Postmarket Modifications of High-Risk Therapeutic Devices in Otolaryngology Cleared by the US Food and Drug Administration

Objective:

The US Food and Drug Administration (FDA) grants initial marketing clearance for novel high-risk medical devices via the premarket approval (PMA) pathway, which requires clinical data demonstrating safety and effectiveness. Manufacturers may subsequently file supplemental PMA applications (supplements) to implement incremental device changes, usually without additional clinical data. Given the potentially significant clinical implications of using new device models, this study characterized the frequency and nature of changes to high-risk therapeutic otolaryngic devices cleared via the PMA pathway.

Study Design:

Retrospective cohort study.

Setting:

FDA PMA database.

Methods:

Original high-risk therapeutic otolaryngic devices and supplements were identified. Supplements were characterized by clearance date, change type, and review track, including real-time (design-minor) and 180-day (design-major) tracks. Median device lineage life span (postmarket period over which changes occurred) and median number of changes per original device were calculated.

Results:

Through 2014, the FDA cleared 14 original high-risk therapeutic otolaryngic devices via the PMA pathway and 528 incremental changes via supplements. Devices were modified over a median 10.5-year life span (interquartile range, 4.4-15.8; range, 0.7-24.1), and they underwent a median 22 changes (interquartile range, 10-70; range, 2-108). Over half (272 of 528; 52%) altered device design, most of which were reviewed via the 180-day track (199 of 272; 73%) intended for major design changes. Few real-time design changes (11 of 73; 15%) were designated by the FDA as “minor.”

Conclusion:

A substantial number of incremental changes have been made to high-risk therapeutic otolaryngic devices over time, including many major design changes without supporting clinical data.

Industry Ties in Otolaryngology

Objective

To characterize nonresearch payments made by industry to otolaryngologists in order to explore how the potential for conflicts of interests varies among otolaryngologists and compares between otolaryngologists and other surgical specialists.

Study Design

Retrospective cross-sectional database analysis.

Setting

Open Payments program database recently released by Centers for Medicare and Medicaid Services.

Subjects

Surgeons nationwide who were identified as receiving nonresearch payment from industry in accordance with the Physician Payment Sunshine Act.

Methods

The proportion of otolaryngologists receiving payment, the mean payment per otolaryngologist, and the standard deviation thereof were determined using the Open Payments database and compared to other surgical specialties. Otolaryngologists were further compared by specialization, census region, sponsor, and payment amount.

Results

Less than half of otolaryngologists (48.1%) were reported as receiving payments over the study period, the second smallest proportion among surgical specialties. Otolaryngologists received the lowest mean payment per compensated individual ($573) compared to other surgical specialties. Although otolaryngology had the smallest variance in payment among surgical specialties (SD, $2806), the distribution was skewed by top earners; the top 10% of earners accounted for 87% ($2,199,254) of all payment to otolaryngologists. Otolaryngologists in the West census region were less likely to receive payments (38.6%, P < .001).

Conclusion

Over the study period, otolaryngologists appeared to have more limited financial ties with industry compared to other surgeons, though variation exists within otolaryngology. Further refinement of the Open Payments database is needed to explore differences between otolaryngologists and leverage payment information as a tool for self-regulation.

Database and registry research in thyroid cancer: striving for a new and improved national thyroid cancer database

BACKGROUND

Health registries have become extremely powerful tools for cancer research. Unfortunately, certain details and the ability to adapt to new information are necessarily limited in current registries, and they cannot address many controversial issues in cancer management. This is of particular concern in differentiated thyroid cancer, which is rapidly increasing in incidence and has many unknowns related to optimal treatment and surveillance recommendations.

SUMMARY

In this study, we review different types of health registries used in cancer research in the United States, with a focus on their advantages and disadvantages as related to the study of thyroid cancer. This analysis includes population-based cancer registries, health systems-based cancer registries, and patient-based disease registries. It is important that clinicians understand the way data are collected in, as well as the composition of, these different registries in order to more critically interpret the clinical research that is conducted using that data. In an attempt to address shortcoming of current databases for thyroid cancer, we present the potential of an innovative web-based disease management tool for thyroid cancer called the Thyroid Cancer Care Collaborative (TCCC) to become a patient-based registry that can be used to evaluate and improve the quality of care delivered to patients with thyroid cancer as well as to answer questions that we have not been able to address with current databases and registries.

CONCLUSION

A cancer registry that follows a specific patient, is integrated into physician workflow, and collects data across different treatment sites and different payers does not exist in the current fragmented system of healthcare in the United States. The TCCC offers physicians who treat thyroid cancer numerous time-saving and quality improvement services, and could significantly improve patient care. With rapid adoption across the nation, the TCCC could become a new paradigm for database research in thyroid cancer to improve our understanding of thyroid cancer management.

Intrathyroidal tumors presenting with extranodal extension: what are we missing?

Extranodal extension (ENE) is an indicator of poor prognosis in well-differentiated thyroid cancer (WDTC). We have demonstrated that extrathyroidal extension (ETE) predicts ENE in patients with positive lymph nodes, indicating concordance between primary tumor and lymph node biology. In an effort to determine if there were other histologic features of the primary tumors that indicated an aggressive biology, we examined a subset of patients with intrathyroidal (T1/T2) disease whose lymph nodes had ENE. A review was conducted from January 2004 to March 2013. The histologic features of ETE-negative/ENE-positive tumors (group A, 12 cases) were compared with a random sample of ETE-negative/ENE-negative node-positive patients (group B, 27 cases). Cases were reviewed for size, capsule presence, infiltration, sclerosis, lymphocytic thyroiditis (LT), psammoma bodies, lymphovascular invasion (LVI), perineural invasion (PNI), architecture/cytomorphology, and focality. Size was compared using the Mann-Whitney test, while the remaining features were compared using a Fischer exact test. The breakdown of pathologic features of groups A/B were as follows: 2.28 cm/1.46 cm mean tumor size, 90 %/67 % unencapsulated, 100 %/89 % infiltrative, 100 %/89 % sclerotic, 60 %/52 % LT, 30 %/59 % positive psammoma bodies, 0 %/11 % LVI, 0 %/4 % PNI, 90 %/96 % classic architecture, 50 %/44 % multifocal. Neither size (p = 0.072) nor the other nine histologic features examined reached statistical significance. None of the histologic features appeared to significantly predict ENE. Further examination of intrathyroidal tumors at a molecular level is necessary to determine if there are any identifiable features of intrathyroidal tumors that predict ENE and thus a more aggressive phenotype.

Prevalence and clinical profiles of 'autoantibody-negative' systemic sclerosis subjects

OBJECTIVES

To determine the prevalence of autoantibody negative systemic sclerosis (SSc) and to identify the clinical correlates thereof.

METHODS

Clinical data and sera from 874 SSc subjects were collected and autoantibodies were tested in a central laboratory using 1) indirect immunofluorescence (IIF), 2) commercially available ELISA, addressable laser bead immunoassay (ALBIA), and line immunoassay (LIA), and 3) a sensitive immunoprecipitation (IP) assay.

RESULTS

Fifteen (15; 1.7%) subjects were autoantibody negative by IIF, ELISA, ALBIA, LIA and IP, and 16 (1.8%) were antinuclear antibody (ANA) positive by IIF but otherwise negative by ELISA, ALBIA, LIA and IP. Thirty-seven (37; 4.2%) were ANA positive by IIF, autoantibody negative by commercially available immunoassays, but had autoantibodies identified by IP (including Th/To in 20). Autoantibody-negative subjects had generally less severe disease than positive subjects.

CONCLUSIONS

Autoantibody-negative SSc is rare (<2%) and appears to be associated with a favourable prognosis.

IRF5rs2004640 single nucleotide polymorphism is associated with susceptibility to rheumatoid arthritis in South Indian Tamils

Polymorphism of interferon regulatory factor 5 (IRF5), a latent transcription factor gene has been associated with various auto-immune diseases. Our aim was to study the IRF5rs2004640 gene polymorphism and its association with disease susceptibility, disease phenotype and treatment response in South Indian Tamil patients with rheumatoid arthritis (RA).The study was conducted on 217 RA patients fulfilling the American College of Rheumatology (ACR) 2010 criteria and 482 healthy controls (HCs) without family history of autoimmune disease. The IRF5rs2004640 genotyping was performed using a TaqMan 5' allelic discrimination assay. We found that the IRF5rs2004640T allele [P < 0.0001, odds ratio (OR) 3.25, 95% confidence interval (CI) 2.55-4.12] and TT genotype (P < 0.0001, OR 4.60, 95% CI 3.23-6.57) were significantly more frequent in RA patients as compared with HCs. No association was found between IRF5rs2004640 polymorphism, clinical manifestations, autoantibody profile and treatment response. IRF5rs2004640 T (mutant) allele may be a susceptibility factor conferring risk for RA in South Indian Tamils, whereas G allele (wild type) may be protective.

What is the gold standard for comprehensive interinstitutional communication of perioperative information for thyroid cancer patients? A comparison of existing electronic health records with the current American Thyroid Association recommendations

BACKGROUND

Appropriate management of well-differentiated thyroid cancer requires treating clinicians to have access to critical elements of the patient's presentation, surgical management, postoperative course, and pathologic assessment. Electronic health records (EHRs) provide an effective method for the storage and transmission of patient information, although most commercially available EHRs are not intended to be disease-specific. In addition, there are significant challenges for the sharing of relevant clinical information when providers involved in the care of a patient with thyroid cancer are not connected by a common EHR. In 2012, the American Thyroid Association (ATA) defined the critical elements for optimal interclinician communication in a position paper entitled, "The Essential Elements of Interdisciplinary Communication of Perioperative Information for Patients Undergoing Thyroid Cancer Surgery."

SUMMARY

We present a field-by-field comparison of the ATA's essential elements as applied to three contemporary electronic reporting systems: the Thyroid Surgery e-Form from Memorial Sloan-Kettering Cancer Center (MSKCC), the Alberta WebSMR from the University of Calgary, and the Thyroid Cancer Care Collaborative (TCCC). The MSKCC e-form fulfills 21 of 32 intraoperative fields and includes an additional 14 fields not specifically mentioned in the ATA's report. The Alberta WebSMR fulfills 45 of 82 preoperative and intraoperative fields outlined by the ATA and includes 13 additional fields. The TCCC fulfills 117 of 120 fields outlined by the ATA and includes 23 additional fields.

CONCLUSIONS

Effective management of thyroid cancer is a highly collaborative, multidisciplinary effort. The patient information that factors into clinical decisions about thyroid cancer is complex. For these reasons, EHRs are particularly favorable for the management of patients with thyroid cancer. The MSKCC Thyroid Surgery e-Form, the Alberta WebSMR, and the TCCC each meet all of the general recommendations for effective reporting of the specific domains that they cover in the management of thyroid cancer, as recommended by the ATA. However, the TCCC format is the most comprehensive. The TCCC is a new Web-based disease-specific database to enhance communication of patient information between clinicians in a Health Insurance Portability and Accountability Act (HIPAA)-compliant manner. We believe the easy-to-use TCCC format will enhance clinician communication while providing portability of thyroid cancer information for patients.

Positive Surgical Margins in Early Stage Oral Cavity Cancer

Objective

To report the incidence of positive surgical margins in early oral cavity cancer and identify patient, tumor, and system factors associated with their occurrence.

Study Design and Setting

Retrospective analysis of the National Cancer Database.

Subjects and Methods

Patients diagnosed with stage I or II oral cavity squamous cell cancer between 1998 and 2011 were identified. Univariate and multivariate analyses of factors associated with positive margins were conducted.

Results

In total, 20,602 patients with early oral cancer were identified. Margin status was reported in 94.8% of cases, and positive margins occurred in 7.5% of those cases. Incidence of positive margins by institution varied from 0% to 43.8%, with median incidence of 7.1%. Positive margins were associated with clinical factors including stage II disease (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.55-1.98), intermediate grade (OR, 1.20; 95% CI, 1.04-1.37), high grade (OR, 1.68; 95% CI, 1.39-2.03), and floor of mouth (OR, 1.78; 95% CI, 1.52-2.08), buccal mucosa (OR, 2.06; 95% CI, 1.59-2.68), and retromolar locations (OR, 2.40; 95% CI, 1.85-3.11). Positive margins were also associated with treatment at nonacademic cancer centers (OR, 1.23; 95% CI, 1.04-1.44) and institutions with a low oral cancer case volume (OR, 1.45; 95% CI, 1.23-1.69).

Conclusion

Positive margins are associated with tumor factors, including stage, grade, and site, reflecting disease aggressiveness and difficulty of resection. Positive margins also are associated with factors such as treatment facility type, hospital case volume, and geographic region, suggesting potential variation in quality of care. Margin status may be a useful quality measure for early oral cavity cancer.

Noninvasive anaplastic thyroid carcinoma: report of a case and literature review

Anaplastic thyroid carcinoma (ATC) is an uncommon thyroid malignancy. Noninvasive ATC is a rare, surgically resectable variant with only four reported cases. We report a case of an 81-year-old man who presented with a 3.1 cm right thyroid lobe mass that on fine-needle aspiration biopsy was diagnosed as an ATC. Preoperative imaging revealed an encapsulated thyroid tumor without evidence of invasion of surrounding structures and no locoregional and distant metastases. A total thyroidectomy was performed that by histologic and immunohistochemical evaluation was diagnostic for a noninvasive ATC. Given the diagnosis of noninvasive ATC, adjuvant therapy was not administered. At 14 months following diagnosis, the patient remains disease free based on positron emission tomography/computed tomography imaging. A review of the outcomes of similar cases reported in the literature, as well as observations from our case, suggest a favorable prognosis for patients with noninvasive ATC. Noninvasive ATC may represent a distinct subset of resectable ATCs with an improved prognosis. The recently published American Thyroid Association (ATA) Guidelines for Management of Patients with ATC do not include this specific form of ATC. We encourage other authors to report similar cases in order to determine whether noninvasive ATC should be considered as a separate disease entity from the traditional highly lethal form of ATC.

The effect of surgeon experience on the detection of metastatic lymph nodes in the central compartment and the pathologic features of clinically unapparent metastatic lymph nodes: what are we missing when we don't perform a prophylactic dissection of central compartment lymph nodes in papillary thyroid cancer?

BACKGROUND

Prophylactic central neck dissection (PCND) for papillary thyroid cancer (PTC) is controversial. Recent publications suggest that the number and size of nodes and the presence of extranodal extension (ENE) are important features for risk stratification of lymph node metastases. We analyzed these features in clinically unapparent nodes that would not otherwise be removed. We also investigated the impact of surgeon experience on the ability to detect metastatic lymph nodes intraoperatively.

METHODS

Forty-seven patients with well-differentiated PTC, with no preoperative evidence of central metastases, were included in this study. Intraoperatively, clinically apparent disease was determined by inspection and palpation by the senior surgeon and a fellow/senior resident, and recorded in a blinded fashion. Rate of occult metastases based on intraoperative evaluation were tabulated for each group of surgeons. Histopathologic features of occult nodes were analyzed to determine what clinicians would be missing by foregoing a PCND, and how that would have impacted the patient management.

RESULTS

The rate of occult metastases, based on senior surgeon assessment, was 26%, and did not differ significantly from fellow/senior resident assessment. The level of agreement between these two surgeon groups was moderate (k=0.665). Analysis of the false negative cases revealed that the size of the largest undetected node ranged from 0.1 to 1.3 cm; 36% of patients with occult metastases demonstrated five or more positive nodes, and 27% showed ENE.

DISCUSSION

Clinical assessment based on intraoperative inspection and palpation had poor sensitivity and specificity in identifying metastatic central nodes, regardless of the level of experience of the surgeon. There was moderate agreement between surgeons of different experience levels. Sensitivity improved significantly with larger size of positive nodes, but not with the presence of multiple positive nodes or presence of ENE. In foregoing PCND in this patient population, our results suggest that treating clinicians miss potentially virulent disease with a large number of occult positive central nodes and occult nodes with ENE. This is the first report to address the pathologic features of clinically nonevident central nodes showing a high incidence of clinically relevant, adverse histologic features, as well as the impact of surgeon experience in performing the important intraoperative determination of whether there are clinically evident nodes that require removal.

Extrathyroidal extension predicts extranodal extension in patients with positive lymph nodes: an important association that may affect clinical management

BACKGROUND

While there is consensus that significant extrathyroidal extension (ETE) (T4) should upstage a patient with well-differentiated thyroid cancer, the importance of minimal ETE (T3) remains controversial. Additionally, the importance of nodal metastases on prognosis has come under scrutiny. Recent publications highlight the importance of size, number of positive nodes, and, in particular, the presence of extranodal extension (ENE) as measures of disease aggressiveness. In this study, we examined whether ETE is a predictor of ENE.

METHODS

A retrospective review was conducted from January 2004 to March 2013. All node-positive patients who underwent total or completion thyroidectomy were included. Histologic features defined by the College of American Pathologists (CAP) protocol for thyroid carcinoma were recorded.

RESULTS

A total of 193 patients qualified for review. Patients who were found to have ETE were 12 times more likely to have lymph nodes in the primary setting with ENE than patients with intrathyroidal primary tumors (p<0.000). After exclusion of all T4 cases (n=6), patients with minimal ETE were 13 times more likely to have ENE than those with no ETE (p<0.000). Twenty percent of microcarcinomas with ETE demonstrated ENE.

CONCLUSION

We have found that the biology of the primary tumor is conferred to the lymph node in that the presence of ETE leads to a significantly higher incidence of ENE. Awareness of this relationship should be accounted for in the management of primary and recurrent lymph nodes. This study shows that minimal ETE is a significant predictor of ENE. Although long-term survival and recurrence follow-up is not available for the majority of patients in this series, the presence of ENE as a surrogate for more aggressive disease biology and its strong association with minimal ETE supports the upstaging of patients with minimal ETE.

Improving the quality of thyroid cancer care: how does the Thyroid Cancer Care Collaborative cross the Institute of Medicine's Quality Chasm?

BACKGROUND

The current systems of healthcare delivery in the United States suffer from problems that often leave patients with inadequate quality of care. In their report entitled "Crossing the Quality Chasm," the Institute of Medicine (IOM) identified reasons for poor and/or inconsistent quality of healthcare delivery and provided recommendations to improve it. The purpose of this review is to describe features of an innovative web-based program called the Thyroid Cancer Care Collaborative (TCCC) and see how it addresses IOM recommendations to improve the quality of healthcare delivery.

SUMMARY

The TCCC addresses the three actionable IOM recommendations directed at healthcare organizations and clinicians to redesign the care process. It does so by exploiting information technology (IT) in ways suggested by the IOM, and it fits within a set of 10 rules provided by the IOM. Some features of the TCCC include: (i) automated disease staging based on three validated scoring systems; (ii) highly illustrated educational videos on all aspects of thyroid cancer care; (iii) personalized clinical decision-making modules for clinicians and physicians; (iv) portability of data to share among treating physicians; (v) virtual tumor boards, "ask the expert," and frequently asked questions modules; (vi) physician workflow integration; and (vii) data for comprehensive analysis to answer difficult questions in thyroid cancer management.

CONCLUSION

The TCCC has the potential to improve thyroid cancer care delivery and offers several benefits to patients, clinicians, and researchers. The TCCC is a valuable example of how IOM initiatives can improve the healthcare system.

Transtracheal approach to repair of a tracheo-colonic fistula 44 years after colonic interposition

BACKGROUND

We present a case report of a trachea-colonic fistula and demonstrate our unique approach to repair, which was efficient and effective.

METHODS

The patient was a 50-year-old man who had a congenital tracheoesophageal fistula repair with colonic interposition as a child who now developed a fistula between his colon and trachea.

RESULTS

We performed a transtracheal approach, with primary closure of redundant colon mucosa as well as direct repair of the trachea. An inferiorly based sternocleidomastoid muscle flap was interposed between these 2 layers to augment the repair. The patient had an uneventful recovery with an effective reconstitution of the alimentary tract and the airway.

CONCLUSION

Tracheo-colonic fistula is an extremely rare pathology, and the scarring that develops after a prior esophagectomy makes a traditional lateral approach very difficult. The transtracheal approach is an effective method to obtain needed exposure in order to carry out the repair.

Factors Predictive of Voice and Swallowing Outcomes after Anterior Approaches to the Cervical Spine

Objective

To quantify the incidence of postoperative voice, swallowing, and other problems, including time to resolution following anterior transcervical approaches to the cervical spine, and to assess surgical factors associated with outcomes.

Study Design

Historical cohort study.

Setting

Academic medical center.

Subjects and Methods

One hundred eighty-eight consecutive patients with cervical spine disease who underwent an anterior transcervical approach to the spine by a single head and neck surgeon over a 4-year time period. Rather than primary, single-level approaches, all patients in this study had multilevel, high-cervical (above C4), low-cervical (below C6), and/or revision approaches. Postoperative voice, swallowing, and other complaints were measured as well as time to resolution using Kaplan-Meier method. Surgical factors related to outcomes were analyzed using regression analysis.

Results

Follow-up was available for 129 patients, with average and median time of 35 months. Seventy-seven patients (60%) had a postoperative issue, including 35 patients (27%) with postoperative voice complaint, 62 patients (48%) with postoperative swallowing complaint, and 16 patients (12%) with other problems. Swallowing and voice complaints persisted beyond 1 year in 28% and 9% of patients, respectively. Approaching spinal levels above C4 and exposing more than 3 spinal levels were 2 factors significantly related to voice and swallowing problems.

Conclusion

There is a high incidence of subjective voice and swallowing complaints following transcervical anterior approaches to the spine, and such complaints can persist beyond 1 year in many patients. Exposure of more than 3 spinal levels or above level C4 are 2 factors significantly associated with outcome.