A translation and validation of the French version of the Gothenburg Trismus Questionnaire 2 (F-GTQ-2)

BACKGROUND

Limitation of mouth opening, widely known as trismus, is a major symptom altering quality of life in individuals presenting from temporomandibular joint disorder or head and neck cancer. A French-language instrument addressing jaw opening limitation following treatment for head and neck cancer (HNC) or temporomandibular joint disorder (TMD) is lacking.

OBJECTIVE

The aim of this study was to translate and validate the Gothenburg Trismus Questionnaire-2 (GTQ-2) into French.

METHODS

A French translation of the GTQ-2 was performed according to established international guidelines, leading to the French-GTQ-2 (F-GTQ-2). The validation study included 154 participants with trismus (minimum interincisal opening of ≤35 mm) following treatment for TMD or HNC and 149 age-matched participants without trismus. All participants completed the F-GTQ-2 and participants with trismus completed additional health-related quality of life questionnaires to allow for analysis of convergent validity.

RESULTS

The F-GTQ-2 demonstrated retained psychometric properties with Cronbach's alpha values above 0.70 for the domains, jaw-related problems, eating limitations, facial pain and somewhat lower for muscular tension (0.60). Mainly moderate correlations were found when comparing the F-GTQ-2 to other instruments, which was in line with the pre-specified hypotheses, indicating satisfactory convergent validity. Discriminant validity was found with statistically significant differences in all domains of the F-GTQ-2 between trismus and non-trismus participants.

CONCLUSION

The F-GTQ-2 can be considered a reliable and valid instrument to assess jaw-related difficulties in individuals with trismus due to HNC or TMD.

m7G-related genes-NCBP2 and EIF4E3 determine immune contexture in head and neck squamous cell carcinoma by regulating CCL4/CCL5 expression

Aberrant N7 -methylguanosine (m7G) levels closely correlate with tumor genesis and progression. NCBP2 and EIF4E3 are two important m7G-related cap-binding genes. This study aimed to identify the relationship between the EIF4E3/NCBP2 function and immunological characteristics of head and neck squamous cell carcinoma (HNSCC). Hierarchical clustering was employed in classifying HNSCC patients into two groups based on the expressions of NCBP2 and EIF4E3. The differentially expressed genes were identified between the two groups, and GO functional enrichment was subsequently performed. Weighted gene co-expression network analysis was conducted to identify the hub genes related to EIF4E3/NCBP2 expression and immunity. The differential infiltration of immune cells and the response to immunotherapy were compared between the two groups. Single-cell sequence and trajectory analyses were performed to predict cell differentiation and display the expression of EIF4E3/NCBP2 in each state. In addition, quantitative real-time PCR, spatial transcriptome analysis, transwell assay, and western blotting were conducted to verify the biological function of EIF4E3/NCBP2. Here, group A showed a higher EIF4E3 expression and a lower NCBP2 expression, which had higher immune scores, proportion of most immune cells, immune activities, expression of immunomodulatory targets, and a better response to cancer immunotherapy. Besides, 56 hub molecules with notable immune regulation significance were identified. A risk model containing 17 hub genes and a prognostic nomogram was successfully established. Moreover, HNSCC tissues had a lower EIF4E3 expression and a higher NCBP2 expression than normal tissues. NCBP2 and EIF4E3 played a vital role in the differentiation of monocytes. Furthermore, the expression of CCL4/CCL5 can be regulated via EIF4E3 overexpression and NCBP2 knockdown. Collectively, NCBP2 and EIF4E3 can affect downstream gene expression, as well as immune contexture and response to immunotherapy, which could induce "cold-to-hot" tumor transformation in HNSCC patients.

Concurrent Chemoradiotherapy Induces Body Composition Changes in Locally Advanced Head and Neck Squamous Cell Carcinoma: Comparison between Oral Cavity and Non-Oral Cavity Cancer

Few prospective cohort trials have evaluated the difference in treatment-interval total body composition (TBC) changes assessed by dual-energy X-ray absorptiometry (DXA) between two patient subgroups with locally advanced head and neck squamous cell carcinoma (LAHNSCC) receiving concurrent chemoradiotherapy (CCRT): oral cavity cancer with adjuvant CCRT (OCC) and non-oral cavity with primary CCRT (NOCC). This study prospectively recruited patients with LAHNSCC. Clinicopathological variables, blood nutritional/inflammatory markers, CCRT-related factors, and TBC data assessed by DXA before and after treatment were collected. Multivariate linear regression analysis identified the factors associated with treatment-interval changes in body composition parameters, including lean body mass (LBM), total fat mass (TFM), and bone mineral content (BMC). A total of 127 patients (OCC (n = 69) and NOCC (n = 58)) were eligible. Body composition parameters were progressively lost during CCRT in both subgroups. Extremities lost more muscle mass than the trunk for LBM, whereas the trunk lost more fat mass than the extremities for TFM. BMC loss preferentially occurred in the trunk region. Different factors were independently correlated with the interval changes of each body composition parameter for both OCC and NOCC subgroups, particularly mean daily calorie intake for LBM and TFM loss, and total lymphocyte count for BMC loss. In conclusion, treatment-interval TBC changes and related contributing factors differ between the OCC and NOCC subgroups.

Chronic Nutrition Impact Symptoms Are Associated with Decreased Functional Status, Quality of Life, and Diet Quality in a Pilot Study of Long-Term Post-Radiation Head and Neck Cancer Survivors

BACKGROUND

As a result of tumor location and treatment that is aggressive, head and neck cancer (HNC) survivors experience an array of symptoms impacting the ability and desire to eat termed nutrition impact symptoms (NISs). Despite increasing cancer survival time, the majority of research studies examining the impact of NISs have been based on clinical samples of HNC patients during the acute phase of treatment. NISs are often chronic and persist beyond the completion of treatment or may develop as late side effects. Therefore, our research team examined chronic NIS complications on HNC survivors' functional status, quality of life, and diet quality.

METHODS

This was a cross-sectional study of 42 HNC survivors who were at least 6 months post-radiation. Self-reported data on demographics, NISs, quality of life, and usual diet over the past year were obtained. Objective measures of functional status included the short physical performance battery and InBody© 270 body composition testing. NISs were coded so a lower score indicated lower symptom burden, (range 4-17) and dichotomized as ≤10 vs. >10, the median in the dataset. Wilcoxon rank sum tests were performed between the dichotomized NIS summary score and continuous quality of life and functional status outcomes. Diet quality for HNC survivors was calculated using the Healthy Eating Index 2015 (HEI-2015). Wilcoxon rank sum tests examined the difference between the HNC HEI-2015 as compared to the National Health and Nutrition Examination Survey (NHANES) data calculated using the population ratio method.

RESULTS

A lower NIS score was statistically associated with higher posttreatment lean muscle mass (p = 0.002). A lower NIS score was associated with higher functional (p = 0.0006), physical (p = 0.0007), emotional (p = 0.007), and total (p < 0.0001) quality of life. Compared to NHANES controls, HNC survivors reported a significantly lower HEI-2015 diet quality score (p = 0.0001).

CONCLUSIONS

Lower NIS burden was associated with higher lean muscle mass and functional, physical, emotional, and total quality of life in post-radiation HNC survivors. HNC survivors reported a significantly lower total HEI-2015 as compared to healthy NHANES controls, providing support for the hypothesis that chronic NIS burden impacts the desire and ability to eat. The effects of this pilot study were strong enough to be detected by straight forward statistical approaches and warrant a larger longitudinal study. For survivors most impacted by NIS burden, multidisciplinary post-radiation exercise and nutrition-based interventions to manage NISs and improve functional status, quality of life, and diet quality in this survivor population are needed.

Distinct nitrogen isotopic compositions of healthy and cancerous tissue in mice brain and head&neck micro-biopsies

BACKGROUND

Cancerous cells can recycle metabolic ammonium for their growth. As this ammonium has a low nitrogen isotope ratio (15N/14N), its recycling may cause cancer tissue to have lower 15N/14N than surrounding healthy tissue. We investigated whether, within a given tissue type in individual mice, tumoral and healthy tissues could be distinguished based on their 15N/14N.

METHODS

Micro-biopsies of murine tumors and adjacent tissues were analyzed for 15N/14N using novel high-sensitivity methods. Isotopic analysis was pursued in Nude and C57BL/6 mice models with mature orthotopic brain and head&neck tumors generated by implantation of H454 and MEERL95 murine cells, respectively.

RESULTS

In the 7 mice analyzed, the brain tumors had distinctly lower 15N/14N than healthy neural tissue. In the 5 mice with head&neck tumors, the difference was smaller and more variable. This was at least partly due to infiltration of healthy head&neck tissue by tumor cells. However, it may also indicate that the 15N/14N difference between tumoral and healthy tissue depends on the nitrogen metabolism of the healthy organ in question.

CONCLUSIONS

The findings, coupled with the high sensitivity of the 15N/14N measurement method used here, suggest a new approach for micro-biopsy-based diagnosis of malignancy as well as an avenue for investigation of cancer metabolism.

Social isolation stress facilitates chemically induced oral carcinogenesis

Social isolation has affected a large number of people and may lead to impairment of physical and mental health. Although stress resulting from social isolation may increase cancer progression, its interference on tumorigenesis is poorly known. In this study, we used a preclinical model to evaluate the effects of social isolation stress on chemically induced oral carcinogenesis. Sixty-two 21-day-old male Wistar rats were divided into isolated and grouped groups. After 90 days of age, the rats from both groups underwent oral carcinogenesis with 4-nitroquinoline 1-oxide (4NQO) for 20 weeks. All rats were assessed for depressive-like behavior and euthanized for oral squamous cell carcinoma (OSCC) diagnosis and measurement of inflammatory mediators in the tumor microenvironment. Social isolation stress increased the OSCC occurrence by 20.4% when compared to control. Isolated rats also showed higher tumor volume and cachexia than the grouped rats. Social isolation did not induce changes in the depressive-like behavior after carcinogenic induction. Tumors from stressed rats had increased levels of the inflammatory mediators, TNF-alpha, IL1-beta and MCP-1. The concentrations of TNF-alpha and MCP-1 were significantly increased in the large tumors from isolated animals. Higher tumor levels of TNF-alpha, IL-6, IL1-beta and MCP-1 were positively correlated with OSCC growth. This study provides the first evidence that social isolation stress may facilitate OSCC occurrence and tumor progression, an event accompanied by increased local levels of inflammatory mediators.

Exercise and Nutrition Interventions in Patients with Head and Neck Cancer during Curative Treatment: A Systematic Review and Meta-Analysis

The aim of this meta-analysis was to examine the effects of nutritional and physical exercise interventions and interventions combining these interventions during radiotherapy treatment for patients with head and neck cancer on body composition, objectively measured physical function and nutritional status. Systematic electronic searches were conducted in MEDLINE (PubMed interface), EMBASE (Ovid interface), CINAHL (EBSCO interface) and Cochrane Library (Wiley interface). We identified 13 randomized controlled trials (RCTs) that included 858 patients. For body composition, using only nutrition as intervention, a significant difference between treatment and control group were observed (SMD 0.42 (95CI 0.23-0.62), p < 0.001). Only pilot RCTs investigated combination treatment and no significant difference between the treatment and control groups were found (SMD 0.21 (95CI -0.16-0.58), p = 0.259). For physical function, a significant difference between treatment and control group with a better outcome for the treatment group were observed (SMD 0.78 (95CI 0.51-1.04), p < 0.001). No effects on nutritional status were found. This meta-analysis found significantly positive effects of nutrition and physical exercise interventions alone in favor of the treatment groups. No effects in studies with combined interventions were observed. Future full-scaled RCTs combining nutrition and physical exercise is warranted.

Ulcerated cutaneous Richter syndrome

Richter syndrome or Richter transformation comprises the conversion of chronic lymphocytic leukemia into an aggressive type of large cell lymphoma. Classically, patients have diffuse and abrupt lymphadenopathy and organomegaly, in addition to fever, weight loss, and fatigue. Cutaneous involvement is rare and often nonspecific. We report a patient with chronic lymphocytic leukemia who presented with a large and rapidly evolving ulcer, revealed to be a high-grade cutaneous lymphoma.

Reproducibility of measurements on physical performance in head and neck cancer survivors; measurements on maximum mouth opening, shoulder and neck function, upper and lower body strength, level of physical mobility, and walking ability

Background

Survivors of Head and Neck Cancer experience specific problems in functional performance. The aim of this study was to obtain the test-retest reliability of measurements on Maximal Mouth Opening (MMO), shoulder and neck function, lower and upper body strength, level of mobility and walking ability.

Materials and methods

Test-retest study design. Measurements on MMO (intra- and extra orally), Active range of motion of shoulders and neck, 30 Seconds Chair Stand Test, Grip Strength, Timed Up and Go test, and Six Minute Walk test.

Results

In total 50 participants were included. The mean age was 68.6. ± 9.9 years and median time since end of treatment was 3.0 years (Q1–Q3: 1.0–5.25 years). We found good to excellent test-retest reliability on the core set of measurements (Intraclass Correlation Coefficient (ICC) 0.77 to 0.98). Measurement of MMO with cardboard card, forward flexion shoulder and Six Minute Walk test had a relatively small measurement error (Smallest Detectable Change (SDC) % 5.4% - 15.1%). Measurement of MMO with a caliper, shoulder abduction, shoulder external rotation, later flexion and rotation of the neck, grip strength, 30 Seconds Chair Stand Test, and Timed up and Go test had a relatively large measurement error (SDC% 19.8% - 44.7%).

Conclusion

This core set of measurements on physical performance is found reliable and therefore able to differentiate in physical performance. The reported measurement errors should be taken into consideration when interpreting the results of repeated measurements.

Implications for cancer survivors

A core set of physical measurements can be used to measure physical performance in survivors of Head and Neck Cancer.

Evaluation of pathologic staging using number of nodes in p16-negative head and neck cancer

OBJECTIVES

The 8th edition AJCC staging guidelines for head and neck squamous cell carcinoma (HNSCC) recently introduced pathologic staging criteria for nodal disease among p16-positive patients. In this study we evaluate pathologic staging in p16-negative HNSCC.

MATERIALS AND METHODS

We compared pathologic staging to the 7th and 8th edition AJCC staging systems using a statewide population-based cohort. All M0 p16-negative surgical patients were included. The outcome was five-year overall survival.

RESULTS

Of 304 patients identified, 113 were N0, 157 had 1-4 positive nodes, and 34 had ≥4 nodes. Survival was 71% (95% CI 61-78%) with no nodes, 48% (36%-60%) for 1-4 nodes, and 24% (11 - 39%) for > 4 nodes. When compared to the AJCC systems, the pathologic staging yielded a larger total survival gradient, more montonic survival, better consistency across primary sites, and a slightly lower Bayesian information criterion (1510 vs 1538). After adjusting for disease characteristics, demographics, and tobacco use, hazard ratios for survival were similar using pathologic and AJCC criteria.

CONCLUSION

In this cohort, pathological staging was more prognostic than AJCC staging. This is the first study to evaluate pathologic staging in p16-negative cancer; if these findings are verified, a universal nodal staging system could be introduced.

Oral Nutritional Supplementation Affects the Dietary Intake and Body Weight of Head and Neck Cancer Patients during (Chemo) Radiotherapy

Considering the symptoms of (chemo) radiotherapy and the reduction in food intake in head and neck cancer (HNC) patients, this study aimed to investigate the association between treatment time points and oral nutritional supplementation (ONS) on dietary intake to estimate the frequency of energy and nutrient inadequacy, and also to evaluate body weight changes (BWC). Dietary intake data of 65 patients were obtained from 24-h dietary recalls and prevalence of inadequacy was calculated before or at the beginning (T0), in the middle (T1), and at the end of treatment (T2). BWC were calculated as the weight difference considering the previous weight reported and/or measured. Energy and macronutrient intake decreased in T1 and then improved in T2 (p < 0.001 for both). Micronutrient intake increased during treatment due to ONS use, but still presented a high probability of inadequate intake. In particular, calcium, magnesium, and vitamin B6 showed almost 100% of probability of inadequacy for those who did not use ONS. Finally, overweight patients suffered a higher weight accumulated deficit with a delta of −15 kg compared to other BMI (body mass index) categories. Therefore, we strongly recommend initiating nutritional counseling in conjunction with prophylactic ONS prescription from diagnosis to adjust nutrient intake and minimize weight loss.

The use of negative pressure wound therapy in the primary setting for high-risk head and neck surgery

BACKGROUND

In head and neck surgery, dead space is typically managed by transferring a secondary pedicled flap or harvesting a larger composite flap with a muscular component. We demonstrate the novel use of prophylactic negative pressure wound therapy (NPWT) to obliterate dead space and reduce possible communication between the upper aerodigestive tract and the contents of the neck.

METHODS

We present a single-institutional case series of five patients with high-risk head and neck cancer treated with NPWT after ablative and reconstructive surgery to eliminate dead space following surgical resection.

RESULTS

All patients achieved successful wound closure following NPWT, which was applied in the secondary setting to combat infection in one patient and the primary setting to prophylactically eliminate dead space in four patients.

CONCLUSION

NPWT can be used to treat unfilled dead space in the primary setting of head and neck ablative and reconstructive surgery and help to avoid wound healing problems as well as the need for secondary flap transfers.

SIP SMART: a parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer

BACKGROUND

Dysphagia or difficulty in swallowing affects quality of life for most patients with head and neck cancer. SIP SMART - [Swallowing Intervention Package: Self-Monitoring, Assessment, Rehabilitation Training] aims to improve post-treatment swallowing outcomes through a targeted and tailored pre-treatment intervention. This feasibility study assessed 1) recruitment and retention, 2) patient acceptability of randomisation and participation, 3) patient adherence, and 4) sought to identify a suitable primary outcome for a definitive trial, including sample size estimation.

METHODS

This two-arm parallel group non-blinded randomised feasibility trial took place within a head and neck centre at a teaching hospital in London, UK. Patients newly diagnosed with stage III/IV head and neck cancer were recruited and underwent 6-month follow-up. Patients were randomised to SIP-SMART or usual care via an online web-based system. SIP SMART comprised two 45-min consultations including a baseline clinical and instrumental swallowing assessment, relevant educational information, targeted swallowing exercises, and specific behaviour change strategies to increase exercise adherence. Usual care comprised a single session including a baseline clinical assessment and generic information about the likely impact of treatment on swallowing.

RESULTS

A total of 106 patients were identified at pre-screening, 70 were assessed for eligibility. Twenty-six patients did not meet eligibility criteria [0.37, 95% CI 0.27 to 0.49]. Five of 44 [0.11, 95% CI 0.05 to 0.24] eligible patients were not approached by researchers during clinic. Seven [0.18, 95% CI 0.08 to 0.33] of the 39 approached declined participation. Target recruitment (32 consented patients) was achieved within the timeframe. At 6-months 29/32 [0.91, 95% CI 0.76 to 0.97] patients remained in the trial. Acceptability of randomisation and participation in the intervention was favourable, and adherence to the exercises exceeded the pre-defined 35% minimum criterion. The MD Anderson Dysphagia Inventory swallow related quality of life measure was selected as the most suitable primary outcome for sample size estimation. No adverse effects arose from the intervention, or study participation.

CONCLUSIONS

A definitive trial of the SIP SMART intervention compared to usual care is feasible and can be undertaken with patients with head and neck cancer treated within the NHS.

TRIAL REGISTRATION

ISRCTN40215425, registered retrospectively.

Changes in Nutrition Impact Symptoms, Nutritional and Functional Status during Head and Neck Cancer Treatment

Background: The purpose of this study is to evaluate changes in nutrition impact symptoms (NIS) and nutritional and functional status that occur throughout radiotherapy in head and neck cancer (HNC) patients. Methods: A prospective observational study of HNC inpatients who underwent radiotherapy with or without chemotherapy were recruited to participate. Fifty patients were followed for the periods before, in the middle and at the end of radiotherapy. Nutritional parameters were collected throughout radiotherapy. Results: According to Patient-Generated Subjective Global Assessment (PG-SGA), there was an increase from a baseline of 56% malnourished HNC patients to 100% malnourished with mean weight loss of 4.53 ± 0.41kg (7.39%) at the end of radiotherapy. Nutritional parameters such as muscle mass, fat mass, body mass index, dietary energy and protein intake decrease significantly (p < 0.0001) while NIS score, energy and protein intake from oral nutritional supplements (ONS) increased significantly (p < 0.0001). Hand grip strength did not differ significantly. All HNC patients experienced taste changes and dry mouth that required ONS at the end of treatment. ONS compliance affected the percentage of weight loss (p = 0.013). Conclusions: The intensive nutritional care time point was the middle of RT. The PG-SGA and NIS checklist are useful for monitoring nutrition for HNC patients.

Neuromuscular function and fatigability in people diagnosed with head and neck cancer before versus after treatment

PURPOSE

Treatment for head and neck cancer is associated with multiple side effects, including loss of body mass, impaired physical function and reduced health-related quality of life. This study aimed to investigate the impact of treatment (radiation therapy ± concurrent chemotherapy) on (i) muscle strength, muscle cross-sectional area and patient-reported outcomes, and (ii) central and peripheral alterations during a whole-body exercise task.

METHODS

Ten people with head and neck cancer (4 female; 50 ± 9 years) completed a lab visit before and after (56 ± 30 days) completion of treatment. Participants performed a neuromuscular assessment (involving maximal isometric voluntary contractions in the knee extensors and electrical stimulation of the femoral nerve) before and during intermittent cycling to volitional exhaustion. Anthropometrics and patient-reported outcomes were also assessed.

RESULTS

From before to after treatment, maximal isometric muscle strength was reduced (P = 0.002, d = 0.73), as was potentiated twitch force (P < 0.001, d = 0.62), and muscle cross-sectional area (e.g., vastus lateralis: P = 0.010, d = 0.64). Exercise time was reduced (P = 0.008, d = 0.62) and peripheral processes contributed to a reduction in maximal force due to cycling. After treatment, the severity of self-reported fatigue increased (P = 0.041, r = - 0.65) and health-related quality of life decreased (P = 0.012, r = - 0.79).

CONCLUSION

Neuromuscular function was impaired in patients with head and neck cancer after treatment. Whole-body exercise tolerance was reduced and resulted in predominantly peripheral, rather than central, disturbances to the neuromuscular system. Future research should evaluate strength training after treatment for head and neck cancer, with the overall aim of reducing fatigue and improving health-related quality of life.

Meta-analysis of the association between dietary inflammatory index (DII) and upper aerodigestive tract cancer risk

BACKGROUND

Epidemiological studies have reported an inconsistent relationship between dietary inflammatory index (DII) and upper aerodigestive tract (UADT) cancer risk. However, no systematic review or meta-analysis has been reported up to now. To quantify the association between DII and UADT cancer risk, we performed this meta-analysis.

METHODS

The PubMed, EMBASE, Web of Science and Cochrane Library database were searched for relevant studies from inception December 2018. All case-control studies investigating the association between DII and UADT cancer risk were selected.

RESULTS

A total of 9 case-control studies were identified, involving 13,714 participants. The adjusted pooled OR of UADT cancer for the highest (the most pro-inflammatory diet) vs lowest (the most anti-inflammatory diet) DII categories were 2.27 (95% CI: 1.89-2.73). Subgroup analysis showed that individuals with the highest category of DII score were independently associated with esophagus cancer (OR = 2.53, 95% CI: 1.74-3.68), oral cavity cancer (OR = 2.23, 95% CI: 1.73-2.86), pharyngeal cancer (OR = 2.02, 95% CI: 1.54-2.64), and laryngeal cancer (OR = 2.05, 95% CI: 0.85-4.93).

CONCLUSION

This meta-analysis suggested that the most pro-inflammatory diets (the highest DII scores) are associated with increased UADT cancer risk. However, the association between DII and laryngeal cancer risk need to be further investigated.

Quantification of Tumor Oxygenation Based on FMISO PET: Influence of Location and Oxygen Level of the Well-Oxygenated Reference Region

Tumor hypoxia may play a fundamental role in determining the radiotherapy outcome for several cancer types. Functional imaging with hypoxia specific radiotracers offers a way to visualize and quantify regions of increased radioresistance, which may benefit from dose escalation strategies. Conversion of the uptake in positron emission tomography (PET) images into oxygenation maps offers a way to quantitatively characterize the microenvironment. However, normalization of the uptake with respect to a well-oxygenated reference volume (WOV), which should be properly selected, is necessary when using conversion functions. This study aims at assessing the sensitivity of quantifying tumor oxygenation based on ¹⁸F-fluoromisonidazole (FMISO) PET with respect to the choice of the location and the oxygenation level of the WOV in head and neck cancer patients. WOVs varying not only in shape and location but also with respect to the assigned pO₂ level were considered. pO₂ values other than the standard 60 mmHg were selected according to the specific tissue type included in the volume. For comparison, the volume which would be considered as hypoxic based on a tissue-to-muscle ratio equal to 1.4 was also delineated, as conventionally done in clinical practice. Hypoxia mapping strategies are found highly sensitive to selection of the location of well-oxygenated region, but also on its assigned oxygenation level, which is crucial for hypoxia-guided adaptive dose escalation strategies.

The changing landscape of head and neck cancer radiotherapy patients: is high-risk, prolonged feeding tube use indicative of on-treatment weight loss?

INTRODUCTION

Precision radiotherapy relies heavily on optimal weight management. Our group previously developed a risk stratification model for patients at risk of prolonged feeding tube (FT) intervention. The study objective was to assess on-treatment weight loss according to stratified risk of prolonged FT use.

METHODS

One hundred and one (n = 101) definitive head and neck radiotherapy patients were included in this study. Patients were stratified into high risk (HRi: T-classification ≥ 3 with level 2 Nodal disease), high-intermediate risk (HIRi: T-classification ≥ 3 without level 2 Nodes) and low-intermediate risk (LIRi: T-classification < 3 with level 2 Nodes) of prolonged FT use. Demographic variables and on-treatment weight loss were evaluated according to risk status.

RESULTS

Oropharyngeal carcinoma (OPC) was present in a larger proportion in the LIRi cohort (HRi: 71%, HIRi: 52%, LIRi: 81%, P = 0.008). LIRi patients were more likely to have human papilloma virus (HPV)-associated disease (88%, P = 0.001). Never/minimal smoking (P = 0.003), good performance status (P < 0.001), healthy BMI (P = 0.050) and no pre-existing dysphagia (P < 0.001) were predominant within the LIRi prognostic group. LIRi patients lost significantly more weight in total (HRi = 4.8% vs. LIRi = 8.2%, P = 0.002; HIRi = 5.2% vs. LIRi = 8.2%, P = 0.006) and when using a FT (HRi = 4.6% vs. LIRi = 8.8%, P < 0.001; HIRi = 5.3% vs. LIRi = 8.8%, P = 0.002).

CONCLUSIONS

Patients identified as low-intermediate risk of prolonged, ≥25% FT use report significantly increased weight loss compared with patients at higher risk of FT use. This cohort is typical of the increasing number of patients presenting with HPV-associated OPC. Results of this study suggest we should closely observe such patients throughout treatment, to ensure optimal weight maintenance, facilitating precision radiotherapy.

Resilience and quality of life (QoL) of head and neck cancer and brain tumour survivors in Pakistan: an analytical cross-sectional study protocol

BACKGROUND

Cancer is a devastating disease and has detrimental effects on the quality of life (QoL) of cancer survivors and interferes with their treatment compliance. The aim of the study is to assess resilience and QoL among cancer survivors and to evaluate the important factors affecting their resilience and QoL, with respect to the Pakistani cultural context.

METHOD AND ANALYSIS

A cross-sectional study will be conducted at a tertiary care hospital in Karachi, Pakistan. A minimum sample size of 250 head and neck cancers and 250 brain tumour survivors with 10% inflation for non-response rate will be required. The SD of QoL and resilience will range from 16.5 to 40.8 for head and neck cancer, and 12.7 to 34.1 for brain tumour, at 5% level of significance, with 2.5 precision. QoL will be assessed by European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, EORTC QLQ-H&N35 and EORTC QLQ-BN20 and resilience will be evaluated by Wagnild and Young's 14-item scale. Mean±SD will be reported for resilience and QoL scores. Unadjusted and adjusted β-coefficients, with 95% CI, will be reported by using multiple linear regression analysis. Correlation analysis will also be performed using Pearson or Spearman rank correlation coefficients. A p value of <0.05 will be considered significant.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Aga Khan University Pakistan's Ethical Review Committee. Written informed consent will be taken from the participants by trained research assistants. A trained psychologist will provide on-spot counselling to the participants and those identified with severe depression will be referred to a psychiatrist. The study materials will be kept under lock and key and the electronic data base will be password protected and will only be accessed by the research team. The study findings will be disseminated through publications conferences and workshops and research briefs.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov registry (NCT03466762).

Late systemic symptoms in head and neck cancer survivors

PURPOSE

Neuroinflammation and central sensitization from cancer and its therapy may result in chronic systemic symptoms (CSS) such as fatigue, sleep disturbance, chronic widespread pain, mood disorders, neuropsychiatric symptoms, and temperature dysregulation. We undertook a cross-sectional study of CSS in head and neck cancer (HNC) survivors to determine their frequency, severity, and impact.

METHODS

HNC patients without evidence of recurrence who were at least 12 months post-treatment completed a one-time battery of self-report measures including the Vanderbilt Head and Neck Symptom survey plus the General Symptom Subscale, the Body Image Quality of Life Inventory, Neurotoxicity Rating Scale, the Profile of Mood States, and a five-item quality of life measure.

RESULTS

One hundred five patients completed the surveys. Forty-eight point four percent of patients experienced one or more moderate-to-severe systemic symptom. The frequency of individual symptoms was between 20% and 56% with almost half of patients rating symptoms as moderate-to-severe in intensity. Low and high systemic symptom burden populations were identified. Previously undescribed chronic neuropsychiatric symptoms were also found to be frequent and severe. The vigor score on the POMS was low. Body image was not adversely impacted. At least 40% of HNC survivors have diminished quality of life, and up to 15% have a poor quality of life.

CONCLUSIONS

CSS are common among HNC survivors and are frequently moderate to severe in intensity. Of note, previously underrecognized neuropsychiatric symptoms were endorsed by a significant cohort of patients warranting further study. Quality of life was diminished in a significant cohort.

Modeling symptom drivers of oral intake in long-term head and neck cancer survivors

PURPOSE

This study examined the relationship between self-reported symptom severity and oral intake in long-term head and neck cancer (HNC) survivors.

METHODS

An observational survey study with retrospective chart abstraction was conducted. HNC patients who had completed an MD Anderson Symptom Inventory-Head and Neck (MDASI-HN) questionnaire and also had clinician graded oral intake ratings (Functional Oral Intake Scale [FOIS]) were included. Correlation coefficients were computed. FOIS scores were regressed on MDASI-HN symptom items using stepwise backwards elimination for multivariate models.

RESULTS

One hundred and fifty-two survey pairings were included in the analysis (median 44 months follow-up, range 7-198). Per FOIS, 28% of survivors maintained a total oral diet with no restrictions, 67% reported a restricted oral diet (without tube), 3% were partially tube-dependent with some oral intake, and 2% were NPO. Of the 22 symptom items, the most severe items in decreasing order were dry mouth, difficulty swallowing\chewing, problems with mucus, tasting food, and choking/coughing. Significant bivariate correlations, after Bonferroni correction for multiple comparisons, were present for 8 of 22 symptoms with FOIS. On multivariate analysis, symptom severity for difficulty swallowing and problems with teeth/gums remained significantly associated with FOIS.

CONCLUSIONS

Oral intake in HNC survivorship is a multidimensional issue and functional outcome that is impacted not only by dysphagia but also by dental status. Symptom drivers of oral intake likely differ in acute survivorship. Nonetheless, these findings highlight the lack of specificity in this end point and also the need for multidisciplinary supportive care to optimize oral intake in survivors.

Swallowing-related quality of life after free flap surgery due to cancer of the head and neck

PURPOSE

Treatment of head and neck cancers (HNC) often leads to impairment in speech and swallowing functions. This study evaluated swallowing problems and the impact of complications on swallowing-related QOL after free flap surgery for HNC.

METHODS

Swallowing-related QOL was assessed using MDADI and SWAL questionnaires.

RESULTS

Of 45 assessed patients, 25 (45.5%) had at least one postoperative complication. Patients reported less than < 86 points in 8/9 SWAL-QOL domains. The SWAL-QL total score or MDADI composite scores were not related to surgical complications. Those with medical complications had lower scores in SWAL-QOL domains of mental health (82.8 (21.8) vs 65.5 (24.2), p = 0.024) and sleep (77.6 (23.0) vs 52.3 (24.3), p = 0.003).

CONCLUSIONS

In conclusion, swallowing related QOL is significantly impaired after 2 years of the tumor resection and free flap reconstruction for cancer of the head and neck, when using the cut-off value of 86 points in SWAL-QOL assessment tool. Surgical complications did not have an impact on swallowing-related QOL but medical complications were related to impairment in general QOL-related domains.

Metallic Nanoislands on Graphene for Monitoring Swallowing Activity in Head and Neck Cancer Patients

There is a need to monitor patients with cancer of the head and neck postradiation therapy, as diminished swallowing activity can result in disuse atrophy and fibrosis of the swallowing muscles. This paper describes a flexible strain sensor comprising palladium nanoislands on single-layer graphene. These piezoresistive sensors were tested on 14 disease-free head and neck cancer patients with various levels of swallowing function: from nondysphagic to severely dysphagic. The patch-like devices detected differences in (1) the consistencies of food boluses when swallowed and (2) dysphagic and nondysphagic swallows. When surface electromyography (sEMG) is obtained simultaneously with strain data, it is also possible to differentiate swallowing vs nonswallowing events. The plots of resistance vs time are correlated to specific events recorded by video X-ray fluoroscopy. Finally, we developed a machine-learning algorithm to automate the identification of bolus type being swallowed by a healthy subject (86.4%. accuracy). The algorithm was also able to discriminate between swallows of the same bolus from either the healthy subject or a dysphagic patient (94.7% accuracy). Taken together, these results may lead to noninvasive and home-based systems for monitoring of swallowing function and improved quality of life.

Gender differences in melanoma prognostic factors

BACKGROUND

Although previous studies identify gender differences in melanoma, limited research on the phenomenon exists.

METHODS

In this retrospective chart review, 1,156 adults diagnosed with melanoma, between 2006-2016, at the University of Colorado were included. Breslow depth, mitotic rate, ulceration status, and location were extracted from charts between March and August 2016. Cochran-Armitage trend tests and cumulative logistic regression were used to examine the association between gender and Breslow depth, univariately and after adjusting for potential confounders.

RESULTS

In univariate analysis, males were significantly more likely to present with lesions with higher Breslow depths (p for trend=0.005). In models adjusted for age, melanoma subtype, and location, males were marginally more likely to present with lesions with higher Breslow depths (cumulative OR: 1.261, 95% CI: 0.988-1.611, p=0.060). Males were also marginally more likely to present with lesions with higher mitotic rates, after further adjustments for all other prognostic factors (cumulative OR: 1.244, 95% CI: 0.979-1.580, p=0.074).

LIMITATIONS

This was a retrospective single-institution study.

CONCLUSION

Differences in mitotic rates among melanomas in males versus females, even after adjustments for all other prognostic factors, suggests that biological differences may contribute to the female prognosis advantage.

Prospective evaluation of the early effects of radiation on the auditory system frequencies of patients with head and neck cancers and brain tumors after radiotherapy

Patients with head and neck cancer after radiotherapy often suffer disability such as hearing disorders. In this study, the effect of radiotherapy (RT) on hearing function of patients with head and neck cancer after RT was determined according to the total dose delivered to specific parts of the auditory system. A total of 66 patients treated with primary or postoperative radiation therapy for various cancers in the head and neck region were selected. All patients had audiologic evaluation with pure tone audiometry for the frequencies of 250, 500, 1,000, 2,000, 3,000, 4,000, 6,000, and 8,000 Hz before and immediately after completion of treatment and again 3 months later. The cochlea dose volume histograms of the patients were derived from their computed-tomography-based treatment plans. At study's end, RT-induced auditory complications developed in 33% of patients. The greatest hearing loss (changes >15 dB) occurred immediately after RT at frequencies of 3,000 (14.5%), 4,000 (12.9%), 6,000 (13.6%), and 8,000 Hz (10.6%), and after 3 months of follow-up, at 3,000 (6.8%), 4,000 (7.7%), 6,000 (10.7%), and 8,000 Hz (12.1%). Univariate and multivariate analyses indicated a positive relationship between dose delivered to the cochlea and hearing loss (p < 0.001, r = 0.484). An increased risk of hearing loss was present for patients receiving ≥40 Gy as their mean dose compared with those receiving <30 Gy. We conclude that radiation dose has negative effects on the auditory system. This effect occurs more in high-frequency hearing. The received dose to the cochlea was the main cause of damage to hearing.

Durable usage of patient-reported outcome measures in clinical practice to monitor health-related quality of life in head and neck cancer patients

Purpose

To investigate the long-term follow-up (5 years) of implementing patient-reported outcome measures (PROMs) in clinical practice to monitor health-related quality of life (HRQOL) in head and neck cancer (HNC) patients.

Methods

A mixed method design was used. The usage rate of OncoQuest (a touch screen computer system to monitor HRQOL) and the subsequent nurse consultation was calculated among HNC patients who visited the outpatient clinic for regular follow-up, as well as differences between ever users and never users (sociodemographic and clinical characteristics). The content of the nurse consultation was investigated. Reasons for not using (barriers) or using (facilitators) OncoQuest and the nurse consultation were explored from the perspective of HNC patients, and of head and neck surgeons.

Results

Usage rate of OncoQuest was 67% and of the nurse consultation 79%. Usage of OncoQuest was significantly related to tumor subsite and tumor stage. Topics most frequently (>40%) discussed during the nurse consultation were global quality of life (97%), head and neck cancer related symptoms (82%), other physical symptoms such as pain (61%), and psychological problems such as anxiety (44%). Several barriers and facilitators to implement PROMs in clinical practice were reported by both patients and head and neck surgeons.

Conclusion

Usage of PROMs in clinical practice and a nurse consultation is durable, even 5 years after the introduction. This study contributes to better insight into long-term follow-up of implementation, thereby guiding future research and projects that aim to implement PROMs in clinical practice to monitor HRQOL among (head and neck) cancer patients.

Sleep quality in long-term survivors of head and neck cancer: preliminary findings

PURPOSE

This preliminary study evaluated sleep quality in long-term head and neck cancer survivors, using demographic data and clinical features of the cancers as assessment criteria. In addition, a possible correlation was examined between scores on self-rated questionnaires of sleep quality and assessments of quality of life and oral health status.

METHODS

Subjects were 77 head and neck cancer survivors. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale. Oral and general health status was assessed using The Oral Health Impact Profile (OHIP-14) and the Short-Form Health Survey (SF-36), respectively, and correlated with clinical parameters. Spearman's correlation coefficients were calculated to examine relationships between variables. Logistic regression analysis was performed to identify independent variables associated with poor sleep quality.

RESULTS

Eighty-three percent of patients had poor sleep quality (global scores ≥5) and 40% had a global Pittsburgh Sleep Quality Index score ≥8, indicating significantly poor sleep quality. Nocturnal enuresis, daytime sleepiness, and early morning awakening were the most common complaints. Extensive neck dissection, a lower SF-36 mental component score, and a higher OHIP-14 psychological disability score were independently associated with poor sleep quality. OHIP-14 global score was linked independently with daytime sleepiness.

CONCLUSION

This is the first study to demonstrate a high prevalence of poor sleep quality in long-term head and neck cancer survivors. Extensive neck dissection, poor mental health, and psychological disability may contribute to poor sleep quality. Maintaining good oral health-related quality of life could promote better sleep in these patients.

Feasibility of an iPad to Facilitate Communication in Postoperative Patients With Head and Neck Cancer

PURPOSE

To measure the feasibility of a communication application and an iPad to facilitate communication in postoperative patients with head and neck cancer.

DESIGN

A prospective feasibility study.

METHODS

This IRB-approved study was conducted in the postanesthesia care unit at an urban comprehensive cancer center. The participants included patients with head and neck cancer who underwent surgery that resulted in altered communication. Questionnaires were developed and administered to measure feasibility and patient satisfaction at different time points (preoperative, postoperative, and 1 to 4 days postoperatively).

FINDINGS

Of 38 patients in the study, 25 (66%) were able to use the customized iPad. Of these 25 patients, 15 (60%) were satisfied or somewhat satisfied with it. 84% found the customized iPad to be very or somewhat helpful for communication after surgery.

CONCLUSIONS

Patients were satisfied with the customized iPad, and the study found that using technology such as this was feasible in the immediate postoperative period.

Blocking of stromal interaction molecule 1 expression influence cell proliferation and promote cell apoptosis in vitro and inhibit tumor growth in vivo in head and neck squamous cell carcinoma

Calcium signal plays an important role in a variety of cancer cell metabolism, but knowledge on its role in head and neck squamous cell carcinoma (HNSCC) is limited. Store-operated calcium entry (SOCE) is the principal Ca2+ entry mechanism that maintains calcium concentration and produces calcium signal in non-excitable cells. SOCE is triggered by stromal interaction molecule 1 (STIM1), which is located in endoplasmic reticulum (ER) as Ca2+ sensor. Although, many studies demonstrated that STIM1 and SOCE play important functions in the regulation of many cancer progressions, their clinical relevance in HNSCC remains unclear. In this study, STIM1 expression levels notably increased in 89% HNSCC tissues compared with those in adjacent normal tissues. Meanwhile, this overexpression was close associated with tumor size but not with neck lymph node metastasis. Thus, this study mainly focuses on STIM1 function in HNSCC tumor growth. Three HNSCC cell lines, namely, TSCCA (oral cancer cell line) and Hep2 (laryngeal cell line) with high STIM1 expression levels and Tb3.1 (oral cancer cell line) with STIM1 expression level lower than previous two cell lines, were selected for in vitro study. Downregulated STIM1 expression levels in TSCCA and Hep2 arrested cells in G0/G1 stages, promoted cell apoptosis, and inhibited cell proliferation. By contrast, upregulated STIM1 expression in Tb3.1 inhibited cell apoptosis and promoted cell proliferation. Induced by thapsigargin (TG), ER stress was amplified when STIM1 expression was downregulated but was attenuated as STIM1 expression was upregulated. Furthermore, TSCCA cell xenograft models confirmed that STIM1 could promote HNSCC tumor growth in vivo. The present study provides new insight into HNSCC molecular mechanism and potential therapeutic target through targeting SOCE-dependent process. However, whether STIM1 participates in HNSCC metastasis requires further study.

Improving swallowing outcomes in patients with head and neck cancer using a theory-based pretreatment swallowing intervention package: protocol for a randomised feasibility study

INTRODUCTION

The incidence of head and neck cancer (HNC) in the UK is rising, with an average of 31 people diagnosed daily. Patients affected by HNC suffer significant short-term and long-term post-treatment morbidity as a result of dysphagia, which affects daily functioning and quality of life (QOL). Pretreatment swallowing exercises may provide additional benefit over standard rehabilitation in managing dysphagia after primary HNC treatments, but uncertainty about their effectiveness persists. This study was preceded by an intervention development phase to produce an optimised swallowing intervention package (SIP). The aim of the current study is to assess the feasibility of this new intervention and research processes within a National Health Service (NHS) setting.

METHOD AND ANALYSIS

A two-arm non-blinded randomised controlled feasibility study will be carried out at one tertiary referral NHS centre providing specialist services in HNC. Patients newly diagnosed with stage III and IV disease undergoing planned surgery and/or chemoradiation treatments will be eligible. The SIP will be delivered pre treatment, and a range of swallowing-related and QOL measures will be collected at baseline, 1, 3 and 6 months post-treatment. Outcomes will test the feasibility of a future randomised controlled trial (RCT), detailing rate of recruitment and patient acceptance to participation and randomisation. Salient information relating to protocol implementation will be collated and study material such as the case report form will be tested. A range of candidate outcome measures will be examined for suitability in a larger RCT.

ETHICS AND DISSEMINATION

Ethical approval was obtained from an NHS Research Ethics Committee. Findings will be published open access in a peer-reviewed journal, and presented at relevant conferences and research meetings.

TRIAL REGISTRATION NUMBER

ISRCTN40215425; Pre-results.

Morphological and functional imaging of neck paragangliomas

OBJECTIVE

To review the optimal techniques for localization and characterization of neck paragangliomas (PGL).

MATERIAL AND METHODS

Systematic review of the literature from the PubMed/Medline database.

RESULTS

Neck PGL are hypervascular tumours essentially arising from paraganglionic tissue situated at the carotid bifurcation (carotid body) and along the vagus nerve. Morphological and functional imaging are indicated to confirm the diagnosis, identify multifocal disease and for local and regional staging. MR angiography is the noninvasive technique of choice. CT scan and especially CT angiography are excellent alternatives for diagnosis and staging. Conventional arteriography remains useful preoperatively for embolization and occlusion tests. Functional imaging allows localization and characterization of PGLs. Somatostatin receptor scintigraphy (SRS) was the reference imaging technique for staging of sporadic PGLs. The indications for PET imaging have been extended over recent years in parallel with the development of new tracers such as [¹⁸F]-FDOPA PET or ⁶⁸Gallium-labelled DOTA peptides. ⁶⁸Gallium-labelled DOTA peptides has become the first-line imaging modality in the evaluation of cervical PGLs, regardless of the genetic background.

CONCLUSION

Morphological and functional imaging is essential for the staging of neck PGL.

Symptoms of patients with head and neck cancers undergoing radiotherapy

Radiotherapy is a reliable and effective treatment method for the treatment of head and neck cancers. This study was conducted as a descriptive work with the purpose of determining the symptoms experienced by patients with head and neck cancer who are undergoing radiotherapy. The study was carried out on 47 patients receiving treatment in oncology clinics. Data were obtained at mid-radiotherapy (RT), at the end of radiotherapy and 1 month after the end of radiotherapy using the Memorial Symptom Assessment Scale (MSAS) and Personal Information Forms. The mean scores of MSAS GDI (Global Distress Index), MSAS Physical, MSAS Psychological and Total Memorial Symptom Assessment Scale, which were highest by the end of radiotherapy, declined during the 1-month period following the end of radiotherapy. A statistically significant difference (p < .05) was found between the subscale groups in the evaluations made at mid-RT, at the end of RT and 1 month after the end of RT. Patients generally experienced symptom frequency, severity and distress levels at highest rates at the end of RT. During the radiotherapy process, determining these symptoms will contribute to improve the well-being of the patient. These results may be useful to control symptoms effectively.

Relationship Between the Eating Assessment Tool-10 and Objective Clinical Ratings of Swallowing Function in Individuals with Head and Neck Cancer

The Eating Assessment Tool-10 (EAT-10) represents a validated, easy to administer patient report dysphagia severity scale. Although its ability to detect swallowing impairment has been investigated in other patient populations, the utility of this instrument in individuals with head and neck cancer (HNC) has not been studied. The aim of the current investigation was to determine the relationship between patient ratings of swallowing impairment (EAT-10) and objective clinical ratings of swallow physiology in individuals with HNC. Forty-four HNC participants completed the EAT-10 and a standardized videofluoroscopy swallow study. Blinded raters determined airway safety using the penetration-aspiration scale (PAS) and swallowing function using the modified barium swallow impairment profile (MBSImP™©). Participants were stratified into three groups (pre-treatment through 1 year post-treatment, 1-5 years post-treatment, and >5 years post-treatment). Independent t tests, Pearson's and Spearman's Rho correlations, and a Bonferroni correction for multiple comparisons were performed. EAT-10 scores were significantly higher in HNC patients with unsafe swallowing (M 24.45, SD 8.32) compared to those with safe swallowing (M 16.20, SD 12.14), t(21) = -2.36, p  < 0.04. Significant correlations were revealed between EAT-10 scores and the MBSImP™© (pharyngeal composite), and PAS scores (p < 0.05) for the pre-treatment to within 1 year post-treatment group. No associations, however, were observed for HNC patients in the time groups representing greater than 1-year post cancer treatment.

Models for predicting stage in head and neck squamous cell carcinoma using proteomic data

Head and neck squamous cell carcinoma (HNSCC) that is detected at an advanced stage is associated with much worse patient outcomes than if detected at early stages. This study uses reverse phase protein array (RPPA) data to build predictive models that discriminate between early and advanced stage HNSCC. Individual and ensemble binary classifiers, using filter-based and wrapper-based feature selection, are used to build several models which achieve moderate MCC and AUC values. This study identifies informative protein feature sets which may contribute to an increased understanding of the molecular basis of HNSCC.

An Introduction to a Head and Neck Cancer-Specific Frailty Index and Its Clinical Implications in Elderly Patients: A Prospective Observational Study Focusing on Respiratory and Swallowing Functions

INTRODUCTION

Frailty refers to a decreased physiologic reserve in geriatric patients and its importance in terms of treatment planning and outcome prediction has been emphasized in oncologic practices for older patients with cancer. We investigated the clinical implications of a head and neck cancer (HNC)-specific frailty index suggested by prospective clinical and functional evaluations of HNC patients.

MATERIALS AND METHODS

We analyzed data on 165 elderly patients with HNC who were prospectively enrolled in our hospital from 2010 to 2013. Pretreatment functional evaluations were performed according to all comprehensive geriatric assessment (CGA) domains. We additionally evaluated the patients' respiratory and swallowing functions using pulmonary function tests, voice handicap index (VHI), MD Anderson Dysphagia Inventory (MDADI), and other associated tests. Factors affecting the 2-year morbidity and mortality were also analyzed.

RESULTS

Respiratory and swallowing problems were major causes of 2-year morbidity. Pretreatment performance status, VHI ≥8, MDADI <70, dental problems, and chemotherapy were significantly associated with early morbidity and mortality (all p < .05). CGA-assessed frailty was found in 72 patients (43.6%) and was significantly associated with 2-year mortality (p = .027) but not with morbidity (p = .716). The high-risk group according to our new HNC-specific frailty index that included functional evaluations of respiration and swallowing showed significantly higher 2-year morbidity (p = .043) and mortality (p < .001).

CONCLUSION

Pretreatment functional disabilities related to respiration and swallowing were significantly associated with early morbidity and mortality. The suggested index would be more useful for assessing frailty in elderly HNC patients.

IMPLICATIONS FOR PRACTICE

This study is the first report in terms of suggesting a new frailty index focusing on respiratory and swallowing functions in elderly patients with head and neck cancer. This study shows that functional disabilities associated with respiration and swallowing significantly affected early morbidity and mortality in these elderly patients. The head and neck cancer-specific frailty index described in this report, which includes functional evaluations of respiration and swallowing, significantly predicted both early morbidity and mortality.

Flexible Endoscopic Evaluation of Swallowing with Sensory Testing: Patient Characteristics and Analysis of Safety in 1,340 Consecutive Examinations

Flexible endoscopic evaluation of swallowing with sensory testing (FEESST) is a comprehensive endoscopic assessment of the sensory and motor components of a swallow. Previous studies addressing patient safety issues with respect to FEESST included relatively small numbers of patients and paid almost no attention to patient characteristics. The purpose of this study was to determine the incidence of FEESST-related complications in the outpatient and inpatient settings and to analyze patient diagnoses that led to the performance of FEESST. We performed a prospective study of FEESST complications in 1,340 consecutive evaluations performed over a 4 1/2-year period. The primary outcome variables were incidence of epistaxis and airway compromise. The secondary outcome variable was underlying patient diagnoses. The incidence of epistaxis was 1 in 1,340 (0.07%). There were no instances of airway compromise. Stroke was the most common reason for the performance of FEESST (343; 25.6%), followed by cardiac-related dysphagia (298; 22.2%) following open heart surgery (169/298; 56.7%), heart attack, congestive heart failure, or new arrhythmia. The remaining causes were head and neck cancer (207; 15.4%), pulmonary disease (141; 10.5%), chronic neurologic disease (124; 9.3%), and acid reflux disease (80; 6.0%). We conclude that FEESST is a relatively safe procedure for the sensory and motor assessment of dysphagia in a cohort of patients with a wide variety of underlying diagnoses. The emergence of cardiac surgery as a common cause of dysphagia warrants further study.

Health-related quality of life before and after head and neck squamous cell carcinoma: Analysis of the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey linkage

BACKGROUND

Understanding health-related quality of life (HRQOL) is crucial to providing high-quality survivorship care for patients with head and neck squamous cell carcinoma (HNSCC). Trends in and prognostic significance of HRQOL before and after HNSCC have not been well described.

METHODS

HRQOL for older individuals with HNSCC was examined using the linked Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey database. Surveys assessing HRQOL from 5 years prediagnosis to 10 years postdiagnosis were included. HRQOL over time was modeled using multilevel linear regression with restricted cubic splines and was reported as either total HRQOL or change in HRQOL (denoted Δ). The association of prediagnosis HRQOL with survival was examined.

RESULTS

In total, 1653 individuals were included; of these, 61% completed 1 survey, and 39% completed multiple surveys. Overall HRQOL decreased progressively until 13 months postdiagnosis, then recovered toward baseline between 2 and 5 years. However, after stratification by survival group, the postdiagnosis recovery was not observed. Individuals with shorter survival had lower HRQOL prediagnosis (<2-year survivors, 87.3; > 5-year survivors, 96.4; P = .004) with a steeper decline in HRQOL during diagnosis and treatment (<2-year survivors: Δ, -16.6; 95% confidence interval [CI], -23.8, -9.4; > 5-year survivors: Δ, -0.9; 95% CI, -1.8, 0.08). Radiotherapy and advanced stage were associated with greater declines in HRQOL during diagnosis and treatment (P < .001). Higher prediagnosis HRQOL was independently associated with improved overall survival (adjusted hazard ratio for 10-point increase, 0.91; 95% CI, 0.85-0.97).

CONCLUSIONS

HRQOL declines before and after HNSCC, whereas any observed posttreatment recovery is likely an artifact of shorter survival among individuals with the lowest HRQOL. The prognostic implication of prediagnosis HRQOL may inform patient counseling. Cancer 2016;122:1861-70. © 2016 American Cancer Society.

Association of Body Composition With Survival and Locoregional Control of Radiotherapy-Treated Head and Neck Squamous Cell Carcinoma

IMPORTANCE

Major weight loss is common in patients with head and neck squamous cell carcinoma (HNSCC) who undergo radiotherapy (RT). How baseline and posttreatment body composition affects outcome is unknown.

OBJECTIVE

To determine whether lean body mass before and after RT for HNSCC predicts survival and locoregional control.

DESIGN, SETTING, AND PARTICIPANT

Retrospective study of 2840 patients with pathologically proven HNSCC undergoing curative RT at a single academic cancer referral center from October 1, 2003, to August 31, 2013. One hundred ninety patients had computed tomographic (CT) scans available for analysis of skeletal muscle (SM). The effect of pre-RT and post-RT SM depletion (defined as a CT-measured L3 SM index of less than 52.4 cm2/m2 for men and less than 38.5 cm2/m2 for women) on survival and disease control was evaluated. Final follow-up was completed on September 27, 2014, and data were analyzed from October 1, 2014, to November 29, 2015.

MAIN OUTCOMES AND MEASURES

Primary outcomes were overall and disease-specific survival and locoregional control. Secondary analyses included the influence of pre-RT body mass index (BMI) and interscan weight loss on survival and recurrence.

RESULTS

Among the 2840 consecutive patients who underwent screening, 190 had whole-body positron emission tomography-CT or abdominal CT scans before and after RT and were included for analysis. Of these, 160 (84.2%) were men and 30 (15.8%) were women; their mean (SD) age was 57.7 (9.4) years. Median follow up was 68.6 months. Skeletal muscle depletion was detected in 67 patients (35.3%) before RT and an additional 58 patients (30.5%) after RT. Decreased overall survival was predicted by SM depletion before RT (hazard ratio [HR], 1.92; 95% CI, 1.19-3.11; P = .007) and after RT (HR, 2.03; 95% CI, 1.02-4.24; P = .04). Increased BMI was associated with significantly improved survival (HR per 1-U increase in BMI, 0.91; 95% CI, 0.87-0.96; P < .001). Weight loss without SM depletion did not affect outcomes. Post-RT SM depletion was more substantive in competing multivariate models of mortality risk than weight loss-based metrics (Bayesian information criteria difference, 7.9), but pre-RT BMI demonstrated the greatest prognostic value.

CONCLUSIONS AND RELEVANCE

Diminished SM mass assessed by CT imaging or BMI can predict oncologic outcomes for patients with HNSCC, whereas weight loss after RT initiation does not predict SM loss or survival.

Psychometric Validation of the M. D. Anderson Symptom Inventory-Head and Neck Module in the Spanish Language

CONTEXT

The assessment of cancer-related symptoms requires culturally adapted and psychometrically validated symptom assessment tools. The M. D. Anderson Symptom Inventory-Head and Neck Module (MDASI-HN) is a useful instrument for measuring symptom burden that was specifically developed for head and neck cancer patients.

OBJECTIVES

To validate the Spanish version of the MDASI-HN.

METHODS

We evaluated the psychometric features of the MDASI-HN in patients with head and neck cancer. We evaluated the item-scale correlations and the internal consistency. We conducted principal axis factoring to identify the underlying dimensions as a measure of construct validity. The convergence/concurrent validity was assessed with the University of Washington Quality of Life Questionnaire for Head and Neck Patients, and known-group validity and test-retest reliability also were assessed.

RESULTS

One hundred thirty patients were included. The mean ± SD age was 60.5 ± 13.6 years; 68% of patients were male, 42% had laryngeal tumors, and 45.9% had Stage III tumors. Forty-seven percent of the patients underwent surgery, 55% underwent radiotherapy, and 36% underwent chemotherapy. The global Cronbach alpha for the HN module was 0.81. The factor analysis identified two factors (Factor 1: speech, mucus, coughing, and constipation; Factor 2: teeth, taste, sores, swallowing, and skin). The correlation with the global score of the University of Washington Quality of Life was -0.68. The difference in the MDASI-HN scores according to Eastern Cooperative Oncology Group performance status was statistically significant (2.72 vs. 4.01, P = 0.006). The intraclass test-retest correlation was 0.62.

CONCLUSION

The Spanish version of the MDASI-HN is reliable and valid for evaluating cancer-related symptoms in head and neck cancer patients.

[Effect of DJ-1 silencing by RNA interference on growth of xenografted human laryngeal squamous cell carcinoma Hep-2 cells in nude mice]

Objective: To investigate the effect of silencing DJ-1 on xenografted human laryngeal squamous cell carcinoma (LSCC) Hep-2 cells in nude mice. Methods: Xenograft model of human LSCC was established by subcutaneous transplantation of Hep-2 cells in 24 nude mice. The LSCC-bearing nude mice were randomly divided into 3 groups (n=8 in each):DJ-1 siRNA low dose group and DJ-1 siRNA high dose group were injected in tumors with 20 μg of DJ-1 siRNA or 40 μg of DJ-1 siRNA in 50 μL, respectively; control group was injected with 5% glucose solution in 50 μL, twice a week for 3 weeks. The weight and size of tumors were measured before injection. The animals were sacrificed 48 h after the final treatment, and the tumors were harvested and weighed. The apoptosis and proliferation of tumor cells were determined; the expressions of Caspase-3 and Ki-67 in tumor specimens were detected with immunohistochemistry. The expression of DJ-1, PTEN, survivin mRNA and protein in tumor tissues were detected by RT-PCR and Western blotting, respectively. Results: Tumor weight in low dose group[(0.66±0.15)g] and high dose group[(0.48±0.11)g] were significantly lower than that in control group[(0.83±0.16)g, all P<0.05]. The inhibition rates of low dose group and high dose group were (20.48±0.18)% and (42.16±0.13)%, respectively. Immunohistochemistry showed that the expression of Caspase-3 was increased and Ki-67 was reduced in tumor specimens, compared with the control group (all P<0.05). RT-PCR and Western blot results showed that in low dose group and high dose group the mRNA and protein expression of DJ-1 and survivin significantly decreased (all P<0.05), while PTEN mRNA and protein content increased (all P<0.05). Conclusion: High dose DJ-1 siRNA can inhibit the tumor growth in human LSCC xenograft nude mouse model, which indicates that down-regulating DJ-1 and survivin, and up-regulating PTEN expression may lead to blockage of PI3K-PKB/Akt signaling pathway and promoting tumor cell apoptosis.

Fibromatosis of infratemporal space

Fibromatosis is a rare benign mesenchymal neoplasm which primarily originates in the muscle, connective tissue, fascial sheaths, and musculoaponeurotic structures. It is commonly seen as abdominal tumour but in maxillofacial region, the occurrence of these tumours is very rare and exceedingly rare in infratemporal space. Often misdiagnosed due to its varied clinical behaviour, fibromatosis is benign, slow-growing, infiltrative tumour without any metastatic potential, but is locally aggressive causing organ dysfunction along with high recurrence rate. We report a case of fibromatosis involving the left infratemporal space in a 35-year-old female who presented with chief complaint of limited mouth opening for the preceding 4 years.

Importance of Tumour Suppressor Gene Methylation in Sinonasal Carcinomas

Epigenetic changes are considered to be a frequent event during tumour development. Hypermethylation of promoter CpG islands represents an alternative mechanism for inactivation of tumour suppressor genes, DNA repair genes, cell cycle regulators and transcription factors. The aim of this study was to investigate promoter methylation of specific genes in samples of sinonasal carcinoma by comparison with normal sinonasal tissue. To search for epigenetic events we used methylation-specific multiplex ligation-dependent probe amplification (MS-MLPA) to compare the methylation status of 64 tissue samples of sinonasal carcinomas with 19 control samples. We also compared the human papilloma virus (HPV) status with DNA methylation. Using a 20% cut-off for methylation, we observed significantly higher methylation in RASSF1, CDH13, ESR1 and TP73 genes in the sinonasal cancer group compared with the control group. HPV positivity was found in 15/64 (23.4 %) of all samples in the carcinoma group and in no sample in the control group. No correlation was found between DNA methylation and HPV status. In conclusion, our study showed that there are significant differences in promoter methylation in the RASSF1, ESR 1, TP73 and CDH13 genes between sinonasal carcinoma and normal sinonasal tissue, suggesting the importance of epigenetic changes in these genes in carcinogenesis of the sinonasal area. These findings could be used as prognostic factors and may have implications for future individualised therapies based on epigenetic changes.

Neck trauma: a red-herring to diagnosis of chemodectoma

Chemodectoma, a neuroendocrine tumour of the paraganglionic cells in the carotid body remains an uncommon tumour. We report the first case from University of Ilorin Teaching Hospital, Ilorin, Nigeria. Though with a red herring history of trauma induced swelling, clinical and radiologic features were characteristic of chemodectoma. Histologic features of the excised lesion are presented.

Fidelity considerations in translational research: Eating As Treatment - a stepped wedge, randomised controlled trial of a dietitian delivered behaviour change counselling intervention for head and neck cancer patients undergoing radiotherapy

BACKGROUND

The confidence with which researchers can comment on intervention efficacy relies on evaluation and consideration of intervention fidelity. Accordingly, there have been calls to increase the transparency with which fidelity methodology is reported. Despite this, consideration and/or reporting of fidelity methods remains poor. We seek to address this gap by describing the methodology for promoting and facilitating the evaluation of intervention fidelity in The EAT (Eating As Treatment) project: a multi-site stepped wedge randomised controlled trial of a dietitian delivered behaviour change counselling intervention to improve nutrition (primary outcome) in head and neck cancer patients undergoing radiotherapy.

METHODS/DESIGN

In accordance with recommendations from the National Institutes of Health Behaviour Change Consortium Treatment Fidelity Workgroup, we sought to maximise fidelity in this stepped wedge randomised controlled trial via strategies implemented from study design through to provider training, intervention delivery and receipt. As the EAT intervention is designed to be incorporated into standard dietetic consultations, we also address unique challenges for translational research.

DISCUSSION

We offer a strong model for improving the quality of translational findings via real world application of National Institutes of Health Behaviour Change Consortium recommendations. Greater transparency in the reporting of behaviour change research is an important step in improving the progress and quality of behaviour change research.

TRIAL REGISTRATION NUMBER

ACTRN12613000320752 (Date of registration 21 March 2013).

[New Combination Therapy to Improve the Functional Preservation Rate of the Larynx in Laryngeal, Oropharyngeal, and Hypopharyngeal Cancers]

A new combination therapy has been developed to achieve high overall survival and functional laryngeal preservation rates in head and neck cancers, which require laryngectomy. In order to treat the primary site without resection, superselective intra-arterial infusions with DCF anterogradely and 60 mg/m2 of DOC and 60 mg/m2 of CDDP via the femoral artery on day 1 were administered, followed by continuous intravenous instillation of 750 mg/m2/day of 5-FU for 5 days from day 2. The 5- year survival rate was 70.4% in laryngeal cancer, 72.8% in oropharyngeal cancer, and 68.5% in hypopharyngeal cancer. The 5-year functional laryngeal preservation rate was 71.0% in laryngeal cancer, 63.4% in oropharyngeal cancer, and 65.2% in hypopharyngeal cancer. In addition to regional lymph node control, a thorough neck dissection was performed. Good overall survival and functional laryngeal preservation rates were achieved.

Cardiovascular profile score in 44 fetuses with cervicofacial tumors

BACKGROUND

Cervicofacial tumors are rarely detected by prenatal ultrasound, and prenatal counseling is very difficult as not much information is available about this problem in the literature, other than cases reports.

OBJECTIVES

The aim of this study was to know if fetal echocardiography examination is helpful in those cases.

MATERIAL AND METHODS

Forty-four fetuses with cervicofacial tumors detected in utero by ultrasonography and referred to our unit were assessed and the cardiovascular profile score (CVPS) based on echocardiography examinations was calculated. The data were analyzed by the standard statistical tests and Pearson's χ2-test (significance level P=0.05).

RESULTS

CVPS<8 was diagnosed in 10 fetuses (23%). Structural or functional cardiovascular anomalies were present in 17 fetuses (39%). The statistically significant correlation between the CVPS<8 and the poor outcome was confirmed (P<0.05).

CONCLUSION

We recommend fetal echocardiography and CVPS evaluation before counseling in fetuses with cervicofacial tumors as cardiovascular dysfunction diagnosed prenatally may seriously affect survival of the fetus as well as prenatal counseling and need for cardiac treatment.

Effects of Lingual Effort on Swallow Pressures Following Radiation Treatment

PURPOSE

This article investigated the effects of increased oral lingual pressure on pharyngeal pressures during swallowing in patients who have undergone radiotherapy for head and neck cancer. It was hypothesized that increased oral lingual pressure would result in increased pharyngeal pressures.

METHOD

A within-subject experimental design was used with 20 participants who were status post external beam radiotherapy for head and neck cancer. Participants completed typical swallows and swallows with increased lingual force during manofluoroscopic swallow studies. The swallow condition order was randomized across participants.

RESULTS

Manometric data revealed significant differences in swallow pressure by condition at the base of tongue and upper esophageal sphincter sensor locations without significant pressure differences in the lower pharynx. The effortful lingual swallows resulted in higher mean pressures at all locations.

CONCLUSIONS

The results of this study suggest that use of a maneuver designed to increase oral tongue effort can also increase pharyngeal tongue base pressure. Therefore, therapeutic activities used to generate greater pressure of the oral tongue may also alter pharyngeal response. Further research is needed to determine the direct clinical effect on swallow function for individuals with head and neck cancer.

Evaluation of neck masses in adults

Neck masses are often seen in clinical practice, and the family physician should be able to determine the etiology of a mass using organized, efficient diagnostic methods. The first goal is to determine if the mass is malignant or benign; malignancies are more common in adult smokers older than 40 years. Etiologies can be grouped according to whether the onset/duration is acute (e.g., infectious), subacute (e.g., squamous cell carcinoma), or chronic (e.g., thyroid), and further narrowed by patient demographics. If the history and physical examination do not find an obvious cause, imaging and surgical tools are helpful. Contrast-enhanced computed tomography is the initial diagnostic test of choice in adults. Computed tomography angiography is recommended over magnetic resonance angiography for the evaluation of pulsatile neck masses. If imaging rules out involvement of underlying vital structures, a fine-needle aspiration biopsy can be performed, providing diagnostic information via cytology, Gram stain, and bacterial and acid-fast bacilli cultures. The sensitivity and specificity of fine-needle aspiration biopsy in detecting a malignancy range from 77% to 97% and 93% to 100%, respectively.