Integration of 3D-printed middle ear models and middle ear prostheses in otosurgical training

BACKGROUND

In otosurgical training, cadaveric temporal bones are primarily used to provide a realistic tactile experience. However, using cadaveric temporal bones is challenging due to their limited availability, high cost, and potential for infection. Utilizing current three-dimensional (3D) technologies could overcome the limitations associated with cadaveric bones. This study focused on how a 3D-printed middle ear model can be used in otosurgical training.

METHODS

A cadaveric temporal bone was imaged using microcomputed tomography (micro-CT) to generate a 3D model of the middle ear. The final model was printed from transparent photopolymers using a laser-based 3D printer (vat photopolymerization), yielding a 3D-printed phantom of the external ear canal and middle ear. The feasibility of this phantom for otosurgical training was evaluated through an ossiculoplasty simulation involving ten otosurgeons and ten otolaryngology-head and neck surgery (ORL-HNS) residents. The participants were tasked with drilling, scooping, and placing a 3D-printed partial ossicular replacement prosthesis (PORP). Following the simulation, a questionnaire was used to collect the participants' opinions and feedback.

RESULTS

A transparent photopolymer was deemed suitable for both the middle ear phantom and PORP. The printing procedure was precise, and the anatomical landmarks were recognizable. Based on the evaluations, the phantom had realistic maneuverability, although the haptic feedback during drilling and scooping received some criticism from ORL-HNS residents. Both otosurgeons and ORL-HNS residents were optimistic about the application of these 3D-printed models as training tools.

CONCLUSIONS

The 3D-printed middle ear phantom and PORP used in this study can be used for low-threshold training in the future. The integration of 3D-printed models in conventional otosurgical training holds significant promise.

Clinical decision making when cytology indicates a Warthin tumor

Warthin tumor (WT) is a benign tumor usually affecting the parotid gland. The main diagnostic tool remains ultrasound combined with fine-needle aspiration cytology (FNAC). This study aims to examine how reliably FNAC indicates WT for clinical decision making regarding surgical versus conservative management. We included all patients who underwent FNAC from a parotid gland lesion between 2016 and 2018 at our institution, and whose FNAC revealed WT suspicion. The FNACs were divided into three groups based on the cytology report: certain, likely, and possible WT. The patients were divided into two groups based on having had either surgery or follow-up. We sent a questionnaire to patients who had not undergone surgery in order to obtain follow-up for a minimum of four years. Altogether, 135 FNAC samples, from 133 tumors and 125 patients, showed signs of WT. Of the 125 patients, 44 (35%) underwent surgery, and 81 (65%) were managed conservatively. Preoperative misdiagnosis in FNAC occurred in three (7%) surgically treated tumors. Their FNACs were reported as possible WTs, but histopathology revealed another benign lesion. In the conservatively treated group, two patients underwent surgery later during the follow-up. Cytological statements of WT were seldom false, and none were malignant. The majority of the patients were only followed-up and rarely required further treatment. A certain or likely diagnosis of WT in the FNAC report by an experienced head and neck pathologist is highly reliable in selecting patients for conservative surveillance.

Six-month mortality has decreased for patients with curative treatment intent for head and neck cancer in Sweden

BACKGROUND

In general, survival outcomes for patients with Head and Neck Cancer (HNC) has improved over recent decades. However, mortality within six months after diagnosis for curative patients remains at approximately 5%. The aim of this study was to identify risk factors for early death among patients with curative treatment, and furthermore, to analyze whether the risk of early death changed over recent years.

MATERIAL AND METHOD

This real-world, population-based, nationwide study from the Swedish Head and Neck Cancer Register (SweHNCR) included all patients ≥18 years diagnosed with HNC with a curative treatment intent at the multidisciplinary tumor board from 2008 to 2020. A total of 16,786 patients were included.

RESULTS

During the study period a total of 618 (3.7%) patients with curative-intended treatment died within six months of diagnosis. Patients diagnosed between 2008 and 2012 had a six-month mortality rate of 4.7% compared to 2.5% for patients diagnosed between 2017 and 2020, indicating a risk reduction of 53% (p <0.001) for death within six months. The mean time to radiation therapy from diagnosis in the 2008-2012 cohort was 38 days, compared to 22 days for the 2017-2020 cohort, (p <0.001). The mean time to surgery from diagnosis was 22 days in 2008-2012, compared to 15 days for the 2017-2020 cohort, (p <0.001). Females had a 20% lower risk of dying within six months compared to males (p = 0.013). For every year older the patient was at diagnosis, a 4.8% (p <0.001) higher risk of dying within six months was observed. Patients with a WHO score of 1 had approximately 2.4-times greater risk of early death compared to WHO 0 patients (p <0.001). The risk of early death among WHO 4 patients was almost 28 times higher than for WHO 0 patients (p <0.001). Patients with a hypopharyngeal tumor site had a 2.5-fold higher risk of dying within six months from diagnosis compared to oropharyngeal tumor patients (p <0.001).

CONCLUSIONS

We found that the risk of early death decreased significantly from 2008 to 2020. During this period, the mean time to the start of treatment was significantly reduced both for surgery and oncological treatment regimes. Among patients with a curative treatment intention, increased risk of early death was associated with male sex, older age, advanced disease, increased WHO score, and a hypopharyngeal tumor site.

IGSF3 tissue expression in squamous cell carcinoma of the oropharynx: a novel tool for prognosis assessment in HPV-related and HPV-unrelated disease

Biomarkers are not broadly used in the management of head and neck cancers (HNCs). Biomarkers have been beneficial in the management of other cancers, however, not in HNCs. Therefore, we observed the immunopositivity of a novel biomarker called immunoglobulin superfamily member 3 (IGSF3) in tumor tissues in HPV-related and HPV-unrelated OPSCC. Two patient cohorts (C1 and C2) from separate time periods were available for this study (total N = 282). Both consisted of OPSCC patients treated at the Helsinki University Hospital (HUS, Helsinki, Finland) during 2000-2016. For HPV determination, HPV mRNA in situ hybridization was used. Immunohistochemistry was used to assess IGSF3 immunopositivity in cancer tissues. Overall survival (OS) was used as endpoint in the statistical analysis. In C1, stronger immunopositivity of IGSF3 in tumor-infiltrating lymphocytes (TILs) correlated with favorable OS (p = 0.005). Stronger IGSF3 immunopositivity in tumor cells (TCs) was associated with HPV negativity (p = 0.017). Stronger IGSF3 immunopositivity in TILs correlated with HPV positivity (p < 0.001). Elevated IGSF3 immunopositivity in TILs associates with HPV-related tumors and may signify favorable prognosis. The immunopositivity of IGSF3 differs between HPV-related and HPV-unrelated OPSCC.

Pretreatment fat-free mass index correlates with early death in patients with head and neck squamous cell carcinoma

BACKGROUND

A significant proportion of patients with head and neck squamous cell carcinoma (HNSCC) are malnourished at diagnosis. In this study, we investigated how pretreatment body mass index (BMI) and fat-free mass index (FFMI) correlate with early death, and whether these measurements are useful markers of prognosis for risk stratification of head and neck cancer patients.

METHODS

Patients (n = 404) with newly diagnosed, curable HNSCC and WHO performance status 0-2 were prospectively included and met with a study representative before treatment initiation, as well as up to four follow-up visits. All patients provided an estimate of body weight at 6 months prior to diagnosis. Bioelectrical impedance analysis (BIA) was performed for all patients before treatment initiation.

RESULTS

Most patients had oropharyngeal (46%), oral cavity (28%), or laryngeal cancer (12%). Forty-five (11%) patients met the standardized criteria for malnutrition according to the Global Leadership Initiative on Malnutrition (GLIM) at diagnosis. FFMI at diagnosis was lower in patients who died within 6 and 12 months after the start of treatment than in patients who survived these time points (p = 0.035 and p = 0.005, respectively).

CONCLUSIONS

In this study, pretreatment FFMI was an independent prognostic factor for death within 6 and 12 months after the start of treatment in patients with HNSCC. Pretreatment BMI was not an independent risk factor for death within 6 and 12 months after treatment termination. Thus, FFMI may be useful for risk stratification of patients with head and neck cancer.

Reasons for failure of mandibular advancement splint therapy in the treatment of obstructive sleep apnea

Objective: To investigate the reasons for poor adaptation to mandibular advancement splint (MAS) treatment.Methods: The study consisted of 44 patients with obstructive sleep apnea who had unsuccessful MAS treatment. Data were collected on age, body mass index, gender, general and mental diseases, continuous positive airway pressure (CPAP) tryout, usage of occlusal splint, dental overjet, temporomandibular disorders, shortened dental arch, sleep apnea severity, and Apnea-Hypopnea Index. Sixty patients who underwent successful MAS treatment were controls.Results: Patients with missing molars failed significantly more often in MAS therapy than the controls (p = 0.020). Patients with CPAP tryout prior to MAS treatment had a tendency to fail MAS treatment. MAS treatment was more likely to be successful in patients with prior occlusal splint experience (p = 0.050).Conclusion: The study could not identify a single reason for MAS failure.

Endoscopic management of sinonasal tumours in the Nordic university hospitals: a survey

PURPOSE

The Nordic countries (27 M) all have comparable, publicly funded healthcare systems, and the management of sinonasal tumours is centralised to the 21 university hospitals. We sought to assess and compare the treatment practice of sinonasal tumours across the Nordic countries.

METHODS

A web-based questionnaire was sent to all university hospital departments of otorhinolaryngology-head and neck surgery in the Nordic countries.

RESULTS

Answers were obtained from all 21 Nordic university hospitals. The endoscopic approach was widely utilised by all, with most (62%) centres reporting 3-4 surgeons performing endoscopic sinonasal tumour surgery. Finland reported the lowest rates of centralisation among university hospitals despite having the highest number of 0.1-1 M catchment population hospitals. Most centres (88%) opted for the endoscopic approach in a patient case warranting medial maxillectomy. In a case of a Kadish C esthesioneuroblastoma, most (52%) of the centres preferred an endoscopic approach. Most centres (62%) reported favouring the endoscopic approach in a case describing a juvenile angiofibroma. Regarding a case describing a sinonasal undifferentiated carcinoma, consensus was tied (38% vs. 38%) between endoscopic resection followed by postoperative (chemo)radiotherapy (RT/CRT) and induction chemotherapy followed by RT/CRT or surgery followed by RT/CRT.

CONCLUSION

Endoscopic approach was widely utilised in the Nordic countries. The case-based replies showed differences in treatment practice, both internationally and nationally. The rate of centralisation among university hospitals remains relatively low, despite the rarity of these tumours.

Enhanced recovery after surgery (ERAS) protocol improves patient outcomes in free flap surgery for head and neck cancer

BACKGROUND

In recent years, enhanced recovery after surgery (ERAS) guidelines have been developed to optimize pre-, intra-, and postoperative care of surgical oncology patients. The aim of this study was to compare management outcome of patients undergoing head and neck cancer (HNC) surgery with free flap reconstruction at our institution before and after the implementation of the ERAS guidelines.

METHODS

This retrospective study comprised 283 patients undergoing HNC surgery with free flap reconstruction between 2013 and 2020. Patients operated before and after the implementation of the ERAS protocol in October 2017 formed the pre-ERAS group (n = 169), and ERAS group (n = 114), respectively.

RESULTS

In the pre-ERAS group the mean length of stay (LOS) and intensive care unit length of the stay (ICU-LOS) were 20 days (range 7-79) and 6 days (range 1-32), and in the ERAS group 13 days (range 3-70) and 5 days (range 1-24), respectively. Both LOS (p < 0.001) and ICU-LOS (p = 0.042) were significantly reduced in the ERAS group compared to the pre-ERAS group. There were significantly fewer medical complications in the ERAS group (p < 0.003). No difference was found between the study groups in the surgical complication rate or in the 30-day or 6-month mortality rate after surgery.

CONCLUSIONS

We found reduced LOS, ICU-LOS, and medical complication rate, but no effect on the surgical complication rate after implementation of the ERAS guidelines, which supports their use in major HNC surgery.

Occupational variation in incidence of oropharyngeal cancer in the Nordic countries

PURPOSE

Evaluate the occupational variation in incidence of oropharyngeal cancer (OPC).

METHODS

We calculated standardized incidence ratios (SIRs) of OPC in occupational categories in the Nordic countries relative to the entire national populations. The data covered 6155 OPC cases.

RESULTS

Among men high risk of OPC was observed, among else, in waiters (SIR 6.28, 95% CI 4.68-8.26), beverage workers (SIR 3.00, 95% CI 1.72-4.88), and artistic workers (SIR 2.97, 95% CI 2.31-3.76). Among women high risk of OPC was observed in waiters (SIR 2.02, 95% CI 1.41-2.81) and packers (SIR 1.73, 95% CI 1.07-2.64). The lowest SIRs were observed in female gardeners (SIR 0.27, 95% CI 0.12-0.51) and male farmers (SIR 0.30, 95% CI 0.25-0.35).

CONCLUSION

The 20-fold variation in incidence of OPC between occupations needs further investigation in studies with detailed information on occupational and non-occupational risk factors.

Altered microheterogeneity at several N-glycosylation sites in OPSCC in constant protein expression conditions

Protein glycosylation responds sensitively to disease states. It is implicated in every hallmark of cancer and has recently started to be considered as a hallmark itself. Changes in N-glycosylation microheterogeneity are more dramatic than those of protein expression due to the non-template nature of protein glycosylation. This enables their potential use in serum-based diagnostics. Here, we perform glycopeptidomics on serum from patients with oropharyngeal squamous cell carcinoma (OPSCC), compared to controls and comparing between cancers based on etiology (human papilloma virus- positive or negative). Using MS2, we then targeted glycoforms, significantly different between the groups, to identify their glycopeptide compositions. Simultaneously we investigate the same serum proteins, comparing whether N-glycosylation changes reflect protein-level changes. Significant glycoforms were identified from proteins such as alpha-1-antitrypsin (SERPINA1), haptoglobin, and different immunoglobulins. SERPINA1 had glycovariance at 2 N-glycosylation sites, that were up to 35 times more abundant in even early-stage OPSCCs, despite minimal differences between SERPINA1 protein levels between groups. Some identified glycoforms' fold changes (FCs) were in line with serum protein level FCs, others were less abundant in early-stage cancers but with great variance in higher-stage cancers, such as on immunoglobulin heavy constant gamma 2, despite no change in protein levels. Such findings indicate that glycovariant analysis might be more beneficial than proteomic analysis, which is yet to be fruitful in the search for biomarkers. Highly sensitive glycopeptide changes could potentially be used in the future for cancer screening. Additionally, characterizing the glycopeptide changes in OPSCC is valuable in the search for potential therapeutic targets.

Induction of Collagenolytic MMP-8 and -9 Tissue Destruction Cascade in Mouth by Head and Neck Cancer Radiotherapy: A Cohort Study

The effect of head and neck cancer (HNC) radiotherapy (RT) on biomarkers is not known but there is a lot of potential for gaining more precise cancer treatments and less side effects. This cohort study investigated the levels and molecular forms of the matrix metalloproteinase (MMP) -8 and -9, tissue inhibitor of metalloproteinase (TIMP)-1, myeloperoxidase (MPO) and interleukin (IL)-6 in mouth-rinse samples as well as the clinical periodontal status in HNC patients (n = 21) receiving RT. Complete periodontal examinations were performed pre-RT and one month after RT. Mouth-rinse samples (pre-RT, after six weeks of RT and one month after RT) were assayed using a point-of-care-kit (PerioSafe®/ORALyzer® (Dentognostics GmbH, Jena, Germany)) for active MMP-8 and ELISA analysis for total MMP-8 and -9, MPO, TIMP-1, and IL-6 levels. Molecular forms of MMP-9 were assessed by gelatinolytic zymography and MMP-8 by western immunoblot. Significant changes were observed between the three time points in the mean levels of active and total MMP-8, active MMP-9, and IL-6. Their levels increased during the RT and decreased after the RT period. The aMMP-8 levels stayed elevated even one month after RT compared to the pre-RT. Clinical attachment loss, probing depths, and bleeding on probing were increased between pre- and post-calculations in periodontal status. Elevated inflammatory biomarker levels together with clinical recordings strongly suggest that RT eventually increases the risk to the periodontal tissue destruction by inducing the active proteolytical MMP-cascade, and especially by prolonged activity of collagenolytic aMMP-8. Eventually, the aMMP-8 point-of-care mouth-rinse test could be an easy, early detection tool for estimating the risk for periodontal damage by the destructive MMP-cascade in HNC patients with RT treatment.

Costs of oropharyngeal squamous cell cancer treatment in Finland

BACKGROUND

Oropharyngeal squamous cell carcinoma (OPSCC) can be treated with definitive (chemo)radiotherapy ((C)RT) or primary surgical treatment (PST) with or without postoperative oncologic treatment. The prognosis of OPSCC does not essentially depend on the treatment modality, which allows to consider secondary decision-making aspects such as treatment costs when recommending an individual treatment modality. We attempted to analyze the costs associated with definitive (C)RT and PST in the treatment of OPSCC in Finland.

MATERIALS AND METHODS

We included 73 patients diagnosed with OPSCC at the Helsinki University Hospital (HUS) (Helsinki, Finland) in 2019 and 2020. Treatment costs were defined as the costs incurred in the specialized medical care during the first 12 months after the diagnosis was established.

RESULTS

Definitive RT and definitive CRT were on a 1-year horizon associated with median costs of approximately 10 700€ and 13 300€, respectively; while, the median costs of PST equaled about 40 600€. The costs of definitive (C)RT mostly consisted of the costs of (chemo)radiotherapy sessions; while, the operating room costs and the costs of intensive care and stay on a ward drove the costs of PST.

CONCLUSIONS

PST is associated with 2-3 times higher median costs than definitive (C)RT in Finland. The finding differs from the results previously reported in North America, which is related, e.g., to differences in the treatment practices as well as in the regulation of the health care systems.

Bioelectrical Impedance Analysis (BIA) for the Assessment of Body Composition in Oncology: A Scoping Review

Bioelectrical Impedance Analysis (BIA) is a reliable, non-invasive, objective, and cost-effective body composition assessment method, with high reproducibility. This scoping review aims to evaluate the current scientific and clinical evidence on BIA for body composition assessment in oncology patients, under active treatment. Literature search was conducted through MEDLINE, CINAHL, Scopus and Web of Science databases, following PRISMA-ScR Guidelines. Inclusion criteria comprised studies reporting the use of BIA for body composition evaluation in adults with cancer diagnosis. Studies including non-cancer pathology or only assessing nutritional status were excluded. This scoping review comprised a total of 36 studies: 25 were original studies including 18 prospective studies, six cross-sectional studies and one retrospective study and 11 were systematic reviews. Population size for the included original articles ranged from 18 to 1217 participants, comprising a total of 3015 patients with cancer with a mean baseline Body Mass Index (BMI) ranging from 20.3 to 30.0 kg/m2 and mean age ranging between 47 and 70 years. Review articles included a total of 273 studies, with a total of 78,350 participants. The current review considered studies reporting patients with head and neck cancer (HNC) (n = 8), breast cancer (BC) (n = 4), esophageal cancer (EC) (n = 2), liver cancer (n = 2), pancreatic cancer (PC) (n = 3), gastric cancer (GC) (n = 3), colorectal cancer (CRC) (n = 8), lung cancer (LC) (n = 1), skin cancer (SK) (n = 1) and multiple cancer types (n = 6). BIA is a suitable and valid method for the assessment of body composition in oncology. BIA-derived measures have shown good potential and relevant clinical value in preoperative risk evaluation, in the reduction of postoperative complications and hospital stay and as an important prognostic indicator in persons with cancer. Future research on the diagnostic value and clinical applications of BIA and BIA-derived phase angle (PhA) should be conducted in order to predict its impact on patient survival and other clinical outcomes.

Occupational Etiology of Oropharyngeal Cancer: A Literature Review

While abundant evidence exists linking alcohol, tobacco, and HPV infection to a carcinogenic impact on the oropharynx, the contribution of inhalational workplace hazards remains ill-defined. We aim to determine whether the literature reveals occupational environments at a higher-than-average risk of developing oropharyngeal cancer (OPC) and summarize the available data. To identify studies assessing the relationship between occupational exposure and risk of OPC, a search of the literature through the PubMed-NCBI database was carried out and, ultimately, 15 original articles meeting eligibility criteria were selected. Only original articles in English focusing on the association between occupational exposure and risk or death of specifically OPC were included. The available data are supportive of a potentially increased risk of OPC in waiters, cooks and stewards, artistic workers, poultry and meat workers, mechanics, and World Trade Center responders exposed to dust. However, the available literature on occupation-related OPC is limited. To identify occupational categories at risk, large cohorts with long follow-ups are needed. Identification of causal associations with occupation-related factors would require dose-response analyses adequately adjusted for confounders.

Progress and emerging strategies to preserve function in the treatment of sinonasal cancer

The sinonasal structures and their adjacent organs host several functions including vision, olfaction, nasal respiration and filtration, secretory immunity, facial expression, articulation, and oral deglutition. We reviewed the current evidence supporting functional preservation in sinonasal cancer treatment. Primary surgery with or without adjuvant modalities continues to be the standard of care for sinonasal cancer. Unfortunately, functional compromise remains a dominant negative feature of this approach. More recently, through advances in therapeutic techniques and improved understanding of the relevant tumor biology, treatments aimed at preserving function and cosmesis are emerging. The evidence for such progress involving minimal access surgery, surgical reconstruction for rehabilitation, new techniques in radiation therapy, inclusion of systemic and locally enhanced chemotherapy, and therapeutic agents based on molecular targets are highlighted. This multi-prong approach bodes well for future patients with sinonasal cancer to undergo successful treatment that includes maximal preservation of associated functions.

Cancer incidence among visual artists: 45 years of follow-up in four Nordic countries

INTRODUCTION

Professional visual artists constitute a heterogeneous vocational group, including, but not limited to painters, photographers, textile artists, and sculptors who may face exposure to workplace hazardous substances and lifestyle factors that may contribute to the development of selected cancers. The objective of this registry-based cohort study was to assess the cancer incidence among Nordic visual artists.

MATERIALS AND METHODS

This study is based on data from the Nordic Occupational Cancer (NOCCA) project that combines census data of 15 million people from all Nordic countries and cancer registries from 1961 to 2005. For the present study we selected a cohort of visual artists from Finland, Iceland, Norway, and Sweden. Standardized incidence ratio (SIR) analyses were conducted with the cancer incidence rates for the entire national study populations used as reference rates.

RESULTS

In male visual artists, there were statistically significant excesses in cancers of the tongue (SIR 2.91, 95% confidence interval 1.74-4.55), oral cavity (2.09, 1.26-3.27), pharynx (2.18, 1.45--3.15), testis (1.91, 1.11-3.05), renal pelvis (2.48, 1.42-4.03) and bladder (1.33, 1.14-1.55). The risk was significantly decreased for cancers of the lip (0.45, 0.18-0.93) and stomach (0.65, 0.50-0.84). In female visual artists, the only significantly increased risk was observed for breast cancer (1.29, 1.13-1.48) and the only significantly decreased risk for stomach cancer (0.43, 0.17-0.88). The incidence of lung cancer was close to the population average in both sexes.

CONCLUSIONS

The non-elevated incidence of lung cancer suggests a similar prevalence of smoking between visual artists and the general population, while the elevated risk of cancers of mouth and pharynx among male visual artists is suggestive of more widespread alcohol drinking. The excess risk of urogenital cancers might be associated with exposure to solvents.

Time to act! - A cross-sectional study on how nutritional risk increases during hospitalization and associates with worse outcome

BACKGROUND & AIMS

Nutritional risk is prevalent, and it develops negatively during hospital stay. The aim of this cohort study was to assess the association of nutritional risk with total costs of hospital care, length of stay, and in-hospital mortality.

METHODS

Cross-sectional study with hospitalized patients (n = 3053). Nutritional risk screening 2002 and outcome were investigated. Chi-square, Fisher, and Mann-Whitney tests, univariable and multivariable generalized linear and binary logistic regression models were used.

RESULTS

Nutritional risk was detected in 18% (184/1024) of those patients assessed at admission while the number of patients at risk increased 3-fold (47%,152/265) in those screened 14 days after admission (odds ratio 6.25; 95% CI 4.58-8.53, p < 0.001). Nutritionally at-risk patients had 5.6 days longer length of stay (p < 0.001) and 9% higher adjusted total costs compared with non-risk patients (p < 0.001). Adjusted overall risk for in-hospital mortality was 4.4 (95% CI 2.44-7.92, p < 0.001) for patients at nutritional risk. The screening rate was between 52% and 68%, and only 4% of the nutritionally at-risk patients had dietitian consultation during their hospital stay.

CONCLUSIONS

The number of patients with nutritional risk increased clearly during hospitalization associating with a four times higher in-hospital mortality and substantially increased hospital costs. The results demonstrate that the nutritional risk and its detrimental influence on the outcome increases during hospitalization emphasizing the importance to screen patients at admission and repeated weekly.

Significant risk of second primary cancer among laryngeal squamous cell carcinoma patients even after 20 years

BACKGROUND

Evidence on the risk of second primary cancer (SPC) following primary laryngeal squamous cell carcinoma (LSCC) is limited, especially in Europe.

METHODS

Patients diagnosed with primary LSCC from 1953-2018 were retrieved from the Finnish Cancer Registry. A total of 6241 LSCC patients were identified adding to 49,393 person-years (PY) of follow-up until the end of 2019. Only one patient emigrated and was lost to follow-up. Both standardized incidence ratios (SIR) and excess absolute risk (EAR) per 1000 person-years at risk (PYR) of second primary cancer (SPC) were calculated relative to the general population. Only non-laryngeal SPCs diagnosed six months after diagnosis of primary LSCC were included.

RESULTS

A SPC was diagnosed in 1244 LSCC patients (20% of all LSCC patients) over the 65-year period, predominantly in men (92%, n = 1170). Out of all SPCs, 34% were diagnosed within 0.5 to 5 years and 66% after 5 years from primary LSCC. Among male patients, the overall SIR for SPC at any location was 1.61 (95% CI: 1.52-1.71), corresponding to 9.49 excess SPCs per 1000 PYR (95% CI: 8.19-11). The corresponding SIR for women was 1.47 (95% CI: 1.15-1.84), yielding 4.82 excess SPCs per 1000 PYR (95% CI: 2.36-9.84). The risk remained significant even after 20 years of follow-up (SIR for all 1.73, 95% CI: 1.49-2.01 and EAR 16.8 per 1000 PY, 11.88-23.75). The risk for SPC was also significantly elevated in all age groups, except <40. The highest SIRs were for SPCs arising in the mouth/pharynx (SIR for all 3.08, 95% CI: 2.36-3.95 and EAR 0.80 per 1000 PY, 0.55-1.15) and lungs (3.02, 2.75-3.30 and 5.90 per 1000, 5.13-6.78).

CONCLUSION

Patients with LSCC as primary cancer have a 60% excess risk for an SPC, especially for tobacco-associated cancers, remaining significantly elevated even decades after treatment.

Automated Sarcopenia Assessment and Outcomes in Head and Neck Cancer with Deep Learning Analysis of Cervical Neck Skeletal Muscle

PURPOSE/OBJECTIVE(S)

Sarcopenia is an established prognostic factor in patients diagnosed with head and neck cancers (HNC), typically measured by the skeletal muscle index (SMI) from abdominal muscle mass at L3. While sarcopenia assessment could inform HNC management, it remains impractical, time- and labor-intensive, and operator-dependent. To overcome these challenges, we developed an automated deep learning (DL) platform to calculate SMI at L3 by quantifying cross-sectional cervical skeletal muscle area (SMA) at C3 through auto-segmentation, externally validated it, and evaluated associations with clinical outcomes.

MATERIALS/METHODS

Eight hundred twenty-one patients diagnosed with HNC from multiple institutes from 1999-2013, treated with definitive chemoradiation with baseline pre-treatment CT scans, were included for model development (335 training, 96 tuning) and for independent testing (48 internal, and 342 external). Ground truth single-slice segmentations of SM at the mid-C3 vertebral level were manually annotated by radiation oncologists using an established protocol. A multi-stage DL pipeline was developed, with a 2D DenseNet to select the middle slice of C3 section and a 2D UNet to segment the SM, from which SMA was calculated. The model was evaluated using the Dice Similarity Coefficient (DC) for the internal test set, and human acceptability testing on the external test set was performed by two radiation oncologists not involved in annotations. SMI was calculated from C3 SMA based on prior literature, and sarcopenia was defined by an established, sex-specific SMI cutoff. Sarcopenia associations with overall survival (OS) and toxicities were assessed on the external dataset with Cox and logistic multivariable regressions, as indicated.

RESULTS

Model DC on the internal test set as 0.90 [95% CI: 0.90-0.91], with an intra-class coefficient of 0.96 for SMA. Human acceptability testing showed a pass rate of 94.4%. Of the 342 patients in the clinical analysis, 261 (76.3%) patients had sarcopenia. Five-year survival was 84.4% in patients without sarcopenia vs 73.1% in patients with sarcopenia (HR 2.21, p = 0.028) (median f/u: 44 mo (IQR: 25 - 66 mo)). On multivariable regression, sarcopenia (HR 2.06, p = 0.037), ACE-27 score 2+ (HR 2.25, p = 0.001), non-oropharynx diagnosis (HR 3.96, p<0.001), and T3-4 stage (HR 2.37, p<0.001) were associated with worse OS. Sarcopenia was associated with longer PEG tube duration on multivariable analysis (HR 1.59, p = 0.003), along with ACE-27 score (HR 1.20, p = 0.012) and non-oropharynx primary site (HR 1.46, p = 0.034). Sarcopenia was associated with higher risk of having PEG tube at last follow up (OR 2.25, p = 0.046). An observed increase in risk of hospitalization <3 months after RT was non-significant (OR 2.18, p = 0.117).

CONCLUSION

We developed and externally validated a fully-automated platform for sarcopenia assessment that can be used on routine HNC imaging. This algorithm is positioned for prospective testing to determine if use will inform HNC management.

Pharyngeal Reconstruction Methods to Reduce the Risk of Pharyngocutaneous Fistula After Primary Total Laryngectomy: A Scoping Review

INTRODUCTION

The most common early postoperative complication after total laryngectomy (TL) is pharyngocutaneous fistula (PCF). Rates of PCF are higher in patients who undergo salvage TL compared with primary TL. Published meta-analyses include heterogeneous studies making the conclusions difficult to interpret. The objectives of this scoping review were to explore the reconstructive techniques potentially available for primary TL and to clarify which could be the best technique for each clinical scenario.

METHODS

A list of available reconstructive techniques for primary TL was built and the potential comparisons between techniques were identified. A PubMed literature search was performed from inception to August 2022. Only case-control, comparative cohort, or randomized controlled trial (RCT) studies were included.

RESULTS

A meta-analysis of seven original studies showed a PCF risk difference (RD) of 14% (95% CI 8-20%) favoring stapler closure over manual suture. In a meta-analysis of 12 studies, we could not find statistically significant differences in PCF risk between primary vertical suture and T-shaped suture. Evidence for other pharyngeal closure alternatives is scarce.

CONCLUSION

We could not identify differences in the rate of PCF between continuous and T-shape suture configuration. Stapler closure seems to be followed by a lower rate of PCF than manual suture in those patients that are good candidates for this technique.

Liprin-α1 Expression in Tumor-Infiltrating Lymphocytes Associates with Improved Survival in Patients with HPV-Positive Oropharyngeal Squamous Cell Carcinoma

BACKGROUND

Liprin-α1 is a scaffold protein involved in cell adhesion, motility, and invasion in malignancies. Liprin-α1 inhibits the expression of metastatic suppressor CD82 in cancers such as oral carcinoma, and the expression of these proteins has been known to correlate negatively. The role of these proteins has not been previously studied in human papillomavirus (HPV)-related head and neck cancers. Our aim was to assess the clinical and prognostic role of liprin-α1 and CD82 in HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) in comparison to HPV-negative OPSCC.

METHODS

The data included 139 OPSCC patients treated at the Helsinki University Hospital (HUS) during 2012-2016. Immunohistochemistry was utilized in HPV determination and in biomarker assays. Overall survival (OS) was used in the survival analysis.

RESULTS

Stronger expression of liprin-α1 in tumor-infiltrating lymphocytes (TILs) was linked to lower cancer stage (p < 0.001) and HPV positivity (p < 0.001). Additionally, we found an association between elevated expression of liprin-α1 and weak expression of CD82 in tumor cells (p = 0.029). In survival analysis, we found significant correlation between favorable OS and stronger expression of liprin-α1 in TILs among the whole patient cohort (p < 0.001) and among HPV-positive patients (p = 0.042).

CONCLUSIONS

Increased liprin-α1 expression in the TILs is associated with favorable prognosis in OPSCC, especially among HPV-positive patients.

Occupational variation in the incidence of lip cancer in the Nordic countries

INTRODUCTION

While certain occupations, such as agriculture and fishery, have been associated with an increased risk of lip cancer, the occupational risk profile of lip cancer and its change over time remain poorly known. This study aims to evaluate the incidence of lip cancer across different occupations in the Nordic countries.

METHODS

The Nordic Occupational Cancer Study (NOCCA) covers 14.9 million people and includes 45 years of cancer incidence data, from 1961 to 2005, linked to occupational categories for all the five Nordic populations. Standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) were used to quantify the risk of lip cancer across occupational categories relative to the entire national populations.

RESULTS

There were a total of 14,477 male and 3008 female lip cancer patients identified during follow up. The highest SIRs were observed among male fishermen (SIR 2.26, 95% CI: 2.04-2.50), gardeners (SIR 1.60, 95% CI: 1.48-1.72), and farmers (SIR 1.60, 95% CI: 1.55-1.66). A significantly reduced risk of lip cancer (SIR < 0.50) was observed among male physicians, teachers, religious workers, artistic workers, journalists, administrators, printers, waiters, and hairdressers. Among women, no occupations were associated with an increased risk of lip cancer.

CONCLUSIONS

The incidence of lip cancer varies widely between outdoor and indoor occupations. Occupations involving outdoor activity and exposure to sunlight show the most elevated SIRs.

Multiple genetic variants involved in both autoimmunity and autoinflammation detected in Chinese patients with sporadic Meniere's disease: a preliminary study

Background

The mechanisms of Meniere's disease (MD) remain largely unknown. The purpose of this study was to identify possible genetic variants associated with immune regulation in MD.

Methods

The whole immune genome of 16 Chinese patients diagnosed with sporadic MD was sequenced using next-generation sequencing.

Results

Definite pathological variants of MEFV (c.1223G>A, c.1105C>T), COL7A1 (c.5287C>T), and ADA (c.445C>T) contributing to the clinical phenotype were found in three patients. Limited and likely pathological variants of TLR3 (c.2228G>A) and RAB27A (c.560G>A) were detected in one patient each. The following definite pathological variants impairing the structure and function of translated proteins were detected in 10 patients, and multigene variants occurred in five patients: PRF1 (c.710C>A), UNC13D (c.1228A>C), COLEC11 (c.169C>T), RAG2 (c.200G>C), BLM (c.1937G>T), RNF31 (c.2533G>A), FAT4 (c.11498A>G), PEPD (c.788A>G), TNFSF12 (c.470G>A), VPS13B (c.11972A>T), TNFRSF13B (c.226G>A), ERCC6L2 (c.4613A>G), TLR3 (c.2228G>A), ADA (c.445C>T), PEPD (c.151G>A), and MOGS (c.2470G>A). The following limited pathological variants impairing the structure and function of translated proteins were detected in five patients, with double gene variants identified in one patient: EXTL3 (c.1396G>A), MTHFD1 (c.2057G>A), FANCA (c.2039T>C), LPIN2 (c.1814C>T), NBAS (c.4049T>C), and FCN3 (c.734G>A).

Conclusion

Patients with sporadic MD carry multiple genetic variants involved in multiple steps of immune regulation, which might render patients susceptible to developing inflammation via both autoimmune and autoinflammation mechanisms upon internal stress.

Feasibility of 3D-printed middle ear prostheses in partial ossicular chain reconstruction

Despite advances in prosthesis materials, operating microscopes and surgical techniques during the last 50 years, long-lasting hearing improvement remains a challenge in ossicular chain reconstruction. Failures in the reconstruction are mainly due to inadequate length or shape of the prosthesis, or defects in the surgical procedure. 3D-printed middle ear prosthesis might offer a solution to individualize treatment and obtain better results. The aim of the study was to study the possibilities and limitations of 3D-printed middle ear prostheses. Design of the 3D-printed prosthesis was inspired by a commercial titanium partial ossicular replacement prosthesis. 3D models of different lengths (1.5-3.0 mm) were created with Solidworks 2019-2021 software. The prostheses were 3D-printed with vat photopolymerization using liquid photopolymer Clear V4. Accuracy and reproducibility of 3D printing were evaluated with micro-CT imaging. The acoustical performance of the prostheses was determined in cadaver temporal bones with laser Doppler vibrometry. In this paper, we present an outline of individualized middle ear prosthesis manufacturing. 3D printing accuracy was excellent when comparing dimensions of the 3D-printed prostheses and their 3D models. Reproducibility of 3D printing was good if the diameter of the prosthesis shaft was 0.6 mm. 3D-printed partial ossicular replacement prostheses were easy to manipulate during surgery even though they were a bit stiffer and less flexible than conventional titanium prostheses. Their acoustical performance was similar to that of a commercial titanium partial ossicular replacement prosthesis. It is possible to 3D print functional individualized middle ear prostheses made of liquid photopolymer with good accuracy and reproducibility. These prostheses are currently suitable for otosurgical training. Further research is needed to explore their usability in a clinical setting. In the future, 3D printing of individualized middle ear prostheses may provide better audiological outcomes for patients.

Prognostic histological markers in oral tongue squamous cell carcinoma patients treated with (chemo)radiotherapy

Treatment of oral tongue squamous cell carcinoma (OTSCC) frequently includes surgery with postoperative radiotherapy (RT) or chemoradiotherapy (CRT). Resistance to RT or CRT remains a major clinical challenge and highlights the need to identify predictive markers for it. We included 71 OTSCC patients treated with surgery combined with RT or CRT. We evaluated the association between tumor budding, tumor-stroma ratio (TSR), depth of invasion (DOI), tumor-infiltrating lymphocytes (TILs), hypoxia-inducible factor-1alpha (HIF-1alpha) expression, octamer-binding transcription factor 4 (OCT4) expression, high-endothelial venules (HEVs), and disease-free survival (DFS) using uni- and multivariate analyses. No significant association was observed between the different histological and molecular markers (TSR, DOI, TILs, HEV, HIF-1alph, OCT4) and DFS. However, an associative trend between DOI, budding, and DFS was noted. Further studies with larger cohorts are needed to explore the prognostic value of DOI and budding for OTSCC patients treated with postoperative RT or CRT.

Timing and frequency of oropharyngeal squamous cell carcinoma recurrences after treatment with curative intent

BACKGROUND

The increasing number of patients under surveillance after treatment of human papillomavirus-related oropharyngeal squamous cell carcinoma (OPSCC) places a great burden on healthcare providers.

AIMS/OBJECTIVES

The aim of this study was to explore OPSCC recurrences in a long follow-up period: their site, frequency and timepoint after primary treatment, treatment and outcome. The secondary aim was to investigate if the recurrences are diagnosed on routine follow-up visits, and if the p16 status will have an effect on the pattern of recurrences.

MATERIAL AND METHODS

We analyzed recurrences within a 10-year follow-up period after completed curatively intended treatment among OPSCC patients in Finland treated between 2000 and 2009. Patient-, tumor-, treatment- and follow-up -related parameters were investigated.

RESULTS

Out of 495 patients with no residual tumor during the first six months, 71 (14%) were diagnosed with a recurrence, of which 47 were locoregional and 28 were treated with curative intent. Of the recurrences, 86% were diagnosed during the first 36 months after primary treatment. Only ten recurrences appeared after 36 months. The median OS after recurrence was 10.9 months.

CONCLUSIONS AND SIGNIFICANCE

Routine follow-up longer than three years after treatment seems not to be effective in terms of detecting OPSCC recurrences.

Incidence of head and neck cancer among first-generation immigrants and their children in Finland

INTRODUCTION

Limited data exist regarding head and neck cancer (HNC) burden among immigrants who may have distinct characteristics, and hence different incidence rates from the general population. Variations in behavioral habits, cultural lifestyle, or diet may cause variations across different subgroups.

METHODS

The whole immigrant population of Finnish residents born abroad, and their children were retrieved for the years 1970-2017. First-generation immigrants are defined as individuals born abroad, excluding their children (even if born abroad). The study comprised 0.5 million first-generation immigrants and 0.3 million children, contributing to 6 million and 5 million person-years of follow-up, respectively. Standardized incidence ratios (SIR) and excess absolute risk (EAR) per 100,000 person-years at risk were calculated to quantify the risk of HNC among immigrants relative to the general Finnish population.

RESULTS

The overall risk of any HNC was not increased among first-generation male immigrants (SIR 1.00, 95% CI: 0.88-1.15), but significantly elevated for cancer of the pharynx (SIR 1.56, 95% CI: 1.22-1.95), and larynx (SIR 1.38, 95% CI: 1.02-1.83) and decreased for lip (SIR 0.38, 95% CI: 0.20-0.67). The increased risk of pharyngeal cancer was highest among male immigrants from Asia Pacific (SIR 4.21, 95% CI: 2.02-7.75). First-generation immigrant women had a significantly reduced risk of any HNC (SIR 0.45, 95% CI: 0.37-0.55), which remained even after stratification by site. We observed no increased risk of any HNC among the children of first-generation immigrants.

CONCLUSION

Healthcare professionals need to recognize the groups at higher HNC risk. Efforts to address the main etiological risk factors, such as smoking, are needed among the selected immigrant populations, that haven't yet reached similar decreasing trends, as in for example smoking, as the main population.NOVELTY AND IMPACTCurrently, globally, over 280 million people live outside their country of birth. Limited data exist regarding head and neck cancer (HNC) burden among immigrants who may have distinct characteristics and hence different incidence rates from the general population. Immigrant studies can provide novel data by shedding light on risk alterations and the pace of acculturation of different populations.

Differences in characteristics and infection severity between odontogenic and other bacterial oro-naso-pharyngeal infections

BACKGROUND

Different bacterial infections of the oro-naso-pharyngeal (ONP) region may progress and require hospital care. The present study clarified differences in infection characteristics between hospitalized patients with odontogenic infections (OIs) and other bacterial ONP infections. The specific aim was to evaluate clinical infection variables and infection severity according to infection aetiology, particularly regarding features of OIs compared with other ONPs.

METHODS

Records of patients aged ≥16 years requiring hospital care for an acute bacterial ONP infection in the emergency units of Otorhinolaryngology or Oral and Maxillofacial Surgery at the Helsinki University Hospital (Helsinki, Finland) during 2019 were evaluated retrospectively. The main outcome variables were need for intensive care unit (ICU) treatment and length of hospital stay. The primary predictor variable was infection category, defined as OI or other ONP. The secondary predictor variable was specific ONP infection group. Additional predictor variables were primary clinical infection signs, infection parameters at hospital admission, and delay from beginning of symptoms to hospitalization. Explanatory variables were sex, age, current smoking, heavy alcohol use or substance abuse, and immunosuppressive disease, immunosuppressive medication, or both. Comparison of study groups was performed using Fisher's exact test, student's t-test, and Mann-Whitney U.

RESULTS

A total of 415 patients with bacterial ONPs fulfilled the inclusion criteria. The most common infections were oropharyngeal (including peritonsillar, tonsillar, and parapharyngeal infections; 51%) followed by infections from the odontogenic origin (24%). Clinical features of OIs differed from other ONPs. Restricted mouth opening, skin redness, or facial or neck swelling (or both) were found significantly more often in OIs (p < 0.001). OIs required ICU care significantly more often than other ONPs (p < 0.001) and their hospital stay was longer (p = 0.017).

CONCLUSIONS

Infections originating from the tonsillary and dental origin had the greatest need for hospitalization. Clinical features of OIs differed; the need for ICU treatment was more common and hospital stay was longer compared with other ONPs. Preventive care should be emphasized regarding OIs, and typical infection characteristics of ONP infection subgroups should be highlighted to achieve early and prompt diagnosis and treatment and to reduce hospitalization time.

Patient and health care delays in large (class T3-T4) oral, oropharyngeal, and laryngeal carcinomas

BACKGROUND

Head and neck cancers (HNCs) are often diagnosed at an advanced stage. We investigated the lengths and factors associated with patient, primary health care (PHC), and specialist care (SC) delays in T3-T4 oral, oropharyngeal, and laryngeal cancer.

METHODS

A nationwide prospective questionnaire-based study (n = 203) with the 3-year long data collection period.

RESULTS

The median patient, PHC and SC delays were 58, 13, and 43 days, respectively. Lower level of education, heavy alcohol use, hoarseness, difficulties breathing, and eventual palliative treatment associated with a longer patient delay. A lump on the neck or facial swelling associated with a shorter PHC delay. Conversely, if symptoms were treated as an infection, PHC delay was longer. The treatment modality and tumor site affected SC delay.

CONCLUSIONS

Patient delay stands as the most notable factor contributing to delays before treatment. HNC symptom awareness thus remains especially important among HNC risk groups.

Treatment and outcome among patients with laryngeal squamous cell carcinoma in S tockholm—A population‐based study

Objective

Survival of patients with advanced laryngeal squamous cell carcinoma (LSCC) remains poor and management protocols warrant further development. We thus investigated treatment and outcome-related factors for LSCC in Stockholm, Sweden.

Methods

In a retrospective setting, 520 patients with LSCC diagnosed during 2000-2014, were included. Data on stage, treatment, and outcome were correlated with recurrence-free and overall survival (RFS and OS, respectively).

Results

Five-year OS for all patients was 65%. Five-year RFS for T1a, T1b, T2, T3, and T4 glottic LSCC was 90%, 91%, 77%, 47%, and 80%, respectively. The corresponding figures for T1, T2, T3, and T4 supraglottic LSCC were 64%, 66%, 64%, and 86%.

Conclusion

Patients with a T3 glottic LSCC had unexpectedly poor survival, especially when compared with patients with a T4 tumor. Patients with T4 disease were primarily treated with laryngectomy and postoperative radiotherapy (RT)/chemoradiotherapy (CRT), while most patients with T3 LSCC were treated with RT/CRT.

Application of simultaneous uncertainty quantification for image segmentation with probabilistic deep learning: Performance benchmarking of oropharyngeal cancer target delineation as a use-case

Background

Oropharyngeal cancer (OPC) is a widespread disease, with radiotherapy being a core treatment modality. Manual segmentation of the primary gross tumor volume (GTVp) is currently employed for OPC radiotherapy planning, but is subject to significant interobserver variability. Deep learning (DL) approaches have shown promise in automating GTVp segmentation, but comparative (auto)confidence metrics of these models predictions has not been well-explored. Quantifying instance-specific DL model uncertainty is crucial to improving clinician trust and facilitating broad clinical implementation. Therefore, in this study, probabilistic DL models for GTVp auto-segmentation were developed using large-scale PET/CT datasets, and various uncertainty auto-estimation methods were systematically investigated and benchmarked.

Methods

We utilized the publicly available 2021 HECKTOR Challenge training dataset with 224 co-registered PET/CT scans of OPC patients with corresponding GTVp segmentations as a development set. A separate set of 67 co-registered PET/CT scans of OPC patients with corresponding GTVp segmentations was used for external validation. Two approximate Bayesian deep learning methods, the MC Dropout Ensemble and Deep Ensemble, both with five submodels, were evaluated for GTVp segmentation and uncertainty performance. The segmentation performance was evaluated using the volumetric Dice similarity coefficient (DSC), mean surface distance (MSD), and Hausdorff distance at 95% (95HD). The uncertainty was evaluated using four measures from literature: coefficient of variation (CV), structure expected entropy, structure predictive entropy, and structure mutual information, and additionally with our novel Dice-risk measure. The utility of uncertainty information was evaluated with the accuracy of uncertainty-based segmentation performance prediction using the Accuracy vs Uncertainty (AvU) metric, and by examining the linear correlation between uncertainty estimates and DSC. In addition, batch-based and instance-based referral processes were examined, where the patients with high uncertainty were rejected from the set. In the batch referral process, the area under the referral curve with DSC (R-DSC AUC) was used for evaluation, whereas in the instance referral process, the DSC at various uncertainty thresholds were examined.

Results

Both models behaved similarly in terms of the segmentation performance and uncertainty estimation. Specifically, the MC Dropout Ensemble had 0.776 DSC, 1.703 mm MSD, and 5.385 mm 95HD. The Deep Ensemble had 0.767 DSC, 1.717 mm MSD, and 5.477 mm 95HD. The uncertainty measure with the highest DSC correlation was structure predictive entropy with correlation coefficients of 0.699 and 0.692 for the MC Dropout Ensemble and the Deep Ensemble, respectively. The highest AvU value was 0.866 for both models. The best performing uncertainty measure for both models was the CV which had R-DSC AUC of 0.783 and 0.782 for the MC Dropout Ensemble and Deep Ensemble, respectively. With referring patients based on uncertainty thresholds from 0.85 validation DSC for all uncertainty measures, on average the DSC improved from the full dataset by 4.7% and 5.0% while referring 21.8% and 22% patients for MC Dropout Ensemble and Deep Ensemble, respectively.

Conclusion

We found that many of the investigated methods provide overall similar but distinct utility in terms of predicting segmentation quality and referral performance. These findings are a critical first-step towards more widespread implementation of uncertainty quantification in OPC GTVp segmentation.

FinnGen provides genetic insights from a well-phenotyped isolated population

Population isolates such as those in Finland benefit genetic research because deleterious alleles are often concentrated on a small number of low-frequency variants (0.1% ≤ minor allele frequency < 5%). These variants survived the founding bottleneck rather than being distributed over a large number of ultrarare variants. Although this effect is well established in Mendelian genetics, its value in common disease genetics is less explored^1,2. FinnGen aims to study the genome and national health register data of 500,000 Finnish individuals. Given the relatively high median age of participants (63 years) and the substantial fraction of hospital-based recruitment, FinnGen is enriched for disease end points. Here we analyse data from 224,737 participants from FinnGen and study 15 diseases that have previously been investigated in large genome-wide association studies (GWASs). We also include meta-analyses of biobank data from Estonia and the United Kingdom. We identified 30 new associations, primarily low-frequency variants, enriched in the Finnish population. A GWAS of 1,932 diseases also identified 2,733 genome-wide significant associations (893 phenome-wide significant (PWS), P < 2.6 × 10^-11) at 2,496 (771 PWS) independent loci with 807 (247 PWS) end points. Among these, fine-mapping implicated 148 (73 PWS) coding variants associated with 83 (42 PWS) end points. Moreover, 91 (47 PWS) had an allele frequency of <5% in non-Finnish European individuals, of which 62 (32 PWS) were enriched by more than twofold in Finland. These findings demonstrate the power of bottlenecked populations to find entry points into the biology of common diseases through low-frequency, high impact variants.

Segmentation stability of human head and neck cancer medical images for radiotherapy applications under de-identification conditions: Benchmarking data sharing and artificial intelligence use-cases

Background

Demand for head and neck cancer (HNC) radiotherapy data in algorithmic development has prompted increased image dataset sharing. Medical images must comply with data protection requirements so that re-use is enabled without disclosing patient identifiers. Defacing, i.e., the removal of facial features from images, is often considered a reasonable compromise between data protection and re-usability for neuroimaging data. While defacing tools have been developed by the neuroimaging community, their acceptability for radiotherapy applications have not been explored. Therefore, this study systematically investigated the impact of available defacing algorithms on HNC organs at risk (OARs).

Methods

A publicly available dataset of magnetic resonance imaging scans for 55 HNC patients with eight segmented OARs (bilateral submandibular glands, parotid glands, level II neck lymph nodes, level III neck lymph nodes) was utilized. Eight publicly available defacing algorithms were investigated: afni_refacer, DeepDefacer, defacer, fsl_deface, mask_face, mri_deface, pydeface, and quickshear. Using a subset of scans where defacing succeeded (N=29), a 5-fold cross-validation 3D U-net based OAR auto-segmentation model was utilized to perform two main experiments: 1.) comparing original and defaced data for training when evaluated on original data; 2.) using original data for training and comparing the model evaluation on original and defaced data. Models were primarily assessed using the Dice similarity coefficient (DSC).

Results

Most defacing methods were unable to produce any usable images for evaluation, while mask_face, fsl_deface, and pydeface were unable to remove the face for 29%, 18%, and 24% of subjects, respectively. When using the original data for evaluation, the composite OAR DSC was statistically higher (p ≤ 0.05) for the model trained with the original data with a DSC of 0.760 compared to the mask_face, fsl_deface, and pydeface models with DSCs of 0.742, 0.736, and 0.449, respectively. Moreover, the model trained with original data had decreased performance (p ≤ 0.05) when evaluated on the defaced data with DSCs of 0.673, 0.693, and 0.406 for mask_face, fsl_deface, and pydeface, respectively.

Conclusion

Defacing algorithms may have a significant impact on HNC OAR auto-segmentation model training and testing. This work highlights the need for further development of HNC-specific image anonymization methods.

Otologic injuries are frequent in pediatric patients with temporal bone fractures

This retrospective study aimed to clarify the occurrence and types of otologic injuries in children and adolescents with skull fractures. Files of all patients under 18 years of age who had been diagnosed with skull fractures at a tertiary trauma centre were included. The primary outcome variable was the presence of any otologic symptom or finding. Secondary outcome variables were clinically detected and radiologically detected otologic injuries. The primary predictor variable was a temporal bone fracture. Other study variables were sex, age, mechanism of injury, traumatic brain injury, and mortality. A total of 97 patients were identified for the study. Otologic symptoms and findings were frequent (33.9%). The most common clinical findings were bleeding from the external auditory canal (18.6%) and hemotympanum (13.4%). The prevailing radiological finding was blood and/or cerebrospinal fluid in the middle ear (30.9%). Patients with fractures of temporal bone had a 29-fold risk for otologic symptoms or findings (RR 28.9, 95% CI 4.1-202.9, p < 0.001) relative to those who did not have a temporal bone fracture. Severe otologic complications, such as permanent hearing loss (6.2%), cerebrospinal fluid leak (5.2%), or facial nerve palsy (1%), were infrequent. Within the limitations of the study it seems that there is the necessity of otoscopy in all pediatric patients with blunt head trauma. In case of positive otologic findings, the patient should undergo imaging and ENT consultation.

Legal issues and underexplored data protection in medical 3D printing: A scoping review

Introduction: 3D printing has quickly found many applications in medicine. However, as with any new technology the regulatory landscape is struggling to stay abreast. Unclear legislation or lack of legislation has been suggested as being one hindrance for wide-scale adoption. Methods: A scoping review was performed in PubMed, Web of Science, SCOPUS and Westlaw International to identify articles dealing with legal issues in medical 3D printing. Results: Thirty-four articles fulfilling inclusion criteria were identified in medical/technical databases and fifteen in the legal database. The majority of articles dealt with the USA, while the EU was also prominently represented. Some common unresolved legal issues were identified, among them terminological confusion between custom-made and patient-matched devices, lack of specific legislation for patient-matched products, and the undefined legal role of CAD files both from a liability and from an intellectual property standpoint. Data protection was mentioned only in two papers and seems an underexplored topic. Conclusion: In this scoping review, several relevant articles and several common unresolved legal issues were identified including a need for terminological uniformity in medical 3D printing. The results of this work are planned to inform our own deeper legal analysis of these issues in the future.

Unmet challenges in septoplasty–nordic studies from a uniform healthcare and geographical area

Purpose

Nasal septoplasty is one of the most common surgical procedures in otorhinolaryngology and optimising both patient selection and the surgery is a challenge. The Nordic countries have similar public healthcare systems and comparable populations in terms of size.

Methods

This is a review of studies of outcome and predictors related to septoplasty from Denmark, Finland, Norway and Sweden, published during the last decade. The aim of this review was to identify areas in need of further research to meet the challenges of septoplasty in the Nordic countries with reference to international data.

Results

Postoperative patient satisfaction at 6–12 months was reported in around 2/3 of the patients and well in line with international data. Patients with more severe symptoms had a higher chance of improvement. Lack of standardisation in patient selection, surgical methods and skills, and follow up procedures, still makes it difficult to explain the 25% failure rate in septoplasty surgery.

Conclusion

This review of the Nordic studies from the last decade shows that septoplasty in general is effective in relieving nasal obstruction. There is a need for studies addressing the standardisation of diagnostic tools and algorithms and the systematic and continuous implementation of follow-up of the surgical results at both departmental and personal level. This includes an awareness of how surgical skills in septoplasty are obtained and maintained.

GLIM in diagnosing malnutrition and predicting outcome in ambulatory patients with head and neck cancer

AIM

This study aimed to determine the prevalence of malnutrition in a head and neck cancer (HNC) population according to the Global Leadership Initiative on Malnutrition (GLIM) criteria and to assess its relation to survival. The secondary aim was to compare GLIM criteria to Patient-Generated Subjective Global Assessment (PG-SGA) and Nutritional Risk Screening 2002 (NRS 2002) methods.

METHODS

The assessment was performed in a series of 65 curative patients with newly diagnosed HNC in a nutrition intervention study. Malnutrition was defined as PG-SGA classes BC and nutritional risk as NRS 2002 score ≥3 and was retrospectively diagnosed with GLIM criteria in prospectively collected data at diagnosis. Sensitivity, specificity, and kappa (κ) were analyzed. Predictive accuracy was assessed by calculating the area under curve (AUC) b y receiver operating characteristic (ROC) analysis. Kaplan-Meier and Cox regression analyses were used to evaluate association between malnutrition and overall survival (OS), and disease-free survival (DFS).

RESULTS

GLIM-defined malnutrition was present in 37% (24/65) of patients. The GLIM showed 77% sensitivity and 84% specificity with agreement of κ = 0.60 and accuracy of AUC = 0.80 (p < 0.001) with PG-SGA and slightly higher sensitivity (83%) with NRS 2002 (κ = 0.58). Patients with GLIM-defined malnutrition had shorter OS (56 vs. 72 months, HR 2.26, 95% CI 1.07-4.77, p = 0.034) and DFS (37 vs. 66 months, HR 2.01, 95% CI 0.99-4.09, p = 0.054), than well-nourished patients. The adjusted HR was 2.53 (95% CI 1.14-5.47, p = 0.023) for OS and 2.10 (95% CI 0.98-4.48, p = 0.056) for DFS in patients with GLIM-defined malnutrition.

CONCLUSION

A substantial proportion of HNC patients were diagnosed with malnutrition according to the GLIM criteria and this showed a moderate agreement with NRS 2002- and PG-SGA-defined malnutrition. Even though the GLIM criteria had strong association with OS, its diagnostic value was poor. Therefore, the GLIM criteria seem potential for malnutrition diagnostics and outcome prediction in the HNC patient population. Furthermore, NRS 2002 score ≥3 indicates high nutritional risk in this patient group.

Occupational risk variation of nasopharyngeal cancer in the Nordic countries

Background

The aim of this study was to estimate occupational risk variation in the incidence of nasopharyngeal cancer (NPC) in a large population-based cohort of the Nordic Occupational Cancer (NOCCA) study.

Methods

This study is based on a cohort of almost 15 million persons from Denmark, Finland, Iceland, Norway and Sweden, with 2898 nasopharyngeal cancer cases diagnosed in 1961–2005. The data on occupations were gathered from population censuses and cancer data from the national cancer registries. Standardized incidence ratios (SIR) with 95% confidence intervals (CI) were estimated using the national NPC incidence rates as the reference.

Results

There were 1980 male and 918 female NPC patients. The highest SIRs of NPC were observed among male waiters (SIR 3.69, 95% CI 1.91–6.45) and cooks and stewards (SIR 2.24, 95% CI 1.16–3.91). Among women, launderers had the highest SIR of NPC (2.04, 95% CI 1.02–3.65). Significantly decreased SIRs were found among male farmers (SIR 0.79, 95% CI 0.68–0.92) and male textile workers (SIR 0.49, 95% CI 0.22–0.93).

Conclusions

This study suggests that NPC may be associated with several work-related exposure agents such as smoking, kitchen air pollution and solvents. In future, occupational exposure-risk relations should be studied to understand more about causality and to assess effective prevention strategies.

Assessment of nutritional status of oncology patients at hospital admission: A Portuguese real-world study

Background

Nutritional status in patients with cancer has a determining role in the evolution of the disease and tolerance to treatments. Severity of undernutrition impacts morbidity and mortality in cancer patients and can limit patient response to the optimal therapies if nutritional issues are not appropriately addressed and managed. Despite the importance of malnutrition for the clinical evolution of oncology patients, there is not yet a universally accepted standard method for evaluating malnutrition in such patients. The aim of this study was to stratify the nutritional status of inpatients at an Oncology Department.

Methods

This is an observational study with 561 cancer patients, assessed at admission to a Medical Oncology Department from November 2016 to February 2020. All patients were considered eligible. Non-compliant and/or comatose patients were excluded. Nutritional status was assessed using the PG-SGA, BMI classified with the WHO criteria, and calculation of the percentage of weight loss in the previous 3–6 months.

Results

A total of 561 patients (303 F: 258 M; mean age 65 ± 13 years) were included. One-third of the patients, n=191/561 (34%), lost 6% of their weight in the month prior to admission and 297/561 (53%) patients lost 10.2% of weight in the previous 6 months. Mean BMI was 24.1 ± 5.8 kg/m²; N = 280/561 (50%) patients had regular BMI according to the WHO criteria. N = 331/561 (59%) patients reported eating less in the month prior to admission. N = 303/561 (54%) had moderate/severe deficits of muscle and adipose compartments. The PG-SGA identified 499/561 (89%) patients as moderately/severely malnourished, of which 466/561 (83%) patients scored ≥9 points, meeting criteria for a critical need for nutritional support. Fifteen percent of patients scored >4 points, indicating a need for directed therapy for symptom control and only 1% scored <2 points (maintenance nutritional counseling).

Conclusion

In this oncological setting, a higher proportion of patients were nutritionally-at-risk or with moderate/severe malnutrition. The large majority of patients in this study presented with a critical need for nutritional intervention. These findings highlight the need for an integrated assessment of nutritional status at patient referral. This will allow early and timely nutrition care, which is recommended to prevent or reverse further deterioration of the condition and to optimize treatment administration.

Risk factors for evaluating early mortality after microvascular reconstruction of head and neck cancers

BACKGROUND

Free tissue transfer reconstruction carries significant complication rates in surgical head and neck oncology. A registry-based approach offers a possibility to investigate the factors affecting increased morbidity and early mortality, that is, death within 6 months of treatment.

METHODS

A retrospective registry review was conducted on a series of 317 consecutive microvascular free tissue transfers in head and neck cancer patients performed during 2013-2017 at the Helsinki University Hospital (Helsinki, Finland). All surviving patients had a minimum follow-up of 2 years (range 24-84 months).

RESULTS

Overall, 36 (11.4%) early deaths occurred in this series. In multivariable logistic regression analysis, patients aged 75 years and older (p = 0.019), Adult Comorbidity Evaluation-27 (ACE-27) score of 3 (p = 0.048), tumor class T3 (p = 0.005), lymph node class N2 (p = 0.014), or thrombocyte count of 360 (× 10⁹ L) or more (p = 0.001) were more likely to die within 6 months of surgery. Of these 36 patients, 27 (75%) had a complication warranting hospital care and most (n = 22, 61%) had several complications.

CONCLUSIONS

Early postoperative mortality most frequently affects patients aged 75 years and above, with a high ACE-27 score, advanced tumor stage, or high thrombocyte count. Therefore, preoperative assessment and patient selection should have a crucial role in this patient population.

Measuring the Usability and Quality of Explanations of a Machine Learning Web-Based Tool for Oral Tongue Cancer Prognostication

Background: Machine learning models have been reported to assist in the proper management of cancer through accurate prognostication. Integrating such models as a web-based prognostic tool or calculator may help to improve cancer care and assist clinicians in making oral cancer management-related decisions. However, none of these models have been recommended in daily practices of oral cancer due to concerns related to machine learning methodologies and clinical implementation challenges. An instance of the concerns inherent to the science of machine learning is explainability. Objectives: This study measures the usability and explainability of a machine learning-based web prognostic tool that was designed for prediction of oral tongue cancer. We used the System Usability Scale (SUS) and System Causability Scale (SCS) to evaluate the explainability of the prognostic tool. In addition, we propose a framework for the evaluation of post hoc explainability of web-based prognostic tools. Methods: A SUS- and SCS-based questionnaire was administered amongst pathologists, radiologists, cancer and machine learning researchers and surgeons (n = 11) to evaluate the quality of explanations offered by the machine learning-based web prognostic tool to address the concern of explainability and usability of these models for cancer management. The examined web-based tool was developed by our group and is freely available online. Results: In terms of the usability of the web-based tool using the SUS, 81.9% (45.5% strongly agreed; 36.4% agreed) agreed that neither the support of a technical assistant nor a need to learn many things were required to use the web-based tool. Furthermore, 81.8% agreed that the evaluated web-based tool was not cumbersome to use (usability). The average score for the SCS (explainability) was 0.74. A total of 91.0% of the participants strongly agreed that the web-based tool can assist in clinical decision-making. These scores indicated that the examined web-based tool offers a significant level of usability and explanations about the outcome of interest. Conclusions: Integrating the trained and internally and externally validated model as a web-based tool or calculator is poised to offer an effective and easy approach towards the usage and acceptance of these models in the future daily practice. This approach has received significant attention in recent years. Thus, it is important that the usability and explainability of these models are measured to achieve such touted benefits. A usable and well-explained web-based tool further brings the use of these web-based tools closer to everyday clinical practices. Thus, the concept of more personalized and precision oncology can be achieved.

The relative proportion of comorbidities among rhinitis and rhinosinusitis patients and their impact on visit burden

Background

The aim was to evaluate the relative proportion of Non‐steroidal anti‐inflammatory drug exacerbated respiratory disease (NERD) and other comorbidities, and their impact on the burden of outpatient visits due to allergic rhinitis (AR), non‐allergic rhinitis (NAR), acute rhinosinusitis (ARS), and chronic rhinosinusitis with nasal polyps (CRSwNP) and without (CRSsNP).

Methods

We used hospital registry data of a random sample of 5080 rhinitis/rhinosinusitis patients diagnosed during 2005–2019. International Statistical Classification of Diseases and Related Health Problems (ICD10) diagnoses, visits, and other factors were collected from electronic health records by using information extraction and data processing methods. Cox's proportional hazards model was used for modeling the time to the next outpatient visit.

Results

The mean (±standard deviation) age of the population was 33.6 (±20.7) years and 56.1% were female. The relative proportion of AR, NAR, ARS, CRSsNP and CRSwNP, were 33.5%, 27.5%, 27.2%, 20.7%, and 10.9%, respectively. The most common other comorbidities were asthma (44.4%), other chronic respiratory diseases (38.5%), musculoskeletal diseases (38.4%), and cardiovascular diseases (35.7%). Non‐steroidal anti‐inflammatory drug exacerbated respiratory disease existed in 3.9% of all patients, and 17.7% of the CRSwNP group. The relative proportion of subjects having 1, 2, 3 and ≥ 4 other diseases were 18.0%, 17.6%, 17.0%, 37.0%, respectively. All diseases except AR, ARS, and mouth breathing, were associated with a high frequency of outpatient visits.

Conclusions

Our results revealed a high relative proportion of NERD and other comorbidities, which affect the burden of outpatient visits and hence confirm the socioeconomic impact of upper airway diseases.

The Role of Human Chorionic Gonadotropin Beta (hCGβ) in HPV-Positive and HPV-Negative Oropharyngeal Squamous Cell Carcinoma

Background: This study was carried out to observe the upregulation of the free β-subunit of human chorionic gonadotropin (hCGβ) and its prognostic significance in human papillomavirus (HPV)-positive and HPV-negative oropharyngeal squamous cell carcinoma (OPSCC). Materials and methods: A total of 90 patients with OPSCC treated with curative intent at the Helsinki University Hospital (HUS), Helsinki, Finland, during 2012−2016 were included. Serum samples were collected prospectively, and their hCGβ concentrations (S-hCGβ) were determined by an immunofluorometric assay. The expression of hCGβ in tumor tissues was defined by immunohistochemistry (IHC). HPV determination was performed by combining p16-INK4 IHC and HPV DNA PCR genotyping. Overall survival (OS) and disease-specific survival (DSS) were used as survival endpoints. Results: S-hCGβ positivity correlated with poor OS in the whole patient cohort (p < 0.001) and in patients with HPV-negative OPSCC (p < 0.001). A significant correlation was seen between S-hCGβ and poor DSS in the whole cohort (p < 0.001) and in patients with HPV-negative OPSCC (p = 0.007). In a multivariable analysis, S-hCGβ was associated with poor DSS. Of the clinical characteristics, higher cancer stage and grade were associated with S-hCGβ positivity. No statistically significant correlation with tissue positivity of hCGβ was seen in these analyses. Conclusion: S-hCGβ may be a potential independent factor indicating poor prognosis, notably in HPV-negative OPSCC.