Cancer staging: The Goldilocks principle

Modifications are critical to cancer staging evolution. This piece seeks to contextualize key examples of the necessity for balance when considering and adopting these modifications.

The RVU Compensation Model and Head and Neck Surgical Education

BACKGROUND

The present study aims to quantify the opportunity cost of training residents and fellows for head and neck surgery.

METHODS

A 2005-2015 review of ablative head and neck surgical procedures was performed using the National Surgical Quality Improvement Program (NSQIP). Work relative value units (wRVU) generated per hour were compared among procedures performed by attendings alone, attendings with residents, and attendings with fellows.

RESULTS

Among 34,078 ablative procedures, the rate of wRVU generation per hour was greatest for attendings alone (10.3), followed by attendings with residents (8.9) and attendings with fellows (7.0, p < 0.001). Resident and fellow involvement was associated with opportunity costs of $60.44 per hour (95% CI: $50.21-$70.66/h) and $78.98 per hour ($63.10-$94.87/h, 95% CI), respectively.

CONCLUSION

wRVU-based physician reimbursement does not consider or adjust for the extra effort involved in training future head and neck surgeons.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:113-119, 2024.

Diagnostic challenges and prognostic implications of extranodal extension in head and neck cancer: a state of the art review and gap analysis

Extranodal extension (ENE) is a pattern of cancer growth from within the lymph node (LN) outward into perinodal tissues, critically defined by disruption and penetration of the tumor through the entire thickness of the LN capsule. The presence of ENE is often associated with an aggressive cancer phenotype in various malignancies including head and neck squamous cell carcinoma (HNSCC). In HNSCC, ENE is associated with increased risk of distant metastasis and lower rates of locoregional control. ENE detected on histopathology (pathologic ENE; pENE) is now incorporated as a risk-stratification factor in human papillomavirus (HPV)-negative HNSCC in the eighth edition of the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC) TNM classification. Although ENE was first described almost a century ago, several issues remain unresolved, including lack of consensus on definitions, terminology, and widely accepted assessment criteria and grading systems for both pENE and ENE detected on radiological imaging (imaging-detected ENE; iENE). Moreover, there is conflicting data on the prognostic significance of iENE and pENE, particularly in the context of HPV-associated HNSCC. Herein, we review the existing literature on ENE in HNSCC, highlighting areas of controversy and identifying critical gaps requiring concerted research efforts.

Distribution of the head and neck surgical oncology workforce in the United States

BACKGROUND

The recent trends in education and geographic distribution of the head and neck surgery workforce have not been studied extensively.

METHODS

We reviewed publicly available sources to locate all fellowship-trained head and neck surgeons and recent graduates. The number of surgeons in each state was compared against head and neck cancer incidence data from the Centers for Disease Control.

RESULTS

The number of graduates increased annually by 1 per 100 000 000 people from 2011-2020. The average number of fellowship-trained surgeons per state was 10 (SD: 12). The average number of new head and neck cancer cases per surgeon was 247 (SD: 135). Ten states (20%) had cases >1 SD above the national average/surgeon, while 3 (6%) had cases >1 SD below the national average.

CONCLUSION

Head and neck surgeons are located in most states, but not uniformly. Most states have approximately average density of surgeons; however, several states are outliers.

Needs assessment in head and neck surgical oncology training: A qualitative study of expert opinions

BACKGROUND

Few studies have investigated the needs of head and neck surgery trainees and areas for improvement of fellowship programs.

METHODS

We conducted a qualitative study by interviewing a nationally representative sample of program directors and national leaders in head and neck surgery. We asked about the current state and strengths of training; and areas for further improvement. All interviews were independently coded and analyzed by two reviewers.

RESULTS

All experts (100%) believed that the current training provides a strong foundation and furthermore, a standardized curriculum is beneficial. Multidisciplinary training (80%), participation in tumor boards (75%), and a syllabus (60%) were the most frequently mentioned components. Most believed that a formal certification process would be beneficial (73%), though there was no consensus on the format.

CONCLUSION

Experts in head and neck surgery are generally in favor of a standardized curriculum. Further discussions of a formal certification process might be warranted.

What Pandemic Portraits Illuminate About Balancing Vulnerability and Inurement

Portraits of clinicians quickly became emblematic of what the COVID-19 pandemic has demanded of everyone, especially caregivers who witnessed deaths likely unprecedented in number during their careers. This article describes an arts-based research protocol exploring portraiture as a medium for representing and understanding clinicians' experiences, mostly during the first year of the pandemic. This article presents Shadow of Corona, a large oil on canvas portrait commissioned by the AMA Journal of Ethics to commemorate the American Medical Association's 175th year. The article also includes Sarah, a charcoal study drawing for that portrait, and Front Lines of Care, a 3 by 3 collection of 9 smaller oil on canvas portraits.

Methodological considerations for the design and implementation of a fully longitudinal mixed methods study

Growing interest is evident in longitudinal mixed methods research, particularly fully longitudinal mixed methods designs in which both quantitative and qualitative data are collected concurrently for the duration of the study. Fully longitudinal mixed methods designs are particularly relevant for research on dynamic phenomena because of their ability to illuminate both quantitative and qualitative dimensions of change in real time as the phenomenon of interest changes. However, these are complex research designs and their data-intense nature makes them potentially burdensome for study participants, challenging for research teams, and costly for funding agencies. Despite growing use, the methodological literature on fully longitudinal mixed methods research is sparse and little guidance is available for researchers considering this approach. We address this gap by describing our experience with the design and implementation of a fully longitudinal mixed methods study of a dynamic phenomenon, namely, family caregiving during cancer treatment. We describe important questions and key decisions confronted while developing the research proposal, proactive strategies for study implementation, and implementation realities encountered while the study was in progress. On the basis of insights gained through real-world experience, we offer three guiding principles for researchers undertaking such a study. First, align the study design with the nature of the dynamics in the phenomenon of interest. Second, plan from the start when and how the integration of the longitudinal quantitative and qualitative data will occur. Third, employ implementation strategies that take into account the practical aspects of repeated contacts with study participants for an extended period.

Why Teachers and Learners of Medicine Need Portraiture

Medical and especially surgical teaching stresses the importance of careful observation, developing tolerance for ambiguity, and cultivating empathy for patients' and colleagues' experiences of receiving and giving health care. Portraiture is defined by portraitist Mark Gilbert as a collaborative process between subject and artist; sitting is as critical to this process as painting or drawing. This article draws upon the second author's work with Gilbert to examine how portraiture can motivate key teaching and learning goals in health professions education by facilitating learners' explorations of their own and others' biases, limitations, and approaches to gathering information from and about a source (eg, a subject or a patient).

Anthony and the Role of Silence in Portraiture in Clinical Settings

This article describes one collaborative arts-based research project. Portrait artist Mark Gilbert and coinvestigators consider lessons for art and healing from one patient, Anthony, whose experience of head and neck cancer diagnosis, surgery, and recovery suggests how silence is ethically, artistically, and clinically significant.

Allergic Fungal Sinusitis with Intracranial Extension and Frontal Lobe Symptoms: A Case Report

This is the first report of AFS which caused frontal lobe symptomatology and which resolved with surgical therapy. The surgical approach used provided excellent exposure and the sinuses could be examined and thoroughly cleaned both from above and intranasally. The dural defect, which resulted from the destruction of the cribiform and fovea ethmoidalis, was easily reconstructed with a pericranial flap. This exposure facilitates debridement and reconstruction while minimizing complications such as cerebral spinal fluid leakage or brain injury which may occur with endoscopic manipulations in patients with bony destruction and loss of normal landmarks.

Identification of Baseline Characteristics Associated With Development of Depression Among Patients With Head and Neck Cancer: A Secondary Analysis of a Randomized Clinical Trial

Importance

Patients with head and neck cancer (HNC) experience increased risk of depression and compromised quality of life. Identifying patients with HNC at risk of depression can help establish targeted interventions.

Objective

To identify factors that may be associated with the development of moderate or severe depression during treatment of HNC.

Design, Setting, and Participants

This is a retrospective, ad hoc, secondary analysis of prospectively collected data from a randomized, double-blind, placebo-controlled clinical trial. Patients were screened at academic- and community-based tertiary care HNC centers from January 2008 to December 2011. Of the 125 evaluable patients with stages II through IV HNC but without baseline depression, 60 were randomized to prophylactic antidepressant escitalopram oxalate and 65 to placebo at the time of the initial diagnosis. Data analyses were conducted from May 2016 to April 2017.

Main Outcomes and Measures

Depression outcomes were measured using Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) scores (range, 0-27 with a score of 11 or higher indicative of moderate or greater depression). Factors that may be associated with development of moderate or severe depression were assessed, including patient demographics; cancer site and stage; primary treatment modality (surgery or radiotherapy); history of depression or other psychiatric diagnosis; previous treatment of depression or suicide attempt, family history of depression, suicide, or suicide attempt; and baseline score on the QIDS-SR and clinician-rated QIDS instruments. Participants were stratified by study site, sex, cancer stage (early [stage II] vs advanced [stage III or IV]), primary modality of treatment (radiotherapy with or without chemotherapy vs surgery with or without radiotherapy), and randomization to placebo or escitalopram and balanced within these strata.

Results

The mean (SD) age of the 148 patients in the study population was 63.0 (11.9) years; 118 (79.7%) were men, and 143 (96.6%) were white. In the evaluable population of 125 patients, receiver operating characteristic analyses assessing the area under the curve for baseline QIDS-SR score (0.816; 95% CI, 0.696-0.935) and for initial radiotherapy-based treatment (0.681, 95% CI, 0.552-0.811) suggested that these 2 variables were associated with the likelihood of developing moderate or greater depression during the study period among patients who did not receive prophylactic antidepressants. The diagnostic sensitivity for identifying patients at risk of depression using the baseline QIDS-SR score improved to 100% at a threshold of 2 from 94% at a threshold of 4.

Conclusions and Relevance

Baseline symptoms and initial radiotherapy-based treatment may be associated with development of moderate or greater depression in patients with HNC. Patients with QIDS-SR baseline scores of 2 or higher may benefit the most from pharmacologic prophylaxis of depression.

The Effect of Intranasal Oxymetazoline on Serum Levels of Cocaine after Intranasal Cocaine Application

A prospective analysis was performed on healthy volunteers to determine whether pretreatment with the vasoconstrictor, oxymetazoline, could decrease the blood concentration of cocaine topically applied to the nasal mucosa. Blood pressure, pulse, continuous ECG recordings, and participant responses also were monitored as an indicator of systemic effects. Anesthesia was roughly assessed using a sterile 22-gauge needle touched to the anterior aspect of the inferior turbinate. Blood samples drawn at predetermined intervals were analyzed for cocaine using gas chromatography. Pretreatment with oxymetazoline significantly reduced the rate and extent of the increase in blood cocaine levels and resulted in a statistically significant lower systolic blood pressure and pulse rate. There was no significant difference in topical anesthesia between the two groups. Pretreatment with oxymetazoline before application of nasal cocaine thus appears to be beneficial.

A Prospective Double-Blind Evaluation of Cocaine, Phenylephrine with Xylocaine and Oxymetazoline with Xylocaine for Topical Intranasal Use

A prospective, double-blind evaluation using 3 ml of 10% cocaine, 0.5% phenylephrine with 5% Xylocaine, and 0.05% oxymetazoline with 5% Xylocaine was conducted to compare the anesthetic, decongestant, and systemic effects of each of the drugs. Degree of anesthesia was measured by placing a probe on the nasal mucosa in the area of Kisselbach's plexus and passing an electric current until a sensation could just be felt. Decongestant properties were assessed using anterior rhinomanometry. Systemic effects were determined by continuous blood pressure and pulse recordings and by recording subject comments. Cocaine showed better anesthesia, slower onset of vasoconstriction, significant blood pressure elevation, and multiple subjective side effects. Phenylephrine mixtures showed almost no unpleasant side effects, more rapid vasoconstriction than cocaine, and statistically significant anesthesia. Oxymetazoline mixture did not offer any advantages in anesthesia or vasoconstriction and produced the most unpleasant side effects. Cocaine appears to be the drug of choice for long surgical procedures in patients with normal cardiorespitatory systems. Phenylephrine with Xylocaine may be used as the drug of choice for shorter office procedures for those patients with cocaine sensitivity.

Invasive Fungal Sinusitis following Liver or Bone Marrow Transplantation

Invasive fungal infection of the nose and paranasal sinuses occurs almost exclusively in immunocompromised patients and is increasingly recognized as a complication of organ transplantation. We performed a retrospective chart review of 955 bone marrow and 749 liver transplant patients to identify risk factors, presenting signs and symptoms, methods of diagnosis, and successful management strategies. We report on five cases following bone marrow transplantation and one case following liver transplantation. Neutropenia is the single most important risk factor in the development of and recovery from invasive fungal sinusitis. Early diagnosis, combined with antifungal agents, hematopoietic growth factors, and aggressive surgical debridement is the most effective means of management.

Emergence of a Novel Staging System for Oropharyngeal Squamous Cell Carcinoma Based on HPV Status

The staging of oropharyngeal squamous cell carcinoma has undergone key changes in the eighth edition of the American Joint Committee on Cancer Staging Manual, set to take effect January 1, 2018. The most significant change relates to the development of a novel staging system for human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinomas, distinct from that for non-HPV-associated squamous cell carcinomas of the oropharynx. We describe the revised staging parameters and the rationale in support of the changes.

Afatinib radiosensitizes head and neck squamous cell carcinoma cells by targeting cancer stem cells

The dismal prognosis of locally advanced and metastatic squamous cell carcinoma of the head and neck (HNSCC) is primarily due to the development of resistance to chemoradiation therapy (CRT). Deregulation of Epidermal Growth Factor Receptor (EGFR) signaling is involved in HNSCC pathogenesis by regulating cell survival, cancer stem cells (CSCs), and resistance to CRT. Here we investigated the radiosensitizing activity of the pan-EGFR inhibitor afatinib in HNSCC in vitro and in vivo. Our results showed strong antiproliferative effects of afatinib in HNSCC SCC1 and SCC10B cells, compared to immortalized normal oral epithelial cells MOE1a and MOE1b. Comparative analysis revealed stronger antitumor effects with afatinib than observed with erlotinib. Furthermore, afatinib enhanced in vitro radiosensitivity of SCC1 and SCC10B cells by inducing mesenchymal to epithelial transition, G1 cell cycle arrest, and the attenuating ionizing radiation (IR)-induced activation of DNA double strand break repair (DSB) ATM/ATR/CHK2/BRCA1 pathway. Our studies also revealed the effect of afatinib on tumor sphere- and colony-forming capabilities of cancer stem cells (CSCs), and decreased IR-induced CSC population in SCC1 and SCC10B cells. Furthermore, we observed that a combination of afatinib with IR significantly reduced SCC1 xenograft tumors (median weight of 168.25 ± 20.85 mg; p = 0.05) compared to afatinib (280.07 ± 20.54 mg) or IR alone (324.91 ± 28.08 mg). Immunohistochemical analysis of SCC1 tumor xenografts demonstrated downregulation of the expression of IR-induced pEGFR1, ALDH1 and upregulation of phosphorylated γH2AX by afatinib. Overall, afatinib reduces tumorigenicity and radiosensitizes HNSCC cells. It holds promise for future clinical development as a novel radiosensitizer by improving CSC eradication.

Setting the Stage for 2018: How the Changes in the American Joint Committee on Cancer/Union for International Cancer Control Cancer Staging Manual Eighth Edition Impact Radiologists

The updated eighth edition of the Cancer Staging Manual of the American Joint Committee on Cancer will be implemented in January 2018. There are multiple changes to the head and neck section of the manual, which will be relevant to radiologists participating in multidisciplinary head and neck tumor boards and reading pretreatment head and neck cancer scans. Human papillomavirus-related/p16(+) oropharyngeal squamous cell carcinoma will now be staged separately; this change reflects the markedly better prognosis of these tumors compared with non-human papillomavirus/p16(-) oropharyngeal squamous cell carcinoma. Nodal staging has dramatically changed so that there are different tables for human papillomavirus/p16(+) oropharyngeal squamous cell carcinoma, Epstein-Barr virus-related nasopharyngeal carcinoma, and all other head and neck squamous cell carcinomas. Extranodal extension of tumor is a new clinical feature for this third staging group. In the oral cavity, the pathologically determined depth of tumor invasion is a new staging criterion, while extrinsic tongue muscle invasion is no longer part of staging. This review serves to educate radiologists on the eighth edition changes and their rationale.

Head and Neck cancers-major changes in the American Joint Committee on cancer eighth edition cancer staging manual

Answer questions and earn CME/CNE The recently released eighth edition of the American Joint Committee on Cancer (AJCC) Staging Manual, Head and Neck Section, introduces significant modifications from the prior seventh edition. This article details several of the most significant modifications, and the rationale for the revisions, to alert the reader to evolution of the field. The most significant update creates a separate staging algorithm for high-risk human papillomavirus-associated cancer of the oropharynx, distinguishing it from oropharyngeal cancer with other causes. Other modifications include: the reorganizing of skin cancer (other than melanoma and Merkel cell carcinoma) from a general chapter for the entire body to a head and neck-specific cutaneous malignancies chapter; division of cancer of the pharynx into 3 separate chapters; changes to the tumor (T) categories for oral cavity, skin, and nasopharynx; and the addition of extranodal cancer extension to lymph node category (N) in all but the viral-related cancers and mucosal melanoma. The Head and Neck Task Force worked with colleagues around the world to derive a staging system that reflects ongoing changes in head and neck oncology; it remains user friendly and consistent with the traditional tumor, lymph node, metastasis (TNM) staging paradigm. CA Cancer J Clin 2017;67:122-137. © 2017 American Cancer Society.

Pathology-based staging for HPV-positive squamous carcinoma of the oropharynx

OBJECTIVE

The rapid worldwide rise in incidence of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) has generated studies confirming this disease as an entity distinct from traditional OPSCC. Based on pathology, surgical studies have revealed prognosticators specific to HPV-positive OPSCC. The current AJCC/UICC staging and pathologic nodal (pN)-classification do not differentiate for survival, demonstrating the need for new, HPV-specific OPSCC staging. The objective of this study was to define a pathologic staging system specific to HPV-positive OPSCC.

METHODS

Data were assembled from a surgically-managed, p16-positive OPSCC cohort (any T, any N, M0) of 704 patients from five cancer centers. Analysis was performed for (a) the AJCC/UICC pathologic staging, (b) newly published clinical staging for non-surgically managed HPV-positive OPSCC, and (c) a novel, pathology-based, "HPVpath" staging system that combines features of the primary tumor and nodal metastases.

RESULTS

A combination of AJCC/UICC pT-classification and pathology-confirmed metastatic node count (⩽4 versus ⩾5) yielded three groups: stages I (pT1-T2, ⩽4 nodes), II (pT1-T2, ⩾5 nodes; pT3-T4, ⩽4 nodes), and III (pT3-T4, ⩾5 nodes), with incrementally worse prognosis (Kaplan-Meier overall survival of 90%, 84% and 48% respectively). Existing AJCC/UICC pathologic staging lacked prognostic definition. Newly published HPV-specific clinical stagings from non-surgically managed patients, although prognostic, showed lower precision for this surgically managed cohort.

CONCLUSIONS

Three loco-regional "HPVpath" stages are identifiable for HPV-positive OPSCC, based on a combination of AJCC/UICC primary tumor pT-classification and metastatic node count. A workable, pathologic staging system is feasible to establish prognosis and guide adjuvant therapy decisions in surgically-managed HPV-positive OPSCC.

Anaplastic Thyroid Carcinoma, Version 2.2015

This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Thyroid Carcinoma focuses on anaplastic carcinoma because substantial changes were made to the systemic therapy recommendations for the 2015 update. Dosages and frequency of administration are now provided, docetaxel/doxorubicin regimens were added, and single-agent cisplatin was deleted because it is not recommended for patients with advanced or metastatic anaplastic thyroid cancer.

Head and Neck Cancers, Version 1.2015

These NCCN Guidelines Insights focus on recent updates to the 2015 NCCN Guidelines for Head and Neck (H&N) Cancers. These Insights describe the different types of particle therapy that may be used to treat H&N cancers, in contrast to traditional radiation therapy (RT) with photons (x-ray). Research is ongoing regarding the different types of particle therapy, including protons and carbon ions, with the goals of reducing the long-term side effects from RT and improving the therapeutic index. For the 2015 update, the NCCN H&N Cancers Panel agreed to delete recommendations for neutron therapy for salivary gland cancers, because of its limited availability, which has decreased over the past 2 decades; the small number of patients in the United States who currently receive this treatment; and concerns that the toxicity of neutron therapy may offset potential disease control advantages.

Portrait of a process: arts-based research in a head and neck cancer clinic

The role of art in medicine is complex, varied and uncertain. To examine one aspect of the relationship between art and medicine, investigators analysed the interactions between a professional artist and five adult patients with head and neck cancer as they cocreated portraits in a clinical setting. The artist and four members of an interdisciplinary team analysed the portraits as well as journal entries, transcripts of portrait sessions and semistructured interviews. Over the course of 5 months, 24 artworks evolved from sittings that allowed both the patients and the artist to collaborate around stories of illness, suffering and recovery. Using narrative inquiry and qualitative arts-based research techniques five emergent themes were identified: embracing uncertainties; developing trusting relationships; engaging in reflective practices; creating shared stories; and empowerment. Similar themes are found in successful physician-patient relationships. This paper will discuss these findings and potential implications for healthcare and medical education.

Cancers of major salivary glands

Major salivary gland malignancies are a rare but histologically diverse group of entities. Establishing the diagnosis of a malignant salivary neoplasm may be challenging because of the often minimally symptomatic nature of the disease, and limitations of imaging modalities and cytology. Treatment is centered on surgical therapy and adjuvant radiation in selected scenarios. Systemic therapy with chemotherapeutic agents and monoclonal antibodies lacks evidence in support of its routine use.

Head and neck cancers, Version 2.2014. Clinical practice guidelines in oncology

This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Head and Neck Cancers focuses on glottic laryngeal cancer, which is the most common type of laryngeal cancer and has an excellent cure rate. The lymphatic drainage of the glottis is sparse, and early stage primaries rarely spread to regional nodes. Because hoarseness is an early symptom, most glottic laryngeal cancer is early stage at diagnosis. Updates to these guidelines for 2014 include revisions to "Principles of Radiation Therapy" for each site and "Principles of Surgery," and the addition of a new section on "Principles of Dental Evaluation and Management."

Thyroid carcinoma, version 2.2014

These NCCN Guidelines Insights focus on some of the major updates to the 2014 NCCN Guidelines for Thyroid Carcinoma. Kinase inhibitor therapy may be used to treat thyroid carcinoma that is symptomatic and/or progressive and not amenable to treatment with radioactive iodine. Sorafenib may be considered for select patients with metastatic differentiated thyroid carcinoma, whereas vandetanib or cabozantinib may be recommended for select patients with metastatic medullary thyroid carcinoma. Other kinase inhibitors may be considered for select patients with either type of thyroid carcinoma. A new section on "Principles of Kinase Inhibitor Therapy in Advanced Thyroid Cancer" was added to the NCCN Guidelines to assist with using these novel targeted agents.

A frailty index identifies patients at high risk of mortality after tracheostomy

OBJECTIVE

To evaluate the utility of a modified frailty index as an indicator of postoperative mortality in patients undergoing tracheostomy.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care veterans hospital.

SUBJECTS AND METHODS

A chart review was conducted of consecutive tracheostomies performed between April 2007 and September 2012. A modified frailty index consisting of 11 items based on the Revised Minimum Data Set Mortality Rating Index (MMRI-R) was retrospectively applied using the patient's status immediately prior to tracheostomy. The resultant 6-month calculated mortality risk was compared with both the Veterans Health Administration Surgical Quality Improvement Program's (VASQIP) 30-day calculated mortality and actual mortality.

RESULTS

One hundred consecutive tracheostomies were analyzed. No patients were excluded. Sixty-nine patients died within the study period, with 1-, 6-, and 12-month mortality rates of 25%, 43%, and 59%, respectively. The average calculated 6-month mortality risk using the modified frailty index was 40.5% for nonsurvivors compared with 25.4% for survivors (P = .001). Both the VASQIP calculator and modified frailty index differentiated mortality risks between patients without head and neck cancer who survived less than 6 months versus those who survived longer than 6 months (P = .006 and .01). However, neither the VASQIP nor the modified frailty index differentiated mortality risks for head and neck cancer patients who survived less than 6 months versus greater than 6 months (P = .94 and .26).

CONCLUSION

A modified frailty index identifies patients without head and neck cancer at high risk of postoperative mortality after tracheostomy.

Prevention of depression with escitalopram in patients undergoing treatment for head and neck cancer: randomized, double-blind, placebo-controlled clinical trial

IMPORTANCE

Major depressive disorder develops in up to half the patients undergoing treatment for head and neck cancer, resulting in significant morbidity; therefore, preventing depression during cancer treatment may be of great benefit.

OBJECTIVE

To determine whether prophylactic use of the antidepressant escitalopram oxalate would decrease the incidence of depression in patients receiving primary therapy for head and neck cancer.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, double-blind, placebo-controlled trial of escitalopram vs placebo was conducted in a group of nondepressed patients diagnosed as having head and neck cancer who were about to enter cancer treatment. Patients were stratified by sex, site, stage (early vs advanced), and primary modality of treatment (radiation vs surgery).

MAIN OUTCOME AND MEASURE

The primary outcome measure was the number of participants who developed moderate or greater depression (scores on the Quick Inventory of Depressive Symptomology-Self Rated of ≥11).

RESULTS

From January 6, 2008, to December 28, 2011, 148 patients were randomized. Significantly fewer patients receiving escitalopram developed depression (24.6% in the placebo group vs 10.0% in the escitalopram group; stratified log-rank test, P = .04). A Cox proportional hazards regression model compared the 2 treatment groups after controlling for age, baseline smoking status, and stratification variables. The hazard ratio of 0.37 (95% CI, 0.14-0.96) demonstrated an advantage of escitalopram (P = .04). Patients undergoing radiotherapy as the initial modality were significantly more likely to develop depression than those undergoing surgery (radiotherapy compared with surgery group; hazard ratio, 3.6; 95% CI, 1.38-9.40; P = .009). Patients in the escitalopram group who completed the study and were not depressed rated their overall quality of life as significantly better for 3 consecutive months after cessation of drug use.

CONCLUSIONS AND RELEVANCE

In nondepressed patients undergoing treatment for head and neck cancer, prophylactic escitalopram reduced the risk of developing depression by more than 50%. In nondepressed patients who completed the trial, quality of life was also significantly better for 3 consecutive months after cessation of drug use in the escitalopram group. These findings have important implications for the treatment of patients with head and neck cancer.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00536172.

Human papilloma virus positive oropharyngeal squamous cell carcinoma: a growing epidemic

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing despite a decrease in tobacco use. Almost 20-30% of patients with OPSCC do not have the traditional risk factors of smoking and alcohol use and in a vast majority of these patients, the human papilloma virus (HPV) appears to drive the malignant transformation. HPV induced malignant transformation is attributed to two viral oncogenes and their non-structural protein products (E6 and E7). These two proteins appear to affect carcinogenesis by their inhibitory effects on p53 and retinoblastoma proteins (Rb). Patients with HPV mediated OPSCC seem to have a better prognosis compared to their non-HPV counterparts. However, in the absence of strong evidence, standard of care at this time for OPSCC does not differ based on HPV status. Current research is focused on the role of de-escalation of treatment and elucidation of prognostic markers in this unique population. This review focuses on the pathogenesis of HPV mediated OPSCC and details the current evidence in the management of these patients.

Improved Resource Use following Vascularized Tissue Transfer: Mandatory Intensive Care Unit Stay Is Unnecessary

Objectives:

1) Analyze the impact of elimination of mandatory intensive care stay for patients following vascularized tissue transfer for reconstruction of defects following major head and neck surgical procedures. 2) Propose efficient, cost effective hospital pathways for care of patients following vascularized tissue transfer. 3) Demonstrate portability of such pathways between academic and community based practices.

Methods:

We performed a retrospective study involving two groups of adult patients who underwent vascularized free tissue transfer at a head and neck oncology practice at an academic and a community based hospital between July 2007 and June 2012. The first group of patients mandatorily received their immediate postoperative care in an intensive care unit. Following the institution of a specialized head and neck surgical unit, group 2 was cared for in a protocol driven, non intensive care unit setting. Outcomes and costs were compared between the two patient groups.

Results:

There was no adverse impact on rate of flap failure, inpatient mortality, and overall length of hospitalization. In contrast, a significant reduction in healthcare costs was observed when patients were routinely admitted to the head and neck surgery floor, instead of mandatory postoperative intensive care stay.

Conclusions:

1) Mandatory admission to intensive care following vascularized free tissue transfer for flap monitoring is unnecessary. 2) Results can be replicated in both an academic and community hospital setting.

Head and neck cancers, version 2.2013. Featured updates to the NCCN guidelines

These NCCN Guidelines Insights focus on nutrition and supportive care for patients with head and neck cancers. This topic was a recent addition to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Head and Neck Cancers. The NCCN Guidelines Insights focus on major updates to the NCCN Guidelines and discuss the new updates in greater detail. The complete version of the NCCN Guidelines for Head and Neck Cancers is available on the NCCN Web site (NCCN.org).

Ultrasound for localization in primary hyperparathyroidism

OBJECTIVE

To evaluate the capability of ultrasound for preoperative localization in primary hyperparathyroidism.

STUDY DESIGN

Prospective study.

SETTING

Multi-institutional Midwest Head and Neck Cancer Consortium.

SUBJECTS AND METHODS

Two hundred twenty patients who underwent preoperative localization and had parathyroid surgery were evaluated. The findings of preoperative localization studies were correlated with surgical findings.

RESULTS

Preoperative ultrasonography, sestamibi scintigraphy, or both were obtained in 77%, 93%, and 69% of the patients, respectively. Preoperative ultrasonography and sestamibi scintigraphy localized an abnormality in 71% and 79% of patients, respectively. At the time of surgery, the localization by ultrasound was accurate in 82%. The accuracy of localization was similar for sestamibi scintigraphy (85%). In patients with inaccurate ultrasound localization, the sestamibi scintigraphy correctly identified the site of disease in only 45%. In patients with a nonlocalizing ultrasound, sestamibi scintigraphy was able to localize disease in only 47%, with 2 being in the mediastinum.

CONCLUSIONS

Ultrasonography is an acceptable initial localization study for patients with primary hyperparathyroidism. In patients with nonlocalizing ultrasound, sestamibi scintigraphy should be obtained, but can be expected to detect an abnormality in less than 50% of patients.

Outcomes after thyroidectomy and parathyroidectomy

BACKGROUND

Previous reports on postoperative outcomes following thyroid and parathyroid surgery are limited by relatively small sample size. We report 30-day outcomes following thyroid and parathyroid surgery and analyze factors affecting length of stay (LOS) and postoperative adverse events (AEs).

METHODS

The multicenter, prospective, National Surgical Quality Improvement Program (NSQIP) datasets (2007/2008) were used. Multivariable logistic regression and analysis of covariance (ANCOVA) were performed.

RESULTS

Patients undergoing thyroidectomy, parathyroidectomy, or both were identified (n = 13,380, 6154, 1535, respectively). Thirty-day mortality was 0.08%, 0.16%, and 0.2%, respectively; 30-day morbidity was 3.50%, 3.02%, and 4.04%, respectively. Mean LOS values were 1.1 ± 1.4, 1.1 ± 2.1, and 1.4 ± 3.1 days, respectively. Congestive heart failure, dependent functional status, dialysis dependence, and chronic corticosteroid use were significantly associated with increased LOS and postoperative AE.

CONCLUSIONS

Morbidity and mortality rates following thyroid and parathyroid surgery are low. These data could be used by third-party interests, and surgeons should be aware of them to ensure their outcomes are in the national norm.

Portraits of care: medical research through portraiture

The Portraits of Care study used portraiture to investigate ideas about care and care giving at the intersection of art and medicine. The study employed mixed methods involving both qualitative and quantitative research techniques. All aspects of the study were approved by the Institutional Review Board. The study included 26 patient and 20 caregiver subjects. Patient subjects were drawn from across the lifespan and included healthy and ill patients. Caregiver subjects included professional and familial caregivers. All subjects gave their informed consent for the study and the subsequent exhibition of artwork. The artist drew or painted 100 portraits during the 2-year study. A multi-disciplinary analysis team carried out the initial analysis of portraits and subject data. Findings from their qualitative analysis were used to develop a quantitative survey and qualitative journal tool that the public used to give feedback at the subsequent exhibition. Exhibition data confirmed the initial findings. Study results showed the introspection of subjects that revealed their sense of identity and psychological status. Patients appear as 'whole people', not fragmented by diagnosis. Caregivers' portraits reveal their commitment to care. There is also a sense of mutuality and fluidity in the background stories of subjects. Many patient subjects have been caregivers and, at times, caregivers are also patients. Public data emphasised the identity transformation of subjects, the centrality of the idea of mortality, the presence of hope despite adversity, and the importance of empathy and compassion in care.

A review of depression in the head and neck cancer patient

Head and neck cancer patients experience among the highest rates of major depressive disorder of all oncology patients with an incidence of 15-50%. Correct diagnosis is critical to expeditious management. Oncologists are not always adept at making the diagnosis as medical and treatment side effects can mimic the signs and symptoms of depression. Treatment can be successful and typically involves medical, social, and psychologic interventions. Causes of depression, obtaining an accurate diagnosis, and treatment options are all discussed in this review.

Hamartomas, teratomas and teratocarcinosarcomas of the head and neck: Report of 3 new cases with clinico-pathologic correlation, cytogenetic analysis, and review of the literature

Background

Germ-cell tumors (GCT) are a histologically and biologically diverse group of neoplasms which primarily occur in the gonads but also develop at different extragonadal sites in the midline of the body. The head and neck region including the upper respiratory tract is a very rare location for such tumors in both children and adults, which can cause diagnostic and therapeutic difficulties.

Methods

We describe here two new cases of multilineage tumors including sinonasal teratocarcinosarcoma [SNTCS], and congenital oronasopharyngeal teratoma (epignathus) and compare their features with those of a new case of a rare salivary gland anlage tumor [SGAT], an entity for which the pathogenesis is unclear (i.e. hamartoma versus neoplasm). We correlate their presenting clinico-pathological features and compare histologic and cytogenetic features in an attempt to elucidate their pathogenesis and biologic potentials.

Results and discussion

Cytogenetic analysis revealed chromosomal abnormalities only in the case of SNTCS that showed trisomy 12 and 1p deletion. Both cytogenetic abnormalities are characteristically present in malignant germ cell tumors providing for the first time evidence that this rare tumor type indeed might represent a variant of a germ cell neoplasm. The SGAT and epignathus carried no such cytogenetic abnormalities, in keeping with their limited and benign biologic potential.

Conclusion

The comparison of these three cases should serve to emphasize the diversity of multilineage tumors (hamartomas and GCT) of the upper respiratory tract in regards to their biology, age of presentation and clinical outcomes. Malignant tumors of germ cell origins are more likely to affect adults with insidious symptom development, while benign tumors can nevertheless cause dramatic clinical symptoms which, under certain circumstances, can be fatal.

A randomized, placebo-controlled trial of citalopram for the prevention of major depression during treatment for head and neck cancer

OBJECTIVE

To determine whether prophylactic treatment with the antidepressant citalopram hydrobromide, compared with placebo, could prevent major depressive disorder in patients undergoing therapy for head and neck cancer (HNC).

DESIGN

Prospective, randomized, placebo-controlled trial.

SETTING

Academic medical center.

PATIENTS

Thirty-six subjects were randomized, and 23 completed the study.

INTERVENTIONS

Subjects were randomized to receive 40 mg of citalopram hydrobromide or matching placebo (herein after, citalopram group and placebo group, respectively) for 12 weeks with a final visit at 16 weeks.

MAIN OUTCOME MEASURES

The Hamilton Depression Rating Scale, psychiatric interview, and the University of Washington Quality of Life (UW-QOL) and Clinician Global Impression-Severity (CGI-S) scales.

RESULTS

The numbers of subjects who met predefined cutoff criteria for depression during the 12 weeks of active study were 5 of 10 (50%) taking placebo and 2 of 12 (17%) taking citalopram (Fisher exact test, P = .17). No patients in the citalopram group became suicidal, compared with 2 in the placebo group. Global mood state at the conclusion of the study as measured by the CGI-S scale was rated as at least mildly ill in 15% of those receiving citalopram compared with 60% in the placebo group (Fisher exact test, P = .04). Quality of life, measured by the UW-QOL, deteriorated in both groups from baseline but less so in the citalopram group.

CONCLUSIONS

This study reports data from the first depression prevention trial in HNC and suggests that prophylactic treatment may decrease the incidence of depression during HNC therapy. The clinical significance of the reduction in depression was best demonstrated by the CGI-S scale, which showed a notable difference in global psychiatric and physical well-being.