How applicable is the TNM 8 staging for human papillomavirus (HPV) related oropharyngeal squamous cell carcinoma (OPSCC) to a UK population of 106 patients? : A cohort comparison of the TNM 7 and TNM8 staging systems for HPV positive oropharyngeal cancer in a UK population

PURPOSE

TNM8 introduced a new staging system for HPV positive oropharyngeal squamous cell carcinoma (OPSCC). This study aimed to investigate whether the changes made in TNM8 offer the perceived benefit in prognostication when compared to TNM7 in a specific patient population in the North East of England.

METHODS

A retrospective cohort comparison study of all patients with HPV positive OPSCC (n = 106) through the Newcastle Head and Neck MDT between January 2012 to December 2014. Overall survival (OS) and Disease specific survival (DSS) data at 3 years was gathered for both TNM7 and TNM8. Log rank test was used to compare survival curves. Harrell's C-index adjusted for age and smoking status was used to assess prognostic ability of the two staging methods.

RESULTS

TNM8 downstages disease (TNM7 stage IV patients n = 74, TNM8 stage IV patients n = 2) but gives a more even distribution of patients across disease stages. Survival for TNM8 stage II and III is similar. In our small cohort, the log-rank test detected differences in OS between stages for both scoring methods (TNM7 p = 0.006, TNM8 p < 0.001) and similarly for DSS (TNM7 p = 0.001, TNM8 p < 0.001). Harrell's C-index was similar for both models for OS (TNM7 0.71, TNM8 0.71) and DSS (TNM7 0.74, TNM8 0.70).

CONCLUSION

TNM8 downstages disease and prognosticates well for stage I disease but does not differentiate between stage II and III disease when compared to TNM7. Further adaptation is required to address this to make TNM8 a more accurate prognostic tool.

Trans-oral robotic assisted tongue base mucosectomy for investigation of cancer of unknown primary in the head and neck region. The UK experience

OBJECTIVES

The diagnosis of cancer of unknown primary (CUP) in head and neck occurs when the treating clinicians have utilised all available diagnostic tests and failed to identify the origin of the disease. There is no agreed consensus on which diagnostic investigations to use, or the order in which to use them in, although broad recommendations exist. Small tumours arising in the tongue base can be below the limits of resolution of conventional diagnostic techniques. Given the difficulty in targeting the tongue base, current practice involves blind random biopsies, which leads to a variable detection rate. Robotically assisted surgical removal of the tongue base, tongue base mucosectomy (TBM) has been shown to improve diagnostic yield. This study reports the diagnostic hit rate for tongue base primaries using this technique.

DESIGN

Retrospective case review.

SETTING

UK Head and Neck Centres.

PARTICIPANTS

Patients presenting as an unknown primary, investigated with clinical examination, PET-CT and palatine tonsillectomy.

MAIN OUTCOME MEASURES

The detection of a primary site of head and neck cancer in the otherwise unknown primary tumour.

RESULTS

The primary tumour site was identified in the tongue base in 53% (n=17) of patients. In 15 patients the tumour was in the ipsliateral tongue base (88%) while in two cases (12%) the tumour was located in contra lateral tongue base.

CONCLUSIONS

Trans-oral robotic assisted TBM raises the possibility of identifying over 50% of tumours that would otherwise be classified as CUP. Identifying these in the contralateral tongue base has implications for treatment planning and outcome.

Optimizing the assessment of quality of life after laryngeal cancer treatment

Reports of the impact of larynx cancer treatment modality on quality of life are conflicting, in part due to varying study methodology. The aims of this study were to (1) provide preliminary comparisons of quality of life following radiotherapy or combination therapy; (2) evaluate a number of measures of quality of life and thereby (3) inform future prospective studies. Thirty-six laryngeal cancer patients, 24 following radiotherapy, 12 following radiotherapy and laryngectomy completed the Functional Assessment of Cancer Therapy (FACT) - General/Head and Neck subscale; Nottingham Health Profile (NHP); and the Hospital Anxiety and Depression scale (HAD), three to 12 months post-treatment. Results showed trends towards a less good quality of life in the combined therapy group over a wide range of outcomes, significant for the disease specific FACT head and neck subscale, NHP emotion (p = 0.04) and isolation (p = 0.027). To the authors' knowledge, however, this is the first demonstration of greater impact of laryngeal cancer on quality of life in younger subjects, who had lower scores among others on emotional wellbeing (p = 0.015) and anxiety (p = 0.035). Younger patients thus appear more likely to need more intensive support through treatment. Many of the physical and psychosocial domains derived from the three tools used were highly correlated. In other words, given the known high morbidity of the disease and its treatment, the selection of tools for head and neck quality of life assessment may be much less important than their universal application.

T-cell lymphoma presenting as acute mastoiditis with a facial palsy

Isolated T-cell lymphomas affecting only the mastoid are extremely rare. Presentation with oto-neurological signs prior to systemic involvement of a lymphoproliferative disease is also unusual. This is the youngest reported patient with a peripheral T-cell lymphoma with disease isolated only in the mastoid who presented with acute mastoiditis and a complete seventh cranial nerve palsy.

Tracheostomy, lingular tonsillectomy and sleep-related breathing disorders

Laser resection of lingual tonsils and formal closure of a tracheostomy improved the airway in a 14-yr-old patient with Down's syndrome. Non-invasive airway support to treat obstructive sleep apnoea was postponed with this treatment. During the anaesthetic a laryngeal mask airway was used to support the airway after lingual tonsillectomy, to assess the suitability of defunctioning the tracheostomy. Laryngeal mask airways assist management of lingual tonsils. Lingual tonsillar hypertrophy can lead to obstructive sleep disorders.

Adenoid cystic carcinoma of the head and neck

Adenoid cystic carcinoma (ACC) is a rare malignant tumour believed to arise from the epithelial cells of mucous-secreting glands. It is a slow-growing but aggressive tumour with a propensity for perineural invasion. A 10 year review of 45 patients (19 males and 26 females with a median age of 56 years) treated for ACC at a single institution between 1989 and 1999 was performed to analyse factors involved in treatment failure, local control, treatment-related morbidity and mortality. The data collected were treated for survival curves according to the Kaplan-Meier method and the log-rank test was used to assess the statistical significance of the various groups. The overall survivals at 3 years and 5 years were 71% and 65%, respectively, while the disease-free survivals at 3 years and 5 years were 73% and 63% respectively. Out of the 45 patients, only six had local recurrences, yielding an 87% locoregional freedom from relapse; 16 patients (35.6%) developed distant metastases, with the lung (8/16) being the commonest site. Patients treated for tumours of the nose and paranasal sinuses experienced more morbidity than those with tumours at other sites. Positive margins, perineural invasion and solid histology of ACC were associated with increased morbidity and treatment failure. Patients treated with combined therapy did better than those who underwent a single treatment modality.

Maternal nutrition and reproduction of daughters in wild house mice (Mus musculus)

Food deprivation after weaning often has greater effects on the reproductive success of females than of males. However, if animals are deprived prenatally (that is, through food deprivation of the mother during gestation), the reproductive success of males may be more adversely affected than that of females because of a disruption in the organizational effects of testosterone in neonatal male mice. The hypotheses that daughters of female mice deprived of food during gestation would have lower reproductive success than control daughters, but that the impact of maternal food deprivation would be lower for daughters than it would be for sons, was tested. There was no difference in the proportion of daughters of food-deprived and control mothers that produced one or two litters. However, the mean number of pups weaned in the second litters by daughters of control females (5.9 +/- 0.57 SEM) was greater than the number of pups weaned by daughters of food-deprived females (4.5 +/- 0.65 SEM). There were no differences in the mean birth or weaning body weights of offspring. Therefore, maternal food deprivation in mice may have a small but significant effect on the reproductive success of daughters. However, studies of sons born to females that were subjected to the same food deprivation protocol indicate that maternal food deprivation may have a much greater effect on the reproduction of sons than on that of daughters.

Bone-anchored hearing aid quality of life assessed by Glasgow Benefit Inventory

OBJECTIVE/HYPOTHESIS

The bone-anchored hearing aid (BAHA) is a well established mode of treatment and many studies show the audiological benefit, but none has assessed the benefit to the quality of life of patients. This study uses the validated Glasgow Benefit Inventory to quantify the changes in quality of life.

STUDY DESIGN

Retrospective questionnaire study.

METHODS

Sixty consecutive patients receiving treatment with BAHA were enrolled in the study. The male/female ratio was 1.26 to 1; mean patient age was 45 years. The most common indication was hearing loss secondary to mastoid disease and surgery followed by congenital atresia and chronic discharge from the ear.

RESULTS

The response rate was 85%, which is high and adds weight to the results. The general benefit score was +34 (range, +27-+48), which is comparable to middle ear surgery but just below benefit from cochlear implantation. The social benefit was +21 (range, +12-+37) with only +10 (range, +2-+26) for the physical score. This pattern mirrors that reported for other ear interventions. Maximum benefit was noted in patients with congenital atresias followed by discharging mastoid cavities.

CONCLUSION

This study is the first to demonstrate significant quality of life benefit from BAHA surgical intervention as measured by the Glasgow Benefit Inventory.

Social dominance rank and accessory sex glands in wild adult male house mice born to food-deprived mothers

Food deprivation after weaning often has greater effects on the reproduction of females than males. However, if animals are deprived prenatally (i.e., through deprivation of the mother during gestation), the reproduction of males may be more negatively impacted because it may decrease their ability to compete with other males and their attractiveness to females. We tested the predictions that adult sons of females that are food-deprived during gestation would tend to lose agonistic encounters with sons of well-nourished (control) females and would have smaller accessory sex glands as well. Sons of control mothers were more frequently dominant to sons of deprived mothers. They also had heavier vesicular-coagulating gland complexes and tended to have heavier preputial glands. However, among males that had not been tested for social dominance rank, there were no such differences in accessory gland weights. These data indicate that maternal food deprivation affects sons only if they engage in agonistic encounters. These effects may be due to a disruption of the organizational effects of testosterone that occur in neonatal male mice and they are likely to have a strong negative impact on the reproduction of the sons of deprived mothers.

Bone-anchored hearing aid: quality of life assess by glasgow benefit inventory

INTRODUCTION: The bone-anchored hearing aid (BAHA) uses the system of osseointegration described by Branemark. It is a well-established mode of treatment and many studies show the audiological benefit, but none have assessed the benefit to the quality of life of patients who underwent this surgical intervention. This study uses the validated Glasgow Benefit Inventory (GBI) to quantify the changes in quality of life. The GBI is a specific patient-orientated questionnaire designed to look at the changes in health status secondary to an ORL intervention.1 The GBI gives an overll scorek, but also subscores of general, social and physical benefits. METHOD: Sixty consecutive BAHA patients were enrolled in the study. The male: female ratio was 1 : 26, with a mean age of 45 years. The most common indication was hearing loss secondary to mastoid disease/surgery followed by congenital atresia and chronically discharging ear. The mean bone conduction of the better ear was 19 dB and the mean conductive loss across the speech frequencies was 58 dB. Only patients who were fitted with the classic model were included in the study. RESULTS: The response rate was > 70%, which is high and adds weight to the results. The general benefit score was + 40 which is comparable to middle ear surgery, but just below benefit from chochlear implantation. The social benefit was + 27 with only + 10 for the physical score. This pattern mirrors that reported for other ear interventions. CONCLUSION: This paper is the first to demonstrate that there is significant quality of life benefit from BAHA surgical intervention as measured by the GBI.

Leiomyomatous hamartoma of the posterior tongue: a case report

A case of a rare leiomyomatous hamartoma arising in the posterior tongue of a sixteen-month-old male is reported. There has been no recurrence following simple excision and presenting symptoms of choking on swallowing have resolved. Most other leiomyomatous hamartomas in the upper aerodigestive tract have been reported in Japanese patients and have involved the maxillary gingiva and hard palate.

Ramsay Hunt syndrome mimicking acoustic neuroma on MRI

The authors present a case of Ramsay Hunt syndrome in whish the MRI appearance mimicked that of an intracanalicular acoustic neuroma.

A study of haemostasis following tonsillectomy comparing ligatures with diathermy

The use of diathermy to achieve haemostasis after tonsillectomy remains controversial. We have reviewed the English language literature, and found no convicting evidence that diathermy is any more likely to cause post-operative haemorrhage than the use of ligatures. The results of a prospective, randomized study of 1036 consecutive tonsillectomies are presented. No significant difference was found in post-operative haemorrhage rates when either diathermy or ligatures were used. Diathermy was found to reduce operating time compared to ligatures. The possibilities for day-case tonsillectomy are discussed.

Reinnervation of skeletal muscle: a comparison of nerve implantation with neuromuscular pedicle transfer in an animal model

In recent years there has been increased interest in the possibility of reinnervating paralyzed muscles, particularly the muscles of the face and of the larynx. There has been dispute over the relative effectiveness of different approaches. This study was undertaken to compare direct nerve implantation with the transfer of a neuromuscular pedicle using denervated strap muscles in a rabbit model. Reinnervation was carried out both immediately after denervation and after a delay period. Evidence of return of function was obtained by a method of long-term electromyographic monitoring and was confirmed electrically by evoked electromyography and muscle tension measurement and histologically by brain stem uptake of horseradish peroxidase. Both methods of nerve transfer produced consistently functional neuromuscular units, with physiological activity and muscle strength comparable with those in normally innervated controls. Return of function was apparent within 6 weeks of both nerve implantation and neuromuscular transfer; with this model, neither method showed a clear advantage over the other.

Synchronous parotid tumors of different histological types in association with metastasizing hypopharyngeal carcinoma

At operation for metastasizing carcinoma of the piriform sinus a patient was found to have two separate parotid tumors, one a pleomorphic adenoma and the other a papillary cystadenoma lymphomatosum (Warthin's tumor). These tumors presented as palpable masses on the same side as a lymph node involved with carcinoma. Synchronous parotid tumors of different types are rare; previous reports in the literature show that this combination of pleomorphic adenoma and Warthin's tumor is the most common. We have found no previous report of multiple parotid neoplasms in a patient with coexistent squamous carcinoma of the head and neck.

Interstitial irradiation for squamous carcinoma of the oral cavity

Interstitial radiation delivered by iridium 192 implants was used to treat 38 patients with squamous carcinoma of the oral cavity. Thirty-six patients had either T1 or T2 tumours and no patient had palpable nodes at the time of implantation. Control of the primary tumour was achieved in all but 2 patients; these 2 were successfully treated by surgery. Fifteen patients (39%) went on to develop metastatic neck nodes. Nine were cured by radical neck dissection but the remaining 6 died of their disease. This gives a 5-year actuarial survival of 81%. Since all deaths occurred after the development of metastatic disease in the neck with control of the primary lesion, the evidence for and against prophylactic treatment of the neck lymphatics in clinically negative necks was reviewed. Prophylactic irradiation of the neck is probably preferable to any form of neck dissection but clear evidence that this improves long-term survival compared with careful follow-up and radical neck dissection for palpable nodes is still lacking.

Aspergillosis of the maxillary sinuses in otherwise healthy patients

There is an increasing number of reports of fungal infections of the nose and paranasal sinuses, due in part to increasing recognition of this condition in both healthy and immunologically depressed patients. Three cases of aspergillosis of the maxillary sinus are presented, one of which demonstrates bone destruction in an otherwise healthy individual. In diagnosing aspergillosis sinusitis it is important to submit material for microscopic examination, as cultures are often negative for fungus. Treatment consists of surgery to establish good aeration and drainage with the addition of antifungal drugs in selected cases.