Prevalence of pituitary hormone dysfunction following radiotherapy for sinonasal and nasopharyngeal malignancies

BACKGROUND

There are limited studies and no surveillance protocols on pituitary dysfunction for adults who underwent anterior skull base radiation.

METHODS

Cross-sectional study of 50 consecutive patients with sinonasal or nasopharyngeal cancer who underwent definitive radiotherapy. The mean radiation doses, prevalence of pituitary dysfunction, and associated factors were calculated.

RESULTS

Pituitary hormone levels were abnormal in 23 (46%) patients, including 6 (12%) with symptomatic abnormalities requiring treatment. The most common hormonal abnormality was hyperprolactinemia (30%), central hypothyroidism (8%) and central hypogonadism (6%). Patients with abnormal pituitary hormone values received higher mean radiation doses to the pituitary gland (1143 cGy, P = 0.04), pituitary stalk (1129 cGy, P = 0.02), optic chiasm (1094 cGy, P = 0.01), and hypothalamus (900 cGy, P = 0.01).

CONCLUSIONS

Nearly half of the patients had abnormal pituitary function, including over a tenth requiring treatment. There may be a dose-dependent association between hormonal dysfunction and radiation.

Neoadjuvant chemotherapy for locoregionally advanced squamous cell carcinoma of the paranasal sinuses

BACKGROUND

Squamous cell carcinoma is the most common type of sinonasal malignancy. Despite improvements in surgical resection and adjuvant therapy, which are considered the standard of care, the outcome for patients with locoregionally advanced disease remains poor. The objective of this study was to investigate the role of induction chemotherapy in patients with locoregionally advanced sinonasal squamous cell carcinoma and to determine the oncologic outcomes in those patients.

METHODS

The study included 123 consecutive patients with previously untreated, locoregionally advanced (stage III and IV) sinonasal squamous cell carcinoma who were treated with curative intent at The University of Texas MD Anderson Cancer Center between 1988 and 2017 with induction chemotherapy followed by definitive local therapy. Patient demographics, tumor staging, treatment details, and oncologic outcomes were reviewed. The outcomes of this study included response to induction chemotherapy, recurrence, organ preservation, and survival.

RESULTS

The median follow-up was 32.6 months (range, 12.4-240 months). Of the 123 patients, 110 (89%) had T4 disease, and 13 (11%) had T3 disease. Lymph node metastasis at the time of presentation was observed in 36 patients (29.3%). The overall stage was stage IV in 111 patients (90.2%) and stage III in 12 patients (9.8%). The chemotherapy regimen consisted of the combination of a platinum and taxanes in most cases (109 patients; 88.6%), either as a doublet (41 patients) or in combination with a third agent, such as 5-fluorouracil (34 patients), ifosfamide (26 patients), or cetuximab (8 patients). After induction chemotherapy, 71 patients (57.8%) achieved at least a partial response, and 6 patients had a complete response. Subsequent treatment after induction chemotherapy was either: 1) definitive chemoradiation or radiation followed by surgical salvage for any residual disease, or 2) surgery followed by adjuvant radiation or chemoradiation. Overall, 54 patients (49.5%) underwent surgical resection. The 2-year overall and disease-free survival rates for the whole cohort were 61.4% and 67.9%, respectively. The rate of orbital preservation was 81.5%. The recurrence rate was 26.8% (33 patients), and distant metastases occurred in 8 patients (6.5%). Patients who had at least a partial response or stable disease had significantly better overall and disease-free survival than those who had progressive disease (P = .028 and P = .021, respectively).

CONCLUSIONS

The current results indicate that a high proportion of patients with sinonasal squamous cell carcinoma achieved a favorable response to induction chemotherapy. The data suggest that response to induction chemotherapy is associated with an improved outcome and a good chance of organ preservation. The oncologic outcomes in this cohort with locally advanced (mostly T4) disease are better than those historically reported in the literature. Further study of induction chemotherapy in patients with advanced sinonasal squamous carcinoma is warranted.

Evaluating Perineural Spread to the Intratemporal Facial Nerve on Magnetic Resonance Imaging

Objectives

To determine the sensitivity and specificity of magnetic resonance imaging (MRI) for the detection of perineural spread (PNS) along the intratemporal facial nerve (ITFN) in patients with head and neck cancers.

Study Design

Case series with chart review.

Setting

Tertiary care center.

Subjects and Methods

We included 58 patients with head and neck malignancies who underwent sacrifice of the ITFN between August 1, 2002, and November 30, 2015. Demographics, preoperative facial nerve function, prior oncologic treatment, and timing between MRI and surgery were recorded. Histopathology slides and preoperative MRI were reviewed retrospectively by a neuropathologist and a neuroradiologist, respectively, both blinded to clinical data. The mastoid segment of the facial nerve (referred to as the descending facial nerve [DFN]) and stylomastoid foramen (SMF) were evaluated separately. A grading system was devised when radiographically assessing PNS along the DFN.

Results

Histopathologic evidence of PNS was found in 21 patients (36.2%). The sensitivity and specificity of MRI in detecting PNS to the DFN were 72.7% and 87.8%, respectively. MRI showed higher sensitivity but slightly lower specificity when evaluating the SMF (80% and 82.8%, respectively). Prior oncologic treatment did not affect the false-positive rate ( P = .7084). Sensitivity was 100% when MRI was performed within 2 weeks of surgery and was 62.5% to 73.3% when the interval was greater than 2 weeks. This finding was not statistically significant (SMF, P = .7076; DFN, P = .4143).

Conclusion

MRI shows fair to good sensitivity and good specificity when evaluating PNS to the ITFN.

Induction Chemotherapy Response as a Guide for Treatment Optimization in Sinonasal Undifferentiated Carcinoma

PURPOSE

Multimodal therapy is a well-established approach for the treatment of sinonasal undifferentiated carcinoma (SNUC); however, the optimal sequence of the various treatments modalities is yet to be determined. This study aimed to assess the role of induction chemotherapy (IC) in guiding definitive therapy in patients with SNUC.

METHODS

Ninety-five previously untreated patients diagnosed with SNUC and treated between 2001 and 2018 at The University of Texas MD Anderson Cancer Center were included in the analysis. Patients were treated with curative intent and received IC before definitive locoregional therapy. The primary end point was disease-specific survival (DSS). Secondary end points included overall and disease-free survival, disease recurrence, and organ preservation.

RESULTS

A total of 95 treatment-naïve patients were included in the analysis. For the entire cohort, the 5-years DSS probability was 59% (95% CI, 53% to 66%). In patients who had partial or complete response to IC, the 5-year DSS probabilities were 81% (95% CI, 69% to 88%) after treatment with definitive concurrent chemoradiotherapy (CRT) after IC and 54% (95% CI, 44% to 61%) after definitive surgery and postoperative radiotherapy or CRT after IC (log-rank P = .001). In patients who did not experience at least a partial response to IC, the 5-year DSS probabilities were 0% (95% CI, 0% to 4%) in patients who were treated with concurrent CRT after IC and 39% (95% CI, 30% to 46%) in patients who were treated with surgery plus radiotherapy or CRT (adjusted hazard ratio of 5.68 [95% CI, 2.89 to 9.36]).

CONCLUSION

In patients who achieve a favorable response to IC, definitive CRT results in improved survival compared with those who undergo definitive surgery. In patients who do not achieve a favorable response to IC, surgery when feasible seems to provide a better chance of disease control and improved survival.

Frequent PTEN loss and differential HER2/PI3K signaling pathway alterations in salivary duct carcinoma: Implications for targeted therapy

BACKGROUND

Patients with advanced primary and recurrent salivary duct carcinoma (SDC), a rare and lethal malignancy, have limited therapeutic options. Novel small-molecule agents aimed at targeting critical signaling associated with SDC tumorigenesis may lead to new therapeutic options for patients with these tumors. The human epidermal growth factor receptor 2 (HER2)/phosphoinositide 3-kinase (PI3K) axis, an important oncogenic pathway, has been targeted for therapy in several solid tumors. Currently, little is known about the role and clinical implications of alterations of the HER2/PI3K pathway in patients with SDC.

METHODS

The authors investigated the clinicopathologic features, genetic alterations, and expression of key members of the HER2/PI3K pathway in 43 primary tumors and conducted in vitro functional and targeted drug-response analyses on cell lines derived from salivary epithelial carcinomas.

RESULTS

In primary tumors, loss of phosphatase and tensin homolog (PTEN) expression was identified in 22 of 43 tumors (51%), overexpression of HER2 was observed in 12 of 43 tumors (28%), and phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) mutations were identified in 12 of 43 tumors (28%). Phosphorylated protein kinase B (p-AKT) was highly expressed in most tumors. Most tumors (70%) displayed mutually exclusive alterations of PI3K members, whereas 8 tumors (19%) had 2 or more concurrent abnormalities. In vitro studies demonstrated a direct association between PTEN loss and PI3K pathway activation and evidence of response to combined PI3Kα and PI3Kβ and/or pan-PI3K inhibitors.

CONCLUSIONS

The current analyses reveal frequent PTEN loss and mutually exclusive alterations of key PI3K pathway members in SDC and demonstrate in vitro evidence of a response to pan-PI3K inhibitors. These results provide a framework for a biomarker-based substratification of patients with SDC in future targeted therapy. Cancer 2018;124:3523-32. © 2018 American Cancer Society.

Approaches to regional lymph node metastasis in patients with head and neck mucosal melanoma

BACKGROUND

Mucosal melanomas in the head and neck region are most often located in the nasal cavity and paranasal sinuses. To the authors' knowledge, the prognostic effects of lymph node metastasis in patients with sinonasal mucosal melanoma (SNMM) have not been established. Therefore, the objective of the current study was to determine the effects of lymph node metastasis on survival.

METHODS

The current study included 198 patients with SNMM who had been treated between 1985 and 2016 at The University of Texas MD Anderson Cancer Center in Houston. Patients' clinical and pathologic lymph node statuses were evaluated and characterized. A multivariate analysis was used to assess the associations between regional spread and survival outcomes.

RESULTS

Therapeutic neck dissection was performed in 23 patients with SNMM (11.6%). Regional disease recurrence occurred in 7 of the patients who had lymph node metastasis at the time of presentation (30.4%) and in 30 of those who had N0 disease at the time of presentation (17.1%) (P = .15). Metastasis to the contralateral lymph nodes was present in 7 patients (3.5%). The 5-year disease-specific survival rate was 66% in patients with lymph node spread compared with 45% in patients with N0 status (P = .04, log-rank test). A multivariate analysis demonstrated that distant metastasis was the only variable found to be independently associated with both overall survival (hazard ratio, 2.96; 95% confidence interval, 1.54-6.95 [P = .01]) and disease-specific survival (hazard ratio, 3.32; 95% confidence interval, 1.79-7.14 [P = 0.01]).

CONCLUSIONS

The results of the current study demonstrated that lymph node status in patients with SNMM was not a significant predictor of outcome. This finding, together with the low incidence of lymph node metastases in patients with SNMM, suggests that elective treatment of the neck should be highly selective in this patient population. Cancer 2018;124:514-20. © 2017 American Cancer Society.

Long-Term Outcomes of Lateral Neck Dissection in Patients with Recurrent or Persistent Well-Differentiated Thyroid Cancer

BACKGROUND

Well-differentiated thyroid carcinoma (WDTC) has a high predilection for regional metastatic spread. Rates for WDTC lateral neck recurrence are reported to be as high as 24% in patients after initial thyroidectomy, lateral neck surgery, and adjuvant radioactive (RAI) iodine treatment. The objective of the study was to evaluate the efficacy, safety, and long-term outcome of comprehensive lateral neck dissection (LND) of levels II-V for recurrent or persistent WDTC in a tertiary referral center.

METHODS

This study retrospectively analyzed the standardized approach of LND for recurrent WDTC in the lateral neck compartment. Survival was analyzed by Cox regression analysis.

RESULTS

Three hundred and seven patients underwent 429 LND for cytopathology-confirmed lateral neck recurrent WDTC at the University of Texas MD Anderson Cancer Center between 1994 and 2012. The vast majority (90%) of patients were originally treated elsewhere. Multilevel lateral neck dissection had been originally performed in 80% of patients, with 17% having undergone at least two previous operations. Two hundred and sixty-seven (87%) patients had previous RAI. The most common levels of recurrence were levels III and IV (33% and 33%, respectively). Postoperative complications were seen in 7% of patients. Median follow-up was 7.2 years. In-field lateral neck control was 96% at 10 years. Overall lateral neck regional control, overall survival (OS), and disease-specific survival (DSS) at 10 years was 88%, 78%, and 91%, respectively. When stratifying by age (<24 years, 24-50 years, and >50 years), OS and DSS was significantly better in patients <50 years (OS: p < 0.001; DSS: p < 0.001). However, there was worse overall lateral neck control in the younger group (<24 years; p = 0.04). Regional recurrence after salvage LND occurred within a median time interval of 20.0 months (2.9-121.3 months), of which 2% (8/429) developed in-field lateral neck recurrences. Of those with any lateral neck recurrence after salvage LND, 24/30 (80%) patients successfully underwent another LND, resulting in an ultimate 98% lateral neck regional control rate.

CONCLUSIONS

Expert comprehensive LND of levels II-V is associated with few perioperative complications and results in very high in-field regional control rate and ultimate lateral neck control in recurrent/persistent WDTC.

Basal cell carcinoma of the temporal bone and external auditory canal

OBJECTIVES/HYPOTHESIS

To review the presenting features, treatment, and outcomes for patients with basal cell carcinoma (BCC) involving the temporal bone or external auditory canal (EAC).

STUDY DESIGN

Retrospective case series.

METHODS

Presenting characteristics, treatment strategies, and outcomes for patients with BCC involving the temporal bone or EAC were reviewed. Main outcome measures included rates of overall and disease-free survival at 5 years.

RESULTS

Forty-two patients met the inclusion criteria (mean age, 67 years). The most common presenting symptoms were hearing loss (15 patients, 36%) and otorrhea (11 patients, 26%). The 5-year overall survival rate was 78%, and the 5-year disease-free survival rate was 77%. Patients who had undergone surgery elsewhere and presented with facial weakness had significantly worse overall survival (P = .004). Ten patients (24%) underwent sacrifice of at least a portion of the facial nerve at the time of their initial procedure at our institution. Two patients (5%) developed regional nodal disease. There was a trend toward better disease-free survival for patients who received adjuvant radiation therapy after surgery at our institution (P = .06).

CONCLUSIONS

BCC originating from or extending to the temporal bone can exhibit a wide range of behavior, ranging from superficial lesions readily managed with surgery to extensive locally invasive tumors with propensity for recurrence, treated with multimodality therapy. BCC may be associated with better prognosis than other temporal bone malignancies.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1425-1430, 2018.

Mutation status among patients with sinonasal mucosal melanoma and its impact on survival

BACKGROUND

Sinonasal mucosal melanoma (SNMM) comprises <1% of all melanomas and lacks well-characterised molecular markers. Our aim was to determine the frequencies of common mutations and examine their utility as molecular markers in a large series of primary SNMMs.

METHODS

SNMM patients seen at our institution from August 1991 through July 2016 were identified. Genomic DNA was extracted from 66 formalin-fixed paraffin-embedded tumours and screened for mutations by direct sequencing. We investigated the association of mutations with clinicopathological features and survival outcomes.

RESULTS

Overall, 41% (27 out of 66) of the SNMMs harboured mutations. BRAF and KIT mutations were identified in 8% (five patients) and 5% (three patients) of SNMMs, respectively, whereas NRAS mutations were detected in 30% (20 patients) of SNMMs. Mutation rates in these oncogenes were similar between SNMMs located in the paranasal sinuses and those in the nasal cavity (30% and 13%, respectively, P=0.09). In a multivariate analysis, patients with negative margins had significantly better overall survival (hazard ratio 5.43, 95% confidence interval 1.44-21.85, P=0.01) and disease-specific survival (hazard ratio 21.9, 95% confidence interval 3.71-180, P=0.0004). The mutation status of the tumours showed no association with survival outcomes.

CONCLUSIONS

In SNNM, mutation status does not affect survival outcomes, but NRAS mutations are relatively frequent and could be targeted in this disease by MEK inhibitors.

Influence of timing, radiation, and reconstruction on complications and speech outcomes with tracheoesophageal puncture

BACKGROUND

We evaluated the impact of radiation, reconstruction, and timing of tracheoesophageal puncture (TEP) on complications and speech outcomes.

METHODS

Retrospective review identified 145 patients who underwent TEP between 2003 and 2007.

RESULTS

Ninety-nine patients (68%) had primary and 46 (32%) had secondary TEP, with complications occurring in 65% and 61%, respectively (p = .96). Twenty-nine patients (20%) had major complications (18 primary and 11 secondary; p = .42). Ninety-four patients (65%) had pre-TEP radiation, 39 (27%) post-TEP radiation, and 12 (8%) no radiation. With patients grouped by TEP timing and radiation history, there was no difference in complications, fluency, or TEP use. With mean 4.7-year follow-up, 82% primary and 85% secondary used TEP for primary communication (p = .66). Free-flap patients used TEP more commonly for primary communication after secondary versus primary TEP (90% vs 50%; p = .02).

CONCLUSION

Primary and secondary tracheoesophageal speakers experience similar high rates of complications. Extent of pharyngeal reconstruction, rather than radiation, may be more important in selection of TEP timing. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1765-1771, 2016.

Complications of tympanostomy tubes in head and neck cancer patients

PURPOSE

To assess myringotomy plus tympanostomy tube (MTT) complication rates in head and neck cancer (HNC) patients with otitis media (OM).

MATERIALS AND METHODS

We performed a retrospective review of 182 HNC patients with OM treated between January 2000 and October 2007 for demographic data and data about MTT-related complications, tumor type and outcomes following MTT.

RESULTS

We identified OM in 35 nasopharyngeal (NP), 34 paranasal sinus (PNS), and 24 larynx cancer patient ears; of these, 29 (83%), 31 (91%), and 22 (92%), respectively, were treated with MTT. Of the 29 NP cancer patient ears treated with MTT, 13 (45%) received MTT before radiotherapy; complications included otorrhea in 11 ears (38%), otorrhea with perforation in 3 ears (10%), and cholesteatoma in 1 ear (3%). Of the 31 PNS cancer patient ears treated with MTT, 17 (55%) received MTT before radiotherapy; complications included otorrhea in 10 ears (32%) and otorrhea with perforation in 3 ears (10%). All 22 laryngeal cancer patient ears were treated with MTT before radiotherapy; 5 ears (23%) developed chronic otorrhea. Patients with pre-existing eustachian tube dysfunction had significantly higher rates of tympanostomy tube otorrhea (p=.009).

CONCLUSIONS

The complication rates of OM in the setting of NP or PNS cancer were not significantly different regardless of intervention timing in relation to radiotherapy. Laryngectomy patients had a high rate of tympanostomy sequelae after radiotherapy. MTT for OM has high complication rates in HNC patients.

Association of TERT Promoter Mutation, But Not BRAF Mutation, With Increased Mortality in PTC

CONTEXT

Papillary thyroid carcinoma (PTC) carrying the BRAF mutation has been reported to be associated with high recurrence and potentially increased mortality. PTC carrying the TERT promoter mutation has been associated with older age, recurrence, and aggressive disease.

OBJECTIVE

The objective of this study was to determine the association of BRAF and TERT promoter gene alterations with recurrence and survival in a high-risk population.

DESIGN

Genomic DNA was analyzed for the BRAF mutation from 256 persistent/recurrent PTC (p/rPTC; 202 new, 54 previously reported) and for the TERT promoter mutation and polymorphism (242 p/rPTC). Two-tailed Fisher exact tests or the Pearson χ(2) test were performed for the associations between mutations and other variables. Overall and disease-free survivals were compared by log rank tests on Kaplan-Meier plots and by Cox regression analysis. TERT promoter constructs were tested in PTC cell lines to determine their activities in these cells.

RESULTS

BRAF V600E mutation was identified in 235 of 256 (91.8%), TERT promoter mutation at -124 was detected in 77 of 242 (31.8%), and TERT promoter polymorphism at -245 was found in 113 of 242 (46.7%) p/rPTC patients. A significant difference in survival was found in p/rPTC patients with the TERT promoter mutation, which also displayed increased activity in vitro as compared to the nonmutated promoter sequence. No association was noted between the BRAF mutation or TERT promoter polymorphism and recurrence or survival. A drawback of our study could be the limited number of patients with nonmutated BRAF (21 of 256 [8.2%]).

CONCLUSIONS

Mutation in the TERT promoter, but not in BRAF, was associated with decreased survival in 19 (24.7%) p/rPTC patients who died of disease and in 38 (49.4%) p/rPTC patients who died at last contact. The presence or absence of the BRAF mutation and TERT promoter polymorphism, however, was not significantly correlated with survival.

Sialendoscopy for Patients with Radioiodine-Induced Sialadenitis and Xerostomia

BACKGROUND

We examined outcomes in patients treated for radioactive iodine-induced sialadenitis (RAIS) and xerostomia with sialendoscopy.

METHODS

Data was prospectively collected for all patients undergoing sialendoscopy for RAIS from a single institution. Interventional details and intraoperative findings were recorded. Qualitative data were obtained through patient examination, telephone interviews, and use of a standard quality of life questionnaire, Xerostomia Questionnaire. Quantitative data were obtained from patients who underwent sialometry.

RESULTS

Twenty-six patients (24 women and 2 men; median age, 43 years; age range, 19-57 years) underwent interventional sialendoscopy after conservative management of symptoms proved unsuccessful. Sialadenitis was present in 25 patients and xerostomia in 22 patients. Mucus plugging in the duct of the gland was the most common finding (22 patients) followed by stenosis (18 patients), inflammation (eight patients), and erythema (eight patients). Median follow-up time was 23.4±12.1 months. Sixteen patients (64%) reported complete resolution; seven (28%), partial resolution; one (4%), no change in symptoms; and one (4%), regression in RAIS-related symptoms. Patients subjectively noted the following regarding their xerostomia symptoms: seven (31.8%) had complete resolution; 10 (45.5%), partial resolution; four (18.2%), no change; and one (4.5%), regression. Statistical analysis of the available sialometry data revealed a statistically significant difference in saliva production at 6 months following sialendoscopy for unstimulated saliva production (p=0.028).

CONCLUSION

Sialendoscopy is an effective treatment option for the management of RAIS and xerostomia refractory to conservative therapy and medical management. Patients in our cohort report durable improvement in symptoms after intervention.

Risk Factors and Prognosis for Myoepithelial Carcinoma of the Major Salivary Glands

BACKGROUND

The clinical behavior and treatment outcomes of salivary gland myoepithelial carcinoma have yet to be clearly defined. The current study investigated risk factors and prognoses for this tumor.

METHODS

A retrospective review of the medical records for 32 patients with myoepithelial carcinoma of the major salivary glands was performed. Their clinical parameters were assessed to identify correlations with local-regional recurrence, distant metastasis, and survival.

RESULTS

The 5-year survival rate was 71 %. Of the reviewed patients, 41 % had local-regional recurrences, and 22 % had distant metastases. Age of 60 years or younger was a predictive factor for distant metastasis. Patients with neck lymph nodes clinically positive for carcinoma had shorter overall survival durations than those with nodes negative for carcinoma.

CONCLUSIONS

Myoepithelial carcinoma of the major salivary glands is characterized by a high incidence of local-regional recurrence and distant metastasis. Adjuvant therapy is indicated for selected patients with high-risk disease.

An audit and feedback system for effective quality improvement in head and neck surgery: Can we become better surgeons?

BACKGROUND

An evaluation system was established for measuring physician performance. This study was designed to determine whether an initial evaluation with surgeon feedback improved subsequent performance.

METHODS

After an evaluation of an initial cohort of procedures (2004-2008), surgeons were given risk-adjusted individual feedback. Procedures in a postfeedback cohort (2009-2010) were then assessed. Both groups were further stratified into high-acuity procedure (HAP) and low-acuity procedure (LAP) groups. Negative performance measures included the length of the perioperative stay (2 days or longer for LAPs and 11 days or longer for HAPs); perioperative blood transfusions; a return to the operating room within 7 days; and readmission, surgical site infections, and mortality within 30 days.

RESULTS

There were 2618 procedures in the initial cohort and 1389 procedures in the postfeedback cohort. Factors affecting performance included the surgeon, the procedure's acuity, and patient comorbidities. There were no significant differences in the proportions of LAPs and HAPs or in the prevalence of patient comorbidities between the 2 assessment periods. The mean length of stay significantly decreased for LAPs from 2.1 to 1.5 days (P = .005) and for HAPs from 10.5 to 7 days (P = .003). The incidence of 1 or more negative performance indicators decreased significantly for LAPs from 39.1% to 28.6% (P < .001) and trended downward for HAPs from 60.9% to 53.5% (P = .081).

CONCLUSIONS

Periodic assessments of performance and outcomes are essential for continual quality improvement. Significant decreases in the length of stay and negative performance indicators were seen after feedback. Therefore, an audit and feedback system may be an effective means of improving quality of care and reducing practice variability within a surgical department.

Sinonasal adenocarcinoma: a 16-year experience at a single institution

BACKGROUND

Adenocarcinoma is a rare tumor of the sinonasal tract. The purpose of this study was to characterize a single institution's experience with this malignancy.

METHODS

Retrospective review was performed of patients with adenocarcinoma of the sinonasal tract from 1993 to 2009. Demographic data, disease presentation, treatment, and survival rates were collected and evaluated.

RESULTS

We identified 66 patients with sinonasal adenocarcinoma; 48 were men and 18 women. Average age at time of diagnosis was 57.1 years (range, 20-88 years), and median follow-up was 55.3 months (range, 1-238 months). The ethmoid sinus (38%) and nasal cavity (36%) were the most common sites of origin. Nasal obstruction (36%), epistaxis (30%), and nasal discharge (21%) were the most common presenting symptoms. Fifty-one percent of patients presented with T1 or T2 tumors. Surgery was the primary form of treatment in 81% of patients. Twenty-six percent of surgical patients underwent an endoscopic tumor resection. Adjuvant radiation was utilized in 50% of patients and chemotherapy in 10%. Recurrence was seen in 24 patients (37%): 29% recurred locally and 7.6% recurred distantly. The overall 5-year survival was 65.9%. Survival was decreased significantly in patients with T4 tumors (p < .05), high-grade histology (p < .05), and sphenoid sinus involvement (p < .05). Survival was not affected by surgical approach between endoscopic and open approaches (p = .76).

CONCLUSION

Sinonasal adenocarcinomas are commonly identified in the sinonasal cavity and are associated with a relatively favorable prognosis, despite a substantial local failure rate of 30%. Advanced-stage tumors, sphenoid sinus and skull base invasion, and high-grade histology portend poor prognosis. In our experience, endoscopic resection was not associated with adverse outcomes and suggests that this minimally invasive approach can provide acceptable oncologic outcomes in selected patients.

Optimization of long-term outcomes for patients with esthesioneuroblastoma

BACKGROUND

Esthesioneuroblastoma is a rare cancer of the anterior cranial base that arises in the region of the olfactory rootlets. The purpose of this study was to review the long-term outcomes of patients diagnosed with esthesioneuroblastoma (ENB) treated at a single institution to determine factors associated with improved disease control and survival.

METHODS

A retrospective review of 70 patients with ENB treated at the University of Texas MD Anderson Cancer Center between 1992 and 2007 was undertaken. Survival and recurrence was analyzed and compared using the Kaplan-Meier method and log-rank statistics.

RESULTS

Seventy patients were reviewed. The majority (77%) had T3 or T4 disease at presentation, 38% identified as modified Kadish stage C or D. Ninety percent of patients received surgical resection as part of their treatment, and 66% received postoperative radiation or chemoradiation. The median follow-up was 91.4 months (7.6 years). Forty-eight percent of patients developed recurrent disease and the median time to recurrence was 6.9 years. Overall and disease-specific median survival was 10.5 and 11.6 years, respectively. Patients who were treated with surgery alone had a median disease-specific survival of 87.9 months, whereas those who were treated with surgery and postoperative radiation had a median disease-specific survival of 218.5 months (p = .047).

CONCLUSION

Patients with ENB can achieve favorable long-term survival, even if disease is locally advanced. Survival is improved considerably when surgical resection is followed by postoperative radiation. However, recurrence rates and mortality remain high, and therefore long-term observation in these patients is warranted.

Quantitative Assessment of Outcomes for Sialendoscopy in Patients with Radioiodine-Induced Sialadenitis

Objectives:

Radioiodine (I131) is an effective adjuvant therapy following surgery in patients with high-risk thyroid cancer. Unfortunately, radioiodine treatment may result in significant xerostomia and sialadenitis. We examined outcomes in patients treated for radioiodine-induced sialadenitis with sialendoscopy.

Methods:

Data have been prospectively collected for all patients undergoing sialendoscopy at this institution. Findings of the procedure and the intervention details were recorded. Qualitative data were obtained through patient examination and use of standard quality of life questionnaires (eg, MDASI-HN and Xerostomia Questionnaire). Quantitative data were obtained from patients who underwent sialometry.

Results:

Twenty-six patients (23F/3M) with an average age of 46 yrs (range: 19-57 yrs) underwent interventional sialendoscopy for radioiodine-induced sialadenitis. Sialendoscopy was attempted on 62 glands (45 parotid and 17 submandibular glands). In 2 patients, sialendoscopy could not be completed successfully on submandibular glands. Papillary stenosis was seen in 10 (16%) of the glands treated. Six submandibular glands ducts (9.7%) required sialdochoplasty. Patients subjectively noted the following resolution of symptoms: partial resolution (18; 69.2%), complete resolution (6; 23.1%), no change (1; 3.8%), and worsening of symptoms (1; 3.8%). Preliminary statistical analysis of the sialometry data by Wilcoxon matched pairs test (nonparametric) showed that there was a statistically significant difference in saliva production at 6 months following sialendoscopy for unstimulated saliva production ( P = 0.028) but not for stimulated saliva production ( P = 0.50) as compared to baseline measurements in patients with subjective improvement.

Conclusions:

Sialendoscopy is an effective treatment option for the management of radioiodine-induced sialadenitis.

MicroRNA profiling of salivary adenoid cystic carcinoma: association of miR-17-92 upregulation with poor outcome

Background

Salivary adenoid cystic carcinoma (ACC) is a rare relentlessly progressive malignant tumor. The molecular events associated with ACC tumorigenesis are poorly understood. Variable microRNAs (miRNA) have been correlated with tumorigenesis of several solid tumors but not in ACC. To investigate the association of miRNAs with the development and/or progression of ACC, we performed a comparative analysis of primary ACC specimens and matched normal samples and a pooled salivary gland standard and correlated the results with clinicopathologic factors and validated selected miRNAs in a separate set of 30 tumors.

Methods

MiRNA array platform was used for the identification of target miRNAs and the data was subjected to informatics and statistical interrelations. The results were also collected with the MYB-NFIB fusion status and the clinicopathologic features.

Results

Differentially dysregulated miRNAs in ACC were characterized in comparison to normal expression. No significant differences in miRNA expression were found between the MYB-NFIB fusion positive and -negative ACCs. Of the highly dysregulated miRNA in ACC, overexpression of the miR-17 and miR-20a were significantly associated with poor outcome in the screening and validation sets.

Conclusion

Our study indicates that the upregulation of miR-17-92 may play a role in the biology of ACC and could be potentially targeted in future therapeutic studies.

Gastrostomy tube placement in patients with oropharyngeal carcinoma treated with radiotherapy or chemoradiotherapy: factors affecting placement and dependence

BACKGROUND

Although many patients require nutritional support during radiotherapy or chemoradiotherapy for oropharyngeal cancer, little is known regarding the risk factors that predispose to gastrostomy tube (g-tube) placement and prolonged dependence, or the therapeutic interventions that may abrogate these effects.

METHODS

We performed a retrospective medical chart review of patients who were treated for primary oropharyngeal cancer at a tertiary care center from 2003 to 2008. Patients who had a complete response at the primary site at 1-year posttreatment were included. G-tube placement and dependence ≥6 months were evaluated in relationship to site and stage of primary tumor, baseline characteristics, treatment type, smoking status, and swallowing intervention.

RESULTS

We evaluated 474 patients (79%) with oropharyngeal cancer; 215 patients (40%) had concurrent chemotherapy, 73 patients (15%) had induction chemotherapy, and 69 patients (15%) had induction chemotherapy followed by concurrent chemotherapy. Two hundred ninety-three patients (62%) received g-tubes, of which 238 (81%) received the g-tube during radiation. At 1-year follow-up, 41 patients (9%) remained dependent on enteral feedings. Placement of g-tubes and prolonged g-tube dependence were significantly more likely in patients with T3 to 4 tumors (p < .001), baseline self-reported dysphagia (p < .001), odynophagia (p < .001), >10% baseline weight loss (p < .001), and in those treated with concurrent chemoradiotherapy. Patients who reported adherence to exercises had significantly lower rates of g-tube placement (p < .001), and duration of dependence was significantly shorter in those who reported adherence to swallowing exercises (p < .001).

CONCLUSION

Almost 40% of patients with oropharyngeal cancer treated with nonsurgical organ preservation modalities may avoid feeding tube placement. Factors that predispose to g-tube placement and prolonged dependence include T3 to T4 tumors, concurrent chemotherapy, current smoking status, and baseline swallowing dysfunction or weight loss. Adherence to an aggressive swallowing regimen may reduce long-term dependence on enteral nutrition and limit the rate of g-tube placement overall.

Gastrostomy tube placement in patients with hypopharyngeal cancer treated with radiotherapy or chemoradiotherapy: factors affecting placement and dependence

BACKGROUND

Placement of gastrostomy tubes (g-tubes) in patients with hypopharyngeal cancers undergoing radiation and chemotherapy is generally empirically determined. We examined our experience to identify predictive factors for g-tube placement and length of dependence.

METHODS

We performed a retrospective review of all patients with primary hypopharyngeal cancer treated with nonsurgical modalities at a tertiary care center between 2002 and 2008. Rates of g-tube placement and length of dependence on enteral feedings were analyzed in relationship to multiple risk factors.

RESULTS

Forty-three patients with hypopharyngeal primary tumors (77%) who had a complete response at the primary site after treatment were included. Thirteen patients (30%) never required g-tube placement. At 1-year follow-up, 11 patients (28%) maintained a g-tube. No clinical variables were significantly associated with g-tube placement. Duration of g-tube dependence was significantly longer in patients with a posterior hypopharyngeal wall primary tumors (p = .026), current smokers (p = .001), and patients with >40 pack-years (p = .010). The duration of g-tube dependence was significantly shorter in those who maintained oral intake at the end of treatment (p = .05), and those who reported adherence to dysphagia exercise regimens (p = .048).

CONCLUSION

Approximately one third of patients with hypopharyngeal tumors treated on organ preservation regimens may be able to avoid g-tube placement, but further research is needed to identify clinical factors that predict g-tube placement in this population. A posterior hypopharyngeal wall primary and smoking history correlated with longer gastrostomy tube dependence. Adherence to aggressive targeted swallowing exercise regimens may help to prevent long-term dependence on feeding tubes.

Prognostic factors in mucoepidermoid carcinoma of the salivary glands

BACKGROUND

Mucoepidermoid carcinoma (MEC) is the most common malignancy of the major salivary glands. Prior reports noted histological grade and tumor stage as consistently important prognostic factors. This study reviewed the experience of patients with MEC at the University of Texas MD Anderson Cancer Center to determine the impact of clinical and pathologic findings on disease outcomes.

METHODS

A retrospective clinical review was performed of patients with salivary gland MEC treated at a tertiary cancer center from 1990 to 2007.

RESULTS

A total of 125 patients were included. The 5-year overall survival and disease-free survival of all patients were 79.3% and 76.5%, respectively. Patients with low- and intermediate-grade disease had significantly better overall survival and disease-free survival than patients with high-grade disease, but no difference in survival rates was found between low- and intermediate-grade disease. Pathologic results of positive lymph nodes, extracapsular lymph node spread, and perineural invasion were all found to be poor prognostic indicators. On multivariate analysis, advanced disease stage and perineural invasion were found to be the most significant prognostic factors.

CONCLUSIONS

Patients with either low- or intermediate-grade tumors uniformly have favorable local control and survival. High histological grade, advanced stage, perineural invasion, positive surgical margins, and submandibular location all portend for poor outcomes in MEC. Further advances in therapy are needed to improve outcomes for high-grade and advanced-stage disease.

An evolution in demographics, treatment, and outcomes of oropharyngeal cancer at a major cancer center: a staging system in need of repair

BACKGROUND

In this retrospective review, the authors examined demographic/clinical characteristics and overall survival in patients with squamous cell carcinoma of the oropharynx at a tertiary cancer center, and they report the characteristics that influenced any observed survival trends over time.

METHODS

The study included 3891 newly diagnosed, previously untreated patients who presented at the authors' institution between 1955 and 2004.

RESULTS

Over time, patients presented at younger ages and were more likely to have base of tongue or tonsil tumors and to be never-smokers or former smokers. Patients who were diagnosed between 1995 and 2004 were almost half as likely to die as those who were diagnosed before 1995 (hazard ratio, 0.6; 95% confidence interval, 0.6-0.8). In both multivariable and recursive partitioning survival analyses, the TNM staging system predicted the survival of patients who received treatment before 1995 but did not predict the survival patients treated during the period from 1995 to 2004.

CONCLUSIONS

Survival among patients with squamous cell carcinoma of the oropharynx improved substantially over the past 50 years. The main contributing factors were changes in clinical characteristics, in particular surrogates for positive human papillomavirus status. The current TNM staging system for squamous cell carcinoma of the oropharynx is inadequate. The incorporation of human papillomavirus status and perhaps smoking status into the TNM system is encouraged.

The oncology of otology

OBJECTIVES/HYPOTHESIS

To describe the population of patients with malignancy affecting the ear canal and temporal bone.

STUDY DESIGN

Retrospective review.

METHODS

The charts of 157 patients with temporal bone cancer were reviewed for clinical outcomes.

RESULTS

Between 1999 and 2009, 157 patients underwent temporal bone surgery for cancer involving the ear canal (n = 25), external ear with ear canal involvement (n = 26), periauricular skin (n = 40), parotid gland (n = 40), temporal bone (n = 13), and lateral skull base (n = 13). All surgeries involved one or more otologic approaches: mastoidectomy (28.0%), lateral temporal bone resection (TBR) (59.2%), subtotal TBR (2.5%), total TBR (3.2%), transtemporal approach (TTA) to the jugular foramen (8.2%), TTA to the middle fossa (5.7%), and TTA to the infratemporal fossa (3.2%). Cancers of the cartilaginous ear canal were managed with wide local excision of canal skin and cartilage in nine patients (5.7%). A combination of approaches was performed in 32 patients (20.4%). The 5-year overall survival rate was 58.0%. Patients whose disease was limited to the ear canal had significantly better overall survival than did patients who had skull base primaries (P = .02989), periauricular skin cancer (P = .00138), or temporal bone tumors (P = .02598). Patients with parotid tumors also had better overall survival than did those with periauricular skin tumors (P = .02357).

CONCLUSIONS

Otologic surgery plays an important role in managing cancers that involve the ear canal, temporal bone, or lateral skull base. The specialty of otologic oncology is emerging as a defined area of practice.

Long-term outcome of comprehensive central compartment dissection in patients with recurrent/persistent papillary thyroid carcinoma

BACKGROUND

Persistent or recurrent papillary thyroid carcinoma (PTC) occurs in some patients after initial thyroid surgery and often, radioactive iodine treatment. Here, we identify the efficacy, safety, and long-term outcome of our current surgical management paradigm for persistent/recurrent PTC in the central compartment in an interdisciplinary thyroid cancer clinical and research program at a tertiary thyroid cancer referral center.

METHODS

We retrospectively analyzed our standardized approach of comprehensive bilateral level VI/VII lymph node dissection (SND [VI, VII]) for cytologically confirmed PTC in the central compartment.

RESULTS

From 1994 to 2004, 210 patients, median age 42 (range 12-82) underwent SND (VI, VII). Most patients (106, 51%) had already undergone ≥2 surgical procedures for persistent or recurrent disease, and 31 (15%) had distant metastases at presentation. Postoperatively, 104 (71%) of the 146 patients who were thyroglobulin (Tg) positive had no evidence of disease. Anti-Tg antibodies were present in 38 patients (18%), 17 of whom (53%) did not have anti-Tg antibodies postoperatively. Fourteen patients (7%) were hypoparathyroid at presentation, and 2 more (1%) became permanently hypoparathyroid after surgery. Four patients (2%) experienced recurrent laryngeal nerve paralysis (RLNP) of a previously functioning nerve. Unanticipated RLNP was observed in only one nerve at risk. External beam radiation was given to 33 patients (17%). An additional 17 patients (8%) developed distant metastases during follow-up. At the last follow-up, 130 (66%) of the 196 patients had no detectable Tg; of these, 99 (76%) had no further evidence of disease. A median of 7.25 years after surgery, 167 (90%) of the 185 patients were without evidence of central disease, and 18 (10%) had developed central compartment recurrences within a median interval of 24.3 months. Of those with recurrence, 16 out of 18 patients (89%) underwent a subsequent surgical procedure, thus resulting in an overall 98% central compartment control rate. Kaplan-Meier disease-specific survival at 10 years was 98.9% for patients <45 years old and 77.9% for those ≥45 years old (log-rank p<0.00001). The only predictor of central compartment recurrence was malignancy in a thyroid remnant noted within the central compartment surgical specimen.

CONCLUSIONS

Bilateral comprehensive level VI/VII dissections are safe and effective for long-term control of recurrent/persistent PTC in the central lymphatic compartment.

Novel chromosomal rearrangements and break points at the t(6;9) in salivary adenoid cystic carcinoma: association with MYB-NFIB chimeric fusion, MYB expression, and clinical outcome

OBJECTIVE

To investigate the molecular genetic heterogeneity associated with the t(6:9) in adenoid cystic carcinoma (ACC) and correlate the findings with patient clinical outcome.

EXPERIMENTAL DESIGN

Multimolecular and genetic techniques complemented with massive pair-ended sequencing and single-nucleotide polymorphism array analyses were used on tumor specimens from 30 new and 52 previously analyzed fusion transcript-negative ACCs by reverse transcriptase PCR (RT-PCR). MYB mRNA expression level was determined by quantitative RT-PCR. The results of 102 tumors (30 new and 72 previously reported cases) were correlated with the clinicopathologic factors and patients' survival.

RESULTS

The FISH analysis showed 34 of 82 (41.5%) fusion-positive tumors and molecular techniques identified fusion transcripts in 21 of the 82 (25.6%) tumors. Detailed FISH analysis of 11 out the 15 tumors with gene fusion without transcript formation showed translocation of NFIB sequences to proximal or distal sites of the MYB gene. Massive pair-end sequencing of a subset of tumors confirmed the proximal translocation to an NFIB sequence and led to the identification of a new fusion gene (NFIB-AIG1) in one of the tumors. Overall, MYB-NFIB gene fusion rate by FISH was in 52.9% whereas fusion transcript forming incidence was 38.2%. Significant statistical association between the 5' MYB transcript expression and patient survival was found.

CONCLUSIONS

We conclude that: (i) t(6;9) results in complex genetic and molecular alterations in ACC, (ii) MYB-NFIB gene fusion may not always be associated with chimeric transcript formation, (iii) noncanonical MYB-NFIB gene fusions occur in a subset of tumors, (iv) high MYB expression correlates with worse patient survival.

The results of temporal bone surgery for advanced or recurrent tumors of the parotid gland

OBJECTIVES/HYPOTHESIS

To describe the results of temporal bone surgery in managing advanced or recurrent tumors of the parotid gland.

STUDY DESIGN

Retrospective review.

METHODS

Patients with advanced or recurrent tumors involving the parotid gland who underwent either mastoidectomy or temporal bone resection were reviewed for treatment outcomes.

RESULTS

Forty-nine patients were identified who required either mastoidectomy (n = 33) or temporal bone resection (n = 16) for malignancies involving the parotid gland. Facial nerve sacrifice was required in 35 patients (71.4%). Perineural invasion was found in 51.1% of patients; and negative margins were achieved in 78.2% patients. Six of 10 patients presenting with normal facial function (House-Brackmann I) and recurrent tumors maintained normal facial function following salvage surgery. Trismus, tumors larger than 4 cm, and the need for mandibulectomy were significantly correlated with higher recurrence rates (P = .025, P = .004, and P = .002, respectively). Patients with preoperative House-Brackmann I or II had a lower risk for recurrence (P = .035) and more favorable survival at 3 years (P = .024). Patients who required parapharyngeal space dissection and those with metastatic neck disease had the poorest survival rates. The overall survival at 3 years was 72.4%.

CONCLUSIONS

Mastoidectomy and temporal bone resection permit preservation of the facial nerve when oncologically safe; they may help to achieve negative margins, and they allow facial nerve grafting when nerve sacrifice is required. Despite the poor prognostic indicators of facial paralysis, recurrent tumors, and perineural invasion, a significant number of patients can be salvaged successfully when a temporal bone procedure is combined with parotidectomy.

Antimicrobial efficacy of oral topical agents on microorganisms associated with radiated head and neck cancer patients: an in vitro study

OBJECTIVE

A variety of oral topical agents have been used for prevention and management of radiotherapy-induced adverse effects. The antimicrobial nature of some of the commonly used agents is unknown. The purpose of this study was to evaluate antimicrobial efficacies of various oral topical agents on common microorganisms associated with radiated head and neck cancer patients.

METHOD AND MATERIALS

Seven commonly used topical oral agents-0.12% chlorhexidine with alcohol, 0.12% chlorhexidine without alcohol, baking soda-salt rinse, 0.4% stannous fluoride gel, 0.63% stannous fluoride rinse, calcium phosphate mouthrinse, and acemannan hydrogel (aloe vera) rinse-were evaluated in vitro for their antimicrobial efficacies against four common microorganisms. A combination of baking soda-salt rinse and 0.4% stannous fluoride gel was evaluated as the eighth agent. The microorganisms used were Staphylococcus aureus, group B Streptococcus, Escherichia coli, and Candida albicans. An ELISA reader was used to measure the turbidity of microbial culture wells and optical density (OD) values for each of the 960 wells recorded. Mean OD values were rank ordered based on their turbidity. One-way ANOVA with Tukey HSD post hoc analysis was used to study differences in OD values (P < .05).

RESULTS

Mean OD values classified for topical agents from lowest to highest were chlorhexidine with alcohol, chlorhexidine without alcohol, baking soda- salt, calcium phosphate rinse, and the combination of baking soda-salt and stannous fluoride gel. Mean OD values classified for microorganisms from lowest to highest were Escherichia coli, Staphylococcus aureus, group B Streptococcus, and Candida albicans.

CONCLUSION

A significant difference among the antimicrobial efficacies of topical agents was evident for each of four microorganisms (P < .05). There was also a significant difference among the antimicrobial efficacies of the same topical agent on the four microorganisms tested (P < .05).

Quality and performance indicators in an academic department of head and neck surgery

OBJECTIVE

to create a method for assessing physician performance and care outcomes that are adjusted for procedure acuity and patient comorbidity.

DESIGN

between 2004 and 2008 surgical procedures performed by 10 surgeons were stratified into high-acuity procedures (HAPs) and low-acuity procedures (LAPs). Risk adjustment was made for comorbid conditions examined singly or in groups of 2 or more.

SETTING

a tertiary care medical center.

PATIENTS

a total of 2618 surgical patients.

MAIN OUTCOME MEASURES

performance measures included length of stay; return to operating room within 7 days of surgery; and the occurrence of mortality, hospital readmission, transfusion, and wound infection within 30 days of surgery.

RESULTS

the transfusion rate was 2.7% and 40.6% for LAPs and HAPs, respectively. Wound infection rates were 1.4% for LAPs vs 14.1% for HAPs, while 30-day mortality rate was 0.3% and 1.6% for LAPs and HAPs, respectively. The mean (SD) hospital stay for LAPs was 2.1 (3.6) vs 10.5 (7.0) days for HAPs. Negative performance factors were significantly higher for patients who underwent HAPs and had comorbid conditions. Differences among surgeons significantly affect the incidence of negative performance indicators. Factors affecting performance measures were procedure acuity, the surgeon, and comorbidity, in order of decreasing significance. Surgeons were ranked low, middle, and high based on negative performance indicators.

CONCLUSIONS

performance measures following oncologic procedures were significantly affected by comorbid conditions and by procedure acuity. Although the latter most strongly affects quality and performance indicators, both should weigh heavily in physician comparisons. The incidence of negative performance indicators was also influenced by the individual surgeon. These data may serve as a tool to evaluate and improve physician performance and outcomes and to develop risk-adjusted benchmarks. Ultimately, reimbursement may be tied to quantifiable measures of physician and institutional performance.

Prereferral head and neck cancer treatment: compliance with national comprehensive cancer network treatment guidelines

OBJECTIVE

to evaluate the prereferral treatment of patients referred to our tertiary care center with recurrent or persistent head and neck cancer for compliance with National Comprehensive Cancer Network (NCCN) guidelines.

DESIGN

a prospective recruitment and retrospective chart review.

PATIENTS

the study included new patients identified at multidisciplinary treatment planning conference from October 1, 2008, to February 1, 2009, who had received prior treatment at an outside institution and presented to our department with recurrent or persistent disease.

MAIN OUTCOME MEASURES

all facets of prior care were examined, including the time from initial symptoms to diagnosis and whether their prereferral treatment was compliant with or deviated from NCCN guidelines for head and neck cancer.

RESULTS

a total of 566 consecutive new patients were identified, of whom 107 (18.9%) had persistent or recurrent disease. The average time from first presentation with initial symptoms to diagnosis among patients who presented with persistent disease was 23.8 weeks. Nearly half of the patients who presented with persistent or recurrent disease had either endocrine (21.5%) or cutaneous (24.2%) primary cancers, with the rest of the cases being distributed among 10 other sites. Of the patients who presented with recurrent or persistent disease, 43.0% had prereferral care that was noncompliant with NCCN guidelines. Of these patients, 58.7% had inadequate surgical management, 15.2% were treated for the wrong diagnosis, 10.9% received inadequate adjuvant therapy, 4.4% received inadequate radiotherapy, and 10.9% refused indicated recommended treatment.

CONCLUSIONS

significant deviation from NCCN guidelines for head and neck cancer treatment was observed in the cohort of study patients. The failure to administer adjuvant therapy when indicated by NCCN guidelines is particularly concerning. Economic and noneconomic costs, including lost wages, cost of "do-over" therapy, and potentially diminished survival, are substantial. Measures to ensure that patients receive therapy according to guidelines should be a national priority.

The impact of radiotherapy on facial nerve repair

OBJECTIVE

To study the impact of radiotherapy on the success of primary facial nerve repair and cable nerve grafts.

STUDY DESIGN

Retrospective review.

METHODS

Pre- and postoperative facial nerve function were assessed using the House-Brackmann (HB) grading system.

RESULTS

Thirty-nine patients were identified who had undergone facial nerve repair: 5 patients (13%) underwent primary repair, and 34 patients (87%) underwent nerve grafting. Radiotherapy was administered postoperatively to 34 patients (87%). Preoperative HB scores were I = 18, II = 11, III = 3, IV = 3, V = 3, and VI = 1. Postoperative scores were HB I = 1, II = 4, III = 16, IV = 6, V = 3, and VI = 9. Only patients with single-branch deficits recovered to HB I or II function. Good facial function (HB I-III) was achieved in 17 of 34 patients (50%) who received postoperative radiotherapy compared to 4 of 5 patients (80%) who did not receive postoperative radiotherapy (P = .349). Among the patients who had either HB I or II function preoperatively, 59% achieved good postoperative function (HB I-III). Four out of 10 patients (40%) with significantly compromised preoperative facial function (HB III-VI) were able to achieve HB III function.

CONCLUSIONS

Postoperative radiotherapy appears not to prevent achieving good facial function after a nerve repair, especially when normal or near-normal function is present preoperatively. Some patients with fair to little function preoperatively can achieve reasonable postoperative function with facial nerve reconstruction.

Compliance with quality assurance measures in patients treated for early oral tongue cancer

BACKGROUND

The objective of this study was to identify measurable parameters that provide quality data for assessing how well cancer care adheres to accepted treatment guidelines and is delivered to any given patient with oral tongue cancer.

METHODS

A retrospective chart review included 116 patients treated for T1-T2/N0-N1 squamous cell carcinoma (SCC) of the oral tongue between 1998 and 2003. A set of quality measures considered critical for outcome included: 1) accurate TNM staging at presentation, 2) documentation of margin status, 3) appropriate referral for adjuvant radiation therapy, and 4) neck dissection for depth of invasion>4 mm. In addition, 26 clinical endpoints involving pretreatment assessment, staging, treatment, surveillance, and symptom control were analyzed.

RESULTS

Patients comprised 73 men and 43 women (median age, 57 years). Forty-one (35.3%) patients presented with stage I disease, 61 (52.6%) with stage II, and 14 (12.1%) with stage III. The overall 5-year survival rate for all patients was 68.6%. There was a 90.5% compliance with TNM staging at presentation, 99.1% for documentation of margin status, 98.2% for adequate referral to radiation therapy, and 88.7% for appropriate neck dissection based on depth of invasion. Compliance with clinical endpoints was variable and ranged from 100% for endpoints related to radiation therapy to <40% for endpoints related to speech pathology and rehabilitation.

CONCLUSIONS

Overall compliance with documenting the 4 parameters designated as quality measures for treatment of oral tongue SCC was acceptable, thus demonstrating that it is possible to use these data for measuring effective cancer care.

Malignant fibrous histiocytoma of the head and neck region

BACKGROUND

Malignant fibrous histiocytoma (MFH) is 1 of the most common soft tissue sarcomas in the head and neck.

METHODS

We conducted a retrospective review of patients with MFH of the head and neck region at a large multidisciplinary cancer center between 1973 and 2005.

RESULTS

Ninety-five patients were included in the study. The median age at diagnosis was 53 years (range, 3-90 years); 69% of the patients were men. The parotid or neck was the most common subsite (35%), and 23% of the cases were associated with prior radiation exposure. Although there were no significant differences in the distribution of age, sex, year of presentation, tumor location, size, local extension, or treatment between patients with and without prior radiation exposure, those with radiation-associated tumors were more likely to have positive or unclear surgical margins (p = .037). With a median follow-up of 34 months, 32 (39%) of the 83 patients treated at M. D. Anderson Cancer Center with curative intent had a recurrence (isolated local recurrence in 18, isolated distant recurrence in 8, both local and distant recurrence in 5, and regional recurrence in 1). For patients treated at our institution with curative intent, 5-year overall, disease-free, and disease-specific survival rates were 55%, 44%, and 69%, respectively. Prior radiation exposure and positive margins were associated with worse survival.

CONCLUSION

MFH of the head and neck region is often aggressive and characterized by local and/or distant recurrence and poor survival. Radiation-associated tumors seem to have an especially poor prognosis. Based on a significant body of literature, multidisciplinary evaluation and treatment of such high-grade sarcomas is encouraged.

A PHASE RULE STUDY OF THE PROTEINS OF THE BLOOD SERUM: A COMPARISON OF THE PROTEINS OF HUMAN, RAT, AND HORSE SERUM

There are four different kinds of protein in blood serum as shown by the solubility curves. They must be either single proteins, several continuous series of compounds, or solid solutions. The solid protein phases are hydrated. There are definite sex and species differences.

A PHASE RULE STUDY OF THE PROTEINS OF BLOOD SERUM : III. GLOBULIN

A method has been developed for applying the phase rule to systems of several protein components in serum. The globulin fractions which have been investigated appear to be homogeneous substances.

Squamous cell carcinoma of the temporal bone

OBJECTIVES/HYPOTHESIS

To study the survival outcomes of patients with squamous cell carcinoma (SCC) of the temporal bone. A secondary purpose was to evaluate the University of Pittsburgh staging system as a predictor of survival.

STUDY DESIGN

Retrospective review.

METHODS

We performed a single-institution retrospective review of the medical charts of patients diagnosed with SCC of the temporal bone between 1945 and 2005. We identified the patients' demographic characteristics, presenting symptoms, physical examination findings, tumor histology, disease extent, treatment course, and clinical outcomes. We used the Pittsburgh staging system (2000) to determine the patients' tumor classification and disease state. We then compared the overall and disease-free survival rates between patients with early-stage versus late-stage disease.

RESULTS

We identified 124 patients with SCC of the temporal bone. Of these, 71 had incident (untreated) SCC, 26 had recurrent SCC, and 27 had persistent SCC after treatment elsewhere. The 5-year overall survival rate for patients with incident SCC was 38%, and the disease-free survival rate was 60%. The overall survival rate for patients with incident SCC was similar to that for patients with persistent disease and was significantly better than that for patients with recurrent SCC (P = .008). Patients with early-stage tumors (T1 or T2) had longer overall survival than those with late-stage tumors (T3 or T4; P = .004, log-rank). The 5-year overall survival rate was 48% for patients with early-stage disease and 28% for patients with late-stage disease. Furthermore, patients with T1 tumors had significantly longer overall survival than patients with T2 tumors (P = .039) and patients with T3 and T4 tumors (P = .0008). Overall survival (OS) and disease-free interval (DFI) were improved for T2 tumors when radiotherapy was combined with surgery (OS, P = .011; DFI, P = .02). T1 tumors did not benefit in a statistically significant way with combined therapy. T3 and T4 tumors had relatively poor outcomes in spite of combined therapy. Twenty-two patients (31%) experienced a recurrence within 1 year of treatment, whereas only one patient developed recurrence after 1 year. Lymph node metastasis, facial paralysis, or involvement of the carotid artery, jugular foramen, or infratemporal fossa were not significantly associated with overall or disease-free survival.

CONCLUSIONS

Patients with recurrent SCC of the temporal bone had significantly shorter overall survival and disease-free interval than patients with incident SCC. In addition, patients with early-stage disease (T1 and T2) had significantly longer overall survival and disease-free survival than patients with late-stage tumors.

Mucosal melanoma of the nose and paranasal sinuses, a contemporary experience from the M. D. Anderson Cancer Center

BACKGROUND

Sinonasal mucosal melanoma is a rare disease associated with a very poor prognosis. Because most of the series extend retrospectively several decades, we sought to determine prognostic factors and outcomes with recent treatment modalities.

METHODS

A retrospective chart review of 58 patients treated for sinonasal melanoma at a tertiary cancer center between 1993 and 2004. The patients were retrospectively staged according to the sinonasal American Joint Committee on Cancer (AJCC) staging system. Demographic, clinical and pathological parameters were identified and correlated with outcomes.

RESULTS

There were 35 males and 23 females with a median age of 63 years; 56 patients were treated surgically and 33 received radiation therapy. According to Ballantyne's clinical staging system, 88% of the patients presented with stage I (local) disease. Classification by the AJCC staging classified yielded 27% of the patients with T1, 33% with T2, 21% with T3, and 19% with T4. T-stage and the degree of tumor pigmentation were associated with a worse survival (P = .0096 and P = .018, respectively), while pseudopapillary architecture was associated with a higher locoregional failure (P = .0144). Postoperative radiation therapy improved locoregional control when a total dose greater than 54 Gy was used (P = .0215), but did not affect overall survival.

CONCLUSIONS

Tumor stage according to sinonasal AJCC staging system is an effective outcome predictor and should be the staging system of choice. Postoperative radiation therapy improves locoregional control when a higher dose and standard fractionations are used. Histological features such as pigmentation and pseudopapillary architecture are associated with worse outcome.

Genetic and expression analysis of HER-2 and EGFR genes in salivary duct carcinoma: empirical and therapeutic significance

PURPOSE

Salivary duct carcinoma overexpresses epidermal growth factor receptor (EGFR) and HER-2, although the underlying mechanisms remain undefined. Because of the potential utilization of these markers as treatment targets, we evaluated protein and gene status by several techniques to determine complementary value.

EXPERIMENTAL DESIGN

A tissue microarray of 66 salivary duct carcinomas was used for immunohistochemical analysis of HER-2 and EGFR expression (semiquantitatively evaluated into a three-tiered system), and fluorescence in situ hybridization for gene copy number, and chromosomes 7 and 17 ploidy status. Sequencing of exons 18, 19, and 21 of the EGFR gene for mutations was carried out.

RESULT

For EGFR, 46 (69.7%) of the 66 tumors showed some form of EGFR expression (17 at 3+, 17 at 2+, 12 at 1+) but none gene amplification. Five (9.4%) of 53 tumors showed mutations in exon 18 (n = 3) and exon 19 (n = 2). Polysomy of chromosome 7 (average >2.5 copies/cell) was detected in 15 (25.0%) of 60 tumors (6 at 3+, 5 at 2+, 2 at 1+, 2 at 0+ expression) and correlated with poor 3-year survival (P = 0.015). For HER-2, 17 (25.8%) of 66 tumors expressed HER-2 (10 at 3+, 3 at 2+, 4 at 1+). Eight tumors showed HER-2 gene amplification (6 at 3+, 1 at 1+, 1 at 0+ protein expression). Chromosome 17 polysomy was found in 8 (15.7%) of 51 tumors; two had HER-2 expression (3+, 1+).

CONCLUSION

Our study shows that salivary duct carcinomas (a) harbor EGFR gene mutations in a subset of tumors that may guide therapy, (b) pursue an aggressive clinical course in cases with chromosome 7 polysomy and high EGFR expression, and (c) with HER-2 gene amplification and protein high expression, may be selected for targeted therapy.

Approach and safety of comprehensive central compartment dissection in patients with recurrent papillary thyroid carcinoma

BACKGROUND

Despite the generally favorable prognosis of patients with papillary thyroid cancers, 10-year recurrence rates for patients with stage I to III disease is greater than 20%, with central compartment recurrences common among these recurrent sites.

METHODS

This study is a retrospective analysis of consecutive patients treated by a single surgeon over an 18-month period of time terminating in 2003.

RESULTS

Sixty-three patients underwent a comprehensive dissection of levels VI and VII for papillary thyroid carcinoma during this period. There was a female predominance of 2:1, with 48% of patients being greater than 45 years of age. The median number of lymph nodes identified was 16 (range, 3-52), with 7 (1-20) lymph nodes pathologically involved. Permanent hypoparathyroidism was present on presentation in 13% of patients and developed in an additional 5% following surgery. Although recurrent laryngeal paralysis was present on presentation among 8 (13%) of patients, no patients experienced paralysis of documented functioning recurrent laryngeal nerves or necessitated tracheotomy. Postoperative thyroglobulin levels were reduced to nondetectable in 71% of the informative cases. Over 60% of patients were discharged on their first postoperative day.

CONCLUSION

Bilateral paratracheal and superior mediastinal dissection is an oncologically safe procedure exhibiting minimal morbidity when performed among experienced individuals despite multiple prior surgical procedures or existing vocal cord paralysis.

Functional analysis of swallowing outcomes after supracricoid partial laryngectomy

BACKGROUND

In this study, we analyzed swallowing recovery after supracricoid partial laryngectomy (SCPL).

METHODS

We retrospectively reviewed 27 patients treated with SCPL (September 1997 to March 2005). We evaluated recovery course, nutritional outcomes, and swallowing using objective analysis. Modified barium swallow (MBS) study results identified swallowing physiology and therapeutic effectiveness.

RESULTS

Average length of hospitalization was 7.7+/-9.2 days; time to decannulation was 5.3+/-8.2 weeks. The most common complications included pneumonia and subcutaneous emphysema (26%). Twenty-two patients had MBS studies, in which initially, all patients aspirated due to neoglottic incompetency, and impaired base of tongue and laryngeal movements. Although aspiration rates did not change significantly over time, use of appropriately selected swallowing strategies effectively protected the airway (p= .0365). Ultimately, 81% of patients returned to complete oral intake with median tube removal at 9.4 weeks.

CONCLUSION

SCPL produces severe dysphagia initially. Our findings suggest that objective swallowing assessment is important for return to oral nutrition after SCPL.

Quantitative promoter hypermethylation analysis of cancer-related genes in salivary gland carcinomas: comparison with methylation-specific PCR technique and clinical significance

PURPOSE

To compare the methylation status of tumor-associated genes by quantitative pyrosequencing and qualitative methylation-specific PCR (MSP) techniques and to correlate the results with clinicopathologic features and patients outcome to determine which method might have greater clinical utility.

EXPERIMENTAL DESIGN

The hypermethylation status of the retinoid acid receptor beta2 (RARbeta2), RAS association domain family 1A (RASSF1A), O(6)-methylguanine-DNA methyltransferase (MGMT), and E-cadherin genes was analyzed in five salivary carcinoma cell lines and 69 human salivary gland carcinoma specimens by pyrosequencing and MSP techniques. The two datasets were compared by linear regression. Correlations between methods and with clinicopathologic characteristics were assessed by Pearson's chi(2) test or the two-tailed Fisher exact test, as applicable, using cutoff points determined from the regression curves and empirical fitting. We also investigated the effect of demethylating agents on methylated genes in cell lines to assess their effect on the expression of these genes.

RESULTS

Overall, regression analysis indicated high degrees of correlation of the two methods for measurement of methylation for the RARb2, RASSF1A, and MGMT genes (adjusted R(2) = 0.319, 0.835, and 0.178; P < 0.001, <0.001, and 0.0002, respectively) among the 69 tumors tested. However, the pyrosequencing technique yielded four more instances of methylation above background levels than MSP for RARbeta2 and three more for RASSF1. Methylation of either RARbeta2 and RASSF1A alone or both by pyrosequencing were correlated with tumor type (P = 0.027, 0.014, and 0.012, respectively). Methylation of RARbeta2 alone and in combination with RASSF1A by pyrosequencing were also significantly correlated with tumor grade (P = 0.014 and 0.011, respectively) and 3-year survival (P = 0.002 and 0.004, respectively). The survival curves of patients who had hypermethylation at both RARbeta2 and RASSF1A were significantly lower than those of patients who had hypermethylation at neither or just for the RASSF1A (P = 0.008 and 0.007, respectively). 5-Azadeoxycytidine treatment of methylated cell lines led to the reactivation of RARbeta2 expression in only one of the five cell lines.

CONCLUSIONS

(a) Although the methylation status of RARb2, RASSF1A, and MGMT genes by both techniques were significantly correlated, pyrosequencing is generally more sensitive and its results correlate better with the clinical variables than those of MSP. (b) The methylation level of the RARbeta2 and/or RASSF1A by pyrosequencing is significantly associated with aggressive tumor phenotypes and patients survival.

Oropharyngeal Reconstruction for Advanced Cancer

Objective

To assess perioperative morbidity, functional outcomes, and survival following microvascular and regional flap reconstruction of the oropharynx after advanced oncologic resection.

Methods

65 patients underwent oropharyngeal reconstruction for late stage primary (35.4%), second primary (10.8%), or recurrent (53.8%) oropharyngeal and oral cavity squamous cell carcinoma at a tertiary cancer center between 1997 and 2007. 50 (76.9%) males and 15 (23.1%) females with a median age of 59.2 years (range 28.6 to 76.1 years) were reconstructed with rectus myocutaneous free flaps (30.8%), anterolateral thigh free flaps (27.7%), radial forearm free flaps (20%), pectoralis myocutaneous pedicled flaps (15.4%), and fibula osseocutaneous free flaps (6.2%).

Results

The median follow-up time following oropharyngeal reconstruction was 36.3 months (range 1.3 to 144.2 months). There were no complete flap failures and only 1 partial flap failure. 32 (49.2%) patients experienced postoperative complications including 11 wound infections/dehiscences, 7 fistulas, 7 donor site complications, and 11 postoperative pneumonias. Mean intensive care unit nights and total days hospitalized were 2.8 and 9.6, respectively. Of 56 patients undergoing a tracheostomy, 48 (73.8%) were decannulated a median of 13 days (range 5 to 426 days) following surgery. 42 (64.7%) remained at least partially feeding tube-dependent, but 41 (63.1%) attained at least 80% oral speech intelligibility. 3-and 5-year overall survivals following reconstruction were 49.1% and 37.3%, respectively.

Conclusions

Selected patients who undergo reconstruction for extensive oropharyngeal defects following surgery for advanced cancer can attain long-term survival. While most patients achieve decannulation and functional speech, almost 2/3rds remain feeding tube-dependent.

The usefulness of computed tomography scans in cystic fibrosis patients with chronic sinusitis

BACKGROUND

This study was performed to evaluate the usefulness of computed tomography (CT) scans of the sinuses in children with cystic fibrosis (CF) as an outcomes measurement for medical and surgically treated chronic rhinosinusitis.

METHODS

Patients with CF who had sinus scans performed at the study institution from January 1999 to September 2003 were identified. The scans and any available prior scans were scored according to the Lund-MacKay system. A retrospective chart review determined if hospitalization with i.v. antibiotic therapy or operative intervention had occurred between scans and if the scans showed improvement secondary to the intervention.

RESULTS

One hundred thirty-four patients were identified who met inclusion criteria. A total of 290 scans were reviewed, with the average number of CT scans per patient of 2.24 (range, 1-10). The average Lund-MacKay score for scans closest in time to the first sinus surgery was 14.5. (range, 7-24), and for the first postoperative scans, the score was 14.7 (8-24). There was no significant difference between the preoperative and postoperative Lund-MacKay score after initial surgery (p = 0.99) or in subsequent scans despite medical or surgical interventions (p = 0.90).

CONCLUSION

CT scanning of the sinuses does not appear to be useful in determining outcomes of intervention in CF patients.