Assessment of the Intraoperative Consultation Service Rendered by General Pathologists in a Scenario Where a Well-Defined Decision Algorithm Is Followed.

OBJECTIVES: Intraoperative consultation (IOC) remains an area of general practice even within subspecialized pathology departments. This study assesses the IOCs rendered in a general pathology setting where surgeons integrate these results in a well-defined algorithm, developed with the input of specialized pathologists. METHODS: The surgical decisions to perform lymphadenectomy in patients with endometrial adenocarcinoma operated on at our institution between January 2003 and June 2015 as a result of the IOC assessment of tumor size, histologic grade, and depth of invasion in the hysterectomy specimen were analyzed. RESULTS: Frozen section (FS) was examined in 801 cases. In comparison to permanent section analysis, FS International Federation of Gynecology and Obstetrics (FIGO) grade had an overall accuracy of 0.95 (95% confidence interval [CI], 0.93-0.98). The FS depth of invasion had an overall accuracy of 0.92 (95% CI, 0.89-0.94). FIGO grade was not documented in 47.8%, the depth of myometrial invasion in 45.2%, and tumor size in 41.8% of the pathology reports. CONCLUSIONS: The high omission rate of the needed parameters by the general pathologists would question their overall understanding of the paradigm shift intended by this algorithm. Possible explanations of this phenomenon and potential solutions are discussed.

Perivascular Epithelioid Cell Tumor of the Uterus with Ovarian Involvement: A Case Report and Review of the Literature.

BACKGROUND: Perivascular epithelioid cell tumors (PEComas) are a rare group of neoplasms composed of epithelioid cells that express both melanocytic and myoid markers. When considering PEComas of the female genital tract, the uterus is the most common location. Involvement of the ovary in the context of a primary uterine PEComa, in the absence of systemic disease associated with tuberous sclerosis, however, has only been reported in 1 previous case. CASE REPORT: We report a case of a PEComa of the uterus with metastasis to the left ovary in a 61-year-old Caucasian woman. Gross examination of the uterus revealed a 10.7×10.5×10.2 cm tan-brown, mostly solid, partially cystic mass. Microscopic examination showed epithelioid cells with clear to eosinophilic cytoplasm, arranged in fascicles. Intranuclear pseudoinclusions were also noted. The tumor cells were smooth muscle actin, caldesmon, and desmin positive (diffuse); HMB-45 positive (focal); and Melan-A, AE1/AE3, CD10, and S100 negative by immunohistochemistry. CONCLUSIONS: Distinguishing among mesenchymal neoplasms, including PEComas, endometrial stromal sarcomas, and leiomyosarcomas, can be difficult. Careful analysis of morphologic and immunohistochemical features is of the utmost importance. Differential diagnosis, including morphologic features and immunohistochemical patterns, is also discussed.

USP14 is a predictor of recurrence in endometrial cancer and a molecular target for endometrial cancer treatment.

Endometrial adenocarcinoma is the most common gynecologic malignancy in the United States. Most endometrial cancer cases are diagnosed at an early stage and have good prognosis. Unfortunately a subset of patients with early stage and low grade disease experience recurrence for reasons that remain unclear. Recurrence is often accompanied by chemoresistance and high mortality.Deubiquitinating enzymes (DUBs) are key components of the ubiquitin-dependent protein degradation pathway and act as master regulators in a number of metabolic processes including cell growth, differentiation, and apoptosis. DUBs have been shown to be upregulated in a number of human cancers and their aberrant activity has been linked to cancer progression, initiation and onset of chemoresistance. Thus, selective inhibition of DUBs has been proposed as a targeted therapy for cancer treatment.This study suggests the DUB USP14 as a promising biomarker for stratifying endometrial cancer patients at diagnosis based on their risk of recurrence. Further USP14 is expressed along with the marker of proliferation Ki67 in endometrial cancer cells in situ. Lastly, pharmacological targeting of USP14 with the FDA approved small-molecule inhibitor VLX1570, decreases cell viability in chemotherapy resistant endometrial cancer cells with a mechanism consistent with cell cycle arrest and caspase-3 mediated apoptosis.

Effects of obstructive sleep apnea surgery on middle ear function.

OBJECTIVE: To study the effect of Z-palatopharyngoplasty plus radiofrequency of the base of the tongue on middle ear function. DESIGN: A retrospective review of a prospective data set at a tertiary care center. SETTING: University-affiliated medical center. PATIENTS: The study population included 47 patients (42 men and 5 women; mean age, 40.8 years) who underwent Z-palatopharyngoplasty plus radiofrequency of the base of the tongue for obstructive sleep apnea/hypopnea syndrome. All patients had healthy eardrums and no previous history of chronic ear disease. MAIN OUTCOME MEASURES: Pure-tone audiometric and tympanometric assessments were performed preoperatively and at 3 days, 7 days, 1 month, and 3 months postoperatively. Levels of baseline and postoperative middle ear pressure were compared. RESULTS: Twelve patients (26%) reported otologic concerns, such as ear pressure and/or otalgia, within 1 week postoperatively. No permanent otologic discomfort occurred. A trend toward reduced middle ear pressure was noted in this study. The decrease in middle ear pressure became apparent on day 3. However, mean pressure changes were no longer significantly different than preoperative values by 1 week after surgery. CONCLUSIONS: We found that Z-palatopharyngoplasty plus radiofrequency of the base of the tongue for obstructive sleep apnea/hypopnea syndrome induces changes in middle ear function. However, the changes were temporary and not significant after 3 months of follow-up.

Impact of pH monitoring on laryngopharyngeal reflux treatment: improved compliance and symptom resolution.

OBJECTIVES: Treatment of laryngopharyngeal reflux (LPR) often suffers from poor patient compliance and hence poor symptom improvement. The aim of this study was to determine whether 24-hour oropharyngeal pH monitoring was associated with higher rates of treatment compliance and symptom improvement compared with empirical treatment for LPR. STUDY DESIGN: Retrospective, case-control study. SETTING: Tertiary care center. SUBJECTS AND METHODS: Charts were reviewed from 170 consecutive adult patients diagnosed with LPR from January 2008 to March 2010. After clinical diagnosis, all patients were offered the option of empiric treatment with a proton pump inhibitor versus treatment based on a 24-hour oropharyngeal pH study using the Dx-pH system (Restech, San Diego, California). Treatment compliance and pretreatment and posttreatment reflux symptom index (RSI) scores were compared for the 2 groups. Only consecutive patients with complete data were included. RESULTS: One-hundred and seventy patients were included in 2 groups. Group I consisted of 73 patients who underwent pH monitoring. Group II consisted of 70 patients treated empirically. Compliance with medication therapy (68.5% vs 50.0%, P = .019) and lifestyle modification (82.2 vs 25.7%, P = .0001) were greater among patients in group I. Symptom improvement was greater among patients in group I following treatment compared with patients in group II, with a significantly greater reduction in RSI (36.6% vs 24.4%, P = .023). CONCLUSION: Among our patient population, treatment of LPR based on pH monitoring resulted in greater compliance, as well as greater symptom improvement, compared with empirical therapy alone.

Impact of nasal obstruction on obstructive sleep apnea.

OBJECTIVES: The purpose of this study was to investigate the relationship between nasal obstruction and sleep-disordered breathing. The effect of postoperative nasal packing on sleep parameters was compared between patients with mild obstructive sleep apnea (OSA) and those with moderate/severe OSA. STUDY DESIGN: A prospective, nonrandomized controlled study. SETTING: Tertiary care center. SUBJECTS AND METHODS: Participants were recruited among adult patients with a history of snoring scheduled to undergo nasal surgery from November 2009 to February 2010. All subjects underwent polysomnogram (PSG) testing within 30 days prior to surgery. Patients underwent nasal surgery and received postoperative nasal packing, and a PSG was repeated on the first postoperative night with nasal packing in place. Outcome measures included a change in respiratory disturbance index (RDI), minimum oxygen saturation, oxygen desaturation index (ODI), and duration of snoring. RESULTS: Forty-nine patients were included in the study. Patients were stratified into 2 groups: those with RDI ≥15 (n = 23) and those with RDI <15 (n = 26). Nasal packing was found to significantly increase RDI (5.2 ± 4.0 vs 10.4 ± 10.0; P = .0001), duration of snoring (86.5% ± 13.1% vs 79.3% ± 15.3%; P = .008), and ODI (7.6 ± 7.1 vs 9.9 ± 7.4; P = .001) in patients with mild OSA but not in patients with moderate/severe OSA. Mean minimum arterial oxygen saturation was unchanged in both groups. CONCLUSION: Postoperative nasal packing aggravated measures of OSA in patients with mild OSA but not in patients with moderate/severe OSA.

Decreased retinal nerve fiber layer thickness in patients with obstructive sleep apnea/hypopnea syndrome.

BACKGROUND: To compare parameters for retinal nerve fiber layer (RNFL) thickness, optic nerve head (ONH) measurements, and macular thickness in patients with different severities of obstructive sleep apnea/hypopnea syndrome (OSAHS) versus normal controls. METHODS: Patients presenting with snoring and daytime sleepiness who underwent overnight polysomnography to determine OSAHS severity were recruited, and subsequently referred for ophthalmologic evaluation. Optical coherence tomography was used to evaluate the retinal nerve fiber layer (RNFL), optic nerve head topography, and macular thickness for early detection of glaucoma. Patients determined not to have OSAHS were included as controls. RESULTS: A total of 127 subjects were recruited, including 105 patients with OSAHS and 22 normal control subjects. RNFL thickness was significantly lower for the severe OSAHS group than for the control and mild OSAHS groups in the average (p < 0.0001) and in the superior quadrant (p = 0.0007). When subjects without OSAHS or with mild disease (AHI < 15) were grouped together and compared with patients with moderate/severe OSAHS (AHI ≧ 15), RNFL thickness measurements for the latter group were significantly lower in the average (p < 0.0001), and in the superior (p = 0.001), inferior (p = 0.029), and temporal (p = 0.007) quadrants. Positive correlations were identified between lowest oxygenation saturation on PSG and RNFL thickness in the average (r = 0.260), superior (r = 0.200) and nasal (r = 0.156) quadrants. CONCLUSIONS: Compared to patients without OSAHS or those with mild disease, RNFL thickness was lower in patients with moderate/severe OSAHS. Lowest saturation of oxygen in the moderate/severe OSAHS group correlated with decreased RNFL thickness. Patients with moderate and severe OSAHS are at increased risk for glaucoma.

Otolaryngology office-based treatment of obstructive sleep apnea-hypopnea syndrome with titratable and nontitratable thermoplastic mandibular advancement devices.

OBJECTIVE: 1) Share our experiences treating patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) with titratable and nontitratable thermoplastic mandibular advancement devices (MADs) fitted in our otolaryngology clinic. 2) Compare these devices in terms of objective response (OR), as defined by a > or = 50 percent decrease in baseline apnea-hypopnea index (AHI) and an AHI < 20, and subjective parameters, including adherence. 3) Determine overall success, as defined by OR plus adherence at two months follow-up. STUDY DESIGN: Cohort study. SETTING: Tertiary care center. SUBJECTS AND METHODS: Patients with OSAHS who tried and failed or refused both continuous positive airway pressure (CPAP) and surgical therapy were fitted with a nontitratable Snore Guard (n = 38), nontitratable SomnoGuard 2.0 (n = 8), or titratable SomnoGuard AP (n = 41). Pre- and post-treatment assessment included: 1) Epworth Sleepiness Scale, 2) snoring level, 3) polysomnogram. Patients were contacted at two months follow-up to assess adherence and subjective parameters. RESULTS: OR was achieved in 62.1 percent of patients. Overall mean reduction in AHI was from 39.96 +/- 23.70 to 14.86 +/- 13.46 (P = 0.000). Adherence at two months was 58.5 percent. No significant differences were observed in OR or adherence according to MAD type, though improvements in AHI and minimum oxygen saturation were significantly better for the SomnoGuard AP than for the nontitratable devices. Overall success was 38.6 percent. CONCLUSION: Thermoplastic MADs are a relatively inexpensive treatment alternative for patients with OSAHS who fail/refuse CPAP and upper airway surgery. They can be easily fitted in the otolaryngology clinic. Long-term compliance, efficacy, and safety are unknown at this time.

Long-term results of radiofrequency turbinoplasty for allergic rhinitis refractory to medical therapy.

OBJECTIVE: To study the long-term outcomes of radiofrequency (RF) turbinate surgery for the treatment of allergic rhinitis refractory to medical therapy. DESIGN: A retrospective review of a prospective data set. SETTING: Tertiary referral center. PATIENTS: A total of 146 patients with allergic rhinitis refractory to medical therapy undergoing RF turbinoplasty were included. MAIN OUTCOME MEASURES: A standard 0 to 10 visual analog scale (VAS) was used to assess the allergic symptoms including nasal obstruction, rhinorrhea, sneezing, itchy nose, and itchy eyes prior to RF turbinoplasty and at 6 months and 5 years postoperatively. The long-term clinical benefits and complications were reviewed. Statistical analysis was determined by repeated measures of analysis of variance. RESULTS: No adverse reactions such as bleeding, infection, adhesions, or olfactory change were encountered. Of the 146 patients, 119 were followed up at least 5 years postoperatively. Five years after treatment, 101 patients had complete data available for analysis. They reported improvement of nasal obstruction, with the mean (SD) VAS score decreasing from 6.65 (1.92) to 4.45 (2.54). The mean (SD) VAS score changed from 5.90 (2.79) to 3.79 (2.97) for rhinorrhea; from 5.15 (2.77) to 3.50 (2.77) for sneezing; from 3.67 (3.03) to 2.41 (2.30) for itchy nose; and from 2.94 (3.02) to 2.02 (2.42) for itchy eyes (all P < .001, paired t test with Bonferroni correction). CONCLUSION: This long-term study has demonstrated that the RF turbinoplasty for allergic rhinitis appears to be an effective and safe tool for treating allergic rhinitis refractory to medical therapy.

Measurements of adult lingual tonsil tissue in health and disease.

OBJECTIVES: To report computed tomography (CT) measurements of lingual tonsil tissue (LTT) in patients with laryngopharyngeal reflux (LPR), obstructive sleep apnea-hypopnea syndrome (OSAHS), both LPR and OSAHS, or neither disease. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care center. SUBJECTS AND METHODS: Ninety-eight patients with CT scans including the tongue base and complete historical data regarding the presence or absence of symptoms, signs, and laboratory confirmation of LPR and/or OSAHS were included. LTT was measured on CT. Charts of patients meeting inclusion criteria were subsequently reviewed and patients were divided into four groups: 1) those without LPR or OSAHS, 2) those with LPR only, 3) those with OSAHS only, and 4) those with both LPR and OSAHS. Statistical analysis focused on correlating LTT thickness with the presence or absence of LPR and/or OSAHS. RESULTS: The mean LTT thickness for group 1 (21 patients without reflux or OSAHS) was 0.937 mm (range 0-2.67 mm). The mean for group 2 (29 patients with LPR only) was 3.35 mm (range 0-7.4 mm). The mean for group 3 (16 patients with OSAHS only) was 4.29 mm (range 0-9 mm). The mean for group 4 (32 patients with LPR and OSAHS) was 4.00 mm (range 0-19.2 mm). The mean for group 1 was lower than the other 3 groups (P < 0.001). CONCLUSION: CT images including the tongue base allow precise measurement of LTT thickness. LTT > 2.7 mm was not identified in patients without OSAHS or LPR. The mean LTT for patients with LPR and/or OSAHS was significantly greater than for patients without either disease.

Screening for obstructive sleep apnea/hypopnea syndrome: subjective and objective factors.

OBJECTIVES: To determine the sensitivity and specificity of the Berlin Questionnaire and the Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS) score for individually predicting a diagnosis of OSAHS, and to propose a method for OSAHS screening incorporating objective and subjective factors. STUDY DESIGN: Cross-sectional survey. SETTING: Tertiary care center. METHODS: Charts were reviewed from 223 consecutive patients for whom complete data regarding the Berlin questionnaire, OSAHS score (Friedman tongue position + tonsil size + body mass index grade), Epworth Sleepiness Scale, and visual analog scale for snoring were obtained prior to polysomnography (PSG). Sensitivity and specificity were determined for the Berlin questionnaire and OSAHS score for predicting an apnea hypopnea index (AHI) >or= 5. Patient data were subjected to multivariate stepwise discriminant analysis and used to construct a screening system based on the Fisher's linear classification equation. Results were cross-validated by PSG findings. RESULTS: In predicting an AHI >or= 5, the sensitivity and specificity, respectively, were 0.615 and 0.226 for the Berlin questionnaire, 0.863 and 0.468 for OSAHS score, and 0.82 and 0.834 for our predictive equation. When applied case-wise to the study population, this equation correctly predicted 82.5 percent of diagnoses. Accuracy was highest for severe OSAHS (87.4%) and lowest for mild disease (77.0%). Sensitivity was lowest for mild OSAHS (0.50). CONCLUSIONS: Neither the Berlin questionnaire nor the OSAHS score alone was both highly sensitive and specific for diagnosing OSAHS. By incorporating subjective and objective metrics into a single predictive equation, sensitivity and specificity were maximized, and 82.5 percent of diagnoses were accurately predicted.