Patients with human papillomavirus (HPV)-related oropharyngeal cancer (OPC) generally present with more advanced disease but have better survival than patients with HPV-unrelated OPC. The current American Joint Commission on Cancer (AJCC)/Union for International Cancer Control (UICC) TNM staging system for OPC was developed for HPV-unrelated OPC. A new staging system is needed to adequately predict outcomes of patients with HPV-related OPC.

PATIENTS AND METHODS

Patients with newly diagnosed HPV-positive OPC (by p16 immunohistochemistry or in situ hybridization) treated at our institution from January 2003 through December 2012 were included. By using recursive partitioning analysis (RPA), we developed new stage groupings with both traditional OPC regional lymph node (N) categories and nasopharyngeal carcinoma (NPC) N categories. Survival was estimated by the Kaplan-Meier method, and the relationship between stage and survival was examined by using Cox proportional hazards regression analysis.

RESULTS

A total of 661 patients with HPV-positive OPC met the inclusion criteria. With the traditional TNM staging system, there was no difference in survival between stages (P = .141). RPA with NPC N categories resulted in more balanced stage groups and better separation between groups for 5-year survival than RPA with traditional OPC N categories. With the stage groupings that were based in part on NPC N categories, the risk of death increased with increasing stage (P for trend < .001), and patients with stage III disease had five times the risk of death versus patients with stage IA disease.

CONCLUSION

New stage groupings that are based on primary tumor (T) categories and NPC N categories better separate patients with HPV-positive OPC with respect to survival than does the current AJCC/UICC TNM staging system. Although confirmation of our findings in other patient populations is needed, we propose consideration of NPC N categories as an alternative to the traditional OPC N categories in the new AJCC/UICC TNM staging system that is currently being developed.

Current evidence for endolymphatic sac surgery in the treatment of Meniere's disease: a systematic review

This paper aims to identify emerging evidence for endolymphatic sac surgery (ESS) in the treatment of Meniere's disease since the landmark study by Thomsen et al, published in 1998 (conducted from 1981 to 1989). Using the MEDLINE database (PubMed), a systematic review of the literature published from January 1990 to June 2014 was performed. We included all English-language, peer-reviewed randomised controlled trials (RCTs) and controlled studies. Single-arm cohort studies were included if the sample size was ≥ 90 with a response rate > 60%. Altogether, 11 studies fulfilled our inclusion criteria; one was an RCT, two were controlled trials and eight were single-arm cohort studies. There currently exists a low level of evidence for the use of ESS in the treatment of Meniere's disease. Further studies, in particular RCTs and/or controlled studies, are required to fully evaluate this modality. However, there are difficulties in designing a valid placebo and achieving adequate blinding of observers and investigators.

PM10 mass concentration and oxidative capacity of moxa smoke

BACKGROUND

The burning of moxa floss in moxibustion releases moxa smoke containing a substantial amount of particulate matter (PM10) into the environment, which has generated safety concerns about its potential health impact.

DESIGN

Plasmid scission assay was performed using PM10 collected from moxibustion clinics.

METHODS

PM10 was collected in winter 2012 by burning three types of moxa floss samples in moxibustion simulation clinics, and the resulting PM10 mass concentration was calculated. Oxidative capacity of the PM10 samples was measured by plasmid scission assay and the percentage of DNA damage at dosage 500 µg ml(-1) (D500) was calculated by linear regression analysis.

RESULTS

The average PM10 mass concentration of samples A (3 years and 3:1 ratio), B (3 years and 8:1 ratio) and C (10 years and 3:1 ratio) was 273.33, 172.22 and 168.89 μg/m(3), respectively. The D500 oxidative capacity of PM10 was on average 24.25%, 27.83% and 28.07% for samples A, B and C, respectively. No significant difference was found in the PM10-induced oxidative damage by moxa smoke produced from the three types of moxa floss.

CONCLUSIONS

PM10 mass concentrations from the three types of moxa floss combustion exceeded internationally recommended levels. Despite so, PM10 mass concentration of moxa smoke was much lower than biomass and coal combustion and similar to that of gas combustion. The oxidative DNA damage induced by individual PM10 in moxibustion environment was lower than that reported in other environments, indicating that moxibustion-derived PM10 might not be as injurious to human health as generally assumed.

The music listening preferences and habits of youths in Singapore and its relation to leisure noise-induced hearing loss

INTRODUCTION

Noise-induced hearing loss (NIHL) is a preventable condition, and much has been done to protect workers from it. However, thus far, little attention has been given to leisure NIHL. The purpose of this study is to determine the possible music listening preferences and habits among young people in Singapore that may put them at risk of developing leisure NIHL.

METHODS

In our study, the proportion of participants exposed to > 85 dBA for eight hours a day (time-weighted average) was calculated by taking into account the daily number of hours spent listening to music and by determining the average sound pressure level at which music was listened to.

RESULTS

A total of 1,928 students were recruited from Temasek Polytechnic, Singapore. Of which, 16.4% of participants listened to portable music players with a time-weighted average of > 85 dBA for 8 hours. On average, we found that male students were more likely to listen to music at louder volumes than female students (p < 0.001). We also found that the Malay students in our study listened to louder music than the Chinese students (p < 0.001).

CONCLUSION

We found that up to one in six young persons in Singapore is at risk of developing leisure NIHL from music delivered via earphones. As additional risks due to exposure to leisure noise from other sources was not taken into account, the extent of the problem of leisure NIHL may be even greater. There is a compelling need for an effective leisure noise prevention program among young people in Singapore.

Arthroscopic resection of The Distal Clavicle With Concomitant Subacromial Decompression: A Case Series

Shoulder impingement syndrome and acromioclavicular joint osteoarthritis often occur simultaneously and easily missed. Kay et al. reported excellent results with combined arthroscopic subacromial decompression and resection of the distal end of the clavicle in patients with both disorders¹. Arthroscopic treatment of these disorders produces more favourable results than open procedures. We report two patients who were not responding to conservative management and were treated with direct arthroscopic distal clavicle excision and subacromial decompression in single setting. Both patients gained good postoperative outcome in terms of pain score, function and strength improvement assessed objectively with visual analogue score (VAS) and University of California Los Angeles Score (UCLA).

Rituximab as first-line treatment for the management of adult patients with non-severe hemophilia A and inhibitors

BACKGROUND

The role of immunosuppression in the management of patients with congenital hemophilia and inhibitors is uncertain. The use of rituximab has been limited to case reports and case series. In most reports, rituximab was used as second-line or third-line treatment following failure of conventional immune tolerance induction therapy, and more commonly in pediatric patients.

OBJECTIVES

The objective of this study was to describe our experience with rituximab for the eradication of factor VIII inhibitors in adult patients with non-severe hemophilia A.

PATIENTS

We retrospectively reviewed the medical records of adult patients with non-severe hemophilia A and a diagnosis of FVIII inhibitor treated with rituximab (four weekly doses of 375 mg m(-2) ) as first-line treatment at our hemophilia center.

RESULTS

We identified nine consecutive adult patients with hemophilia A (moderate, n = 5; mild, n = 4) at our institution between 2000 and 2013, with a median age of 54 years (range, 24-77 years) at the time of inhibitor diagnosis. No patient received concomitant immune tolerance induction therapy. All nine patients had successful eradication of FVIII inhibitors. The median time from the first dose of rituximab to a clinical response was 95 days (range, 12-278 days). The median follow-up was 56 months (range, 13-139 months). Following inhibitor eradication, eight patients were rechallenged with FVIII concentrates. Two patients developed inhibitor recurrence associated with surgery.

CONCLUSION

This case series demonstrates that rituximab is a useful first-line treatment to achieve sustained inhibitor eradication in adult patients with non-severe hemophilia A.