Is Nuclear Imaging Important in the Management of Head and Neck Paragangliomas?

Nuclear medical imaging is indicated in most, but not all, patients with suspected paragangliomas of the head and neck. Advances in technology and somatostatin receptor analogs have improved the selectivity and sensitivity of this imaging.

Perceived value drives use of routine asymptomatic surveillance PET/CT by physicians who treat head and neck cancer.

BACKGROUND: Why physicians use surveillance imaging for asymptomatic cancer survivors despite recommendations against this is not known. METHODS: Physicians surveilling head and neck cancer survivors were surveyed to determine relationships among attitudes, beliefs, guideline familiarity, and self-reported surveillance positron-emission-tomography/computed-tomography use. RESULTS: Among 459 responses, 79% reported using PET/CT on some asymptomatic patients; 39% reported using PET/CT on more than half of patients. Among attitudes/beliefs, perceived value of surveillance imaging (O.R. 3.57, C.I. 2.42-5.27, P = <.0001) was the strongest predictor of high imaging, including beliefs about outcome (improved survival) and psychological benefits (reassurance, better communication). Twenty-four percent of physicians were unfamiliar with guideline recommendations against routine surveillance imaging. Among physicians with high perceived-value scores, those less familiar with guidelines imaged more (O.R. 3.55, C.I. 1.08-11.67, P = .037). CONCLUSIONS: Interventions to decrease routine surveillance PET/CT use for asymptomatic patients must overcome physicians' misperceptions of its value. Education about guidelines may modify the effect of perceived value.

Perioperative Management of Total Laryngectomy Patients: A Survey of American Head and Neck Society Surgeons.

OBJECTIVES: Standards of care for total laryngectomy (TL) patients in the postoperative period have not been established. Perioperative care remains highly variable and perhaps primarily anecdotally based. The aim of this study was to survey members of the American Head and Neck Society to capture management practices in the perioperative care of TL patients. METHODS: In this survey study, an electronic survey was distributed to the international attending physician body of the American Head and Neck Society. Forty-five-question electronic surveys were distributed. A total of 777 members were invited to respond, of whom 177 (22.8%) fully completed the survey. The survey elicited information on management preferences in the perioperative care of TL patients. Differences in management on the basis of irradiation status and pharyngeal repair (primary closure vs regional or free flap reconstruction) were ascertained. Main outcomes and measures were time to initiate oral feeding, perioperative antibiotic selection and duration, and estimated pharyngocutaneous fistula rates. These measures were stratified by patient type. RESULTS: Most respondents completed head and neck fellowships (77.0%) and practice at academic tertiary centers (72.3%). Ampicillin/sulbactam was the most preferred perioperative antibiotic (43.2%-49.1% depending on patient type), followed by cefazolin and metronidazole in combination (32.0%-33.7%) and then clindamycin (10.8%-12.6%). Compared with nonirradiated patients, irradiated patients were significantly more likely to have longer durations of antibiotics ( P < .05), longer postoperative times to initiate oral feeding ( P < .05), and higher estimated fistula rates ( P < .05). Additionally, in nonirradiated patients, flap-repaired patients (vs primary repair) were significantly more likely to have longer durations of antibiotics (odds ratio, 1.29; 95% confidence interval, 1.13-1.48) and postoperative times to initiate oral feeding (odds ratio, 2.24; 95% confidence interval, 1.76-2.84). CONCLUSIONS: Perioperative management of TL patients is highly variable. Management of antibiotics and oral feeding are significantly affected by irradiation status and scope of pharyngeal repair. Further studies are needed to standardize perioperative care for this unique patient population.

Factors predictive of the development of surgical site infection in thyroidectomy - An analysis of NSQIP database.

BACKGROUND: Surgical Site Infection (SSI) is an uncommon but serious complication of thyroidectomy when encountered. STUDY DESIGN: NSQIP Participant Use File (PUF) from 2012 to 2015 were queried. Thyroidectomy was identified with CPT 60210, 12, 20, 25, 40, 52, 54, 60 in patients ≥18 years and clean (Wound Classification 1) wounds. Uni- and multivariate logistic regression testing were performed. A subgroup analysis for patients that underwent thyroidectomy for cancer was performed. RESULTS: 57,371 patients were included in the study. SSI incidence was 0.4%. On univariate analysis age 18-29, age>70, male gender, BMI 19 to <25, BMI 40 to <50, ASA classes other than class 4, diabetes, White race, COPD, current smoker, CHF, hypertension disseminated cancer and ventilator dependent within 48 h prior to surgery were pre-operative variables with P-value <0.2 between the two groups. On multivariate regression analysis age ≥80, gender male, BMI 40 to <50, current smoker and ventilation within 48 h preceding surgery remained statistically significant. After ventilation, age≥80 was associated with the greatest odds (OR) ratio (2.382). In the subgroup analysis age ≥80, White race, and CHF were predictive of SSI. CONCLUSION: SSI following thyroidectomy with a clean wound is rare. Routine use of antibiotics should not be undertaken in patients undergoing thyroidectomy and should only be considered for high risk patients or for those patients with contaminated wounds.

Endoscope-assisted approach to excision of branchial cleft cysts.

OBJECTIVES/HYPOTHESIS: The purpose of this study is to describe an endoscope-assisted surgical technique for the excision of branchial cleft cysts and compare it to the standard approach. STUDY DESIGN: Retrospective case series review. METHODS: Twenty-seven cases described as branchial cleft excisions performed by a single surgeon at one academic medical center were identified between 2007 and 2014. Twenty-five cases (8 endoscopic, 17 standard approach) were included in the study. Cases were excluded if final pathology was malignant. Patient charts were reviewed, and two techniques were compared through analysis of incision size, operative time, and surgical outcomes. RESULTS: This study showed that the length of incision required for the endoscopic approach (mean = 2.13 ± 0.23) was significantly less than that of the standard approach (mean = 4.10 ± 1.46, P = 0.008) despite the fact that there was no significant difference in cyst size between the two groups (P = 0.09). The other variables examined, including operative time and surgical outcomes, were not significantly different between the two groups. CONCLUSION: This transcervical endoscope-assisted approach to branchial cleft cyst excision is a viable option for uncomplicated cases. It provides better cosmetic results than the standard approach and does not negatively affect outcomes, increase operative time, or result in recurrence. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1339-1342, 2016.

Necessity for lifelong follow-up of patients with familial paraganglioma syndrome: A case report.

BACKGROUND: Patients with established familial paraganglioma (PGL) syndrome may have multiple metachronous lesions. This article illustrates, via imaging and findings, the need for lifetime follow-up of patients with familial PGL syndromes. METHODS: Patients' medical charts and radiological images were reviewed in a retrospective analysis. RESULTS: Over the course of 18 years, this patient developed 2 simultaneous carotid PGLs, a cardiac PGL, and a biochemically active interaortocaval PGL. CONCLUSION: PGLs do not necessarily occur simultaneously in patients with familial PGL syndrome. Lifelong observation is needed to detect these lesions before they become large and symptomatic. Lack of biochemical activity is not a predictor of future lesions being inactive. Cardiac PGLs are rare and require resection.

Guideline familiarity predicts variation in self-reported use of routine surveillance PET/CT by physicians who treat head and neck cancer.

BACKGROUND: Use of routine surveillance testing beyond guideline recommended levels is common in many oncologic disciplines, including head and neck cancer. The impact of guideline familiarity and other physician characteristics on surveillance imaging use are not well understood. METHODS: A cross-sectional national survey was performed of physicians responsible for surveillance of patients with head and neck squamous cell carcinoma (HNSCC). The primary outcome was self-reported use of routine surveillance PET/CT in asymptomatic patients. A secondary outcome was familiarity with guideline recommendations. Using multivariable regression, the impact of guideline familiarity and other physician characteristics on PET/CT use was examined. RESULTS: Of the 502 responders, 79% endorsed ever using PET/CT scans for routine surveillance imaging, and 39% were high imaging users (used PET/CT scans on more than half of their asymptomatic patients); 76% were familiar with the NCCN Clinical Practice Guidelines in Oncology for Head and Neck Cancers recommending against routine surveillance PET/CT scans. Although guideline familiarity was associated with being a low imaging user or a never-user, among those who were familiar with guidelines, 31% were nonetheless high imaging users and 73% endorsed ever using PET/CT scans. In multivariable analysis controlling for physician characteristics, guideline familiarity was the strongest predictor of PET/CT use. CONCLUSIONS: Familiarity with the NCCN Guidelines predicts self-reported routine surveillance PET/CT use among physicians who treat patients with HNSCC. However, given the observed variation and high levels of imaging even among physicians who are familiar with the guidelines, further research should examine the reasons physicians choose to use surveillance PET/CT scans.

Metformin inhibits salivary adenocarcinoma growth through cell cycle arrest and apoptosis.

The inhibitory effects of metformin have been observed in many types of cancer. However, its effect on human salivary gland carcinoma is unknown. The effect of metformin alone or in combination with pp242 (an mTOR inhibitor) on salivary adenocarcinoma cells growth were determined in vitro and in vivo. We found that metformin suppressed HSY cell growth in vitro in a time and dose dependent manner associated with a reduced expression of MYC onco-protein, and the same inhibitory effect of metformin was also confirmed in HSG cells. In association with the reduction of MYC onco-protein, metformin significantly restored p53 tumor suppressor gene expression. The distinctive effects of metformin and PP242 on MYC reduction and P53 restoration suggested that metformin inhibited cell growth through a different pathway from PP242 in salivary carcinoma cells. Furthermore, the anti-tumor efficacy of metformin was confirmed in vivo as indicated by the increases of tumor necrosis and reduced proliferation in xenograft tumors from metformin treated group. For the first time, the inhibitory effect of metformin on human salivary gland tumor cells was documented. Moreover, metformin inhibitory effects were enhanced by mTOR inhibitor suggesting that metformin and mTOR inhibitor utilize distinctive signaling pathways to suppress salivary tumor growth.

An algorithm approach to diagnosing bilateral parotid enlargement.

OBJECTIVE: This contemporary review aims to categorize the disease entities that cause bilateral parotid enlargement and to develop a question-based algorithm to improve diagnosis of bilateral parotid masses. DATA SOURCES: A PubMed search for bilateral and parotid showed 818 results. Of these, 68 relevant studies were reviewed to compile a list of disease processes that can cause bilateral parotid enlargement. REVIEW METHODS: A total of 22 diseases entities were reviewed. The disease processes were initially grouped into 6 categories based on etiology: sialadenosis, infection, neoplasm, autoimmune, iatrogenic, and miscellaneous. For each lesion, the incidence, history, and physical examination were compiled in a matrix. CONCLUSION: After reviewing the matrix, it was clear that grouping diseases based on specific history and physical findings limits the differential diagnosis. The most important factors included disease incidence, timing of onset, nodular or diffuse, pain, and overlying skin changes. With this algorithm, the differential diagnosis can be limited from 28 to 7 or fewer likely diagnoses for a given presentation. Implications for Practice Bilateral parotid disease has a wide differential diagnosis with an expanding number of available tests. An algorithm, based solely on data obtained from the history and physical examination in the first patient encounter, may reduce the differential and aid the clinician in deciding on further workup and treatment. Following the algorithm presented here should allow the clinician to arrive at a diagnosis rapidly without ordering unnecessary tests and wasting resources.

Patient perspectives on dysphonia after thyroidectomy for thyroid cancer.

OBJECTIVES: To determine the frequency and consequences of patient-reported post-thyroidectomy voice disorder (PTVD) after surgery for thyroid cancer. STUDY DESIGN: Retrospective review of data gathered from a survey. PARTICIPANTS: Members of the Thyroid Cancer Survivors' Association (ThyCa). METHODS: ThyCa members were asked about their thyroid disease and surgery, voice disturbance, impact on quality of life, treatment, and non-identifying demographics in a 36-item electronic questionnaire. Patients with preoperative voice disturbance or vocal fold immobility and those reporting postoperative vocal fold paralysis were excluded. RESULTS: A total of 4426 members responded (37% response rate), and PTVD was reported by 51.1% of responders. Most were temporary (85.9%), with a minority reporting permanent hoarseness. Rates of postoperative dysphonia were similar between the extent of surgery and histology. Patients with PTVD predominantly characterized their impairment as loss of loudness and an inability to shout or sing. Nearly a quarter of patients reporting PTVD identified detrimental impact to their professional or personal lives. Only 57 patients (3.4%) were offered voice therapy; however, more than two-thirds of them (73.7%) experienced at least partial improvement. CONCLUSIONS: We report the results of a large-scale patient survey to underscore the commonness of postoperative hoarseness and its impact on patients. LEVEL OF EVIDENCE: 4.

Improved detection does not fully explain the rising incidence of well-differentiated thyroid cancer: a population-based analysis.

BACKGROUND: The increasing incidence of thyroid cancer may be an artifact of increased diagnostic scrutiny, permitting detection of smaller, subclinical thyroid cancers. Our objective was to examine trends in the incidence of well-differentiated thyroid cancers with large size and adverse pathological features. METHODS: Detailed population-based analysis of incidence trends in well-differentiated thyroid carcinoma (1973-2006) in the Surveillance Epidemiology and End Results (SEER) cancer registry, using weighted least squares and Joinpoint regression models. RESULTS: The incidence of well-differentiated thyroid cancer (WDTC) in the United States has tripled since 1973 (P < .0001). Incidence trends differ significantly between geographic regions and racial groups. Large WDTCs, including those >4 cm or >6 cm, have more than doubled in incidence (P < .0001). Cancers with extrathyroidal extension and with cervical metastases have also more than doubled in incidence (P < .0001). CONCLUSIONS: While the model of improving screening does explain increased diagnoses of small thyroid cancers, significant rises in the incidence of large cancers, and cancers with clinically significant pathological adverse features, are harder to explain. Alternative hypotheses, including a true increase in cancer incidence, would seem to merit exploration.

Validation of the histologic risk model in a new cohort of patients with head and neck squamous cell carcinoma.

BACKGROUND: Half of the patients with head and neck squamous cell carcinoma (HNSCC) can be expected to fail therapy, indicating that more aggressive treatment is warranted for this group. We have developed a novel risk model that can become a basis for developing new treatment paradigms. Here we report on the performance of our model in a new multicenter cohort. DESIGN: Eligible patients from 3 institutions (Montefiore Medical Center, University of Manitoba, and New York University Medical Center) were identified and pathology slides from their resection specimens were reviewed by Margaret Brandwein-Gensler; risk category was assigned as previously published. Kaplan-Meier analysis was performed for disease progression and survival. Cox proportional hazards regression was performed, adjusted for potential confounders. A teaching module was also developed; attending pathologists were asked to score coded slides after a lecture and multiheaded microscope teaching session. Agreement was assessed by calculating Cohen unweighted kappa coefficients. RESULT: The validation cohort consisted of 305 patients, from the above institutions, with 311 primary HNSCC of the oral cavity, oropharynx, and larynx. The median follow-up period for all patients was 27 months. Risk category predicts time to disease progression (P=0.0005), locoregional recurrence (P=0.013), and overall survival (P=0.0000) by Kaplan-Meier analysis. High-risk status is significantly associated with decreased time to disease progression, adjusted for clinical confounders (P=0.015, hazard ratio 2.32, 95% confidence interval 1.18-4.58) compared with collapsed intermediate and low-risk groups. We also demonstrate substantial interrater agreement (kappa=0.64), and very good rater agreement when compared with the standard (kappa=0.87). CONCLUSIONS: We demonstrate significant predictive performance of the risk model in a new cohort of patients with primary HNSCC, adjusted for confounders. Our training experience also supports the feasibility of adapting the risk model in clinical practice.

Tongue necrosis: a rare complication of oral intubation.

OBJECTIVES: (1) Present a unique case of partial necrosis of the dorsal tongue caused by an endotracheal tube; (2) highlight the importance of verifying proper endotracheal tube positioning during cases requiring prolonged intubation. METHODS: Case report and literature review. RESULTS: A 50 year-old man underwent total thyroidectomy and bilateral lymphadenectomies for papillary thyroid carcinoma. A nerve monitoring endotracheal tube was used during the case. Postoperatively, the patient reported tongue pain and examination revealed partial necrosis of his dorsal tongue. On follow up, the patient had improved tongue pain and well-healing dorsal tongue. DISCUSSION: We present the a case of tongue ischemia and partial necrosis due to oral endotracheal intubation, specifically with a nerve monitoring endotracheal tube, which has not previously been reported in the English literature. Tongue necrosis due to compression by an endotracheal tube during prolonged intubation is unusual, however surgeons, anesthesiologists and those involved in the care of intubated patients should consider the potential for this complication when orienting and securing endotracheal tubes. CONCLUSIONS: This unique case of tongue necrosis underscores the importance of proper endotracheal tube positioning during prolonged intubation.

Staged surgical management of hypopharyngeal traction diverticulum.

A 50-year-old woman who had undergone cervical spine fixation 6 years earlier presented with dysphagia, regurgitation of undigested food, halitosis, and weight loss. Operative examination demonstrated a hypopharyngeal diverticulum with spinal hardware visible in a defect in the mucosa. She underwent an open cervical approach to removal of the hardware. Endoscopic staple diverticulotomy as described by Scher and Richtsmeier was performed 8 weeks later in the ambulatory surgical setting. After a period of enteral feeding via a nasogastric tube in the initial postoperative period, she was able to resume oral nutrition in the interim between the surgical procedures. After the second procedure, she was able to resume a normal diet immediately and she experienced minimal symptoms. It is established that traction diverticulum is appropriately treated by removing the inciting anatomic factor(s). We propose that staged surgical management begin with the removal of the nidus followed by marsupialization of the diverticulum pouch. Standard staple diverticulotomy is a viable option for the second stage. This technique allows the patient to minimize the length of, or avoid, the second hospitalization for diverticulum management.

The basis of racial differences in the incidence of thyroid cancer.

BACKGROUND: The incidence of thyroid cancer in black Americans is half that in white Americans. It is unknown whether this gap represents a population difference in disease or is attributable to inferior cancer screening in the black population. METHODS: A population-based cohort study of 53,990 patients (1973-2003) was performed using the National Cancer Institute's Surveillance Epidemiology End Results database. Socioeconomic variables were explored using the Healthcare Cost and Utilization Project database and macroeconomic data. RESULTS: Since 1973, thyroid cancer incidence among whites has increased 150.2% (4.0 to 9.9 of 100,000), while incidence among blacks has increased 73.2% (3.0 to 5.1 of 100,000). Across 17 regions, the incidence correlated with the percentage of the population with health insurance (r = 0.56, P = .02). Regression analysis suggested that half of the black-white incidence gap might be attributable to differences in health insurance status. Patients with thyroid cancer were more likely to be insured or reside in wealthier ZIP codes. Black patients were more likely to present at advanced age (RR 1.08, P < .0001) and with tumors >4 cm in size (RR 1.13, P <.0001). Black patients were slightly less likely to present with advanced disease (RR 0.96, P = .0008). Cancer-specific mortality was identical in the two populations. DISCUSSION: Sociodemographic data and differences at presentation support a small detection disparity in thyroid cancer, which may contribute to part of the incidence gap. However, this effect is not sufficiently strong to fully explain the incidence gap. A population difference in the incidence of disease may be coexistent.

Screening for familial paragangliomas.

Paragangliomas of the head and neck are uncommon, slow-growing, multicentric and are usually benign. Ever since familial paragangliomas were first described a genetic explanation for their existence has been sought. An international collaboration finally elucidated the SDHB, SDHC and SDHD genes for three paraganglioma syndromes (PGL 4, 3, 1). A familial origin should be suspected if other family members have paraganglioma, paragangliomas are multiple, the patient is young or the patient has a vagal paraganglioma. Once familial disease is suspected the best initial screening method is by genetic testing of the patient in question. If genetic testing detects PGL 1, 3 or 4 mutations then the patient's siblings and children should be tested. All genotypically positive patients should be followed periodically as soon as detected. Surveillance is best performed with periodic radionuclide imaging and by directed magnetic resonance imaging. The purpose of surveillance is early detection and consequently earlier treatment. Abundant evidence exists that the risk of complications from surgical intervention increases with increasing tumor size. If tumors are detected and eradicated before they become large, then younger patients can be spared the dysphagia, dysphonia, dysarthria and stroke that have plagued patients undergoing surgery for these tumors.