Complications related to thyroidectomy among patients with hyperthyroidism: Exploring the potential for ambulatory surgery

BACKGROUND

Total thyroidectomy for hyperthyroidism is typically followed by overnight admission to monitor for complications including thyrotoxicosis. Outpatient thyroid surgery is increasingly common, but its safety in patients with hyperthyroidism has not been well studied.

METHODS

This retrospective study reviewed 183 patients with hyperthyroidism who underwent total thyroidectomy from 2015 to 2022 at one urban, academic center. The main outcomes were rates of thyroid storm, surgical complications, and 30-day ED visits and readmissions.

RESULTS

Among 183 patients with hyperthyroidism (mean age, 45 ± 14.5 years; 82.5% female), there were no cases of thyroid storm and complications included recurrent laryngeal nerve (RLN) palsy (7.0%), symptomatic hypocalcemia (4.4%), and hematoma (1.6%). ED visits were present in 1.1% and no patients were readmitted.

CONCLUSION

Total thyroidectomy was not associated with thyroid storm and <6% of patients required inpatient management. Ambulatory total thyroidectomy for hyperthyroidism warrants further consideration through identification of predictive factors for postoperative complications.

Harnessing In Situ Simulation to Identify Human Errors and Latent Safety Threats in Adult Tracheostomy Care

BACKGROUND

Tracheostomies are associated with high rates of complications and preventable harm. Safe tracheostomy management requires highly functioning teams and systems, but health care providers are poorly equipped with tracheostomy knowledge and resources. In situ simulation has been used as a quality improvement tool to audit multidisciplinary team emergency response in the actual clinical environment where care is delivered but has been underexplored for tracheostomy care.

METHODS

From July 2021 to May 2022, the study team conducted in situ simulations of a tracheostomy emergency scenario at Montefiore Medical Center to identify human errors and latent safety threats (LSTs). Simulations included structured debriefs as well as audiovisual recording that allowed for blind rating of these human errors and LSTs. Provider knowledge deficits were further characterized using pre-simulation quizzes.

RESULTS

Twelve human errors and 15 LSTs were identified over 20 simulations with 88 participants overall. LSTs were divided into the following categories: communication, equipment, and infection control. Only 50.0% of teams successfully replaced the tracheostomy tube within the scenario's five-minute time limit. In addition, knowledge gaps were highly prevalent, with a median pre-simulation quiz score of 46% (interquartile range 36-64) among participants.

CONCLUSION

An in situ simulation-based quality improvement approach shed light on human errors and LSTs associated with tracheostomy care across multiple settings in one health system. This method of engaging frontline health care provider key stakeholders will inform the development, adaptation, and implementation of interventions.

Value of Adherence to Posttreatment Follow-Up Guidelines for Head and Neck Squamous Cell Carcinoma

OBJECTIVES

The utility of intensive posttreatment surveillance of head and neck squamous cell carcinoma (HNSCC) has been debated. The objective is to investigate adherence to the National Comprehensive Cancer Network (NCCN) posttreatment follow-up guidelines and assess the association with recurrence and survival.

METHODS

A total of 452 patients diagnosed with HNSCC at an academic medical center in a socioeconomically disadvantaged, urban setting were categorized by adherence to NCCN follow-up guidelines. Survival analyses were conducted to study the association between adherence and the 5-year overall survival and disease-specific survival in the entire cohort and subset of patients with documented recurrence.

RESULTS

We found that 23.5% of patients were adherent to NCCN follow-up guidelines in the first year after treatment, and 15.9% were adherent over 5 years. Adherence in the first year was significantly associated with 5-year overall survival (HR 0.634; 95% CI 0.443-0.906; p = 0.0124) and disease-specific survival (HR 0.556; 95% CI 0.312-0.992; p = 0.0470), but consistent adherence over 5 years did not show a significant association. Among the 21.7% of the cohort with recurrence, adherence was not associated with early-stage recurrence (AJCC stage I/II). In this subset, first year adherence was associated with improved disease-specific but not overall survival, and adherence over 5 years was not associated with survival.

CONCLUSION

Adherence to NCCN follow-up guidelines in the first year after treatment was associated with a better chance of 5-year overall and disease-specific survival, but this significant association was not observed among those who demonstrated consistent adherence over 5 years.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:708-716, 2024.

Establishment of a diverse head and neck squamous cancer cell bank using conditional reprogramming culture methods

Most laboratory models of head and neck squamous cell cancer (HNSCC) rely on established immortalized cell lines, which carry inherent bias due to selection and clonality. We established a robust panel of HNSCC tumor cultures using a "conditional reprogramming" (CR) method, which utilizes a rho kinase inhibitor (Y-27632) and co-culture with irradiated fibroblast (J2 strain) feeder cells to support indefinite tumor cell survival. Sixteen CR cultures were successfully generated from 19 consecutively enrolled ethnically and racially diverse patients with HNSCC at a tertiary care center in the Bronx, NY. Of the 16 CR cultures, 9/16 were derived from the oral cavity, 4/16 were derived from the oropharynx, and 3/16 were from laryngeal carcinomas. Short tandem repeat (STR) profiling was used to validate culture against patient tumor tissue DNA. All CR cultures expressed ΔNp63 and cytokeratin 5/6, which are markers of squamous identity. Human papillomavirus (HPV) testing was assessed utilizing clinical p16 staining on primary tumors, reverse transcription polymerase chain reaction (RT-PCR) of HPV16/18-specific viral oncogenes E6 and E7 in RNA extracted from tumor samples, and HPV DNA sequencing. Three of four oropharyngeal tumors were p16 and HPV-positive and maintained HPV in culture. CR cultures were able to establish three-dimensional spheroid and murine flank and orthotopic tongue models. CR methods can be readily applied to all HNSCC tumors regardless of patient characteristics, disease site, and molecular background, providing a translational research model that properly includes patient and tumor diversity.

Impact of Nonadherence to NCCN Adjuvant Radiotherapy Initiation Guidelines in Head and Neck Squamous Cell Carcinoma in an Underserved Urban Population

BACKGROUND

Nonadherence to NCCN Guidelines during time from surgery to postoperative radiotherapy (S-PORT) can alter survival outcomes in head and neck squamous cell carcinomna (HNSCC). There is a need to validate this impact in an underserved urban population and to understand risk factors and reasons for delay. We sought to investigate the impact of delayed PORT with outcomes of overall survival (OS) in HNSCC, to analyze predictive factors of delayed PORT, and to identify reasons for delay.

METHODS

We conducted a retrospective cohort study in an urban, community-based academic center. A total of 184 patients with primary HNSCC were identified through the Montefiore Medical Center cancer registry who had been treated between March 1, 2005, and March 8, 2017, and met the inclusion and exclusion criteria. The primary exposure was S-PORT. OS, recurrence, and risk factors and reasons for treatment delay were the main outcomes and measures.

RESULTS

Among 184 patients with HNSCC treated with PORT, the median S-PORT was 48.5 days (interquartile range, 41-67 days). The S-PORT threshold that optimally differentiated worse OS outcomes was >50 days (46.7% of our cohort; n=86). Independent of other relevant factors, patients with HNSCC and S-PORT >50 days had worse OS (hazard ratio, 2.30; 95% CI, 1.34-3.95) and greater recurrence (odds ratio, 3.51; 95% CI, 1.31-9.39). Predictors of delayed S-PORT included being underweight or obese, prolonged postoperative length of stay, and age >70 years. The most frequent reasons for PORT delay were complications related to surgery (22.09%), unrelated medical comorbidities (18.60%), and nonadherence/missed appointments (6.98%).

CONCLUSIONS

Delayed PORT beyond 50 days after surgery was associated with decreased OS and greater recurrence. Identification of predictive factors and reasons for treatment delay helps to target at-risk patients and facilitates interventions in underserved populations.

Abstract 2986: Conditional reprogramming of primary head and neck tumor cells to establish consistent and diverse cell line models

Introduction

Head and neck squamous cell carcinoma (HNSCC) most commonly arise in the oral cavity, pharynx, and larynx and exhibit diverse molecular characteristics and clinical behavior across sites. Current models of HNSCC largely rely on immortalized cell lines, which suffer from selection bias and clonality. Primary cell cultures, on the other hand, are difficult to maintain and are limited by their finite ability to proliferate. Here, we describe the establishment of a robust HNSCC cell line bank using a “conditional reprogramming” (CR) method which relies on treatment with a rho kinase inhibitor (Y-27632) and co-culture with irradiated fibroblast (J2 strain) feeder cells to support indefinite tumor cell survival.

Methods

HNSCC tumors were acquired on an IRB-approved prospective tissue banking protocol. Tumor tissue and blood were collected from each patient, and tumor cells were digested and cultured using previously described CR methods. DNA was collected from tumor tissue and CR cultures and short tandem repeat (STR) profiling was used to validate culture against patient tumor tissue. To verify that the cultures were of squamous origin, western blot analysis was used to detect cytokeratin 5, cytokeratin 6 and p63. Tumor cell phenotype and growth characteristics were examined with light microscopy. HPV testing was carried out on DNA from CR cultures and matched tumor samples using PCR and specific genotyping by oligonucleotide hybridization. HPV testing was correlated with clinical p16 testing results. Whole exome sequencing was carried out on a subset of blood/tumor/CR culture samples.

Results

Eighteen CR lines were successfully cultured and validated with STR genotyping from 25 sequentially procured tumors. 10/18 were derived from oral cavity squamous cell cancers (SCCs), 5/18 were derived from oropharyngeal SCCs, and 3/18 were derived from laryngeal SCCs. 18/18 lines were found to express p63 and either cytokeratin 5 or 6, verifying these cultures contained tumor cells of squamous origin. 4/5 tumors from oropharyngeal SCCs were p16-positive on clinical testing and considered HPV-mediated. These 4 tumors all tested positive for HPV DNA in both tumor samples and CR cultures. Preliminary comparison of exome sequencing results between CR cultures and primary tumors suggests that overall mutational profiles are preserved through the tumor “conditional programming” process. Tumor heterogeneity between original tumor and CR culture is being actively compared in ongoing analyses.

Conclusion

We have consistently generated primary tumor CR cultures from patients with HNSCC arising in three major anatomical subsites of HNSCC disease, including HPV-mediated tumors. CR methods can be readily applied to all HNSCC tumors regardless of disease site and molecular background, providing a translational research model that can capture the molecular and phenotypic breadth of HNSCC disease.

Citation Format: Daniel Li, Carlos Thomas, Nitisha Shrivastava, Nicholas Gadsden, Nicole Kawachi, Bradley A. Schiff, Richard V. Smith, Nicolas F. Schlecht, Michael B. Prystowsky, Gregory Rosenblatt, Stelby Augustine, Chandan Guha, Evripidis Gavathiotis, Robert D. Burk, Vikas Mehta, Thomas J. Ow. Conditional reprogramming of primary head and neck tumor cells to establish consistent and diverse cell line models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2986.

Biphenotypic Sinonasal Sarcoma: A Case Report and Review of Literature

OBJECTIVES

Biphenotypic sinonasal sarcoma (BSNS), previously low-grade sinonasal sarcoma with neural and myogenic features, is a rare tumor of the sinonasal tract first described in 2012. Due to its rarity, limited literature is available in providing clinicians with a standardized treatment regimen, particularly in cases of positive surgical margins. This article aims to provide a clinical review of the currently available reported cases of BSNS, as well as presenting clinical, radiologic, and pathologic details of 2 novel cases.

METHODS

Online electronic databases include PubMed and Embase where queried for reports of biphenotypic sinonasal sarcoma or low-grade sinonasal sarcoma with neural and myogenic features. Two previously unpublished cases were included in the results. Data including clinical presentation, epidemiologic data, radiologic evaluation, intraoperative details, histopathology, treatment modality, and postoperative follow-up information were included.

RESULTS

A total of 100 previously published cases were identified in 12 prior articles. Mean age at presentation was 52.9 years. Extrasinonasal extension was observed in 27.4% of cases with most common site of extension being cribriform plate. Forty-seven cases included treatment details with surgical excision being the most common modality. Recurrence rates were identical for both surgical excision alone and surgical excision with adjuvant radiotherapy (33.3%).

CONCLUSIONS

Biphenotypic sinonasal sarcoma is a slow-growing tumor that is amenable to surgical resection. Recurrence rates are similar between surgical excision and surgical excision with adjuvant radiation therapy, but limited data in reported cases preclude a determination of treatment superiority.

Use of Predictive Modeling to Tailor Molecular Testing Utilization for Thyroid Nodules

OBJECTIVE

Various risk stratification systems for cytologically indeterminate thyroid nodules are available. However, malignancy risk assessment data, such as ultrasound features, are not always used when the decision is to order molecular testing or not. Our aim was to investigate the utility of molecular testing after incorporating an algorithm with ultrasound-based risk of malignancy (ROM) estimation.

STUDY DESIGN

Diagnostic/prognostic study.

SETTING

Single-institution urban tertiary care center.

METHODS

We performed a single-institution retrospective chart review of all thyroid nodules that had undergone molecular testing. A web-based Malignancy Risk Estimation System for Thyroid Nodules was utilized with ultrasound findings to stratify malignancy risk according to the Korean Thyroid Imaging Reporting and Data System (TI-RADS), French TI-RADS, American Association of Clinical Endocrinology guideline, and American Thyroid Association guideline. A novel algorithm for utilizing molecular testing at our institution was developed with the Korean TI-RADS and with recommendations from the American Thyroid Association and National Comprehensive Cancer Network.

RESULTS

The Korean TI-RADS performed best in our population (area under the curve = 0.83). A positive molecular test result had a positive association with a higher ROM according to all 4 models (P < .05). Use of our algorithm prior to molecular testing would have prevented 38% of benign/low-ROM negative nodules (n = 28) from being tested.

CONCLUSION

In patients with indeterminate thyroid nodules, an algorithm built on pre- and posttest probability to guide molecular testing might reduce unnecessary testing of benign and low-risk nodules.

Tracheotomy Outcomes in 64 Ventilated COVID-19 Patients at a High-Volume Center in Bronx, NY

OBJECTIVES/HYPOTHESIS

The COVID-19 pandemic has resulted in a dramatic increase in the number of patients requiring prolonged mechanical ventilation. Few studies have reported COVID-19 specific tracheotomy outcomes, and the optimal timing and patient selection criteria for tracheotomy remains undetermined. We delineate our outcomes for tracheotomies performed on COVID-19 patients during the peak of the pandemic at a major epicenter in the United States.

METHODS

This is a retrospective observational cohort study. Mortality, ventilation liberation rate, complication rate, and decannulation rate were analyzed.

RESULTS

Sixty-four patients with COVID-19 underwent tracheotomy between April 1, 2020 and May 19, 2020 at two tertiary care hospitals in Bronx, New York. The average duration of intubation prior to tracheotomy was 20 days ((interquartile range [IQR] 16.5-26.0). The mortality rate was 33% (n = 21), the ventilation liberation rate was 47% (n = 30), the decannulation rate was 28% (n = 18), and the complication rate was 19% (n = 12). Tracheotomies performed by Otolaryngology were associated with significantly improved survival (P < .05) with 60% of patients alive at the conclusion of the study compared to 9%, 12%, and 19% of patients undergoing tracheotomy performed by Critical Care, General Surgery, and Pulmonology, respectively.

CONCLUSIONS

So far, this is the second largest study describing tracheotomy outcomes in COVID-19 patients in the United States. Our early outcomes demonstrate successful ventilation liberation and decannulation in COVID-19 patients. Further inquiry is necessary to determine the optimal timing and identification of patient risk factors predictive of improved survival in COVID-19 patients undergoing tracheotomy.

LEVEL OF EVIDENCE

4-retrospective cohort study Laryngoscope, 131:E1797-E1804, 2021.

Safety Recommendations for Evaluation and Surgery of the Head and Neck During the COVID-19 Pandemic

Importance

The rapidly expanding novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2, has challenged the medical community to an unprecedented degree. Physicians and health care workers are at added risk of exposure and infection during the course of patient care. Because of the rapid spread of this disease through respiratory droplets, health care workers who come in close contact with the upper aerodigestive tract during diagnostic and therapeutic procedures, such as otolaryngologists-head and neck surgeons, are particularly at risk. A set of safety recommendations was created based on a review of the literature and communications with physicians with firsthand knowledge of safety procedures during the COVID-19 pandemic.

Observations

A high number of health care workers were infected during the first phase of the pandemic in the city of Wuhan, China. Subsequently, by adopting strict safety precautions, other regions were able to achieve high levels of safety for health care workers without jeopardizing the care of patients. The most common procedures related to the examination and treatment of upper aerodigestive tract diseases were reviewed. Each category was reviewed based on the potential risk imposed to health care workers. Specific recommendations were made based on the literature, when available, or consensus best practices. Specific safety recommendations were made for performing tracheostomy in patients with COVID-19.

Conclusions and Relevance

Preserving a highly skilled health care workforce is a top priority for any community and health care system. Based on the experience of health care systems in Asia and Europe, by following strict safety guidelines, the risk of exposure and infection of health care workers could be greatly reduced while providing high levels of care. The provided recommendations, which may evolve over time, could be used as broad guidance for all health care workers who are involved in the care of patients with COVID-19.

Tracheotomy in a High-Volume Center During the COVID-19 Pandemic: Evaluating the Surgeon's Risk

Objective

Performing tracheotomy in patients with COVID-19 carries a risk of transmission to the surgical team due to potential viral particle aerosolization. Few studies have reported transmission rates to tracheotomy surgeons. We describe our safety practices and the transmission rate to our surgical team after performing tracheotomy on patients with COVID-19 during the peak of the pandemic at a US epicenter.

Study Design

Retrospective cohort study.

Setting

Tertiary academic hospital.

Methods

Tracheotomy procedures for patients with COVID-19 that were performed April 15 to May 28, 2020, were reviewed, with a focus on the surgical providers involved. Methods of provider protection were recorded. Provider health status was the main outcome measure.

Results

Thirty-six open tracheotomies were performed, amounting to 65 surgical provider exposures, and 30 (83.3%) procedures were performed at bedside. The mean time to tracheotomy from hospital admission for SARS-CoV-2 symptoms was 31 days, and the mean time to intubation was 24 days. Standard personal protective equipment, according to Centers for Disease Control and Prevention, was worn for each case. Powered air-purifying respirators were not used. None of the surgical providers involved in tracheotomy for patients with COVID-19 demonstrated positive antibody seroconversion or developed SARS-CoV-2–related symptoms to date.

Conclusion

Tracheotomy for patients with COVID-19 can be done with minimal risk to the surgical providers when standard personal protective equipment is used (surgical gown, gloves, eye protection, hair cap, and N95 mask). Whether timing of tracheotomy following onset of symptoms affects the risk of transmission needs further study.

Apoptosis signaling molecules as treatment targets in head and neck squamous cell carcinoma

OBJECTIVES

To evaluate BCL-2 family signaling molecules in head and neck squamous cell carcinoma (HNSCC) and examine the ability of therapeutic agents with variable mechanisms of action to induce apoptosis in HNSCC cells.

METHODS

messenger ribonculeic acid (mRNA) expression of BAK, BAX, B-cell lymphoma (Bcl-2), BCL2 Like 1 (BCL2L1), and MCL1 were measured in The Cancer Genome Atlas (TCGA) head and neck cancer dataset, as well as in a dataset from a cohort at Montefiore Medical Center (MMC). Protein expression was similarly evaluated in a panel of HNSCC cell lines (HN30, HN31, HN5, MDA686LN, UMSCC47). Cell viability and Annexin V assays were used to assess the efficacy and apoptotic potential of a variety of agents (ABT-263 [navitoclax], A-1210477, and bortezomib.

RESULTS

Expression of BAK, BAX, BCL2L1, and MCL1 were each significantly higher than expression of BCL2 in the TCGA and MMC datasets. Protein expression demonstrated the same pattern of expression when examined in HNSCC cell lines. Treatment with combined ABT-263 (navitoclax)/A-1210477 or with bortezomib demonstrated apoptosis responses that approached or exceeded treatment with staurospaurine control.

CONCLUSION

HNSCC cells rely on inhibition of apoptosis via BCL-xL and MCL-1 overexpression, and induction of apoptosis remains a potential therapeutic option as long as strategies overcome redundant anti-apoptotic signals.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:2643-2649, 2020.

Association of Delayed Time to Treatment Initiation With Overall Survival and Recurrence Among Patients With Head and Neck Squamous Cell Carcinoma in an Underserved Urban Population

Importance

Delay in time to treatment initiation (TTI) can alter survival and oncologic outcomes. There is a need to characterize these consequences and identify risk factors and reasons for treatment delay, particularly in underserved urban populations.

Objectives

To investigate the association of delayed treatment initiation with outcomes of overall survival and recurrence among patients with head and neck squamous cell carcinoma (HNSCC), to analyze factors that are predictive of delayed treatment initiation, and to identify specific reasons for delayed treatment initiation.

Design, Setting, and Participants

Retrospective cohort study at an urban community-based academic center. Participants were 956 patients with primary HNSCC treated between February 8, 2005, and July 17, 2017, identified through the Montefiore Medical Center Cancer Registry.

Exposures

The primary exposure was TTI, defined as the duration between histopathological diagnosis and initial treatment. The threshold for delayed treatment initiation was determined by recursive partitioning analysis.

Main Outcomes and Measures

Overall survival, recurrence, and reasons for treatment delay.

Results

Among 956 patients with HNSCC (mean [SD] age, 60.8 [18.2] years; 72.6% male), the median TTI was 40 days (interquartile range, 28-56 days). The optimal TTI threshold to differentiate overall survival was greater than 60 days (20.8% [199 of 956] of patients in our cohort). Independent of other relevant factors, patients with HNSCC with TTI exceeding 60 days had poorer survival (hazard ratio, 1.69; 95% CI, 1.32-2.18). Similarly, TTI exceeding 60 days was associated with greater risk of recurrence (odds ratio, 1.77; 95% CI, 1.07-2.93). Predictors of delayed TTI included African American race/ethnicity, Medicaid insurance, body mass index less than 18.5, and initial diagnosis at a different institution. Commonly identified individual reasons for treatment delay were missed appointments (21.2% [14 of 66]), extensive pretreatment evaluation (21.2% [14 of 66]), and treatment refusal (13.6% [9 of 66]).

Conclusions and Relevance

Delaying TTI beyond 60 days was associated with decreased overall survival and increased HNSCC recurrence. Identification of predictive factors and reasons for treatment delay will help target at-risk patients and facilitate intervention in hospitals with underserved urban populations.

Preoperative 18F-FDG-PET/CT vs Contrast-Enhanced CT to Identify Regional Nodal Metastasis among Patients with Head and Neck Squamous Cell Carcinoma

Objective Our objective was to compare the accuracy of preoperative positron emission tomography (PET)/computed tomography (CT) and contrast-enhanced CT (CECT) in detecting cervical nodal metastases in patients treated with neck dissection and to scrutinize the ability of each modality to determine nodal stage. Study Design Case series with chart review. Setting Montefiore Medical Center, Bronx, New York. Subjects and Methods Patients who underwent neck dissection at our institution for primary treatment of head and neck squamous cell carcinoma (HNSCC) and had received preoperative PET/CT and CECT were included in this study. Imaging studies were reinterpreted by 3 specialists within the field and compared for interreader agreement. Concordance between radiology and histopathology was measured using neck levels and sides, along with patient nodal stage. Sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and agreement coefficients were calculated. Results Seventy-three patients were included in the study. Sensitivity was 0.69 and 0.94 (level and side) for PET/CT vs 0.53 and 0.66 for CECT ( P = .056, P = .001). Specificity was 0.86 and 0.56 for PET/CT vs 0.91 and 0.76 for CECT ( P = .014, P = .024). No significant difference was found in overall accuracy ( P = .33, P = .88). The overall agreement percentages between N stage called by imaging modality and pathology were 52% and 55% for PET/CT and CECT, respectively. Conclusion No significant difference in sensitivity was found between PET/CT and CECT. CECT was found to have superior specificity compared with PET/CT. The information gleaned from each modality in the pretreatment evaluation of HNSCC appears to be complementary.

Minimal Margin Extracapsular Dissection

Objective:

Extracapsular dissection (ECD) has become an accepted, less invasive alternative for the removal of select benign parotid lesions that may reduce complications. Minimal margin extracapsular dissection (MECD) with dissection on or closer to the tumor capsule may be a reasonable alternative to ECD. The objective of this study is to review the complications and safety of the MECD technique at a single institution.

Subjects and Methods:

Medical records for patients who underwent MECD for suspected benign parotid lesions were reviewed. Outcome measurements included intraoperative findings, complications, and recurrences.

Results:

Forty patients underwent a MECD for suspected benign parotid lesions. The average tumor size was 2.2 cm. Frozen section revealed low-intermediate grade mucoepidermoid carcinoma in 2 (5%) cases, requiring completion of a superficial parotidectomy at the same setting. There was 1 case of temporary facial nerve weakness and no cases of Frey syndrome. No tumor recurrences were observed within the follow-up period (average 3.5 years.)

Conclusion:

In the hands of an experienced surgeon, MECD may be a viable alternative to formal superficial parotidectomy. This study reports low rates of nerve weakness and Frey syndrome. Long-term follow-up is necessary to determine the ultimate risk of recurrence.

Tumor Debulking in the Management of Laryngeal Cancer Airway Obstruction

Patients presenting with advanced aerodigestive malignancy and respiratory compromise often undergo tracheotomy as initial airway management. Tumor debulking is a potential alternative. We present a case series with chart review to communicate our institutional experience with this technique. T3/4 glottic and supraglottic cancers treated between 2004 and 2014 underwent review, and 14 patients were identified for this study. Of these, 5 (35.7%) required subsequent tracheotomy, and 9 (64.3%) did not. Patients requiring subsequent tracheotomy had a delay in initiating definitive treatment when compared with those who did not (83.3 vs 31.3 days, P = .0025). No patient required a tracheotomy after initiation of definitive treatment. Our experience suggests that tumor debulking may be a viable option in select patients but that a delay in initiating treatment is associated with patients requiring tracheotomy subsequent to debulking. Further research is needed to better delineate patient scenarios in which tumor debulking alone is sufficient.

How radiologic/clinicopathologic features relate to compressive symptoms in benign thyroid disease

OBJECTIVES/HYPOTHESIS

To identify compressive symptomatology in a patient cohort with benign thyroid disease who underwent thyroidectomy. To determine radiographic/clinicopathologic features related to and predictive of a compressive outcome.

STUDY DESIGN

Retrospective cohort study.

METHODS

Medical records of 232 patients with benign thyroid disease on fine needle aspiration who underwent thyroidectomy from 2009 to 2012 at an academic medical center were reviewed. Data collection and analyses involved subjects' demographics, compressive symptoms, preoperative airway encroachment, intubation complications, specimen weight, and final pathologic diagnosis.

RESULTS

Subjects were ages 14 to 86 years (mean: 52.4 years). Ninety-six subjects (41.4%) reported compressive symptomatology of dysphagia (n =74; 32%), dyspnea (n = 39; 17%), and hoarseness (n = 24; 10%). Ninety-seven (42.2%) had preoperative airway encroachment. Dyspnea was significantly related to tracheal compression, tracheal deviation, and substernal extension. Dysphagia was related to tracheal compression and tracheal deviation. Compressive symptoms and preoperative airway encroachment were not related to intubation complications. Final pathologic diagnosis was not related to compressive symptoms, whereas specimen weight was significantly related to dyspnea and dysphagia. Final pathology revealed 74 subjects (32%) with malignant lesions. Malignant and benign nodular subject groups differed significantly in substernal extension, gland weight, tracheal deviation, and dyspnea. Logit modeling for dyspnea was significant for tracheal compression as a predictor for the likelihood of dyspnea.

CONCLUSION

Dyspnea was closely related to preoperative airway encroachment and most indicative of a clinically relevant thyroid in our cohort with benign thyroid disease. Tracheal compression was found to have predictive value for the likelihood of a dyspneic outcome.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:993-997, 2017.

Use of computed tomography to assess volume change after endoscopic orbital decompression for Graves' ophthalmopathy

BACKGROUND

Orbital decompression is frequently performed in the management of patients with sight-threatening and disfiguring Graves' ophthalmopathy. The quantitative measurements of the change in orbital volume after orbital decompression procedures are not definitively known. Furthermore, the quantitative effect of septal deviation on volume change has not been previously analyzed.

OBJECTIVES

To provide quantitative measurement of orbital volume change after medial and inferior endoscopic decompression and describe a straightforward method of measuring this change using open-source technologies. A secondary objective was to assess the effect of septal deviation on orbital volume change.

METHODS

A retrospective review was performed on all patients undergoing medial and inferior endoscopic orbital decompression for Graves' ophthalmopathy at a tertiary care academic medical center. Pre-operative and post-operative orbital volumes were calculated from computed tomography (CT) data using a semi-automated segmenting technique and Osirix™, an open-source DICOM reader. Data were collected for pre-operative and post-operative orbital volumes, degree of septal deviation, time to follow-up scan, and individual patient Hertel scores.

RESULTS

Nine patients (12 orbits) were imaged before and after decompression. Mean pre-operative orbital volume was 26.99 cm(3) (SD=2.86 cm(3)). Mean post-operative volume was 33.07 cm(3) (SD=3.96 cm(3)). The mean change in volume was 6.08 cm(3) (SD=2.31 cm(3)). The mean change in Hertel score was 4.83 (SD=0.75). Regression analysis of change in volume versus follow-up time to imaging indicates that follow-up time to imaging has little effect on change in volume (R=-0.2), and overall mean maximal septal deviation toward the operative side was -0.5mm. Negative values were attributed to deviation away form the operative site. A significant correlation was demonstrated between change in orbital volume and septal deviation distance site (R=0.66), as well as between change in orbital volume and septal deviation angle (R=0.67). Greater volume changes were associated with greater degree of septal deviation away from the surgical site, whereas smaller volume changes were associated with greater degree of septal deviation toward the surgical site.

CONCLUSION

A straightforward, semi-automated segmenting technique for measuring change in volume following endoscopic orbital decompression is described. This method proved useful in determining that a mean increase of approximately 6 cm in volume was achieved in this group of patients undergoing medial and inferior orbital decompression. Septal deviation appears to have an effect on the surgical outcome and should be considered during operative planning.

Randomized Controlled Trial Assessing the Feasibility of Shortened Fasts in Intubated ICU Patients Undergoing Tracheotomy

Objective

American Society of Anesthesiology guidelines recommend preoperative fasts of 6 hours after light snacks and 8 hours after large meals. These guidelines were designed for healthy patients undergoing elective procedures but are often applied to intubated intensive care unit (ICU) patients. ICU patients undergoing routine procedures may be subjected to unnecessary prolonged fasts. This study tests whether shorter fasts allow for better nutrition delivery and patient outcomes without increasing the risk.

Study Design

Randomized blinded controlled trial.

Setting

Tertiary academic medical center.

Subjects

ICU patients undergoing bedside tracheotomy.

Methods

Intubated ICU patients who were receiving enteral feeding and for whom bedside tracheotomy was indicated were enrolled prospectively and randomly allocated to 2 parallel preoperative fasting regimens: a 6-hour fast (control) and a 45-minute fast (intervention). Patients were assessed for aspiration, caloric delivery, metabolic markers, and infectious and noninfectious complications.

Results

Twenty-four patients were enrolled and randomized. There were no complications related to the procedure. There were no cases of intraoperative aspiration identified. There was a single postoperative pneumonia in the control group. Median (interquartile range) length of fast and caloric delivery were significantly different between the control group and the shortened fast group: 22 hours (18, 34) vs 14 hours (5, 25; P < .001) and 429 kcal (57, 1125) vs 1050 kcal (825, 1410; P = .01), respectively.

Conclusions

Shortening preoperative fasts in intubated ICU patients allowed for better caloric delivery in the preoperative period.

Transoral Robotic Surgery in Oropharyngeal Carcinoma

Context

The incidence of oropharyngeal squamous cell carcinoma has increased during the past decade and is related primarily to the human papillomavirus. This change in etiology, from tobacco and alcohol to human papillomavirus, has resulted in improved survival for the disease. In the United States, open resection had largely been replaced by concurrent chemotherapy and/or radiotherapy by the early 2000s. The advent of transoral surgery has led to an increase in surgery as the primary treatment for both early- and advanced-stage oropharyngeal squamous cell carcinoma because it has potential advantages over open surgery and nonsurgical modalities.

Objective

To provide an overview of transoral robotic surgery for oropharyngeal squamous cell carcinoma and contrast it with other surgical and nonsurgical modalities.

Data Sources

Articles from 2000 to 2014 were accessioned on PubMed and reviewed for utility by the primary authors.

Conclusions

Transoral surgery has become more commonly used as a minimally invasive approach to treat oropharyngeal tumors. Other strategies, including radiation, chemotherapy with radiation, and open surgery, are still important treatment approaches. The treatment options for an individual patient rely on multiple factors, including the tumor location and size, features of the tumor, and patient comorbidities. The continued study of these techniques is important to match the patient with the most appropriate treatment.

Combined P16 and human papillomavirus testing predicts head and neck cancer survival

While its prognostic significance remains unclear, p16(INK4a) protein expression is increasingly being used as a surrogate marker for oncogenic human papillomavirus (HPV) infection in head and neck squamous cell carcinomas (HNSCC). To evaluate the prognostic utility of p16 expression in HNSCC, we prospectively collected 163 primary tumor specimens from histologically confirmed HNSCC patients who were followed for up to 9.4 years. Formalin fixed tumor specimens were tested for p16 protein expression by immunohistochemistry (IHC). HPV type-16 DNA and RNA was detected by MY09/11-PCR and E6/E7 RT-PCR on matched frozen tissue, respectively. P16 protein expression was detected more often in oropharyngeal tumors (53%) as compared with laryngeal (24%), hypopharyngeal (8%) or oral cavity tumors (4%; p<0.0001). With respect to prognosis, p16-positive oropharyngeal tumors exhibited significantly better overall survival than p16-negative tumors (log-rank test p=0.04), whereas no survival benefit was observed for nonoropharyngeal tumors. However, when both p16 and HPV DNA test results were considered, concordantly positive nonoropharyngeal tumors had significantly better disease-specific survival than concordantly negative nonoropharyngeal tumors after controlling for sex, nodal stage, tumor size, tumor subsite, primary tumor site number, smoking and drinking [adjusted hazard ratio (HR)=0.04, 0.01-0.54]. Compared with concordantly negative nonoropharyngeal HNSCC, p16(+)/HPV16(-) nonoropharyngeal HNSCC (n=13, 7%) demonstrated no significant improvement in disease-specific survival when HPV16 was detected by RNA (adjusted HR=0.83, 0.22-3.17). Our findings show that p16 IHC alone has potential as a prognostic test for oropharyngeal cancer survival, but combined p16/HPV testing is necessary to identify HPV-associated nonoropharyngeal HNSCC with better prognosis.

Risk Factors for Perioperative Airway Difficulty and Evaluation of Intubation Approaches Among Patients With Benign Goiter

Objective:

The objective was to determine patient and gland characteristics associated with difficult intubation in patients undergoing thyroidectomy for goiter and to assess different methods of intubation in these patients.

Methods:

This study was an IRB-approved, retrospective chart review of 112 consecutive patients undergoing hemithyroidectomy or total thyroidectomy for thyroid goiter from 2009-2012 at an academic tertiary care facility in Bronx, New York. Patient demographics, thyroid gland characteristics (gland weight and nodule size), presence of preoperative symptoms (dyspnea, dysphagia, and hoarseness), and radiographical findings (tracheal compression, tracheal deviation, and substernal extension of the thyroid gland) were recorded. Anesthesia records were reviewed for method of intubation, as well as success or failure of intubation attempts.

Results:

Nineteen patients (17.0%) were men and 93 (83.0%) were women. The age of the patients included in the study ranged from 14 to 86 years with a mean ± SD age of 53.5 ± 14.7 years. Difficult intubation was noted with 13 (11.6%) patients. Only patient age was significantly associated with difficult intubation. The mean age of patients with airway difficulty was 60.7 ± 3.7 years compared to 52.1 ± 1.5 years in those who did not experience airway difficulty ( P = .04). No other reviewed risk factors were found to be significantly associated with difficult intubation. Fiberoptic intubation (FOI) was used in 38 patients and difficult intubation occurred in 18.4% (7/38). Direct laryngoscopy with transoral intubation (LTOI) was used in 58 patients, in whom 3.4% (2/58) experienced a difficult intubation. FOI was aborted 6 times and LTOI was subsequently successful in each of these cases.

Conclusions:

Our results suggest that benign nodular goiter disease does not pose significant challenges to intubation in our patient cohort. The technique of intubation deviated from the initial plan several times in the FOI group, whereas LTOI was ultimately successful in every case. Our data suggest that the role of fiberoptic intubation for patients with large goiters should be further refined.

Tracheal invasion and perforation from advanced primary thyroid lymphoma: a case report and literature review

OBJECTIVE

We report a case of an elderly female with primary diffuse large B-cell thyroid lymphoma causing an extensive tracheal defect that was managed expectantly with good results.

METHOD

Case report

RESULTS

This is the only known reported case of a patient with tracheal invasion and perforation caused by primary thyroid lymphoma who has subsequently survived.

CONCLUSION

Due to the rarity of invasive primary thyroid lymphoma there is currently no standard surgical management of the airway. We propose that expectant management with temporary airway protection is an alternative to invasive procedures such as tracheotomy or tracheal stent placement, even in the scenario of serious airway defects.

Transoral robotic total laryngectomy

OBJECTIVES/HYPOTHESIS

Minimally invasive surgery has become the standard of care in many organ systems. Head and neck surgery has incorporated transoral surgery, either laser microsurgery or robotic resection, in the management of pharyngeal and laryngeal cancers. To date, the laryngeal procedures have taken the form of partial laryngectomy, as transoral approaches have not allowed reconstruction following total laryngectomy. We present the first series of transoral total laryngectomies.

STUDY DESIGN

Multinational, multi-institutional prospective consecutive case series.

METHODS

Case series of completed and attempted transoral robotic surgery (TORS) total laryngectomy performed under an institutional review board protocol. The procedure was developed in the cadaver laboratory and applied to selected individuals requiring total laryngectomy for recurrent laryngeal cancer or post-therapeutic organ dysfunction.

RESULTS

TORS total laryngectomy was successfully performed in five patients and was unsuccessful in two others. Two of the patients had postoperative fistulae, and all seven are without evidence of recurrent cancer and are swallowing orally without gastrostomy supplementation.

CONCLUSIONS

TORS total laryngectomy is feasible and can be taught to other surgeons. Potential benefits of this approach are present for patients undergoing salvage laryngectomy and include improved wound healing and functional results. This procedure further extends the applications of robotic head and neck surgery.

Prospective analysis of qol in patients undergoing concurrent chemotherapy and radiation therapy for locally advanced head and neck cancer

e16058

Background: This is a prospective analysis of quality of life (QoL) in patients undergoing concurrent chemotherapy and IMRT for locally advanced head and neck cancers. Methods: In a prospective IRB approved study, patients undergoing concurrent chemotradio therapy for head and neck cancers at AECOM/MMC completed a QoL survey (EORTC QLQ-C30 and QLQ-H&N 35) pretreatment, during radiation therapy, and at 1, 3 and 6 months after completion. The patients were re-simulated for adaptive planning midway through their treatment. Patients were treated to 66-70Gy (2-2.12 Gy/Fraction) to the primary and 54 to 60Gy (1.64-1.8 Gy/fraction) to the subclinical and high risk areas. Swallowing complex (SC) (base of tongue, constrictor muscles, proximal esophagus and oral cavity) were contoured as avoidance structures along with other critical structures. QoL scores were correlated with radiation dose to swallowing complex to evaluate relationships. Results: The Global Heath Status and Physical Functioning scores fell (mean 58.33 SD 35.36) during the first week of therapy before recovering at the end of second week. There is a 2nd dip in functioning scores at 4th week subsequent to which the scores rise and stabilized. The nausea/vomiting scores correlate with the timing of chemotherapy whereas the pain scores are highest at the second week mark before declining gradually. The mean swallowing specific score is worst at 5 weeks (61.11 SD 31.43) and recover gradually thereafter to level better than pre-RT score at 6-months follow-up. Conclusions: Most studies have reported QoL changes before and after treatment and have not looked at the changes during RT. One would imagine that QoL scores would gradually deteriorate throughout radiation therapy and should be the worst towards the end. In our experience, most of the QoL scores stabilize during the latter half of radiation therapy. This may be a result of multidisciplinary patient care, adaptive radiation therapy as well as tumor response to chemo-radiation therapy. Matched pair analysis is underway to compare dosimetric data and correlate this with QoL results.

Mentoring in otolaryngology training programs

Objective: The Accreditation Council for Graduate Medical Education's focus on outcome-based training has made the mentoring process critical for resident education. It is unknown how otolaryngology training programs mentor residents. Our objective was to determine the current state of mentoring in otolaryngology training programs and describe resident perceptions of mentoring.

Study Design: Cross-sectional survey.

Setting: Accredited U.S. otolaryngology training programs.

Subjects and Methods: All U.S. otolaryngology residents and program directors were contacted via e-mail with a link to an online survey.

Results: Of the 1411 residents contacted, 27.7 percent responded, representing 71 of the 103 accredited otolaryngology programs. Of the 103 program directors contacted, 37.9 percent responded. Of these programs, 26 had formal mentoring programs, 45 did not have formal mentoring programs, and 12 programs were listed in both categories. Fifty-one percent of male residents and 49 percent of female residents had mentors. The most important mentor characteristics were personality match, good clinical role model, and similar subspecialty interests. Least important characteristics were race, gender, and age. Twenty-six percent of residents felt that mentoring was critical to their training, while 63 percent of residents listed mentoring as important but not critical. Programs with fewer faculty and residents were less likely to offer formal mentoring ( P = 0.007 and 0.054, respectively). Of residents who did not have mentors, 80 percent lacked a mentor because their residency had no formal mentoring program.

Conclusion: Residents perceive mentoring as important, and formal mentoring programs should be incorporated into otolaryngology training programs.

Integrin-linked kinase is a potential therapeutic target for anaplastic thyroid cancer

We investigated integrin-linked kinase (ILK), a focal adhesion serine-threonine protein kinase, as a new molecular target for treating anaplastic thyroid cancer. ILK mediates cell growth and survival signals and is overexpressed in a number of cancers. Therefore, we hypothesized that inhibition of ILK leads to growth arrest and apoptosis of thyroid cancer cells. According to Western blotting, the level of ILK protein was highly expressed in one papillary (NPA187) and four of five (Hth74, DRO, ARO, KAT4, and K4) anaplastic thyroid cancer cell lines. Immunohistochemical analysis of a human tissue microarray revealed that ILK was highly expressed in anaplastic thyroid cancer but not in normal human thyroid tissue. Treating thyroid cancer cell lines with a new ILK inhibitor, QLT0267, inhibited epidermal growth factor-induced phosphorylation of AKT, inhibited cell growth, and induced apoptosis in the NPA187, DRO, and K4 cell lines. QLT0267 also inhibited the kinase activity of immunoprecipitated ILK in four of five cell lines. Tumor volumes in mice treated with QLT0267 were significantly reduced compared with those in untreated mice. In immunohistochemical studies, QLT0267 suppressed phosphorylated p-AKT and angiogenesis (i.e., reduced mean vascular density) and induced apoptosis in both tumor cells and tumor-associated endothelial cells of the thyroid DRO xenografts. In summary, we found that ILK expression and activity were elevated in human anaplastic thyroid cancer and ILK inhibition led to growth arrest and apoptosis in vitro and in vivo. Our results provide preliminary evidence that ILK is a potential therapeutic target for treating anaplastic thyroid cancer.

Targeted molecular therapy of anaplastic thyroid carcinoma with AEE788

Anaplastic thyroid carcinoma (ATC) is one of the most aggressive human malignancies with a mean survival of only 6 months. The poor prognosis of patients with ATC reflects the current lack of curative therapeutic options and the need for development of novel therapeutic strategies. In this study, we report the results of a preclinical study of AEE788, a dual inhibitor of epidermal growth factor receptor (EGFR) and vascular endothelial growth factor receptor (VEGFR) tyrosine kinases, against ATC. AEE788 was able to inhibit the proliferation and induce apoptosis of ATC cell lines in vitro. Administration of AEE788, alone and in combination with paclitaxel, to athymic nude mice bearing s.c. ATC xenografts inhibited the growth of ATC xenografts by 44% and 69%, respectively, compared with the control group. Furthermore, tumors from mice treated with AEE788, alone and in combination with paclitaxel, showed increase in apoptosis of tumor cells by approximately 6- and 8-fold, respectively, compared with the control group. The microvessel density within the ATC xenografts was decreased by >80% in the mice treated with AEE788 alone and in combination with paclitaxel compared with the control group. Lastly, immunofluorescence microscopy showed the inhibition of EGFR autophosphorylation on the tumor cells as well as the inhibition of VEGFR-2 autophosphorylation on tumor endothelium. Considering the fact that curative options seldom exist for patients with ATC, concurrent inhibition of EGFR and VEGFR tyrosine kinases seems to be a valid and promising anticancer strategy for these patients.

Selective vs Modified Radical Neck Dissection and Postoperative Radiotherapy vs Observation in the Treatment of Squamous Cell Carcinoma of the Oral Tongue

OBJECTIVES

To assess the role of selective neck dissection in patients with squamous cell carcinoma (SCC) of the oral tongue with advanced nodal disease, and to assess the role of postoperative radiotherapy in patients with SCC of the oral tongue with pathologically N1 necks.

DESIGN

Retrospective study of the medical records of all patients who underwent neck dissection for SCC of the oral tongue from January 1, 1980, to December 31, 1995. Median follow-up was 5.7 years.

SETTING

The University of Texas M. D. Anderson Cancer Center, Houston, a tertiary care cancer hospital.

PATIENTS

A total of 220 patients with SCC of the oral tongue who received surgical treatment of both the primary tumor and the neck and who had an identifiable type of neck dissection, no synchronous or metachronous lesions, and no evidence of local recurrence.

INTERVENTIONS

All patients underwent resection of the primary tumor and neck dissection. The extent of neck dissection was determined by surgeon preference. Some patients received radiotherapy to the neck as well.

MAIN OUTCOME MEASURES

Clinical and pathological nodal status, type of neck dissection, and use of radiotherapy. The end points evaluated included the regional control rates.

RESULTS

For clinically N+ patients, 5 of 45 treated with selective neck dissection and 1 of 19 treated with radical or modified radical neck dissection had recurrences in the ipsilateral neck. If only patients with significant tumor burden on final pathological examination (clinically N+/pathologically N2) are considered, 4 (25.0%) of 16 patients undergoing selective neck dissection had recurrences in the neck, while none of the 14 patients treated with radical or modified radical neck dissection had recurrences in the ipsilateral neck (P = .07). Of the 50 patients who had pathologically N1 disease, 25 received postoperative radiotherapy and 25 did not. Of the latter, 2 had recurrences in the neck, while none of the 25 patients who received radiotherapy had recurrences in the neck (P = .24).

CONCLUSIONS

Selective neck dissection may be sufficient for many N+ patients with SCC of the oral tongue, but some patients with extensive nodal disease may benefit from more aggressive treatment of the neck. Radiotherapy may be beneficial for all of the node-positive patients, but further studies are needed. Prospective, randomized clinical trials will be useful in further defining the role of selective neck dissection in the clinically N2 neck and radiotherapy in the N1 neck for patients with SCC of the oral tongue.

An orthotopic model of anaplastic thyroid carcinoma in athymic nude mice

PURPOSE

To develop an orthotopic model of anaplastic thyroid carcinoma (ATC) in athymic nude mice.

EXPERIMENTAL DESIGN

Various thyroid carcinoma cell lines were injected into the thyroid gland of athymic nude mice to determine whether such injection was technically feasible. ATC cells were then injected into the thyroid gland or the subcutis of nude mice at various concentrations, and the mice were then followed for tumor development. The tumors were examined histopathologically for local invasion or regional or distant metastasis.

RESULTS

Injection of tumor cells into the thyroid glands of nude mice was technically feasible and resulted in the formation of thyroid tumors. The ATC cell line DRO showed significantly higher tumorigenicity in the thyroid gland than in the subcutis. In contrast, oral squamous cell carcinoma cell line TU167 shows no significantly higher tumorigenicity in the thyroid gland than in the subcutis. ATC tumors established in the thyroid gland also produced symptomatic compression of the esophagus and the trachea. Local invasion of the larynx and trachea was as well as high rates of pulmonary metastasis were also observed. Immunohistochemical staining showed higher microvessel density as well as higher expression of vascular endothelial growth factor and interleukin-8 in the orthotopic thyroid tumors than in ectopic tumors.

CONCLUSION

An orthotopic model of ATC in athymic nude mice was developed that closely recapitulates the clinical findings of human ATC. This model should facilitate the understanding of the pathogenesis of ATC and aid in the development of novel therapies against ATC.

Epidermal Growth Factor Receptor (EGFR) Is Overexpressed in Anaplastic Thyroid Cancer, and the EGFR Inhibitor Gefitinib Inhibits the Growth of Anaplastic Thyroid Cancer

PURPOSE

No effective treatment options currently are available to patients with anaplastic thyroid cancer (ATC), resulting in high mortality rates. Epidermal growth factor (EGF) has been shown to play a role in the pathogenesis of many types of cancer, and its receptor (EGFR) provides an attractive target for molecular therapy.

EXPERIMENTAL DESIGN

The expression of EGFR was determined in ATC in vitro and in vivo and in human tissue arrays of ATC. We assessed the potential of the EGFR inhibitor gefitinib ("Iressa," ZD1839) to inhibit EGFR activation in vitro and in vivo, inhibit ATC cellular proliferation, induce apoptosis, and reduce the growth of ATC cells in vivo when administered alone and in combination with paclitaxel.

RESULTS

EGFR was overexpressed in ATC cell lines in vitro and in vivo and in human ATC specimens. Activation of EGFR by EGF was blocked by the addition of gefitinib. In vitro studies showed that gefitinib greatly inhibited cellular proliferation and induced apoptosis in ATC cell lines and slowed tumor growth in a nude mouse model of thyroid carcinoma cells injected subcutaneously.

CONCLUSIONS

ATC cells consistently overexpress EGFR, rendering this receptor a potential target for molecular therapy. Gefitinib effectively blocks activation of EGFR by EGF, inhibits ATC cellular proliferation, and induces apoptosis in vitro. Our in vivo results show that gefitinib has significant antitumor activity against ATC in a subcutaneous nude mouse tumor model and therefore is a potential candidate for human clinical trials.

Tumor Cell and Endothelial Cell Therapy of Oral Cancer by Dual Tyrosine Kinase Receptor Blockade

Expression of the epidermal growth factor (EGF) and activation of its receptor (EGFR), a tyrosine kinase, are associated with progressive growth of head and neck cancer. Expression of the vascular endothelial growth factor (VEGF) is associated with angiogenesis and progressive growth of tumor. The tyrosine kinase inhibitor NVP-AEE788 (AEE788) blocks the EGF and VEGF signaling pathways. We examined the effects of AEE788 administered alone, or with paclitaxel (Taxol), on the progression of human head and neck cancer implanted orthotopically into nude mice. Cells of two different human oral cancer lines, JMAR and MDA1986, were injected into the tongues of nude mice. Mice with established tumors were randomized to receive three times per week oral AEE788, once weekly injected paclitaxel, AEE788 plus paclitaxel, or placebo. Oral tumors were resected at necropsy. Kinase activity, cell proliferation, apoptosis, and mean vessel density were determined by immunohistochemical immunofluorescent staining. AEE788 inhibited cell growth, induced apoptosis, and reduced the phosphorylation of EGFR, VEGFR-2, AKT, and mitogen-activated protein kinase in both cell lines. Mice treated with AEE788 and AEE788 plus paclitaxel had decreased microvessel density, decreased proliferative index, and increased apoptosis. Hence, AEE788 inhibited tumor vascularization and growth and prolonged survival. Inhibition of EGFR and VEGFR phosphorylation by AEE788 effectively inhibits cellular proliferation of squamous cell carcinoma of the head and neck, induces apoptosis of tumor endothelial cells and tumor cells, and is well tolerated in mice. These data recommend the consideration of patients with head and neck cancer for inclusion in clinical trials of AEE788.

Epidermal growth factor receptor blockade potentiates apoptosis mediated by Paclitaxel and leads to prolonged survival in a murine model of oral cancer

PURPOSE

Because survival for patients with oral cancer has not improved over the past 25 years, new approaches for treatment are needed. Targeted molecular therapy against epidermal growth factor receptor (EGFR) has shown promise as an adjuvant therapy in preliminary studies in several solid tumors, including head and neck cancer. The objective of this study was to determine the efficacy of paclitaxel and PKI166, a novel inhibitor of EGFR, against oral cavity cancer.

EXPERIMENTAL DESIGN AND RESULTS

JMAR human oral cancer cells were pretreated for 1 h with PKI166 and then stimulated with epidermal growth factor. EGFR-specific tyrosine kinase autophosphorylation measured by Western immunoblotting was inhibited by PKI166 in a dose-dependent fashion at all doses tested (0.01-1 micro M). Next, the induction of apoptosis in JMAR cells treated with paclitaxel (0.001 to 0.1 micro M) with or without PKI166 (0, 1, or 2 micro M) was determined using a propidium iodide assay. The addition of 2.0 micro M PKI166 significantly increased tumor cell death, shifting the amount of paclitaxel needed to induce apoptosis in 50% of cells from 0.1 to 0.001 micro M. These in vitro findings were confirmed using an orthotopic model of oral cancer. JMAR oral cancer cells were implanted into the tongues of nude mice. After lingual tumors developed, mice were randomized into four groups (n = 10): (a) oral PKI166 (100 mg/kg); (b) i.p. paclitaxel (200 micro g/wk); (c) PKI166 and paclitaxel; or (d) placebo. Mice treated with PKI166/paclitaxel demonstrated a significant increase in survival (P = 0.028). After necropsy, all tongue tumors were evaluated for apoptosis by the terminal deoxynucleotidyl transferase-mediated nick end labeling assay. A greater apoptotic fraction of tumor cells was found in tumors of mice treated with paclitaxel and PKI166 as compared with the other treatment groups (136.4 versus 37.8; P = 0.016).

CONCLUSIONS

Combination therapy with paclitaxel and PKI166 prolongs survival in an orthotopic preclinical model of tongue cancer by increasing programmed cell death of oral cancer.