Pediatric Cystic Deep Neck Mass Presenting With Stridor and Dysphagia

A 6-month-old girl presented to the emergency department for evaluation of fever and was noted to have mild inspiratory stridor, which began acutely at 4 months of age without any inciting illness or event. What is your diagnosis?

Incidental Papillary Thyroid Cancer Identified During Parathyroidectomy

Current treatment guidelines recommend surgical excision of papillary thyroid carcinoma. However, the precise surgical treatment, including thyroid lobectomy, total thyroidectomy, and the need for neck dissection, is dictated by disease extent and tumor cytology. Incidental papillary thyroid carcinoma discovered during another surgery therefore presents a surgical conundrum due to lack of information. Surgeons must consider short- and long-term surgical morbidities, as well as individual patient factors, when deciding how to treat an unexpected thyroid carcinoma.

In-depth analysis of thyroid cancer mortality

BACKGROUND

There are reports of an increasing thyroid cancer mortality rate. This study aimed to analyze the latest trends in this rate over time and compare findings from different cancer registries.

METHODS

Thyroid cancer incidence-based mortality (IBM) rates were obtained from the Surveillance, Epidemiology, and End Results (SEER) program, including SEER-9, SEER-13, and SEER-18. The National Center for Health Statistics (NCHS) thyroid cancer mortality rate was acquired for comparison. Statistical analysis was performed using the JoinPoint software.

RESULTS

NCHS data revealed an overall annual percent change (APC) over 1987 to 2017 of 0.61 (P < .01), and the value was nearly four times greater for males compared to females. The overall IBM APC values for SEER-9, SEER-13, and SEER-18 were also positive and statistically significant (P < .01).

CONCLUSIONS

The increased thyroid cancer mortality rate observed in previous studies continues to be statistically significant based on updated NCHS and SEER IBM data.

Best Practice Recommendations for Pediatric Otolaryngology during the COVID-19 Pandemic

Objective

To review the impact of coronavirus disease 2019 (COVID-19) on pediatric otolaryngology and provide recommendations for the management of children during the COVID-19 pandemic.

Data Sources

Clinical data were derived from peer-reviewed primary literature and published guidelines from national or international medical organizations. Preprint manuscripts and popular media articles provided background information and illustrative examples.

Methods

Included manuscripts were identified via searches using PubMed, MEDLINE, and Google Scholar, while organizational guidelines and popular media articles were identified using Google search queries. Practice guidelines were developed via consensus among all authors based on peer-reviewed manuscripts and national or international health care association guidelines. Strict objective criteria for inclusion were not used due to the rapidly changing environment surrounding the COVID-19 pandemic and a paucity of rigorous empirical evidence.

Conclusions

In the face of the COVID-19 pandemic, medical care must be judiciously allocated to treat the most severe conditions while minimizing the risk of long-term sequelae and ensuring patient, physician, and health care worker safety.

Implications for Practice

The COVID-19 pandemic will have a profound short- and long-term impact on health care worldwide. Although the full repercussions of this disease have yet to be realized, the outlined recommendations will guide otolaryngologists in the treatment of pediatric patients in the face of an unprecedented global health crisis.

Commentary on the management of total laryngectomy patients during the COVID-19 pandemic

The coronavirus disease‐2019 (COVID‐19) pandemic has rapidly spread across the world, placing unprecedented strain on the health care system. Health care resources including hospital beds, ICUs, as well as personal protective equipment are becoming increasingly rationed and scare commodities. In this environment, the laryngectomee (patient having previously undergone a total laryngectomy) continues to represent a unique patient with unique needs. Given their surgically altered airway, they pose a challenge to manage for the otolaryngologist within the current COVID‐19 pandemic. In this brief report, we present special considerations and best practice recommendations in the management of total laryngectomy patients. We also discuss recommendations for laryngectomy patients and minimizing community exposures.

Impact of coronavirus (COVID-19) on otolaryngologic surgery: Brief commentary

Background

The Coronavirus disease—2019 (COVID‐19) pandemic is a global health crisis and otolaryngologists are at increased occupational risk of contracting COVID‐19. There are currently no uniform best‐practice recommendations for otolaryngologic surgery in the setting of COVID‐19.

Methods

We reviewed relevant publications and position statements regarding the management of otolaryngology patients in the setting of COVID‐19. Recommendations regarding clinical practice during the severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) outbreaks were also reviewed.

Results

Enhanced personal protective equipment (N95 respirator and face shield or powered air‐purifying respirator, disposable cap and gown, gloves) is required for any otolaryngology patient with unknown, suspected, or positive COVID‐19 status. Elective procedures should be postponed indefinitely, and clinical practice should be limited to patients with urgent or emergent needs.

Conclusion

We summarize current best‐practice recommendations for otolaryngologists to ensure safety for themselves, their clinical staff, and their patients.

A Commentary on Safety Precautions for Otologic Surgery during the COVID-19 Pandemic

There are insufficient data regarding the safety of otologic procedures in the setting of the coronavirus disease 2019 (COVID-19) pandemic. Given the proclivity for respiratory pathogens to involve the middle ear and the significant aerosolization associated with many otologic procedures, safety precautions should follow current recommendations for procedures involving the upper airway. Until preoperative diagnostic testing becomes standardized and readily available, elective cases should be deferred and emergent/urgent cases should be treated as high risk for COVID-19 exposure. Necessary otologic procedures on positive, suspected, or unknown COVID-19 status patients should be performed using enhanced personal protective equipment, including an N95 respirator and eye protection or powered air-purifying respirator (PAPR, preferred), disposable cap, disposable gown, and gloves. Powered instrumentation should be avoided unless absolutely necessary, and if performed, PAPR or sealed eye protection is recommended.

Genetic Variants Implicate Dual Oxidase-2 in Familial and Sporadic Nonmedullary Thyroid Cancer

Highly penetrant hereditary thyroid cancer manifests as familial nonmedullary thyroid cancer (FNMTC), whereas low-penetrance hereditary thyroid cancer manifests as sporadic disease and is associated with common polymorphisms, including rs965513[A]. Whole-exome sequencing of an FNMTC kindred identified a novel Y1203H germline dual oxidase-2 (DUOX2) mutation. DUOX2_Y1203H is enzymatically active, with increased production of reactive oxygen species. Furthermore, patients with sporadic thyroid cancer homozygous for rs965513[A] demonstrated higher DUOX2 expression than heterozygous rs965513[A/G] or homozygous rs965513[A]-negative patients. These data suggest that dysregulated hydrogen peroxide metabolism is a common mechanism by which high- and low-penetrance genetic factors increase thyroid cancer risk. SIGNIFICANCE: This study provides novel insights into the genetic and molecular mechanisms underlying familial and sporadic thyroid cancers.

Satellite and In-Transit Metastatic Disease in Melanoma Skin Cancer: A Retrospective Review of Disease Presentation, Treatment, and Outcomes

BACKGROUND

Satellitosis and in-transit metastases (SITM) are uncommon in cutaneous melanoma and are associated with poor prognosis. However, the disease- and treatment-specific variables that predict outcomes among patients with SITM are poorly defined.

OBJECTIVE

To identify factors that predict prognosis among patients with SITM.

MATERIALS AND METHODS

Retrospective chart review of patients treated for melanoma at a large academic medical center in central Pennsylvania between 2000 and 2012. Patients with pathology reports containing "satellite lesions" or "in-transit metastases" were selected for analysis. Data were collected regarding tumor stage, the timing of SITM discovery, treatment, recurrence-free survival after SITM discovery, and overall survival (OS).

RESULTS

We identified SITM in 32 (1.9%) of 1,650 patients with pathology-diagnosed melanoma over the study period. Reduced recurrence-free survival after SITM discovery was associated with higher pathologic stage, metastatic disease, lymph node dissection, and use of adjuvant chemotherapy. Reduced OS was associated with higher T, N, M, and overall prognostic stage; positive surgical margins; disease recurrence; and SITM on initial presentation.

CONCLUSION

Our data support previous findings that higher stage disease confers a worse prognosis among patients with SITM. Patients with SITM on initial presentation had worse outcomes, suggesting SITM is indicative of more aggressive disease.

Integrative detection and analysis of structural variation in cancer genomes

Structural variants (SVs) can contribute to oncogenesis through a variety of mechanisms. Despite their importance, the identification of SVs in cancer genomes remains challenging. Here, we present a framework that integrates optical mapping, high-throughput chromosome conformation capture (Hi-C), and whole-genome sequencing to systematically detect SVs in a variety of normal or cancer samples and cell lines. We identify the unique strengths of each method and demonstrate that only integrative approaches can comprehensively identify SVs in the genome. By combining Hi-C and optical mapping, we resolve complex SVs and phase multiple SV events to a single haplotype. Furthermore, we observe widespread structural variation events affecting the functions of noncoding sequences, including the deletion of distal regulatory sequences, alteration of DNA replication timing, and the creation of novel three-dimensional chromatin structural domains. Our results indicate that noncoding SVs may be underappreciated mutational drivers in cancer genomes.

Evidence of a positive association between malpractice climate and thyroid cancer incidence in the United States

The incidence of thyroid cancer has risen dramatically in the past few decades. The cause of this is unclear, but several lines of evidence indicate it is largely due to overdiagnosis, the diagnosis of tumors that would have never manifest clinically if untreated. Practices leading to overdiagnosis may relate to defensive medicine. In this study, we evaluated the association between malpractice climate and incidence of thyroid, breast, prostate, colon, and lung cancer in U.S. states from 1999-2012 using publicly available government data. State-level malpractice risk was quantified as malpractice payout rate, the number of malpractice payouts per 100,000 people per state per year. Associations between state-level cancer incidence, malpractice payout rate, and several cancer risk factors were evaluated. Risk factors included several social determinants of health, including factors predicting healthcare access. States with higher malpractice payout rate had higher thyroid cancer incidence, on both univariate analysis (r = 0.51, P = 0.009, Spearman) and multivariate analysis (P<0.001, multilevel model). In contrast, state-level malpractice payout rate was not associated with incidence of any other cancer type. Malpractice climate may be a social determinant for being diagnosed with thyroid cancer. This may be a product of greater defensive medicine in states with higher malpractice risk, which leads to increased diagnostic testing of patients with thyroid nodules and potential overdiagnosis. Alternatively, malpractice risk may be a proxy for another, unmeasured risk factor.

Altered molecular profile in thyroid cancers from patients affected by the Three Mile Island nuclear accident

OBJECTIVES/HYPOTHESIS

In 1979, Three Mile Island (TMI) nuclear power plant experienced a partial meltdown with release of radioactive material. The effects of the accident on thyroid cancer (TC) in the surrounding population remain unclear. Radiation-induced TCs have a lower incidence of single nucleotide oncogenic driver mutations and higher incidence of gene fusions. We used next generation sequencing (NGS) to identify molecular signatures of radiation-induced TC in a cohort of TC patients residing near TMI during the time of the accident.

STUDY DESIGN

Case series.

METHODS

We identified 44 patients who developed papillary thyroid carcinoma between 1974 and 2014. Patients who developed TC between 1984 and 1996 were at risk for radiation-induced TC, patients who developed TC before 1984 or after 1996 were the control group. We used targeted NGS of paired tumor and normal tissue from each patient to identify single nucleotide oncogenic driver mutations. Oncogenic gene fusions were identified using quantitative reverse transcription polymerase chain reaction.

RESULTS

We identified 15 patients in the at-risk group and 29 patients in the control group. BRAF_V600E mutations were identified in 53% patients in the at-risk group and 83% patients in the control group. The proportion of patients with BRAF mutations in the at-risk group was significantly lower than predicted by the The Cancer Genome Atlas cohort. Gene fusion or somatic copy number alteration drivers were identified in 33% tumors in the at-risk group and 14% of tumors in the control group.

CONCLUSIONS

Findings were consistent with observations from other radiation-exposed populations. These data raise the possibility that radiation released from TMI may have altered the molecular profile of TC in the population surrounding TMI.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:S1-S9, 2017.

Trends in the Incidence of Oropharyngeal Cancers in the United States

Objective

The incidence of oropharyngeal squamous cell carcinoma (SCCa) has increased in the United States despite a decrease in tobacco usage, and it may be driven by an increase in oral human papilloma virus (HPV) infection. We studied the incidence of tongue base and tonsillar SCCa over time to understand the changing epidemiology of oropharyngeal SCCa.

Setting

Large national tumor registry.

Subjects and Methods

We studied patients diagnosed with oropharyngeal SCCa in SEER data (Surveillance, Epidemiology, and End Results) from 1973 to 2009. Age-adjusted incidence rates standardized to the 2000 US population were computed, with stratifications for age, sex, race, and stage.

Results

The sample included 10,061 tongue base and 11,515 tonsillar oropharyngeal cancers. When stratified by age, the incidence of oropharyngeal SCCa in patients ≤55 years of age more than doubled over 30 years. While the incidence rate in females remained stable, the rate in males more than doubled, from 2 per 100,000 persons in 1973 to >4 per 100,000 persons in 2009. The age-adjusted incidence of oropharyngeal SCCa in patients of black race/ethnicity remained consistently elevated, but the incidence in patients of white race/ethnicity rose from 1.3 per 100,000 persons to >2.5 per 100,000 persons, surpassing the incidence in black patients starting in 2002.

Conclusion

The observation that the incidence of oropharyngeal SCCa is increasing among younger white males, despite a reduction in tobacco usage in the United States, is consistent with HPV as the source. Primary and secondary prevention strategies may be warranted in this population.

The effects of race and ethnicity on thyroid cancer incidence

IMPORTANCE

The incidence of thyroid cancer has increased over the past 30 years. Thyroid cancer is less common in blacks than in persons of white descent, and it has been most common in Asians/Pacific Islanders until recently.

OBJECTIVE

To determine whether the incidence of thyroid cancer is increasing at disproportionate rates for different races and ethnicities.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective review. Study participants were individuals with thyroid cancer in the US National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) 13 database from 1992 through 2010. The SEER 13 registry consists of records from Atlanta (Georgia), Connecticut, Detroit (Michigan), Hawaii, Iowa, New Mexico, San Francisco-Oakland (California), Seattle-Puget Sound (Washington), Utah, Los Angeles (California), San Jose-Monterey (California), rural Georgia, and the Alaska Native Tumor Registry.

MAIN OUTCOMES AND MEASURES

The SEER*Stat Joinpoint Regression Program was used to determine the average annual percentage change in thyroid cancer incidence for different races and ethnicities from 1992 through 2010. Trends in thyroid cancer incidence were compared between groups using comparability testing.

RESULTS

During the study period, the average annual percentage change for thyroid cancer was 5.3% (95% CI, 4.8%-5.7%) per year. Stratification of the study population by race revealed that whites experienced the largest increase in age-adjusted thyroid cancer incidence (5.6% per year), followed by blacks (4.8% per year), American Indian/Alaskan natives (3.2% per year), and Asians/Pacific Islanders (2.3% per year). Joinpoint regression comparability testing showed that the increase in disease incidence was not significantly different between whites and blacks (P = .25). However, the increase in incidence for Asians/Pacific Islanders was significantly lower than that for whites and blacks (P < .05). Stratification of the study population by ethnicity revealed that non-Hispanics experienced a larger increase in incidence (5.5% per year) than Hispanics (3.3% per year).

CONCLUSIONS AND RELEVANCE

The incidence of thyroid cancer continues to increase in all races and ethnicities. No significant difference was observed between the increase in incidence for whites and blacks. However, the increase in incidence for non-Hispanics was significantly larger than that for Hispanics. The increase in incidence of thyroid cancer was greater in whites than in Asians/Pacific Islanders, so whites now have a higher incidence of thyroid cancer than persons of Asian/Pacific Islander descent.

Increasing incidence of thyroid cancer in the Commonwealth of Pennsylvania

IMPORTANCE

The incidence of thyroid cancer in the United States has increased rapidly and Pennsylvania is the state with the highest rate of thyroid cancer in the country, although the factors driving this increase are unknown. Moreover, it remains unclear whether the increase in thyroid cancer represents a true increase in disease or is the result of overdiagnosis.

OBJECTIVE

To compare the increase in thyroid cancer incidence and tumor characteristics in Pennsylvania with the rest of the United States and gain insight into the factors influencing the increased incidence of thyroid cancer.

DESIGN, SETTING, AND PARTICIPANTS

In a population-based study, data on thyroid cancer from the Surveillance Epidemiology and End Results 9 (SEER-9) registry and the Pennsylvania Cancer Registry (PCR) from 1985 through 2009 were collected and reviewed for information regarding sex, race, histologic type of thyroid cancer, staging, and tumor size at diagnosis. International Classification of Diseases for Oncology, Third Edition code C739 (thyroid carcinoma) was used to identify 110,615 records in the SEER-9 registry and 29,030 records in the PCR.

MAIN OUTCOMES AND MEASURES

Average annual percent change (AAPC) in thyroid cancer incidence across various demographic groups in Pennsylvania.

RESULTS

The AAPC for thyroid cancer in Pennsylvania was 7.1% per year (95% CI, 6.3%-7.9%) vs 4.2% (95% CI, 3.7%-4.7%) per year in the remainder of the United States, and trends in incidence were significantly different (P < .001). Females experienced a higher AAPC (7.6% per year; 95% CI, 6.9%-8.3%) compared with males (6.1% per year; 95% CI, 4.9%-7.2%) (P < .01), and trend analysis revealed that thyroid cancer may be increasing more rapidly among black females (8.6% per year; 95% CI, 5.4%-11.9%) than among white females (7.6% per year; 95% CI, 6.8%-8.4) (P = .60; but despite the similarity in AAPC between the 2 groups, the joinpoint models fit to the data were not parallel [P < .005]). The rate of tumors with regional (7.0% per year; 95% CI, 5.8%-8.1%) or distant (1.1% per year; 95% CI, 0.3%-1.8%) spread (P < .05) and tumors that were 2 to 4 cm (7.1% per year; 95% CI, 5.2%-9.0%) (P < .05) or larger than 4 cm (6.4% per year; 95% CI, 4.5%-8.2%) (P < .05) at diagnosis also increased.

CONCLUSIONS AND RELEVANCE

The incidence of thyroid cancer is rising at a faster rate in Pennsylvania than in the rest of the nation, as is the rate of tumors that are larger and higher stage at diagnosis. These findings suggest that rising disease burden has contributed to the increased incidence of thyroid cancer. Etiologic factors promoting the rise in thyroid cancer in Pennsylvania must be investigated and may provide insight into the drivers of the national increase in thyroid cancer.

Age and stage as determinants of treatment for oral cavity and oropharyngeal cancers in the elderly

BACKGROUND

We investigate treatment selection for oral cavity and oropharyngeal (OC&OP) cancers to understand factors that influence treatment selection.

METHODS

We studied 7023 patients, ⩾66 years, diagnosed with a first primary OC&OP cancer using SEER-Medicare data. Multinomial logistic regression was to model treatment selection, controlling for other factors.

RESULTS

Most patients with OC cancer were treated with surgery alone (56.5%); most patients with OP cancer were treated with chemotherapy and radiation (28.9%). Age, stage and site were the most important predictors of treatment selection. As age increased from 70 to 81 (the interquartile range), treatment shifted toward surgery alone (OR=1.26; CI: 1.08-1.46) and no treatment (OR=1.5, 95% CI: 1.25-1.80), and away from combined surgery, radiation and treatments involving chemotherapy.

CONCLUSIONS

Age, stage, and site are the most important determinants of treatment selection for patients with OC&OP cancers. Increasing age and stage drive treatment toward non-surgical options and no treatment at all.

A murine retrovirus co-Opts YB-1, a translational regulator and stress granule-associated protein, to facilitate virus assembly

The Gag protein of the murine retrovirus mouse mammary tumor virus (MMTV) orchestrates the assembly of immature virus particles in the cytoplasm which are subsequently transported to the plasma membrane for release from the cell. The morphogenetic pathway of MMTV assembly is similar to that of Saccharomyces cerevisiae retrotransposons Ty1 and Ty3, which assemble virus-like particles (VLPs) in intracytoplasmic ribonucleoprotein (RNP) complexes. Assembly of Ty1 and Ty3 VLPs depends upon cellular mRNA processing factors, prompting us to examine whether MMTV utilizes a similar set of host proteins to facilitate viral capsid assembly. Our data revealed that MMTV Gag colocalized with YB-1, a translational regulator found in stress granules and P bodies, in intracytoplasmic foci. The association of MMTV Gag and YB-1 in cytoplasmic granules was not disrupted by cycloheximide treatment, suggesting that these sites were not typical stress granules. However, the association of MMTV Gag and YB-1 was RNA dependent, and an MMTV RNA reporter construct colocalized with Gag and YB-1 in cytoplasmic RNP complexes. Knockdown of YB-1 resulted in a significant decrease in MMTV particle production, indicating that YB-1 plays a role in MMTV capsid formation. Analysis by live-cell imaging with fluorescence recovery after photobleaching (FRAP) revealed that the population of Gag proteins localized within YB-1 complexes was relatively immobile, suggesting that Gag forms stable complexes in association with YB-1. Together, our data imply that the formation of intracytoplasmic Gag-RNA complexes is facilitated by YB-1, which promotes MMTV virus assembly.

IMPORTANCE

Cellular mRNA processing factors regulate the posttranscriptional fates of mRNAs, affecting localization and utilization of mRNAs under normal conditions and in response to stress. RNA viruses such as retroviruses interact with cellular mRNA processing factors that accumulate in ribonucleoprotein complexes known as P bodies and stress granules. This report shows for the first time that mouse mammary tumor virus (MMTV), a mammalian retrovirus that assembles intracytoplasmic virus particles, commandeers the cellular factor YB-1, a key regulator of translation involved in the cellular stress response. YB-1 is essential for the efficient production of MMTV particles, a process directed by the viral Gag protein. We found that Gag and YB-1 localize together in cytoplasmic granules. Functional studies of Gag/YB-1 granules suggest that they may be sites where virus particles assemble. These studies provide significant insights into the interplay between mRNA processing factors and retroviruses.