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1.
Ear Nose Throat J ; 100(5_suppl): 500S-504S, 2021 Sep.
Article in English | MEDLINE | ID: mdl-31722565

ABSTRACT

BACKGROUND AND PURPOSE: Mandibulectomy remains the treatment of choice for oral cavity squamous cell carcinoma with infiltration of bone and for benign tumors with full mandibular thickness involvement. Although bone resection margins are critical for patient outcomes, intraoperative immediate bone margins assessment is inadequate, and few alternative options have been described. The purpose of this study was to describe the use of an existing intraoperative radiographic system for objective determination of bone resection margins during mandibulectomy. METHODS: We conducted a retrospective case series of all patients at the Greater Baltimore Medical Center who underwent mandibulectomy and received intraoperative Faxitron radiography from January 1, 2016, to March 1, 2019. Patient characteristics including age, sex, diagnosis, tumor location, clinical and pathologic stage, procedure performed, and bone resection margins were reviewed. RESULTS: A total of 10 patients underwent mandibulectomy with intraoperative radiography. Nine (90%) received surgery for squamous cell carcinoma, with 1 (10%) for ameloblastoma. Out of those with squamous cell carcinoma, tumor location varied, and all were clinically stage T4. Final pathologic margins were negative in all cases (10/10), though in 2 cases, close margins were assessed intraoperatively, leading to further resection or change in operative plan. CONCLUSION: Intraoperative radiographic assessment of bone resection margins is a promising technique, though further validation is required.


Subject(s)
Intraoperative Care/methods , Mandibular Osteotomy , Mouth Neoplasms/diagnostic imaging , Radiography/methods , Squamous Cell Carcinoma of Head and Neck/diagnostic imaging , Adult , Aged , Female , Humans , Male , Mandible/diagnostic imaging , Mandible/pathology , Mandible/surgery , Margins of Excision , Middle Aged , Mouth Neoplasms/pathology , Mouth Neoplasms/surgery , Retrospective Studies , Squamous Cell Carcinoma of Head and Neck/pathology , Squamous Cell Carcinoma of Head and Neck/surgery , Treatment Outcome , Young Adult
2.
JAMA Otolaryngol Head Neck Surg ; 145(10): 939-947, 2019 Oct 01.
Article in English | MEDLINE | ID: mdl-31465102

ABSTRACT

IMPORTANCE: High-volume hospital care for laryngectomy has been shown to be associated with reduced morbidity, mortality, and costs; however, most hospitals in the United States do not perform high volumes of laryngectomies. The influence of market competition on charges and costs for such patients has not been defined. OBJECTIVE: To examine the association between regional hospital market concentration, hospital charges, and costs for laryngectomy. DESIGN, SETTING, AND PARTICIPANTS: The Nationwide Inpatient Sample was used to identify 34 193 patients who underwent laryngectomy for a malignant laryngeal or hypopharyngeal neoplasm from January 1, 2003, to December 31, 2011. Hospital laryngectomy volume was modeled as a categorical variable. Hospital market concentration was evaluated using a variable-radius Herfindahl-Hirschman Index from the 2003, 2006, and 2009 Hospital Market Structure Files. Statistical analysis was performed from May 19 to August 15, 2018. MAIN OUTCOMES AND MEASURES: Multivariable generalized linear regression was used to evaluate associations between market concentration and total charges and costs for laryngectomy. RESULTS: Among the 34 193 patients (19.3% female and 80.7% male; mean age, 62.7 years [range, 20.0-96.0 years]), 69.2% of procedures were performed at hospitals in highly concentrated (noncompetitive) markets and 26.2% were performed at hospitals in unconcentrated (highly competitive) markets. Most high-volume hospitals (68.0%) were located in highly concentrated markets, followed by unconcentrated markets (32.0%). Market share and volume were not associated with significant differences in total charges. Unconcentrated markets were associated with 28% higher costs (95% CI, 8%-53%) relative to moderately concentrated and highly concentrated markets. High-volume hospitals were associated with 22% lower costs (95% CI, -36% to -5%). CONCLUSIONS AND RELEVANCE: Competition among hospitals is associated with increased costs of care for laryngectomy. High-volume hospital care is associated with lower costs of care. These data suggest that hospital market consolidation of laryngectomy at centers able to meet minimum volume thresholds may improve health care value.

3.
Cancer ; 125(8): 1281-1289, 2019 04 15.
Article in English | MEDLINE | ID: mdl-30645761

ABSTRACT

BACKGROUND: In the era of deintensification, little data are available regarding patients' treatment preferences. The current study evaluated treatment-related priorities, concerns, and regret among patients with head and neck squamous cell cancer (HNSCC). METHODS: A total of 150 patients with HNSCC ranked the importance of 10 nononcologic treatment goals relative to the oncologic goals of cure and survival. The level of concern regarding 11 issues and decision regret was recorded. Median rank was reported overall, and factors associated with odds of rank as a top 3 priority were modeled using logistic regression. RESULTS: Among the treatment effects analyzed, the odds of being a top 3 priority was especially high for cure (odds, 9.17; 95% confidence interval [95% CI], 5.05-16.63), followed by survival and swallow (odds, 1.26 [95% CI, 0.88-1.80] and odds, 0.85 [95% CI, 0.59-1.21], respectively). Prioritization of cure, survival, and swallow was similar based on human papillomavirus (HPV) tumor status. By increasing decade of age, older participants were found to be significantly less likely than younger individuals to prioritize survival (odds ratio, 0.72; 95% CI, 0.52-1.00). Concerns regarding mortality (P = .04) and transmission of HPV to the patient's spouse (P = .03) were more frequent among participants with HPV-associated HNSCC. Regret increased with additional treatment modalities (P = .02). CONCLUSIONS: Patients with HNSCC overwhelming prioritize cure, followed by survival and swallow. The decreased prioritization of survival by older age supports further examination of treatment preference by age. The precedence of oncologic over nononcologic priorities among patients regardless of HPV tumor status supports the conservative adoption of deintensification regimens until the interplay between competing oncologic and nononcologic treatment goals is better understood.


Subject(s)
Decision Making , Head and Neck Neoplasms/therapy , Health Priorities/classification , Papillomavirus Infections/therapy , Squamous Cell Carcinoma of Head and Neck/therapy , Adult , Age Factors , Aged , Aged, 80 and over , Female , Head and Neck Neoplasms/virology , Humans , Logistic Models , Male , Middle Aged , Papillomaviridae , Patient Satisfaction , Patient-Centered Care , Prospective Studies , Squamous Cell Carcinoma of Head and Neck/virology , Survival Analysis , Treatment Outcome
4.
Dysphagia ; 34(1): 89-104, 2019 02.
Article in English | MEDLINE | ID: mdl-29922848

ABSTRACT

Head and neck cancer (HNC) guidelines recommend regular multidisciplinary team (MDT) monitoring and early intervention to optimize dysphagia outcomes; however, many factors affect the ability to achieve these goals. The aims of this study were to explore the barriers/facilitators to establishing and sustaining a MDT HNC care pathway and to examine the dysphagia-related speech-language pathology (SLP) and dietetic components of the pathway. Using the Consolidated Framework for Implementation Research (CFIR), a mixed methods study design was used to evaluate an established MDT HNC pathway. Ten MDT members provided perceptions of facilitators/barriers to implementing and sustaining the pathway. Patients attending the SLP and dietetic components of the pathway who commenced treatment between 2013 and 2014 (n = 63) were audited for attendance, outcome data collected per visit, and swallowing outcomes to 24-month post-treatment. Dysphagia outcomes were compared to a published cohort who had received intensive prophylactic dysphagia management. Multiple CFIR constructs were identified as critical to implementing and sustaining the pathway. Complexity was a barrier. Patient attendance was excellent during treatment, with low rates of non-compliance (< 15%) to 24 months. Collection of clinician/patient outcome tools was good during treatment, but lower post-treatment. Dysphagia outcomes were good and comparable to prior published data. The pathway provided patients with access to regular supportive care and provided staff opportunities to provide early and ongoing dysphagia monitoring and management. However, implementing and sustaining a HNC pathway is complex, requiring significant staff resources, financial investment, and perseverance. Regular audits are necessary to monitor the quality of the pathway.


Subject(s)
Critical Pathways/standards , Deglutition Disorders/therapy , Dietetics/methods , Health Plan Implementation/methods , Speech-Language Pathology/methods , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Medical Audit/methods , Middle Aged , Patient Care Team
5.
JAMA Otolaryngol Head Neck Surg ; 145(1): 62-70, 2019 01 01.
Article in English | MEDLINE | ID: mdl-30476965

ABSTRACT

Importance: A volume-outcome association exists for larynx cancer surgery, but to date it has not been investigated for specific surgical procedures. Objectives: To characterize the volume-outcome association specifically for laryngectomy surgery and to identify a minimum hospital volume threshold associated with improved outcomes. Design, Setting, and Participants: In this cross-sectional study, the Nationwide Inpatient Sample was used to identify 45 156 patients who underwent laryngectomy procedures for a malignant laryngeal or hypopharyngeal neoplasm between January 2001 and December 2011. The analysis was performed in 2018. Hospital laryngectomy volume was modeled as a categorical variable. Main Outcomes and Measures: Associations between hospital volume and in-hospital mortality, complications, length of hospitalization, and costs were examined using multivariate logistic regression analysis. Results: Among 45 156 patients (mean age, 62.6 years; age range, 20-96 years; 80.2% male) at 5516 hospitals, higher-volume hospitals were more likely to be teaching hospitals in urban locations; were more likely to treat patients who had hypopharyngeal cancer, were of white race/ethnicity, were admitted electively, had no comorbidity, and had private insurance; and were more likely to perform flap reconstruction or concurrent neck dissection. After controlling for all other variables, hospitals treating more than 6 cases per year were associated with lower odds of surgical and medical complications, with a greater reduction in the odds of complications with increasing hospital volume. High-volume hospitals in the top-volume quintile (>28 cases per year) were associated with decreased odds of in-hospital mortality (odds ratio, 0.45; 95% CI, 0.23-0.88), postoperative surgical complications (odds ratio, 0.63; 95% CI, 0.50-0.79), and acute medical complications (odds ratio, 0.63; 95% CI, 0.48-0.81). A statistically meaningful negative association was observed between very high-volume hospital care and the mean incremental length of hospitalization (-3.7 days; 95% CI, -4.9 to -2.4 days) and hospital-related costs (-$4777; 95% CI, -$9463 to -$900). Conclusions and Relevance: Laryngectomy outcomes appear to be associated with hospital volume, with reduced morbidity associated with a minimum hospital volume threshold and with reduced mortality, morbidity, length of hospitalization, and costs associated with higher hospital volume. These data support the concept of centralization of complex care at centers able to meet minimum volume thresholds to improve patient outcomes.


Subject(s)
Hospitals, High-Volume , Hospitals, Low-Volume , Laryngeal Neoplasms/surgery , Laryngectomy , Adult , Aged , Aged, 80 and over , Cross-Sectional Studies , Databases, Factual , Female , Hospital Costs/statistics & numerical data , Hospital Mortality , Hospitals, Low-Volume/economics , Humans , Laryngeal Neoplasms/economics , Laryngeal Neoplasms/mortality , Laryngectomy/mortality , Length of Stay/economics , Length of Stay/statistics & numerical data , Logistic Models , Male , Middle Aged , Postoperative Complications/economics , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Risk Factors , Treatment Outcome , United States
6.
Hemodial Int ; 22(3): 394-404, 2018 07.
Article in English | MEDLINE | ID: mdl-29446565

ABSTRACT

BACKGROUND: The long-term results of surgical parathyroidectomy (PTX) in end-stage renal disease (ESRD) patients are less well known in the modern era of newer activated vitamin-D analogs, calcimimetics and intraoperative monitoring of parathyroid hormone (PTH). METHODS: We performed a retrospective chart review of all ESRD patients undergoing PTX at the University of Mississippi Medical Center between January 2005 and August 2011, with follow-up data as available up to 4 years. All PTXs were performed with intraoperative second-generation PTH monitoring and targeted gland size reduction. RESULTS: The cohort (N = 37) was relatively young with a mean (±SD) age of 48.4 ± 13.9. 94.6% of the subjects were African American and 59.5% female. Preoperatively, 45.9% received cinacalcet (CNC) at a mean dose of 63.5 ± 20.9 mg. The size of the largest removed glands measured 1.7 ± 0.8 cm and almost all (94.6%) glands had hyperplasia on histology. The mean length of inpatient stay was 5.5 ± 2.4 days. Preoperative calcium/phosphorus measured 9.6 ± 1.2/6.6 ± 1.7 mg/dL with PTH concentrations of 1589 ± 827 pg/mL. Postoperative PTH values measured 145.4 ± 119.2 pg/mL. Preoperative PTH strongly correlated (P < 0.0001) with both alkaline phosphatase (ALP) levels (r: 0.596) and the number of inpatient days (r: 0.545), but not with CNC administration. Independent predictors for the duration of hospitalization were preoperative ALP (beta 0.469; P = 0.001) and age (beta -0.401; P = 0.005) (R2 0.45); for postoperative hypocalcemia, age (beta: -0.321; P = 0.006) and preoperative PTH (beta: 0.431; P = 0.036) were significant in linear regression models with stepwise selection. CONCLUSION: Gland-sparing PTX achieved acceptable control of ESRD-associated hyperparathyroidism in most patients from a socioeconomically challenged, underserved population of the United States.


Subject(s)
Kidney Failure, Chronic/surgery , Parathyroidectomy/methods , Renal Dialysis/methods , Cohort Studies , Female , Humans , Kidney Failure, Chronic/pathology , Male , Middle Aged , Retrospective Studies
7.
Laryngoscope ; 128(1): 102-110, 2018 01.
Article in English | MEDLINE | ID: mdl-28731497

ABSTRACT

OBJECTIVE: To determine the relationship between frailty and comorbidity, in-hospital mortality, postoperative complications, length of hospital stay (LOS), and costs in head and neck cancer (HNCA) surgery. STUDY DESIGN: Cross-sectional analysis. METHODS: Discharge data from the Nationwide Inpatient Sample for 159,301 patients who underwent ablative surgery for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm in 2001 to 2010 was analyzed using cross-tabulations and multivariate regression modeling. Frailty was defined based on frailty-defining diagnosis clusters from the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. RESULTS: Frailty was identified in 7.4% of patients and was significantly associated with advanced comorbidity (odds ratio [OR] = 1.5[1.3-1.8]), Medicaid (OR = 1.5[1.3-1.8]), major procedures (OR = 1.6[1.4-1.8]), flap reconstruction (OR = 1.7[1.3-2.1]), high-volume hospitals (OR = 0.7[0.5-1.0]), discharge to a short-term facility (OR = 4.4[2.9-6.7]), or other facility (OR = 5.4[4.5-6.6]). Frailty was a significant predictor of in-hospital death (OR = 1.6[1.1-2.4]), postoperative surgical complications (OR = 2.0[1.7-2.3]), acute medical complications (OR = 3.9[3.2-4.9]), increased LOS (mean, 4.9 days), and increased mean incremental costs ($11,839), and was associated with higher odds of surgical complications and increased costs than advanced comorbidity. There was a significant interaction between frailty and comorbidity for acute medical complications and length of hospitalization, with a synergistic effect on the odds of medical complications and LOS in patients with comorbidity who were also frail. CONCLUSION: Frailty is an independent predictor of postoperative morbidity, mortality, LOS, and costs in HNCA surgery patients, and has a synergistic interaction with comorbidity that is associated with an increased likelihood of medical complications and greater LOS in patients with comorbidity who are also frail. LEVEL OF EVIDENCE: 2c. Laryngoscope, 128:102-110, 2018.


Subject(s)
Frailty , Head and Neck Neoplasms/surgery , Adolescent , Adult , Aged , Aged, 80 and over , Comorbidity , Cross-Sectional Studies , Female , Head and Neck Neoplasms/mortality , Health Care Costs , Hospital Mortality , Humans , Length of Stay/statistics & numerical data , Male , Middle Aged , Postoperative Complications/epidemiology , Risk Factors , Treatment Outcome , United States/epidemiology
8.
Cancer ; 123(10): 1768-1777, 2017 05 15.
Article in English | MEDLINE | ID: mdl-28055120

ABSTRACT

BACKGROUND: Patients with human papillomavirus (HPV)-related oropharyngeal cancer (OPC) have improved survival when compared with those with HPV-negative OPC. Unfortunately, the American Joint Committee on Cancer seventh edition (AJCC-7ed) staging system does not account for the prognostic advantage observed with HPV-positive OPC. The purpose of the current study was to validate and compare 2 recently proposed staging systems for HPV-positive OPC. METHODS: Patients treated for HPV-positive OPC from 2005 to 2015 at Johns Hopkins Hospital (JHH) were included for analysis. The International Collaboration on Oropharyngeal cancer Network for Staging (ICON-S) and The University of Texas MD Anderson Cancer Center (MDACC) staging systems were applied and survival was calculated using Kaplan-Meier methods. Cox proportional hazard regression was used to determine the relationship between stage of disease and survival. Models were compared using the Akaike information criterion (AIC). RESULTS: A total of 435 patients were eligible for analysis. There was a dramatic shift in lymph node category and overall stage of disease when ICON-S and MDACC stage were applied to the JHH cohort. There was superior stratification of overall survival and progression-free survival by ICON-S stage. Both proposed models had an improved fit based on AIC scores (P<.001 for both) over the AJCC-7ed. The ICON-S staging system had the lowest AIC score, and thus a better fit within the JHH population. CONCLUSIONS: The current analysis provides external validation for both staging systems in an independent and heterogeneously treated patient population. Although the MDACC staging system is an improvement over the AJCC-7ed, the ICON-S stage provides superior stratification of overall and progression-free survival, thereby supporting its use as the updated AJCC staging system for OPC. Cancer 2017;123:1768-1777. © 2017 American Cancer Society.


Subject(s)
Carcinoma, Squamous Cell/pathology , Head and Neck Neoplasms/pathology , Lymph Nodes/pathology , Oropharyngeal Neoplasms/pathology , Papillomavirus Infections/pathology , Aged , Carcinoma, Squamous Cell/complications , Carcinoma, Squamous Cell/therapy , Carcinoma, Squamous Cell/virology , Disease-Free Survival , Female , Head and Neck Neoplasms/complications , Head and Neck Neoplasms/therapy , Head and Neck Neoplasms/virology , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Neck , Neoplasm Staging , Oropharyngeal Neoplasms/complications , Oropharyngeal Neoplasms/therapy , Oropharyngeal Neoplasms/virology , Papillomaviridae , Papillomavirus Infections/complications , Prognosis , Proportional Hazards Models , Reproducibility of Results , Retrospective Studies , Squamous Cell Carcinoma of Head and Neck , Survival Rate
9.
Adv Ther ; 33(4): 553-79, 2016 04.
Article in English | MEDLINE | ID: mdl-27084720

ABSTRACT

Adenoid cystic carcinoma (AdCC) of the head and neck is a well-recognized pathologic entity that rarely occurs in the larynx. Although the 5-year locoregional control rates are high, distant metastasis has a tendency to appear more than 5 years post treatment. Because AdCC of the larynx is uncommon, it is difficult to standardize a treatment protocol. One of the controversial points is the decision whether or not to perform an elective neck dissection on these patients. Because there is contradictory information about this issue, we have critically reviewed the literature from 1912 to 2015 on all reported cases of AdCC of the larynx in order to clarify this issue. During the most recent period of our review (1991-2015) with a more exact diagnosis of the tumor histology, 142 cases were observed of AdCC of the larynx, of which 91 patients had data pertaining to lymph node status. Eleven of the 91 patients (12.1%) had nodal metastasis and, based on this low proportion of patients, routine elective neck dissection is therefore not recommended.


Subject(s)
Carcinoma, Adenoid Cystic , Laryngeal Neoplasms , Lymph Nodes , Neck Dissection/methods , Carcinoma, Adenoid Cystic/pathology , Carcinoma, Adenoid Cystic/surgery , Elective Surgical Procedures/methods , Humans , Laryngeal Neoplasms/pathology , Laryngeal Neoplasms/surgery , Lymph Nodes/pathology , Lymph Nodes/surgery , Lymphatic Metastasis , Patient Selection
10.
Auris Nasus Larynx ; 43(5): 477-84, 2016 Oct.
Article in English | MEDLINE | ID: mdl-27017314

ABSTRACT

The purpose of this study was to suggest general guidelines in the management of the N0 neck of oral cavity and oropharyngeal adenoid cystic carcinoma (AdCC) in order to improve the survival of these patients and/or reduce the risk of neck recurrences. The incidence of cervical node metastasis at diagnosis of head and neck AdCC is variable, and ranges between 3% and 16%. Metastasis to the cervical lymph nodes of intraoral and oropharyngeal AdCC varies from 2% to 43%, with the lower rates pertaining to palatal AdCC and the higher rates to base of the tongue. Neck node recurrence may happen after treatment in 0-14% of AdCC, is highly dependent on the extent of the treatment and is very rare in patients who have been treated with therapeutic or elective neck dissections, or elective neck irradiation. Lymph node involvement with or without extracapsular extension in AdCC has been shown in most reports to be independently associated with decreased overall and cause-specific survival, probably because lymph node involvement is a risk factor for subsequent distant metastasis. The overall rate of occult neck metastasis in patients with head and neck AdCC ranges from 15% to 44%, but occult neck metastasis from oral cavity and/or oropharynx seems to occur more frequently than from other locations, such as the sinonasal tract and major salivary glands. Nevertheless, the benefit of elective neck dissection (END) in AdCC is not comparable to that of squamous cell carcinoma, because the main cause of failure is not related to neck or local recurrence, but rather, to distant failure. Therefore, END should be considered in patients with a cN0 neck with AdCC in some high risk oral and oropharyngeal locations when postoperative RT is not planned, or the rare AdCC-high grade transformation.


Subject(s)
Carcinoma, Adenoid Cystic/therapy , Lymph Nodes/pathology , Mouth Neoplasms/therapy , Neck Dissection , Neoplasm Recurrence, Local , Oropharyngeal Neoplasms/therapy , Radiotherapy , Carcinoma, Adenoid Cystic/pathology , Disease Management , Humans , Lymphatic Metastasis , Mouth Neoplasms/pathology , Neck , Oropharyngeal Neoplasms/pathology
11.
Adv Ther ; 33(3): 357-68, 2016 Mar.
Article in English | MEDLINE | ID: mdl-26895332

ABSTRACT

Adenoid cystic carcinoma (AdCC) is among the most common malignant tumors of the salivary glands. It is characterized by a prolonged clinical course, with frequent local recurrences, late onset of metastases and fatal outcome. High-grade transformation (HGT) is an uncommon phenomenon among salivary carcinomas and is associated with increased tumor aggressiveness. In AdCC with high-grade transformation (AdCC-HGT), the clinical course deviates from the natural history of AdCC. It tends to be accelerated, with a high propensity for lymph node metastasis. In order to shed light on this rare event and, in particular, on treatment implications, we undertook this review: searching for all published cases of AdCC-HGT. We conclude that it is mandatory to perform elective neck dissection in patients with AdCC-HGT, due to the high risk of lymph node metastases associated with transformation.


Subject(s)
Carcinoma, Adenoid Cystic/pathology , Lymphatic Metastasis/pathology , Salivary Gland Neoplasms/pathology , Adult , Carcinoma, Adenoid Cystic/mortality , Carcinoma, Adenoid Cystic/surgery , Female , Humans , Lymph Nodes/pathology , Male , Middle Aged , Salivary Gland Neoplasms/mortality , Salivary Gland Neoplasms/surgery
12.
Ann Surg Oncol ; 22(11): 3708-15, 2015 Oct.
Article in English | MEDLINE | ID: mdl-25670018

ABSTRACT

BACKGROUND: [(99m)Tc]Tilmanocept, a novel CD206 receptor-targeted radiopharmaceutical, was evaluated in an open-label, phase III trial to determine the false negative rate (FNR) of sentinel lymph node biopsy (SLNB) relative to the pathologic nodal status in patients with intraoral or cutaneous head and neck squamous cell carcinoma (HNSCC) undergoing tumor resection, SLNB, and planned elective neck dissection (END). Negative predictive value (NPV), overall accuracy of SLNB, and the impact of radiopharmaceutical injection timing relative to surgery were assessed. METHODS AND FINDINGS: This multicenter, non-randomized, single-arm trial (ClinicalTrials.gov identifier NCT00911326) enrolled 101 patients with T1-T4, N0, and M0 HNSCC. Patients received 50 µg [(99m)Tc]tilmanocept radiolabeled with either 0.5 mCi (same day) or 2.0 mCi (next day), followed by lymphoscintigraphy, SLNB, and END. All excised tissues were evaluated for tissue type and tumor presence. [(99m)Tc]Tilmanocept identified one or more SLNs in 81 of 83 patients (97.6 %). Of 39 patients identified with any tumor-positive nodes (SLN or non-SLN), one patient had a single tumor-positive non-SLN in whom all SLNs were tumor-negative, yielding an FNR of 2.56 %; NPV was 97.8 % and overall accuracy was 98.8 %. No significant differences were observed between same-day and next-day procedures. CONCLUSIONS: Use of receptor-targeted [(99m)Tc]tilmanocept for lymphatic mapping allows for a high rate of SLN identification in patients with intraoral and cutaneous HNSCC. SLNB employing [(99m)Tc]tilmanocept accurately predicts the pathologic nodal status of intraoral HNSCC patients with low FNR, high NPV, and high overall accuracy. The use of [(99m)Tc]tilmanocept for SLNB in select patients may be appropriate and may obviate the need to perform more extensive procedures such as END.


Subject(s)
Carcinoma, Squamous Cell/diagnostic imaging , Dextrans , Lymph Nodes/diagnostic imaging , Mannans , Mouth Neoplasms/diagnostic imaging , Radiopharmaceuticals , Technetium Tc 99m Pentetate/analogs & derivatives , Carcinoma, Squamous Cell/secondary , Carcinoma, Squamous Cell/surgery , Dextrans/administration & dosage , False Negative Reactions , Humans , Lymph Nodes/pathology , Lymphatic Metastasis , Lymphoscintigraphy/methods , Mannans/administration & dosage , Mouth Neoplasms/pathology , Mouth Neoplasms/surgery , Neck , Neck Dissection , Predictive Value of Tests , Radiopharmaceuticals/administration & dosage , Sentinel Lymph Node Biopsy , Technetium Tc 99m Pentetate/administration & dosage , Tomography, Emission-Computed, Single-Photon
13.
Head Neck ; 37(6): 915-26, 2015 Jun.
Article in English | MEDLINE | ID: mdl-24623715

ABSTRACT

Neck dissection is an important treatment for metastases from upper aerodigestive carcinoma; an event that markedly reduces survival. Since its inception, the philosophy of the procedure has undergone significant change from one of radicalism to the current conservative approach. Furthermore, nonsurgical modalities have been introduced, and, in many situations, have supplanted neck surgery. The refinements of imaging the neck based on the concept of neck level involvement has encouraged new philosophies to evolve that seem to benefit patient outcomes particularly as this relates to diminished morbidity. The purpose of this review was to highlight the new paradigms for surgical removal of neck metastases using an evidence-based approach.


Subject(s)
Carcinoma, Squamous Cell/secondary , Carcinoma, Squamous Cell/surgery , Head and Neck Neoplasms/surgery , Lymph Nodes/surgery , Neck Dissection/methods , Carcinoma, Squamous Cell/mortality , Disease-Free Survival , Evidence-Based Medicine , Female , Head and Neck Neoplasms/mortality , Head and Neck Neoplasms/pathology , Humans , Lymph Node Excision/methods , Lymph Nodes/pathology , Lymphatic Metastasis , Male , Neck Dissection/mortality , Prognosis , Risk Assessment , Survival Analysis , Treatment Outcome
14.
Head Neck ; 37(12): 1829-39, 2015 Dec.
Article in English | MEDLINE | ID: mdl-24954811

ABSTRACT

Regional metastasis is a prominent feature of head and neck squamous cell carcinoma (HNSCC) and is an important prognostic factor. The currently available imaging techniques for assessment of the neck have limitations in accuracy; thus, elective neck dissection has remained the usual choice of management of the clinically N0 neck (cN0) for tumors with significant (≥20%) incidence of occult regional metastasis. As a consequence, the majority of patients without regional metastasis will undergo unnecessary treatment. The purpose of this review was to discuss new developments in techniques that potentially improve the accuracy of the assessment of the neck in patients with HNSCC. Although imaging has improved in the last decades, a limitation common to all imaging techniques is a lack of sensitivity for small tumor deposits. Therefore, complementary to improvements in imaging techniques, developments in more invasive diagnostic procedures, such as sentinel node biopsy (SNB) will add to the accuracy of diagnostic algorithms for the staging of the neck.


Subject(s)
Carcinoma, Squamous Cell/pathology , Head and Neck Neoplasms/pathology , Neck Dissection , Sentinel Lymph Node Biopsy , Ultrasonography, Interventional , Humans , Lymphatic Metastasis , Neck Dissection/methods , Neoplasm Invasiveness , Neoplasm Staging , Prognosis , Sentinel Lymph Node Biopsy/methods
15.
Cytoskeleton (Hoboken) ; 71(11): 628-37, 2014 Nov.
Article in English | MEDLINE | ID: mdl-25355403

ABSTRACT

In 2014, more than 40,000 people in the United States will be diagnosed with head and neck squamous cell cancer (HNSCC) and nearly 8400 people will die of the disease (www.cancer.org/acs/groups). Little is known regarding molecular targets that might lead to better therapies and improved outcomes for these patients. The incorporation of taxanes into the standard cisplatin/5-fluouracil initial chemotherapy for HNSCC has been associated with improved response rate and survival. Taxanes target the ß-subunit of the tubulin heterodimers, the major protein in microtubules, and halt cell division at G2/M phase. Both laboratory and clinical research suggest a link between ß-tubulin expression and cancer patient survival, indicating that patterns of expression for ß-tubulin isotypes along with activity of tumor suppressors such as p53 or micro-RNAs could be useful prognostic biomarkers and could suggest therapeutic targets. © 2014 Wiley Periodicals, Inc.


Subject(s)
Carcinoma, Squamous Cell/immunology , Head and Neck Neoplasms/immunology , Tubulin/metabolism , Tumor Suppressor Protein p53/metabolism , Biomarkers , Humans , Microarray Analysis , Prognosis , Real-Time Polymerase Chain Reaction , Squamous Cell Carcinoma of Head and Neck , Tumor Suppressor Protein p53/genetics
16.
South Med J ; 107(1): 34-43, 2014 Jan.
Article in English | MEDLINE | ID: mdl-24389785

ABSTRACT

Graves orbitopathy (GO) is an autoimmune disorder representing the most frequent extrathyroidal manifestation of Graves disease. It is rare, with an age-adjusted incidence of approximately 16.0 cases per 100,000 population per year in women and 2.9 cases per 100,000 population per year in men. GO is an inflammatory process characterized by edema and inflammation of the extraocular muscles and an increase in orbital connective tissue and fat. Despite recent progress in the understanding of its pathogenesis, GO often remains a major diagnostic and therapeutic challenge. It has become increasingly important to classify patients into categories based on disease activity at initial presentation. A Hertel exophthalmometer measurement of >2 mm above normal for race usually categorizes a patient as having moderate-to-severe GO. Encouraging smoking cessation and achieving euthyroidism in the individual patient are important. Simple treatment measures such as lubricants for lid retraction, nocturnal ointments for incomplete eye closure, prisms in diplopia, or botulinum toxin injections for upper-lid retraction can be effective in mild cases of GO. Glucocorticoids, orbital radiotherapy, and decompression/rehabilitative surgery are generally indicated for moderate-to-severe GO and for sight-threatening optic neuropathy. Future therapies, including rituximab aimed at treating the molecular and immunological basis of GO, are under investigation and hold promise for the future.


Subject(s)
Graves Ophthalmopathy/diagnosis , Graves Ophthalmopathy/therapy , Orbital Diseases/diagnosis , Orbital Diseases/therapy , Decompression, Surgical , Diagnostic Techniques, Ophthalmological , Female , Glucocorticoids/therapeutic use , Humans , Lubricants , Male , Ointments , Radiotherapy , Risk Factors
17.
Am J Clin Oncol ; 37(4): 332-6, 2014 Aug.
Article in English | MEDLINE | ID: mdl-23275276

ABSTRACT

OBJECTIVES: In this retrospective study we evaluate the tolerability and outcomes after induction chemotherapy for patients with predominately low socioeconomic status (SES) with locally advanced head and neck cancer (LAHNC). METHODS: One hundred eighteen patients with LAHNC of the hypopharynx, larynx, oral cavity, or oropharynx began curative intent therapy with induction cisplatin (75 or 100 mg/m), docetaxel (75 mg/m), and 5-fluorouracil (750 mg/m×5 d or 1000 mg/m×4 d; continuous infusion) every 3 weeks (DPF) for a planned 2 to 3 cycles. All patients were to receive curative radiotherapy with concurrent systemic therapy. Associations were tested using χ test, and survival estimates were calculated using the Kaplan-Meier method. RESULTS: Most patients (75.4%) were of low SES. Induction DPF was delivered for a median of 2 cycles (range, 1 to 3) and 14% of the patients (n=17) died during induction DPF. After DPF, 38.2% of patients were unable to complete or receive planned definitive therapy. Overall 15.3% of patients died during therapy, and mortality was associated with a Karnofsky performance status <80 (P=0.04). At 2 years the locoregional control was 52.7%, whereas the distant metastases free rate was 72.6%, and the overall survival rate was 34.1%. Low SES patients were less likely to achieve locoregional control (P=0.05) or survive (P=0.08). CONCLUSIONS: In this population of LAHNC patients of low SES with a high tumor burden and poor performance status, use of induction DPF was associated with 15.3% mortality during therapy and precluded 38.2% of patients from initiating or completing planned definitive therapy.


Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Head and Neck Neoplasms/drug therapy , Head and Neck Neoplasms/mortality , Head and Neck Neoplasms/radiotherapy , Induction Chemotherapy , Social Class , Adult , Aged , Chemoradiotherapy , Cisplatin/administration & dosage , Docetaxel , Female , Fluorouracil/administration & dosage , Follow-Up Studies , Head and Neck Neoplasms/pathology , Humans , Kaplan-Meier Estimate , Male , Medicaid , Middle Aged , Mississippi , Retrospective Studies , Taxoids/administration & dosage , Treatment Outcome , United States
18.
Am J Surg ; 206(5): 724-6, 2013 Nov.
Article in English | MEDLINE | ID: mdl-24011569

ABSTRACT

Otolaryngology-head and neck surgery, more commonly known as ear, nose, and throat surgery, is more than ear tubes and children's tonsils. It is an exciting and diverse surgical subspecialty that focuses on every kind of disorder of the head and neck. Otolaryngologists treat patients from infancy to geriatrics, delivering both medical and surgical care. There are also multiple opportunities to subspecialize after residency training. The information in this career development resource provides an understanding of otolaryngology and its subspecialty areas and training requirements.


Subject(s)
Otolaryngology/education , Biomedical Research , Fellowships and Scholarships , Humans , Internship and Residency , Societies, Medical , Students, Medical , Training Support
19.
Hormones (Athens) ; 12(2): 298-304, 2013.
Article in English | MEDLINE | ID: mdl-23933699

ABSTRACT

UNLABELLED: Euthyroid Graves' orbitopathy (GO) combined with incidental papillary thyroid microcarcinoma has rarely been reported. CASE REPORT: A 61-year-old Caucasian woman initially presented with progressive fatigue, exophthalmos, and thyroid function tests within normal limits. She underwent thyroidectomy, was found to have two incidental papillary thyroid microcarcinomas, and received radioactive iodine ablation to eliminate thyroid antigen. In addition to following her eye disease, TSH-receptor antibodies, thyroid stimulating immunoglobulins, and serum thyroglobulin measurements were recorded, demonstrating no evidence of thyroid cancer at four-year follow-up. At first, she had mild GO, developing into moderate-to-severe GO, and at 4 years she had Hertel measurements of 20 mm in both eyes. CONCLUSION: This report underscores the difficulty of managing GO even when thyroid function is normal(ized) and thyroid antigen exposure has been minimized. In addition, it illustrates why antithyroidal antibodies should be considered in cases of concomitant papillary thyroid cancer, as thyroid cells can be stimulated not only by TSH but also by TSH-receptor stimulating antibodies.


Subject(s)
Carcinoma, Papillary/complications , Graves Ophthalmopathy/complications , Thyroid Gland/physiopathology , Thyroid Neoplasms/complications , Carcinoma, Papillary/physiopathology , Carcinoma, Papillary/radiotherapy , Carcinoma, Papillary/surgery , Disease Progression , Exophthalmos/etiology , Fatigue/etiology , Female , Graves Disease/complications , Graves Disease/physiopathology , Graves Disease/surgery , Graves Ophthalmopathy/etiology , Graves Ophthalmopathy/immunology , Graves Ophthalmopathy/physiopathology , Humans , Incidental Findings , Iodine Radioisotopes/therapeutic use , Middle Aged , Radiopharmaceuticals/therapeutic use , Radiotherapy, Adjuvant , Thyroid Gland/immunology , Thyroid Gland/surgery , Thyroid Neoplasms/physiopathology , Thyroid Neoplasms/radiotherapy , Thyroid Neoplasms/surgery , Thyroidectomy , Treatment Outcome
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