Single cell transcriptomic analysis of HPV16-infected epithelium identifies a keratinocyte subpopulation implicated in cancer

Persistent HPV16 infection is a major cause of the global cancer burden. The viral life cycle is dependent on the differentiation program of stratified squamous epithelium, but the landscape of keratinocyte subpopulations which support distinct phases of the viral life cycle has yet to be elucidated. Here, single cell RNA sequencing of HPV16 infected compared to uninfected organoids identifies twelve distinct keratinocyte populations, with a subset mapped to reconstruct their respective 3D geography in stratified squamous epithelium. Instead of conventional terminally differentiated cells, an HPV-reprogrammed keratinocyte subpopulation (HIDDEN cells) forms the surface compartment and requires overexpression of the ELF3/ESE-1 transcription factor. HIDDEN cells are detected throughout stages of human carcinogenesis including primary human cervical intraepithelial neoplasias and HPV positive head and neck cancers, and a possible role in promoting viral carcinogenesis is supported by TCGA analyses. Single cell transcriptome information on HPV-infected versus uninfected epithelium will enable broader studies of the role of individual keratinocyte subpopulations in tumor virus infection and cancer evolution.

Association of Neoadjuvant Pembrolizumab for Oral Cavity Squamous Cell Carcinoma With Adverse Events After Surgery in Treatment-Naive Patients

Importance

Pembrolizumab, a monoclonal antibody targeting programmed cell death 1, is currently approved by the US Food and Drug Administration for recurrent or metastatic head and neck squamous cell carcinoma (HNSCC). The potential neoadjuvant role of programmed cell death 1 inhibitors in primary surgical management of HNSCC and effects on surgical outcomes are poorly understood.

Objective

To evaluate the incidence of postoperative adverse events in treatment-naive patients with advanced oral cavity cancer receiving neoadjuvant pembrolizumab when compared with matched controls, as part of a window-of-opportunity multi-institutional clinical trial assessing neoadjuvant pembrolizumab for locally advanced HNSCC.

Design, Setting, and Participants

This retrospective cohort study at a single tertiary academic institution included treatment-naive patients with local regionally advanced oral cavity squamous cell carcinoma (OCSCC) who were undergoing surgical resection.

Exposures

Patients with local regionally advanced resectable OCSCC who received neoadjuvant pembrolizumab were retrospectively reviewed for postoperative adverse events. Controls were matched by age, race, smoking status, and overall cancer stage based on historical data at the same institution. Matched-cohort analysis was performed using a McNemar test to assess differences between the groups.

Main Outcomes and Measures

Incidence of adverse events following surgical resection of advanced OCSCC within 30 days of surgery and on continued follow-up.

Results

A total of 64 patients (32 as part of the prospective clinical trial and 32 as controls; mean [SD] age, 59.6 [10.3] years; 28 [44%] women) were included in the analysis. Postoperative adverse events in the 32 patients receiving pembrolizumab included lymphedema (n = 20 [63%]), trismus (n = 7 [22%]), return to operating room (n = 7 [22%]), wound infection (n = 7 [22%]), fistula (n = 6 [19%]), wound dehiscence (n = 4 [13%]), flap failure (n = 3 [9%]), and hematoma (n = 2 [6%]). The matched control group demonstrated similar complication rates without considerable differences, except for trismus (n = 16 [50%]), which was greater by a difference of 28.1% (95% CI, 5.6%-50.6%) in the control group.

Conclusions and Relevance

This cohort study examined surgical complications among patients with local regionally advanced OCSCC treated with neoadjuvant pembrolizumab and found that serious adverse events were similar to those in patients who underwent standard-of-care treatment. This suggests that there is no increased perioperative morbidity in the use of preoperative treatment with immunotherapy. Further prospective studies are needed to validate these findings for oral cavity cancer and other subsites of the head and neck.

Phase II Trial of Adjuvant Nivolumab Following Salvage Resection in Patients with Recurrent Squamous Cell Carcinoma of the Head and Neck

PURPOSE

Locoregional relapse in patients with head and neck squamous cell carcinoma (HNSCC) is common, approaching 50% for some subsites despite multimodality therapy. Salvage surgery is the standard of care, but able to achieve durable control in only a minority of patients. While adjuvant radiotherapy or chemo-radiotherapy is offered to select patients, this approach can be prohibitively toxic. Given the activity and tolerability of programmed death-1 inhibitors in metastatic HNSCC, we investigated the safety and efficacy of adjuvant nivolumab after salvage surgical resection.

PATIENTS AND METHODS

This was an open-label, multi-institutional phase II clinical trial (NCT03355560). Patients with recurrent, resectable HNSCC were enrolled within 6 weeks of salvage surgery. Six 28-day cycles of adjuvant nivolumab were planned. The primary endpoint was 2-year disease-free survival (DFS) more than 58%, based on an institutional historical control group of 71 patients with recurrent HNSCC who underwent salvage surgery.

RESULTS

Between February 2018 and February 2020, 39 patients were enrolled. At a median follow-up of 22.1 months, 2-year DFS was 71.4% [95% confidence interval (CI), 57.8-88.1] and the 2-year overall survival (OS) was 73% (95% CI, 58-91.8). Three of 39 (8%) patients experienced grade 3 treatment-related adverse events and 3 of 39 (8%) discontinued treatment due to side effects. Ten of 39 had locoregional recurrence, while 2 of 10 also had synchronous metastatic disease. There was no difference in DFS between PD ligand-1 (PD-L1)-positive and PD-L1-negative patients. There was a nonsignificant trend toward improved DFS in patients with high tumor mutational burden (P = 0.083).

CONCLUSIONS

Adjuvant nivolumab after salvage surgery in locally recurrent HNSCC is well tolerated and showed improved DFS compared with historical controls.

Primary Dural Repair via an Endoscopic Endonasal Corridor: Preliminary Development of a 3D-Printed Model for Training

Objectives Endonasal suturing is an investigational method for dural repair that has been reported to decrease the incidence of cerebrospinal fluid fistula. This method requires handling of single-shaft instrumentation in the narrow endonasal corridor. In this study, we designed a low-cost, surgical model using three-dimensional (3D) printing technology to simulate dural repair through the endonasal corridor and subsequently assess the utility of the model for surgical training.

Methods Using an Ultimaker 2+ printer, a 3D-printed replica of the cranial base and nasal cavity was fitted with tissue allograft to recapitulate the dural layer. Residents, fellows, and attending surgeons were asked to place two sutures using a 0-degree endoscope and single-shaft needle driver. Task completion time was recorded. Participants were asked to fill out a Likert scale questionnaire after the experiment.

Results Twenty-six participants were separated into groups based on their prior endoscope experience: novice, intermediate, and expert. Twenty-one (95.5%) residents and fellows rated the model as “excellent” or “good” in enhancing their technical skills with endoscopic instrumentation. Three of four (75%) of attendings felt that the model was “excellent” or “good” in usefulness for training in dural suturing. Novice participants required an average of 11 minutes for task completion, as compared with 8.7 minutes for intermediates and 5.7 minutes for experts.

Conclusion The proposed model appears to be highly effective in enhancing the endoscopic skills and recapitulating the task of dural repair. Such a low-cost model may be especially important in enhancing endoscopic facility in countries/regions with limited access to cadaveric specimens.

Comparison of cervical neck strain in common otolaryngology surgeries

BACKGROUND

Cervical neck strain and surgical ergonomics is an increasingly important topic being addressed in this time and age. With new technologies, visualizations, and approaches to surgeries, there are now different strains and duration of strains to the cervical neck. Recently the effect of chronic cell phone use has been described as "text neck." In a similar fashion we understand that certain otolaryngology surgeries can also impart chronic strain to the cervical neck. We aim to quantitatively describe strain for different types of surgeries by looking at posture, duration of surgery, and anatomic ergonomics of specific surgeries.

METHODS

Lateral photo documentation of posture during 6 common otolaryngology procedures, used to estimate cervical neck angle and calculate force and impulse to cervical neck.

RESULTS

Six common otolaryngology procedures show various cervical neck angles ranging from around 0° to 60° of neck flexion, with subsequent forces ranging from 16 lb to 60 lb of force. When accounting for surgical time, bigger differences arose with impulses ranging from 270,000 N∗s to 3,300,000 N∗s. Noticeably, thyroidectomy and cleft palate showed much higher impulses than the other four types of surgeries.

CONCLUSION

Both cervical neck flexion and duration of surgery play important roles in total neck theoretical strain. Variance exists between neck strains of common otolaryngology surgeries. There is a necessity for continued study and improvement in surgical ergonomics.

Sternocleidomastoid Tendon as a Consistent Landmark for Identifying the Spinal Accessory Nerve: A Case Series

Objective

We propose a standardized approach of using the tendon of the sternocleidomastoid (SCM) muscle to locate the spinal accessory nerve (SAN) in neck dissection.

Study Design

Cross-sectional anatomic study.

Setting

Tertiary academic medical center.

Methods

Adult patients aged ≥18 years undergoing primary neck dissection for head and neck cancer were included. Anatomic measurements included the length of the SCM tendon, the distance from the mastoid tip to the entrance of the SAN into the SCM, the distance from the SAN to the distal edge of the SCM tendon, and the perpendicular distance from the anterior edge of the SCM to the SAN. Five cadaveric specimens also underwent bilateral modified radical neck dissections with the same anatomic measurements taken.

Results

Twenty-two living subjects and 5 cadavers were included. No statistical correlation was noted between patient demographics and any measurement. The mean (SD) length of the SCM tendon was 63.7 mm (11.8) in living subjects and 61.5 mm (10.4) in cadaveric specimens. The average distance from the mastoid tip to the entrance of SAN into the SCM was 51.6 mm (12.2) in living subjects and 51.6 mm (7.1) in cadaveric subjects. The distance of the SAN insertion into the SCM muscle from the anterior edge was 8.9 mm (3.4) in living subjects and 16.2 mm (7.2) in cadaver specimens. Laterality was compared in the cadaveric specimens; there was no statistically significant difference in any of the measurements between sides.

Conclusion

This study demonstrates the SCM tendon to be a reliable and safe surgical landmark to identify and preserve the SAN during neck dissection.

Phase II Clinical Trial of Neoadjuvant and Adjuvant Pembrolizumab in Resectable Local-Regionally Advanced Head and Neck Squamous Cell Carcinoma

PURPOSE

Patients with resected, local-regionally advanced, head and neck squamous cell carcinoma (HNSCC) have a one-year disease-free survival (DFS) rate of 65%-69% despite adjuvant (chemo)radiotherapy. Neoadjuvant PD-1 immune-checkpoint blockade (ICB) has demonstrated clinical activity, but biomarkers of response and effect on survival remain unclear.

PATIENTS AND METHODS

Eligible patients had resectable squamous cell carcinoma of the oral cavity, larynx, hypopharynx, or oropharynx (p16-negative) and clinical stage T3-T4 and/or two or more nodal metastases or clinical extracapsular nodal extension (ENE). Patients received neoadjuvant pembrolizumab 200 mg 1-3 weeks prior to surgery, were stratified by absence (intermediate-risk) or presence (high-risk) of positive margins and/or ENE, and received adjuvant radiotherapy (60-66 Gy) and concurrent pembrolizumab (every 3 weeks × 6 doses). Patients with high-risk HNSCC also received weekly, concurrent cisplatin (40 mg/m2). Primary outcome was one-year DFS. Secondary endpoints were one-year overall survival (OS) and pathologic response (PR). Safety was evaluated with CTCAE v5.0.

RESULTS

From February 2016 to October 2020, 92 patients enrolled. The median age was 59 years (range, 27-80), 30% were female, 86% had stage T3-T4, and 69% had ≥N2. At a median follow-up of 28 months, one-year DFS was 97% (95% CI, 71%-90%) in the intermediate-risk group and 66% (95% CI, 55%-84%) in the high-risk group. Patients with a PR had significantly improved one-year DFS relative to patients without response (93% vs. 72%, hazard ratio 0.29; 95% CI, 11%-77%). No new safety signals were identified.

CONCLUSIONS

Neoadjuvant and adjuvant pembrolizumab increased one-year DFS rate in intermediate-risk, but not high-risk, HNSCC relative to historical control. PR to neoadjuvant ICB is a promising surrogate for DFS.

2D versus 3D Endoscopy: Head-to-Head Comparison in a Simulated Model of Endoscopic Endonasal Dural Suturing

Objective Endonasal dural suturing (EDS) has been reported to decrease the incidence of cerebrospinal fluid fistula. This technique requires handling of single-shaft instrumentation in the narrow endonasal corridor. It has been proposed that three-dimensional (3D) endoscopes were associated with improved depth perception. In this study, we sought to perform a comparison of two-dimensional (2D) versus 3D endoscopy by assessing surgical proficiency in a simulated model of EDS.

Materials and Methods Twenty-six participants subdivided into groups based on previous endoscopic experience were asked to pass barbed sutures through preset targets with either 2D (Storz Hopkins II) or 3D (Storz TIPCAM) endoscopes on 3D-printed simulation model. Surgical precision and procedural time were measured. All participants completed a Likert scale questionnaire.

Results Novice, intermediate, and expert groups took 11.0, 8.7, and 5.7 minutes with 2D endoscopy and 10.9, 9.0, and 7.6 minutes with 3D endoscopy, respectively. The average deviation for novice, intermediate, and expert groups (mm) was 5.5, 4.4, and 4.3 with 2D and 6.6, 4.6, and 3.0 with 3D, respectively. No significant difference in procedural time or accuracy was found in 2D versus 3D endoscopy. 2D endoscopic visualization was preferred by the majority of expert/intermediate participants, while 3D endoscopic visualization by the novice group.

Conclusion In this pilot study, there was no statistical difference in procedural time or accuracy when utilizing 2D versus 3D endoscopes. While it is possible that widespread familiarity with 2D endoscopic equipment has biased this study, preliminary analysis suggests that 3D endoscopy offers no definitive advantage over 2D endoscopy in this simulated model of EDS.

Adjuvant nivolumab following salvage resection in head and neck squamous cell carcinoma patients previously treated with definitive therapy: A single-arm phase II multi-institutional study

6031

Background: Salvage surgery for locally recurrent head and neck squamous cell carcinoma (rHNSCC) results in local control rates of 33-50% but only 20-40% of patients achieve long-term survival necessitating additional therapy (Haque et al., Oral Oncol. 2019). Many patients are ineligible for re-irradiation and chemotherapy alone after salvage surgeryhas shown no survival benefit. The clinical activity and tolerability of immune checkpoint inhibitors has been demonstrated in metastatic HNSCC, but the benefit after salvage surgery (SS) has not been studied. Here we report the results of a multi-center phase II investigation of nivolumab, a PD-1 inhibitor, after SS in recurrent HNSCC (NCT03355560). Methods: HNSCC patients undergoing curative-intent SS were enrolled to receive 6 months of nivolumab beginning 4-11 weeks after surgery. All received radiation with or without chemotherapy as prior definitive therapy and had no other curative treatment options at the time of surgery. Key exclusion criteria included: distant metastatic disease, gross residual disease, or a history of immunodeficiency, autoimmunity, or pneumonitis. The primary endpoint was 2-year disease-free survival (DFS) measured by Kaplan Meier curves. Safety was evaluated by CTCAE v5.0. Results: 39 patients were enrolled. Median age was 68 years (range, 49-85). 12/39 (31%) were female. 34/39 (87%) were white. Disease sites included oropharynx 9/39 (23%), oral cavity 14/39 (36%), and larynx 16/39 (41%). P16 status was 26% (+), 48% (-), and 26% (unknown). 17/39 (44%) had high risk pathologic features (positive margins or extranodal spread) at time of SS. 28/39 (72%) patients experienced treatment-related adverse events (TRAE), the most common of which were fatigue (26%), hypothyroidism (10%) and acneiform rash (13%). Grade 3-4 TRAEs were rare, occurring in 3/39 (8%) patients and included diarrhea, oral pain, neck pain, productive cough, stridor, and COPD exacerbation. 3/39 (8%) required treatment discontinuation and there were no grade 5 events. The 2-year DFS was 60% (95%CI 0.39-0.91). 2-year overall survival was 74% (95% CI 0.54-1). In single-cell multiplex cytokine analysis, patients who relapsed following adjuvant nivolumab had a significantly higher proportion of peripheral blood CD8 T cells which displayed a polyfunctional cytokine profile. IFN-γ and Granzyme were the dominant CD8 cytokines in both responders and non-responders, however CD8 expression of MIP1a and TNF-α were significantly higher in patients who ultimately relapsed. Conclusions: Nivolumab after salvage surgery in rHNSCC is well tolerated and shows promising antitumor activity in this high-risk patient population with unmet need. Immunotherapy after salvage surgery should be studied in randomized clinical trials. Clinical trial information: NCT03355560.

Association of pathological response to neoadjuvant pembrolizumab with tumor PD-L1 expression and high disease-free survival (DFS) in patients with resectable, local-regionally advanced, head and neck squamous cell carcinoma (HNSCC)

6006

Background: Patients with resected HNSCC, with high-risk (positive margins, extracapsular spread [ECE]) or intermediate-risk pathological features have an estimated 1-year DFS of 65% and 69%, respectively. Immune checkpoint blockade improved survival of patients with recurrent/metastatic HNSCC, and preclinical models indicate radiotherapy (RT) synergizes with anti-PD-1. Therefore, we administered the PD-1 inhibitor pembrolizumab (pembro) pre- and post-surgery with adjuvant RT +/- cisplatin in patients with resectable, locoregionally advanced (clinical T3/4 and/or ≥2 nodal metastases) HNSCC (NCT02641093). Methods: Eligible patients received pembro (200 mg I.V. x 1) 1-3 weeks before resection. Adjuvant pembro (q3 wks x 6 doses) was administered with RT (60-66Gy) with or without weekly cisplatin (40mg/m2 X 6) for patients with high-risk and intermediate-risk features, respectively. The primary endpoint was 1-year DFS estimated by Kaplan Meier curves. Safety was evaluated by CTCAE v5.0. Pathological response (PR) to neoadjuvant pembro was evaluated by comparing pre- and post-surgical tumor specimens for treatment effect (TE), defined as tumor necrosis and/or histiocytic inflammation and giant cell reaction to keratinaceous debris. PR was classified as no (NPR, < 20%), partial (PPR, ≥20% and < 90%) and major (MPR, ≥90%). Tumor PD-L1 immunohistochemistry was performed with 22c3 antibody and reported as combined positive score (CPS). Results: Ninety-two patients were enrolled. Seventy-six patients received adjuvant pembro and were evaluable for DFS. Patient characteristics included: median age 58 (range 27 – 80) years; 32% female; 88% oral cavity, 8% larynx, and 3% human papillomavirus negative oropharynx; 86% clinical T3/4 and 65% ≥2N; 49 (53%) high-risk (positive margins, 45%; ECE, 78%); 64% (44/69 available) had PD-L1 CPS ≥1. At a median follow-up of 20 months, 1-year DFS was 67% (95%CI 0.52-0.85) in the high-risk group and 93% (95%CI 0.84-1) in the intermediate-risk group. Among 80 patients evaluable for PR, TE scoring resulted in 48 NPR, 26 PPR and 6 MPR. Patients with PPR/MPR had significantly improved 1-year DFS when compared with those with NPR (100% versus 68%, p = 0.01; HR = 0.23). PD-L1 CPS ≥ 1 was not independently associated with 1-year DFS, but was highly associated with MPR/PPR (p = 0.0007). PPR/MPR in PD-L1 CPS < 1, ≥1 and ≥20, were estimated as 20, 55 and 90%, respectively. Grade ≥ 3 adverse events occurred in 62% patients with most common including dysphagia (15%), neutropenia (15%), skin/wound infections (10%), and mucositis (9%). Conclusions: PR to neoadjuvant pembro is associated with PD-L1 CPS≥1 and high DFS in patients with resectable, local-regionally advanced, HNSCC. Clinical trial information: NCT02641093.

Modified Head and Neck Swallow Scale: Using EORTC-QLQ-H&N35 to Predict Overall Survival

OBJECTIVES/HYPOTHESIS

Dysphagia is a treatment-related complication of head and neck cancer (HNCA). We demonstrate the predictive value of a modified head and neck swallow scale (m-HNSW) adapted from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck 35 (EORTC-QLQ-H&N35).

STUDY DESIGN

Retrospective Cohort Study.

METHODS

Retrospective, single-center cohort study utilizing a prospectively collected database of HNCA patients in a high-volume tertiary referral center. 736 HNCA patients more than 2 years from completion of treatment were identified. EORTC-QLQ-H&N35 data collected from at least one of three defined episodes of care were used. The m-HNSW uses three questions to form a 9-point dysphagia scale. A Cox proportional hazards model was used to determine the effect of the m-HNSW while controlling for demographics, tumor staging, site, and treatment.

RESULTS

Using data from 3, 6, 12 months from treatment, we analyzed a subset that included 328 patients. Three months after the completion of therapy, the m-HNSW score had a significant association with 1 (HR = 1.24, P = .0005) and 5 year survival (HR = 1.19, P = .0002) after accounting for body mass index. Six (HR = 1.14, P = .014) and 12 month (hazard ratio (HR) = 1.33, P < .0001) scores post completion of therapy predict 5-year survival. An increase of the m-HNSW score by 1 point was associated with an increase in death by 24%, and 19% at 1 and 5 years following therapy.

CONCLUSIONS

The m-HNSW is a simple assessment of dysphagia using previously validated EORTC-QLC-H&N35 data that when taken at 3, 6, and 12 months after completion of therapy is predictive of overall survival.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Single-cell multiplexed proteomics to identify novel polyfunctional CD8+ T cell signatures induced by nivolumab in head and neck cancer patients after salvage surgery

6576

Background: Immune checkpoint inhibitors (ICIs) are FDA approved for use in head and neck squamous cell cancer (HNSCC), however, only ~20% patients achieve a response. Identification of biomarkers of response or toxicity remains a challenge. Polyfunctional T-cells, or T-cells producing multiple cytokines, have been recognized as contributors to durable immunity against various cancers. However, their role has not been studied prospectively in HNSCC patients receiving ICIs. To look for an early predictor of response, we used single-cell functional proteomic profiling (IsoPlexis) on blood samples pre- and post- first dose of nivolumab (nivo) in patients on our phase-II study of locally recurrent HNSCC (NCT03355560). Methods: HNSCC patients who failed definitive radiation +/-chemotherapy and were subsequently treated with curative intent salvage resection were enrolled to receive 6 months of nivo beginning 4 to 11 weeks after surgery. Blood samples were collected before and after the first dose of nivo. Peripheral blood mononuclear cells were isolated, enriched for CD8+ T cells and using the 32-plex IsoCode technology, single-cell cytokine signals were captured and polyfunctional strength of CD8+ T cells was evaluated across four groups (effector, stimulatory, regulatory, inflammatory). A comparison analysis was performed between pre- and post- nivo treatment and between patients who relapsed (non-responders) vs those who did not (responders). Results: Thirty-three of 39 planned patients have been enrolled, of which 28 are evaluable and 5/28 (18%) developed recurrence. Median age is 68 years (range 51-85), 9/28 (32%) patients are female, 26/28 (93%) are white, disease sites include oropharyngeal 6/28 (21%), oral cavity 11/28 (39%) and larynx 11/28 (39%). Samples were evaluated at a median follow up of 5.9 months from enrollment. Single-cell analysis demonstrated a strong upregulation of polyfunctional human CD8+ T cell subsets in responders. Polyfunctional Strength Index (PSI) was enhanced in CD8+ T cells across the responders’ samples, composed largely of effector cytokines (granzyme-β, IFN-γ, MIP-1α, perforin, TNF-α). Conclusions: Single-cell functional proteomic analysis revealed significantly upregulated polyfunctional profiles and an increase in effector cytokines in patients who responded to nivo. This data provides important insights into PD-1 inhibitor triggered T-cell activity and may be used to predict response to ICIs in HNSCC patients using a blood test. Clinical trial information: NCT03355560 .

Syncope caused by a pleomorphic adenoma: Case report and literature review

Pleomorphic adenomas are considered the most common salivary gland tumors, although they rarely occur in the parapharyngeal space. To the best of our knowledge, this is the first case report of a parapharyngeal parotid pleomorphic adenoma causing syncope. A 57-year-old man was admitted for left-sided blurred vision, left-sided weakness, dysarthria, lightheadedness, and syncope. Upon his admission, an electrocardiogram showed sinus bradycardia, and computed tomography of the neck with contrast showed a large parapharyngeal mass involving the prestyloid compartment, leading to compression of blood flow through the internal carotid artery. The mass was biopsied via intraoral fine-needle aspiration, which revealed cytology consistent with pleomorphic adenoma. The mass was resected via a transcervical approach, and a total parotidectomy was performed. The patient's hypotensive and bradycardic episodes disappeared after surgery. Surgical pathology showed a benign pleomorphic adenoma with a hemorrhagic and necrotic center and without capsular invasion or malignant transformation.

Tonsillar Small Cell Carcinoma: Potential Contribution of Human Papillomavirus

Patient: Female, 64

Final Diagnosis: Small cell carcinoma of the tonsil

Symptoms: Sore throat

Medication: —

Clinical Procedure: —

Specialty: Oncology

Decreased plasma DEK Oncogene Levels Correlate with p16-Negative Disease and Advanced Tumor Stage in a Case-Control Study of Patients with Head and Neck Squamous Cell Carcinoma

Head and neck cancer (HNC) remains the sixth most common malignancy worldwide and survival upon recurrence and/or metastasis remains poor. HNSCC has traditionally been associated with alcohol and nicotine use, but more recently the Human Papilloma Virus (HPV) has emerged as a favorable prognostic risk factor for oropharyngeal HNSCC. However, further stratification with additional biomarkers to predict patient outcome continues to be essential. One candidate biomarker is the DEK oncogenic protein, which was previously detected in the urine of patients with bladder cancer and is known to be secreted by immune cells such as macrophages. Here, we investigated if DEK could be detected in human plasma and if DEK levels correlated with clinical and pathological variables of HNSCC. Plasma was separated from the peripheral blood of newly diagnosed, untreated HNSCC patients or age-matched normal healthy controls and analyzed for DEK protein using ELISA. Plasma concentrations of DEK protein were lower in p16-negative tumors compared to both normal controls and patients with p16-positive tumors. Patients with lower plasma concentrations of DEK were also more likely to have late stage tumors and a lower white blood cell count. Contrary to previously published work demonstrating a poor prognosis with high intratumoral DEK levels, we show for the first time that decreased concentrations of DEK in patient plasma correlates with poor prognostic factors, including HPV-negative status as determined by negative p16 expression and advanced tumor stage.

Abstract 50: Plasma concentrations of the DEK oncogene correlate with pathological variables in a case-control study of patients with HNSCC

Background: Head and neck squamous cell carcinoma (HNSCC) has traditionally been associated with alcohol and nicotine use, but more recently the Human Papilloma Virus (HPV) has emerged as a favorable prognostic risk factor for oropharyngeal HNSCC. However, further stratification with additional biomarkers to predict patient outcome continues to be essential. One candidate biomarker is the chromatin remodeling DEK protein, which is both an auto-antigen in autoimmune diseases and an oncogene in epithelial tissues. DEK is secreted by stimulated macrophages and neutrophils and was previously detected in the urine of patients with bladder cancer. Previously, we have reported that DEK mRNA and protein is upregulated in HNC tumor tissue and higher DEK levels are associated with poor prognoses in many types of solid tumors. We hypothesized that DEK could be detected in the plasma of HNC patients, either due to secretion from the tumor or as part of the antitumor immune response, and therefore may be a biomarker for disease status.

Methods: We recruited 38 newly diagnosed HNSCC patients and 37 age-matched normal healthy controls into the study. Plasma isolated from peripheral blood was subjected to DEK specific ELISA and DEK concentration levels were compared to levels found in normal controls, and to clinical and pathological variables.

Results: We show for the first time that DEK can be detected in human plasma. We did not find an association between DEK plasma concentrations and variables including sex, age, race, or drinking/smoking status. However, we detected decreased concentrations of DEK in HNC patients with p16-negative disease and in patients with larger tumor sizes, indicating an association between DEK levels and known prognostic markers. In addition, HNC patients with lower DEK concentrations had a decreased white blood cell count, largely due to differences in lymphocyte and eosinophil counts. This direct association between plasma DEK levels and white blood cell count was independent of p16 status.

Conclusions: Together, the data suggest that lower levels of DEK in HNC patient plasma may be predictive of poor outcome. This is in direct contrast to what is observed with intratumoral levels of DEK protein, in which higher levels of DEK expression are an independent factor predicting poor prognosis. Future studies will investigate the role that secreted DEK, such as that found in the plasma, may have in the antitumor immune response.

Citation Format: Trisha Wise-Draper, Arun Sendilnathan, Sarah Palackdharry, Nicholas Pease, Julianne Qualtieri, Randy Butler, Nooshin Hashemi Sadraei, John C. Morris, Yash Patil, Keith Wilson, Jonathan Mark, Keith Casper, Vinita Takiar, Adam Lane, Lisa M. Privette Vinnedge. Plasma concentrations of the DEK oncogene correlate with pathological variables in a case-control study of patients with HNSCC [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; April 23-25, 2017; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(23_Suppl):Abstract nr 50.

Mechanical venous anastomosis in head and neck microvascular reconstruction as an equivalent to the gold standard

To define the most successful and efficient manner to perform venous microvascular anastomoses, the effectiveness of mechanical venous anastomosis in head and neck microvascular reconstruction is reviewed. Head and neck reconstruction with free flap techniques has become the norm and gold standard for large defects. This retrospective, multicenter case series of a single microvascular surgeon's experience with mechanical venous anastomoses specifically assessed the effectiveness of head and neck reconstruction and the complications associated with it. Data were collected from two separate academic centers and are reported from a consecutive series of patients over the course of 10 years. All patients underwent microvascular reconstruction of the head and neck region using venous couplers and flap survival. Flap survival was greater than 98% using mechanical venous couplers as the primary means for venous outflow in this series of 402 consecutive patients and 431 total microvascular flaps. Venous couplers were performed in every instance. The study shows that mechanical venous anastomosis provides a highly effective and efficient means for venous outflow in head and neck microvascular reconstruction, and should be considered equivalent to the gold standard suture technique, even in the most difficult cases.

pH-Sensitive amphiphilic block-copolymers for transport and controlled release of oxygen

The synthesis of a library of amphiphilic-fluorous block-copolymers is described, and the capacity of these copolymers for oxygen transport in water is systematically investigated. The release of O₂ from some of the polymer dispersions could be triggered simply by changing the pH of the solution.

A case of radiation-induced mucosal melanoma in an immunohistochemically S-100-negative patient

We report a case of radiation-induced mucosal melanoma in a 41-year-old woman with a history of childhood rhabdomyosarcoma of the nasal cavity that had been treated with radiotherapy. During the workup for the melanoma, the patient was found to be negative for S-100 protein on immunostaining. While many melanotic markers for the histologic confirmation of melanoma exist, they can be negative in some cases, such as ours. To the best of our knowledge, only 1 case of radiation-induced melanoma has been previously reported in the English-language literature, and in that case the patient was S-100-positive. Although our case is rare, it suggests another possible long-term adverse effect of radiotherapy. We also describe the morphologies and histology associated with diagnosing melanoma in an S-100-negative patient.

Survival and Prognosis for Malignant Tumors of Odontogenic Origin

Objective

Determine survival and factors affecting survival for patients with malignant tumors of odontogenic origin.

Study Design

Retrospective analysis of the National Cancer Institute’s SEER database (Surveillance, Epidemiology, and End Results).

Setting

Tertiary medical center.

Subjects and Methods

All cases of malignant tumors of odontogenic origin were extracted from the SEER database for the period of 1973 to 2011. Demographic, tumor-specific, and survival data were tabulated and Kaplan-Meier survival analysis conducted according to histopathologic results. Cox regression analysis stratified for histopathology was conducted to determine factors that influenced survival.

Results

A total of 308 cases of malignant tumors with odontogenic origin were analyzed. Malignant ameloblastoma accounted for 59.7% of cases, followed by malignant odontogenic tumor (35.4%; including odontogenic carcinoma, odontogenic sarcoma, primary intraosseous carcinoma, and ameloblastic carcinoma) and ameloblastic fibrosarcoma (2.9%). The overall mean and median were 229 and 227 months, respectively, while the 5-year survival rate was 81% for the entire cohort. Malignant ameloblastoma exhibited the best mean survival (237 months), whereas malignant odontogenic tumor (139 months) and ameloblastic fibrosarcoma (42 months) had lower mean survival rates. Younger age, surgery with adjuvant radiation, and smaller tumor size were found to improve survival.

Conclusions

Significantly different survival can be expected depending on individual tumor histopathology, tumor size, age at diagnosis, and treatment modality.

Pressure-Flow Measurements for Selected Oral Sound Segments Produced by Normal Children and Adolescents: A Basis for Clinical Testing

Despite advances in surgery, a significant number of patients who undergo cleft palate repair have residual velopharyngeal insufficiency. Maxillary advancement may also result in velopharyngeal openings during speech. Instrumental approaches providing objective measures of palatal function assisting in the accurate diagnosis of these patients include pressure-flow measurements of velopharyngeal valving during speech. There is little information to guide clinicians in interpreting pressure-flow data when testing pediatric patients, however. The primary purpose of this study was to develop a method for categorizing pressure-flow data used in the diagnosis of children and adolescents with suspected velopharyngeal insufficiency. This prospective study involved 56 male and female subjects 5 to 18 years of age. Subjects had normal speech and resonance at the time of testing, no history of speech therapy, no upper respiratory infections or allergies at the time of testing, and no orofacial anomalies. Subjects repeated oral syllables and the word "hamper" after an examiner. Mean pressures, airflows, and velopharyngeal orifice areas were obtained for each utterance produced by each subject. A discriminate function analysis was performed to determine whether data could be grouped by age, gender, or utterance type. Results indicated significant differences in data for age groups 5 to 8 years, 9 to 13 years, and 14 to 18 years. There were no significant differences between data for male subjects versus female subjects or for different utterance types. Pressures generally decreased, whereas airflows and orifice areas increased with age. Results for 14 to 18 year olds were like those for adults. Using these data, a categorization scheme for velopharyngeal function was proposed for use in clinical testing.

Pressure-flow measurements for selected nasal sound segments produced by normal children and adolescents

OBJECTIVE

The purpose of this prospective study was to: (1) report simultaneous oral-nasal pressures, nasal airflow rates, and velopharyngeal orifice areas for nasal sounds produced by children and adolescents; (2) determine whether data could be statistically classified by age, sex, or utterance type; and (3) provide guidelines for determining typical from atypical productions.

PARTICIPANTS

The study involved 56 subjects, with two boys and two girls representing each age from 5 to 18 years. Subjects had no history of speech therapy, were judged as having normal speech and resonance at the time of testing, and had no upper respiratory tract infections or allergies at the time of testing.

METHODS

All subjects repeated /mphaaa;/ and "hamper" at normal pitch and loudness after an examiner model. Mean oral-nasal pressures, nasal airflow rates, and velopharyngeal orifice areas were calculated for each subject's utterances. A discriminate function analysis determined whether data could be grouped by age and sex.

RESULTS

Significant differences in mean data for age groups of 5 to 9 years, 10 to 13 years, and 14 to 18 years were observed. Data showed decreases in pressures and increases in nasal airflow and orifice areas with age. Variability in pressure stayed consistent or decreased with age, but variability in nasal airflow and orifice areas increased with age.

CONCLUSION

We propose a scheme for categorizing velopharyngeal function for oral and nasal sound production to be used in clinical testing.