30-day morbidity and mortality after transoral robotic surgery for human papillomavirus (HPV) associated oropharyngeal squamous cell carcinoma: A retrospective analysis of two prospective adjuvant de-escalation trials (MC1273 & MC1675).

OBJECTIVE: Dose de-escalation of adjuvant therapy (DART) in patients with HPV(+)OPSCC was investigated in two prospective Phase II and III clinical trials (MC1273 and MC1675). We report the 30-day morbidity and mortality associated with primary TORS resection in patients enrolled in these trials. MATERIALS AND METHODS: Patients with HPV(+)OPSCC, who underwent TORS resection between 2013 and 2020 were considered in this analysis. The severity of postoperative transoral bleeding was graded using both the Hinni Grade (HG) transoral surgery bleeding scale and the Common Terminology for Adverse Events (CTCAE) v5.0. Post-surgical complications within 30 days of surgery, as well as rates of tracheostomy, PEG and nasogastric tube placement. RESULTS: 219 patients were included. A total of 7 (3.2 %) patients had a tracheostomy placed at the time of surgery, and all were decannulated within 26 days (median: 5, range: 2-26). There were 33 (15.1 %) returns to the emergency department (ED) with 10 (4.6 %) patients requiring readmission. Using the HG scale, 10 (4.6 %) patients experienced ≥ Grade 3 bleeding with no Grade 5 or 6 bleeds. In contrast, using the CTCAE scale, 15 patients (6.8 %) experienced ≥ Grade 3 bleeding with no Grade 5 bleeds. There was one post-operative death in a patient withdrawn from the trial, and no deaths related to hemorrhage. CONCLUSION AND RELEVANCE: TORS for HPV(+)OPSCC in carefully selected patients at a high volume center was associated with low morbidity and mortality.

The impact of family history on non-medullary thyroid cancer.

INTRODUCTION: Around 10% of patients with non-medullary thyroid cancer (NMTC) will have a positive family history for the disease. Although many will be sporadic, families where 3 first-degree relatives are affected can be considered to represent true familial non-medullary thyroid cancer (FNMTC). The genetic basis, impact on clinical and pathological features, and overall effect on prognosis are poorly understood. METHODS: A literature review identified articles which report on genetic, clinical, therapeutic and screening aspects of FNMTC. The results are presented to allow an understanding of the genetic basis and the impact on clinical-pathological features and prognosis in order to inform clinical decision making. RESULTS: The genetic basis of FNMTC is unknown. Despite this, significant progress has been made in identifying potential susceptibility genes. The lack of a test for FNMTC has led to a clinical definition requiring a minimum of 3 first-degree relatives to be diagnosed with NMTC. Although some have shown an association with multi-centric disease, younger age and increased rates of extra-thyroidal extension and nodal metastases, these findings are not supported by all. The impact of FNMTC is unclear with all groups reporting good outcome, and some finding an association with more aggressive disease. The role of screening remains controversial. CONCLUSION: FNMTC is rare but can be diagnosed clinically. Its impact on prognostic factors and the subsequent role in influencing management is debated. For those patients who present with otherwise low-risk differentiated thyroid cancer, FNMTC should be included in risk assessment when discussing therapeutic options.

Patterns of chromosomal aberrations in metastasizing and nonmetastasizing squamous cell carcinomas of the oropharynx and hypopharynx.

Although several cytogenetic events of the tumor progression cascade have been identified in the past, the specific types of chromosomal alterations that lead to the development of lymph node metastases are still unknown. Operative specimens of 20 patients (10 patients with metastasizing tumors, 10 patients with nonmetastasizing tumors) with squamous cell carcinomas of the oropharynx and hypopharynx, along with the corresponding lymph node metastases, were investigated by quantitative DNA measurements and comparative genomic hybridization (CGH). Nonmetastasizing tumors (N0) displayed overrepresentations on chromosomes 10q (8 cases); 5p (7 cases); 3q and 20q (6 cases each); 8q (5 cases); 1p and 21q (4 cases each); 7p and 20p (3 cases each); and 2p, 15q, and 19q (2 cases each). Loss of chromosomal material was found on 5q, 9p, and 14q (2 cases each). Metastasizing tumors (N+) demonstrated overrepresentations on chromosomes 5p, 15q, and 22q (6 cases each); 3q and 11q13 (5 cases each); 20p and 21q (4 cases each); and 10q (3 cases). In 2 cases, an overrepresentation of the chromosomal arm 3q was accompanied by a loss of chromosomal arm 3p. Less frequent overrepresentations were observed on chromosomes 1q and 17q. Deletions were found on chromosomes 18q (3 cases), 3p, 4q, 5q, and 19p (2 cases each); and sporadic deletions occurred on 2q, 6q, 8p, 9p, 10p, 13q, 14q, 15q, and 16q. Whereas overrepresentations on chromosomes 1p and 7p occurred exclusively in N0 tumors, overrepresentations on chromosomes 1q, 11q, and 22q, along with deletions on 18q, were only observed in N+ tumors. Quantitative DNA measurements revealed a significantly higher percentage of aneuploid cells and a higher degree of DNA entropy in the N+ tumors. Chromosomal overrepresentations on chromosomes 1q, 8q, 11q, 18q, and 19q occurred more frequently in the metastases than in the corresponding primary tumors. Pairwise analysis of chromosomal alterations in the primary tumors and associated lymph node metastases revealed a genetic relationship, although a greater number of chromosomes on average were affected in the lymph node metastases. Quantitative DNA measurements demonstrated greater aneuploid values in the metastases. Recurring patterns of chromosomal alterations in N0 and N+ tumors were demonstrated in this study. In general, metastasizing tumors are characterized by overrepresentations on chromosomes 11q13 and 22q, and deletions on 18q. These aberrations suggest an elevation along the tumor progression cascade.

Giant cell tumor of the larynx.

Giant cell tumors are benign tumors generally found in the long bones. Very rarely, they can occur in the larynx and may present with dysphonia, dysphagia, or dyspnea. A case of giant cell tumor of the larynx was recently identified and successfully treated by a partial laryngectomy. A literature review has revealed 18 case reports of giant cell tumor of the larynx. All cases occurred in men. These 19 cases are reviewed, and follow-up data presented where available. There have been no reports of recurrence regardless of treatment, and an excellent prognosis can be expected when one encounters this unusual laryngeal neoplasm.

Current trends in the detection and management of carotid body tumors.

PURPOSE: Because the natural history of carotid body tumors is believed to be unpredictable, immediate surgical removal has been recommended. The present study reviews our experience in the diagnosis and treatment of these uncommon lesions. METHODS: The medical records of patients who appeared for treatment with carotid body tumors between 1981 and 1997 were reviewed. Patients demographics, mode of presentation, imaging and treatment modalities, Shamblin classification, and neurologic complications (stroke, cranial nerve injuries) were analyzed. RESULTS: Over the past 16 years, 31 patients with 32 carotid body tumors have been evaluated, with an average follow-up of 3.2 years. The patients were arbitrarily classified into two groups on the basis of the mode of detection. Seventy percent (23 of 32) of the tumors discovered on clinical or self-examination were classified as Group 1; 28% (9 of 32) of the tumors detected during duplex scanning for carotid artery disease (8) or MRI (1) were classified as Group 2. The mean size of chemodectomas found on palpation (4.3 +/- 1.7 cm) was larger than that of those detected by duplex ultrasound (2.7 +/- 1.0 cm; p < 0.05, by paired t test). Preoperative embolization was successfully performed in 5 of 6 instances of large tumors; the remaining patient suffered a procedure-related stroke. Thirty-one carotid body tumors were resected. In one case, the tumor was felt by the primary surgeon to be too small (0.9 x 0.7 cm on duplex scan) to warrant immediate excision; this patient is being followed by periodic duplex scanning. Five neurologic complications were noted in Group 1, one after preoperative embolization and four after surgery. One cranial nerve injury occurred in Group 2. One patient had a large recurrent chemodectoma with clinical evidence of metastatic disease. CONCLUSION: The increasing use of sophisticated imaging modalities may allow earlier discovery of carotid body tumors before they can be clinically detected. Resection of carotid body tumors of all sizes in appropriate surgical candidates remains the standard of care. Unfortunately, resection of even small tumors is associated with a low but constant incidence of neurologic complications.

Psychogenic coma after use of general anesthesia for ethmoidectomy.

Failure of a patient to awaken promptly after use of general anesthesia may be due to various causes, including medication-related effects, neurologic insults, or metabolic disturbances. Herein we describe a 49-year-old woman with a history of depression, for which she was receiving treatment, who did not awaken promptly after use of general anesthesia for ethmoidectomy. Results of neurologic examinations were normal, as were laboratory tests and radiologic studies. Six hours after completion of the operation, the patient spontaneously awakened. We hypothesize that she underwent a transient, self-limited period of dissociation related to unresolved grief due to the recent death of a family member.

Salivary gland choristoma of the middle ear: report of a case and review of the literature.

Salivary gland choristoma (heterotopic salivary gland tissue) is a rare condition that occurs at various locations within the head and neck. We present a 10-year-old boy with a salivary gland choristoma of the middle ear and compare findings with the 15 similar cases published in the English and German languages. Patients typically have a long-standing conductive hearing loss and visible middle ear mass. Operative findings include a lobulated middle ear mass of histologically normal salivary gland tissue attached posteriorly in the region of the oval window, together with absent or malformed ossicles. Frequently the mass is intimately associated with the facial nerve. The constancy of these findings has led to the proposal of an abnormal developmental syndrome. This syndrome will be described and possible explanations for its cause will be discussed.

Early mucosal changes in experimental sinusitis.

Normal mucociliary flow is a significant defense mechanism in the prevention of acute sinusitis. We have undertaken a study to examine the early sinus mucosal and mucociliary changes that occur in response to acute infection. Twenty rabbits were evaluated for 5 days after an obstructed maxillary sinus was inoculated with either Streptococcus pneumoniae, Hemophilus influenzae, Pseudomonas aeruginosa, or a sterile saline solution. Data collected included measurements of sinus mucosal ciliary beat frequency, quantitation of ciliated cell losses, and electron microscopic observations. Results demonstrate statistically significant (p < 0.05) changes in mucosal ciliary beat frequency that were either excitatory or inhibitory, depending both on the length of the infection and the specific organism. No changes in ciliary beat frequency were observed in the control animals (p > 0.55). Control animals likewise demonstrated no loss of ciliated cells from mucosal epithelium; however, dramatic losses of ciliated cells from the sinus mucosa of the experimental groups were observed. These losses occurred at different rates, depending on the infecting organism, but all infected groups demonstrated a > 86% decrease in the number of viable ciliated cells from the sinus mucosa after sinusitis of 5 days duration. We conclude that a significant loss of ciliated cells from sinus mucosa and a corresponding disruption of normal mucociliary flow occurs early after exposure to pathogenic organisms and is a significant predisposing factor in the development of acute sinusitis.