Frequent apocrine changes in pleomorphic adenoma with malignant transformation: a possible pre-malignant step in ductal carcinoma ex pleomorphic adenoma

Background@#The most common type of carcinoma ex pleomorphic adenoma (CPA) is histologically equivalent to salivary duct carcinoma, which has an apocrine phenotype. Invasive CPA is often accompanied by non-invasive or in situ carcinoma, an observation that suggests the presence of precursor lesions. The aim of this study was to identify candidate precursor lesions of CPA within pleomorphic adenoma (PA). @*Methods@#Eleven resected cases of CPA with residual PA and 17 cases of PA with atypical changes were subjected to immunohistochemistry (IHC) for p53, human epidermal growth factor receptor 2 (HER2), androgen receptor (AR), pleomorphic adenoma gene 1, gross cystic disease fluid protein-15 (GCDFP-15), and anti-mitochondrial antibody. @*Results@#Invasive or in situ carcinoma cells in all CPAs were positive for AR, GCDFP-15, and HER2. Atypical foci in PAs corresponded to either apocrine or oncocytic changes on the basis of their reactivity to AR, GCDFP-15, and anti-mitochondrial antibody. Atypical cells in PAs surrounding CPAs had an apocrine phenotype without HER2 expression. @*Conclusions@#Our study identified frequent apocrine changes in residual PAs in CPA cases, suggesting a possible precursor role of apocrine changes. We recommend the use of HER2 IHC in atypical PAs, and that clinicians take HER2 positivity into serious consideration.

Validation of the Korean Version of the Neck Dissection Impairment Index in Patients Who Underwent Neck Dissection / 대한두경부종양학회지

Background/Objectives@#Shoulder function is an important aspect of health related quality of life (QOL). Neck dissection impairment index (NDII) is a simple shoulder-specific questionnaire. This study aimed to evaluate the association between QOL and NDII in patients who underwent neck dissection to validate the Korean version of NDII.Materials & Methods: This study enrolled 74 patients with head and neck cancer who underwent neck dissection from December 2013 to April 2014. Patients completed questionnaires on QOL including the European Organization of Research and Treatment of Cancer 30-item Core QOL questionnaire (EORTC QLQ-C30) and NDII which was translated into Korean. Validity was evaluated by calculating the Pearson correlation coefficient between NDII and EORTC QLQ-C30. @*Results@#We compared preoperative, postoperative within a week, 1st and 3rd months NDII scores. The total NDII scores were 14.7, 47.4, 33.7 and 34.3 each. Clinical variables including gender, site of primary tumor, performing revision neck dissection, radiotherapy and flap reconstruction were not significantly associated with NDII. However NDII mean score of patients who underwent unilateral neck dissection over 3 levels is most increased after operation. During all periods NDII scores were significantly associated with functioning score. Although other scores are lower correlation than function scores, global health status scores and symptom scores are also correlation with NDII. @*Conclusion@#NDII was valid instrument and can be used not only in the clinical practice to assess shoulder dysfunction but also in the simple instrument to evaluate global QOL in Korea patients with having neck dissection.

Treatment Outcome of Scalp Angiosarcoma: A Single Institute Experience / 대한이비인후과학회지

Background and Objectives@#Scalp angiosarcoma is a rare but aggressive vascular malignancy. It is often found in the advanced state and tends to cause distant metastasis at an early stage. There is no consensus on a treatment modality, although wide excision followed by adjuvant therapy is currently used. The purpose of this study was to analyze the treatment results and disease progress pattern of scalp angiosarcoma in a single institution.Subjects and Method We enrolled patients who diagnosed with scalp angiosarcoma at Asan Medical Center from March 2011 to September 2019. Disease course and prognostic factors were analyzed by estimating overall survival rate and disease free survival. @*Results@#A total 12 patients were enrolled in this study. The median overall survival was 16.0 months. The 3-year-survival rate was 10.6%, and the median disease free survival was 5.0 months. On the average, it took 11.4 months till death after recurrence. @*Conclusion@#Although wide surgical excision and multiple adjuvant therapies are employed, scalp angiosarcoma showed frequent recurrences and metastasis which led to poor outcomes. Further investigations for scalp angiosarcoma are necessary to improve treatment outcomes.

Primary squamous cell carcinoma of the salivary gland: immunohistochemical analysis and comparison with metastatic squamous cell carcinoma

Background@#Primary squamous cell carcinoma (SCC) of the salivary gland is a rare disease, and distinguishing primary SCC from metastatic SCC is difficult. This study investigated the histological and immunohistochemical differences between primary and metastatic salivary gland SCC to improve the accuracy of diagnosis and to explore the pathogenesis of this disease. @*Methods@#Data of 16 patients who underwent surgery for SCC of salivary glands between 2000 and 2018 at Asan Medical Center were retrieved. Eight patients had a history of SCC at other sites, and eight patients had only salivary gland SCC. Immunostaining for p16, p53, androgen receptor (AR), gross cystic disease fluid protein 15 (GCDFP-15), and c-erbB2, as well as mucicarmine staining, were compared between the two groups. @*Results@#Most tumors were located in the center of the salivary glands with extraparenchymal extension. The histology of primary SCC of the salivary gland was consistent with moderately differentiated SCC with extensive desmoplastic reaction and peritumoral inflammation. Involvement of the salivary gland ducts and transition into the ductal epithelium were observed in two cases. Metastatic SCC resembled the primary tumor histologically and was associated with central necrosis. Both groups exhibited negative mucin staining. Two, one, and one primary SCC case exhibited AR, GCDFP-15, and c-erbB2 positivity, respectively. @*Conclusions@#A subset of primary SCCs originated in salivary ducts or was related to salivary duct carcinoma. Distinguishing primary from metastatic SCC of the salivary gland is difficult using histologic features and immunoprofiles. A comprehensive review of the medical history is essential.

Primary squamous cell carcinoma of the salivary gland: immunohistochemical analysis and comparison with metastatic squamous cell carcinoma

Background@#Primary squamous cell carcinoma (SCC) of the salivary gland is a rare disease, and distinguishing primary SCC from metastatic SCC is difficult. This study investigated the histological and immunohistochemical differences between primary and metastatic salivary gland SCC to improve the accuracy of diagnosis and to explore the pathogenesis of this disease. @*Methods@#Data of 16 patients who underwent surgery for SCC of salivary glands between 2000 and 2018 at Asan Medical Center were retrieved. Eight patients had a history of SCC at other sites, and eight patients had only salivary gland SCC. Immunostaining for p16, p53, androgen receptor (AR), gross cystic disease fluid protein 15 (GCDFP-15), and c-erbB2, as well as mucicarmine staining, were compared between the two groups. @*Results@#Most tumors were located in the center of the salivary glands with extraparenchymal extension. The histology of primary SCC of the salivary gland was consistent with moderately differentiated SCC with extensive desmoplastic reaction and peritumoral inflammation. Involvement of the salivary gland ducts and transition into the ductal epithelium were observed in two cases. Metastatic SCC resembled the primary tumor histologically and was associated with central necrosis. Both groups exhibited negative mucin staining. Two, one, and one primary SCC case exhibited AR, GCDFP-15, and c-erbB2 positivity, respectively. @*Conclusions@#A subset of primary SCCs originated in salivary ducts or was related to salivary duct carcinoma. Distinguishing primary from metastatic SCC of the salivary gland is difficult using histologic features and immunoprofiles. A comprehensive review of the medical history is essential.

Dysphagia in Patients with Tongue Cancer Treated with Surgery / 대한연하장애학회지

OBJECTIVE: To evaluate the swallowing problems after a primary resection in patients with tongue cancer. METHODS: Thirty-eight patients with primary tongue cancer, who underwent a glossectomy and had undergone a Video Fluoroscopic Swallowing Study (VFSS) prior to surgery in a university hospital between January 2010 and May 2015, were included retrospectively. The clinical and swallowing features, including the VFSS parameters before and after surgery, were analyzed. RESULTS: Among the 38 patients, 33 patients were T1 and T2 stage. Thirty-one, six and one patient underwent a partial glossectomy, hemiglossectomy, and total glossectomy, respectively. More than ninety percent of the patients had a selective neck dissection. All the patients were on a regular diet before surgery and showed no penetration or aspiration on the VFSS. Immediately after surgery, 33 patients (87%) had to change to non-oral feeding. At discharge, 8 patients (21%) maintained non-oral feeding, and 30 patients ate a limited diet. In a telephone survey (mean 19 months after surgery), among the 25 survey participants, 24 patients (96%) reported no problems with their regular diet. CONCLUSION: In tongue cancer patients with low Tumor-Node-Metastasis (TNM), American Joint Committee on Cancer (AJCC) stages, a primary resection of tongue cancer did not cause statistically significant dysphagia after surgery. Although many patients had to change their diet to limited or non-oral feeding immediately after surgery, almost all patients improved and could eat a regular diet after the long term follow up.

Comparison of Squamous Cell Carcinoma of the Tongue between Young and Old Patients

BACKGROUND: The worldwide incidence of squamous cell carcinoma of the tongue (SCCOT) in young patients has been increasing. We investigated clinicopathologic features of this unique population and compared them with those of SCCOT in the elderly to delineate its pathogenesis.METHODS: We compared clinicopathological parameters between patients under and over 45 years old. Immunohistochemical assays of estrogen receptor, progesterone receptor, androgen receptor, p53, p16, mdm2, cyclin D1, and glutathione S-transferase P1 were also compared between them.RESULTS: Among 189 cases, 51 patients (27.0%) were under 45 years of age. A higher proportion of women was seen in the young group, but was not statistically significant. Smoking and drinking behaviors between age groups were similar. Histopathological and immunohistochemical analysis showed no significant difference by age and sex other than higher histologic grades observed in young patients.CONCLUSIONS: SCCOT in young adults has similar clinicopathological features to that in the elderly, suggesting that both progress via similar pathogenetic pathways.

Initial Nutritional Status and Clinical Outcomes in Patients With Deep Neck Infection

OBJECTIVES: The current study aims to determine the correlation between nutritional status upon presentation and disease severity, as well as treatment and survival outcomes. METHODS: Patients who were diagnosed with deep neck infection, underwent at least one surgical drainage/debridement, and had more than 1 week of hospitalization at a tertiary medical center from 2007 to 2015 were retrospectively included. Thereafter, initial serum albumin, C-reactive protein (CRP), and body mass index (BMI) were reviewed. RESULTS: A total of 135 patients were included in the final analysis. Accordingly, the proportion of patients with simultaneous mediastinitis (21.0%), necrotizing fasciitis (12.9%), disease extent >1 cervical level (72.6%), mean CRP (22.4 mg/dL), mean length of hospitalization (25.0 days), and mean 1-week follow-up CRP (7.2 mg/dL) was significantly higher in the hypoalbuminemia group (initial serum albumin 1 cervical level (2.12), initial serum CRP over 20 mg/dL (3.79), hospitalization of more than 14 days (4.10), 1-week follow-up CRP over 5 mg/dL (3.78), and increased duration for an over 50% decrease in initial CRP (2.70) (all P < 0.05). Although intravascular albumin replenishment decreased the proportion of patients with hypoalbuminemia after 2 weeks (P < 0.05), it did not significantly predict better treatment outcomes. CONCLUSION: Among the markers reflecting an individual's nutritional state, an initial serum albumin of less than 3.0 g/dL was an independent serologic marker predicting increased disease severity and complications in patients with deep neck infection.

Predictors of Long Term Prognosis of Dysphagia in Tonsil Cancer Patients / 대한연하장애학회지

OBJECTIVE: To evaluate the factors affecting long-term prognosis for dysphagia in tonsil cancer patients, after treatment. METHOD: This was a retrospective study of subjects who underwent a videofluoroscopic swallowing study (VFSS) following treatment for stage 3 or 4 tonsil cancer. Data including sex, age, cancer characteristics, and methods of cancer treatment were collected. To evaluate the swallowing-related outcome, we collected data including findings regarding the last VFSS, method of feeding, and history of aspiration pneumonia requiring in-patient care. We evaluated the correlation between these data and the characteristics of cancer and treatment methods. RESULT: Among 32 subjects included in this study, eight had aspiration or penetration confirmed by the last VFSS. There were no significant differences in swallowing-related factors according to the presence of aspiration or penetration in the last VFSS. Patients who underwent curative tonsillectomy retained more residues on the last VFSS than those who did not. CONCLUSION: Among subjects with tonsil cancer, history of curative tonsillectomy was correlated with more pharyngeal residue. However, other cancer- or treatment-related factors did not affect the outcome of swallowing.

Basaloid Squamous Cell Carcinoma of the Head and Neck: Subclassification into Basal, Ductal, and Mixed Subtypes Based on Comparison of Clinico-pathologic Features and Expression of p53, Cyclin D1, Epidermal Growth Factor Receptor, p16, and Human Papilloma

BACKGROUND: Basaloid squamous cell carcinoma (BSCC) is a rare variant of squamous cell carcinoma with distinct pathologic characteristics. The histogenesis of BSCC is not fully understood, and the cancer has been suggested to originate from a totipotent primitive cell in the basal cell layer of the surface epithelium or in the proximal duct of secretory glands. METHODS: Twenty-six cases of head and neck BSCC from Asan Medical Center, Seoul, Korea, reported during a 14-year-period were subclassified into basal, ductal, and mixed subtypes according to the expression of basal (cytokeratin [CK] 5/6, p63) or ductal markers (CK7, CK8/18). The cases were also subject to immunohistochemical study for CK19, p53, cyclin D1, epidermal growth factor receptor (EGFR), and p16 and to in situ hybridization for human papillomavirus (HPV), and the results were clinico-pathologically compared. RESULTS: Mixed subtype (12 cases) was the most common, and these cases showed hypopharyngeal predilection, older age, and higher expression of CK19, p53, and EGFR than other subtypes. The basal subtype (nine cases) showed frequent comedo-necrosis and high expression of cyclin D1. The ductal subtype (five cases) showed the lowest expression of p53, cyclin D1, and EGFR. A small number of p16- and/or HPV-positive cases were not restricted to one subtype. BSCC was the cause of death in 19 patients, and the average follow-up period for all patients was 79.5 months. Overall survival among the three subtypes was not significantly different. CONCLUSIONS: The results of this study suggest a heterogeneous pathogenesis of head and neck BSCC. Each subtype showed variable histology and immunoprofiles, although the clinical implication of heterogeneity was not determined in this study.

A Case of Glomangiopericytoma in the Prevertebral Space / 대한이비인후과학회지

Glomanigiopericytoma is a rare vascular neoplasm with a perivascular myoid phenotype. It is rarely found in the neck but most commonly in the nose and paranasal sinuses. We experienced a case of 72-year-old man who presented a 5-year history of a right neck mass. The pathologic diagnosis was glomangiopericytoma. We removed the mass transcervically and the patient showed no postoperative problem. We report this case with a review of literature.

Accuracy of Core Needle Biopsy Versus Fine Needle Aspiration Cytology for Diagnosing Salivary Gland Tumors

BACKGROUND: Core needle biopsy is a relatively new technique used to diagnose salivary gland lesions, and its role in comparison with fine needle aspiration cytology needs to be refined. METHODS: We compared the results of 228 ultrasound-guided core needle biopsy and 371 fine needle aspiration procedures performed on major salivary gland tumors with their postoperative histological diagnoses. RESULTS: Core needle biopsy resulted in significantly higher sensitivity and more accurate tumor subtyping, especially for malignant tumors, than fine needle aspiration. No patient developed major complications after core needle biopsy. CONCLUSIONS: We recommend ultrasoundguided core needle biopsy as the primary diagnostic tool for the preoperative evaluation of patients with salivary gland lesions, especially when malignancy is suspected.

A Case of Facial Nerve Paralysis Following Parotid Abscess Treated by Catheter Drainage / 대한이비인후과학회지

Facial nerve paralysis is one of the complications of parotid abscess. Although a few cases of benign tumor and inflammatory condition of parotid gland with the facial nerve paralysis have been reported, the occurrence of facial nerve palsy following parotid abscess without coexisting tumor is very rare. The mechanism of facial nerve paralysis is not clear, but facial nerve paralysis is usually improved after the treatment of parotid abscess. The treatment of parotid abscess is composed of antibiotics based on proper culture study and drainages. Most of parotid abscess is drained by surgical approach, but catheter drainage is also recommended for selected patients. Here, we report a case of parotid abscess treated by pig-tail catheter drainage.

Risk Factors and Survival Outcomes for Patients With Anastomotic Leakage After Surgery for Head and Neck Squamous Cell Carcinoma

OBJECTIVES: This study evaluated the risk factors for anastomotic leakage (AL) and survival outcomes in patients with head and neck squamous cell carcinoma (HNSCC). METHODS: Patients with HNSCC who underwent surgery carrying potential AL from 2003 through 2009 were included in this study. Univariate and multivariate analyses were performed and patient survival was calculated by the Kaplan-Meier method. RESULTS: Of 232 eligible patients, 25 (10.8%) developed AL. Univariate analyses revealed that primary tumor site, salvage surgery, perineural invasion, radiotherapy, chemotherapy, and blood transfusion were significantly associated with the occurrence of AL (P0.1). CONCLUSION: Patients who received salvage surgery and blood transfusion may require careful surveillance for development of AL, which has a tendency toward decreased survival.

Mdm2 and p53 Expression in Radiation-Induced Sarcomas of the Head and Neck: Comparison with De Novo Sarcomas

BACKGROUND: The pathogenesis of radiation-induced sarcomas (RISs) is not well known. In RIS, TP53 mutations are frequent, but little is known about Mdm2-p53 interaction, which is a recent therapeutic target of sarcomas. METHODS: We studied the immunohistochemical expression of Mdm2 and p53 of 8 RISs. The intervals between radiation therapy and diagnosis of secondary sarcomas ranged from 3 to 17 years. RESULTS: Mdm2 expression was more common in de novo sarcomas than RISs (75% vs 37.5%), and p53 expression was more common in RISs than in de novo cases (75% vs 37.5%). While half of the RISs were Mdm2(-)/p53(+), none of de novo cases showed such combination; while half of de novo sarcomas were Mdm2(+)/p53(-), which are a candidate group of Mdm2 inhibitors, only 1 RIS showed such a combination. Variable immunoprofiles observed in both groups did not correlate with tumor types, except that all of 2 myxofibrosarcomas were Mdm2(+)/p53(+). CONCLUSIONS: In conclusion, we speculated that both radiation-induced and de novo sarcomagenesis are not due to a unique genetic mechanism. Mdm2-expression without p53 overexpression in 1 case of RIS decreases the future possibility of applying Mdm2 inhibitors on a subset of these difficult tumors.

Clinical Outcome of Fibromatosis of the Head and Neck Region / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Fibromatosis is an uncommon soft tissue mass lesion that can occur in all anatomic sites. Fibromatoses arising in the head and neck region comprises of approximately 5% of all fibromatoses, which is associated with an infiltrative growth pattern and thus results in difficulty in complete excision. The authors investigate the clinical characteristics of head and neck fibromatoses. SUBJECTS AND METHOD: Six cases of head and neck fibromatoses were analyzed from 1989 to 2011. The imaging and pathologicfindings, surgical management, and clinicaloutcomes were evaluated. RESULTS: Painless mass effect was the most common symptom. The accuracy of diagnostic tools including computed tomography, magnetic resonance imaging and fine needle aspiration biopsy were under 50%. Recurrence was observed in two patients who had undergone surgical excision during follow-up. Salvage surgery was performed in these patients. CONCLUSION: The aggressive excision of head and neck fibromatosis cannot be achieved easily. Vigilant follow-up with or without conservative surgical excision results in good disease control. Radiotherapy can be applied for inoperable or margin positive cases considering age or performance of patient.

Finding and Characterizing Mammary Analogue Secretory Carcinoma of the Salivary Gland

BACKGROUND: A new tumor entity of the salivary glands, mammary analogue secretory carcinoma (MASC) with ETV6-NTRK3 translocation, has recently been proposed. MASC was originally diagnosed as adenocarcinoma, not otherwise specified (ANOS), or acinic cell carcinoma (AciCC) by the current World Health Organization classification. We aimed to identify MASC cases by molecular tests, and to characterize their clinical, histological, and immunohistochemical features. METHODS: Thirty cases of MASC candidates were selected after review of 196 salivary gland tumors, and subjected to break-apart ETV6 fluorescence in situ hybridization (FISH), and immunohistochemical study for S100 protein, gross cystic disease fluid protein 15, DOG1, estrogen receptor, and progesterone receptor. RESULTS: Valid FISH results were obtained in 23 cases, and 13 positive cases were retrieved. MASCs were histologically varied, and the most frequent features observed in 10 cases were low-grade papillary/cystic/glandular patterns, intraluminal secretory materials, ovoid/wrinkled nuclei, and relatively abundant granular eosinophilic cytoplasms, corresponding to papillary-cystic or follicular types of AciCC. All cases showed diffuse immunopositivity for S100 protein. Three cases developed recurrences, but all patients remained alive. CONCLUSIONS: MASC could be a molecularly well-defined salivary gland neoplasm, encompassing some portions of AciCC and ANOS, but its histological spectrum and clinical implication require further investigation.

Human Papillomavirus Prevalence and Cell Cycle Related Protein Expression in Tonsillar Squamous Cell Carcinomas of Korean Patients with Clinicopathologic Analysis

BACKGROUND: Human papillomavirus (HPV)-related tonsillar squamous cell carcinoma (TSCC) has recently been characterized as a distinct subset with a favorable prognosis. The prevalence and clinicopathologic significance of HPV-related TSCC in Koreans are not well known. METHODS: HPV in situ hybridization (ISH) accompanied by p53, p16, pRb, and cyclin D1 immunohistochemical staining were performed on 89 resection cases of TSCC from 2000 through 2010. RESULTS: HPV was detected by ISH in 59 of 89 cases (66.3%). HPV-positive TSCCs were more common in younger ages (p=0.005), and tumor sizes were smaller in the HPV-positive compared to the HPV-negative group (p=0.040). Positive HPV staining was significantly correlated with p16 expression (p<0.001), pRb inactivation (p=0.003), and cyclin D1 down-regulation (p<0.001) but not with p53 expression (p=0.334). Seventeen cases that showed p16-immunopositivity with HPV-negativity by ISH were retested by HPV typing; HPV DNA was not detected in all cases. There was no significant difference between HPV-positive and HPV-negative patients either in the disease-specific survival (DSS, p=0.857) or overall survival (p=0.910). Furthermore, pRb-inactivated cases showed better DSS (p=0.023), and p53-positive cases showed worse DSS (p=0.001). CONCLUSIONS: Although high HPV prevalence was noted, it was not correlated with histopathologic findings or survival benefit. In addition to p53 expression, pRb inactivation along with p16 overexpression and down-regulation of cyclin D1 are thought to be important pathogenetic steps for developing TSCCs.

Diagnosis and Therapy for Dysphonia in the Professional Voice User / 대한이비인후과학회지

Characteristics of voice problems occurring with professional voice users are not too different from those with general public. However, they react sensitively to relatively subtle changes of voice and have strong demands for their treatments as well. Consequently, treatments for the professional voice users should be implemented in the form of team approach consisting of not only otolaryngologists with plenty of treatment experience and sufficient knowledge but also speech-language pathologist, vocal coach. While treating professional voice users is burdensome and a challenging problem even to otolaryngologists rich in experience, knowledge and experience obtained through treating them will be much help for voice treatments of other general public. In this article, the authors have reviewed approaches and treatment directions for voice problems occurring with professional voice users.

Open-Label Observational Study for Evaluating the Short-term Benefits of Rabeprazole Medication on Laryngopharyngeal Reflux

OBJECTIVES: The aims of this study were to determine the benefits of short-term empirical proton pump inhibitor (PPI) medication on laryngopharyngeal reflux (LPR) and to determine whether scores on the reflux symptom index (RSI) and the reflux finding score (RFS) could be combined to identify subgroups of patients that will more likely to improve with this medication. METHODS: Fifty-one Korean Otolaryngology Board-certified specialists joined this prospective, multi-center, and open-label observational study. A total of 1,142 adult patients with LPR was enrolled for 12 weeks of rabeprazol medication. According to pre-treatment scores on RSI and RFS, patients were divided into 4 subgroups. RFS and RSI were measured repeatedly with a month interval along the treatment period. Changes of RSI and RFS were analyzed in an overall study cohort as well as in each subgroup. RESULTS: Approximately 40% (n=455) of enrolled patients were followed up until 12 weeks of PPI treatment. Significant improvement in RSI was obtained in 29%, 58%, and 75% of patients after 4, 8, and 12 weeks of PPI medication. RFS was improved in 16%, 42%, and 57% of the patients with 4, 8, and 12 weeks of PPI medication. All subgroups showed improvement regardless of their pre-treatment scores on the RSI and RFS. CONCLUSION: Even though RSI and RFS may be used as a general guideline for LPR management, pre-treatment RSI and RFS are not useful in predicting the patients' response to short-term PPI medication in the usual pattern of practice for LPR, which is mostly based on the physical evaluation and history taking.