Diagnostic Delay in HPV-Related Oropharyngeal Squamous Cell Carcinoma

Introduction  Human papillomavirus-related (HPV + ) oropharyngeal squamous cell carcinoma (OPSCC) is increasing in incidence and presents diagnostic challenges given its unique clinical presentation. Objective  The purpose of the present study is to characterize the impact of the unique clinical presentation of HPV-related OPSCC on delays in diagnosis. Methods  Retrospective review of presenting symptoms and clinical characteristics of 284 patients with OPSCC treated from 2002-2014. Delay in diagnosis was defined as the presence of any of the following: multiple non-diagnostic fine needle aspirate (FNA) biopsies; two or more courses of antibiotic therapy; surgery with incorrect preoperative diagnosis; evaluation by an otolaryngologist without further workup; or surgery without definitive postoperative diagnosis. Results  p16+ tumors demonstrated a distinct clinical presentation that more commonly involved a neck mass (85.1% versus 57.3% of p16-; p  < 0.001) and less frequently included odynophagia (24.6% versus 51.7% of p16-; p  < 0.001). Patients who experienced diagnostic delay were more likely to have p16+ tumors (77.7% delayed versus 62.8% not delayed; p  = 0.006). p16+ primary tumors were more likely to be undetectable by physical examination of the head and neck including flexible laryngoscopy (19.0% versus 6.7% of p16-; p  = 0.007) and more frequently associated with nondiagnostic FNA biopsies of a cervical nodal mass (11.8% versus 3.4% of p16-, p  = 0.03). Conclusions  Compared with non-HPV related OPSCC, the unique clinical presentation and characteristics of HPV+ OPSCC are associated with an increased incidence of diagnostic delay. Targeted education of appropriate care providers may improve time to diagnosis and treatment.

Pest status, bio-ecology and management of the false codling moth, Thaumatotibia leucotreta (Meyrick) (Lepidoptera: Tortricidae) and its implication for international trade

The false codling moth (FCM), Thaumatotibia leucotreta (Lepidoptera: Tortricidae) is an insect pest which represents an important threat to the production and marketing of a wide range of agricultural crops in the African-Caribbean-Pacific (ACP) countries. The FCM reduces not only the yield and quality of the crop but also as a quarantine insect pest, restricts the trade of susceptible agricultural produce on the international market. In addition, little research has been conducted in the ACP countries on the bio-ecology and sustainable management of this pest, especially on vegetables for export. Thus, action-oriented research aimed at understanding the bio-ecology of this important pest is essential to achieve effective management. Various management interventions against this pest have been used in some parts of the world, especially in South Africa on citrus. Currently, farm sanitation is regarded as the key management strategy. Exploring and improving on other interventions such as Sterile Insect Technique, monitoring and mass trapping of male moths, augmentative biological control, use of bio-pesticides, protected cultivation and cold treatment may help to mitigate the expansion of FCM into other countries, especially in the European and Mediterranean Plant Protection Organization region where it has become a regulated insect pest since 2014. This review discussed the bio-ecology of FCM and highlighted some of the challenges and opportunities for its effective management and its implication for international trade, especially the export of chillies from the ACP countries into the European Union market which requires strict phytosanitary regulations.

STAT RT: a prospective pilot clinical trial of Scan-Plan-QA-Treat stereotactic body radiation therapy for painful osseous metastases

BACKGROUND

Planning and treatment of bone metastases with palliative radiotherapy often requires 1-3 weeks, resulting in patient inconvenience and delayed palliation. We developed an expedited workflow that delivers palliative stereotactic body radiation therapy (SBRT) to painful bone metastases in which CT, planning, quality assurance (QA), and initial treatment are performed one day. This prospective pilot clinical trial evaluates the feasibility, safety, efficacy, and patient satisfaction of this workflow.

METHODS

Patients with 1-3 painful bone metastases were prospectively enrolled and treated with 2-5 fractions of 5-10 Gy per fraction. Bone pain, opioid use, patient satisfaction, performance status, and quality of life were evaluated prior to and at 1, 4, 8, 12, 26, and 52 weeks post treatment. Outcomes and treatment-related toxicity were analyzed.

RESULTS

Twenty-eight patients were enrolled and 37 metastases treated, receiving an average of 21.6 Gy in 3.1 fractions. Median time from CT simulation to 1st treatment was 6.6 hours. Average worst pain scores were significantly lower at all post-treatment time points with maximal response noted at 3 months. Opioid use was not significantly different from baseline at any follow up. Performance status was significantly increased only at week 12. Bone pain quality of life was significantly increased at all time points except at 52 weeks while general quality of life was significantly increased at only weeks 8 and 26. Ninety-two percent of patients reported being mostly or completely satisfied with the treatment results from week 8 until the end of follow-up. There was no grade 3 or higher toxicities.

CONCLUSIONS

Results demonstrate that treating bone metastases with palliative SBRT via a multi-fraction Scan-Plan-QA-Treat patient centric workflow is feasible and safe. Although performance status, general quality of life, and opioid use were not significantly altered, patient satisfaction was high with this same-day treatment workflow.

Phantomless patient-specific TomoTherapy QA via delivery performance monitoring and a secondary Monte Carlo dose calculation

PURPOSE

To describe the validation and implementation of a novel quality assurance (QA) system for TomoTherapy using a Monte Carlo (MC)-based secondary dose calculation and CT detector-based multileaf collimator (MLC) leaf opening time measurement QA verification. This system is capable of detecting plan transfer and delivery errors and evaluating the dosimetric impact of those errors.

METHODS

The authors' QA process, MCLogQA, utilizes an independent pretreatment MC secondary dose calculation and postdelivery TomoTherapy exit detector-based MLC sinogram comparison and log file examination to confirm accurate dose calculation, accurate dose delivery, and to verify machine performance. MC radiation transport simulations are performed to estimate patient dose utilizing prestored treatment machine-specific phase-space information, the patient's planning CT, and MLC sinogram data. Sinogram data are generated from both the treatment planning system (MC_TPS) and from beam delivery log files (MC_Log). TomoTherapy treatment planning dose (DTPS) is compared with DMC_TPS and DMC_Log via dose-volume metrics and mean region of interest dose statistics. For validation, in-phantom ionization chamber dose measurements (DIC) for ten sample patient plans are compared with the computed values.

RESULTS

Dose comparisons to in-phantom ion chamber measurements validate the capability of the MCLogQA method to detect delivery errors. DMC_Log agreed with DIC within 1%, while DTPS values varied by 2%-5% compared to DIC. The authors demonstrated that TomoTherapy treatments can be vulnerable to MLC deviations and interfraction output variations during treatment delivery. Interfractional Linac output variations for each patient were approximately 2% and average output was 1%-1.5% below the gold standard. While average MLC leaf opening time error from patient to patient varied from -0.6% to 1.6%, the MLC leaf errors varied little between fractions for the same patient plan, excluding one patient.

CONCLUSIONS

MCLogQA is a new TomoTherapy QA process that validates the planned dose before delivery and analyzes the delivered dose using the treatment exit detector and log file data. The MCLogQA procedure is an effective and efficient alternative to traditional phantom-based TomoTherapy plan-specific QA because it allows for comprehensive 3D dose verification, accounts for tissue heterogeneity, uses patient CT density tables, reduces total QA time, and provides for a comprehensive QA methodology for each treatment fraction.

Treatment-related complications of radiation therapy after radical prostatectomy: comparative effectiveness of intensity-modulated versus conformal radiation therapy

Intensity-modulated radiation therapy (IMRT) is frequently utilized after prostatectomy without strong evidence for an improvement in outcomes compared to conformal radiation therapy (RT). We analyzed a large group of patients treated with RT after radical prostatectomy (RP) to compare complications after IMRT and CRT. The Surveillance, Epidemiology and End Results (SEER)-Medicare database was queried to identify male Medicare beneficiaries aged 66 years or older who underwent prostatectomy with 1+ adverse pathologic features and received postprostatectomy RT between 1995 and 2007. Chi-square test was used to compare baseline characteristics between the treatment groups. First complication events, based upon administrative procedure or diagnosis codes occurring >1 year after start of RT, were compared for IMRT versus CRT groups. Propensity score adjustment was performed to adjust for potential confounders. Multivariable Cox proportional hazards models of time to first complication were performed. A total of 1686 patients were identified who received RT after RP (IMRT = 634, CRT = 1052). Patients treated with IMRT were more likely to be diagnosed after 2004 (P < 0.001), have minimally invasive prostatectomy (P < 0.001) and have positive margins (P = 0.019). IMRT use increased over time. After propensity score adjustment, IMRT was associated with lower rate of gastrointestinal (GI) complications, and higher rate of genitourinary-incontinence complications, compared to CRT. The observed outcomes after IMRT must be considered when determining the optimal approach for postprostatectomy RT and warrant additional study.

p16 not a prognostic marker for hypopharyngeal squamous cell carcinoma

OBJECTIVE

To investigate the prognostic significance of p16 in patients with hypopharyngeal squamous cell carcinoma (HPSCC) and to evaluate the relationship between p16 and human papillomavirus (HPV). Unlike in oropharyngeal SCC (OPSCC), the prognostic significance of p16 in HPSCC and its association with HPV is unclear.

DESIGN

Retrospective medical chart review.

SETTING

University tertiary referral center.

PATIENTS

A total of 27 patients with HPSCC treated with definitive radiation therapy between 2002 and 2011 whose tissue was available for immunohistochemical analysis.

INTERVENTIONS

Twenty-two patients were treated with chemoradiation, and 5 with radiation alone. All tumor biopsy specimens were analyzed for p16 and, when sufficient tissue was available, for HPV DNA.

MAIN OUTCOME MEASURES

Overall survival (OS), locoregional control (LRC), disease-free survival (DFS), and laryngoesophageal dysfunction-free survival (LEDFS) were analyzed according to p16 status.

RESULTS

Findings for p16 were positive in 9 tumors and negative in 18 tumors. Median follow-up was 29.3 months. There was no significant difference in OS, LRC, DFS, or LEDFS for patients with p16-positive vs p16-negative tumors. Only 1 of the 19 tumors tested for HPV was found to be HPV positive. When used as a test for HPV, p16 had a positive predictive value of 17%.

CONCLUSIONS

In contrast to OPSCC, p16 expression in patients with HPSCC had a low positive predictive value for HPV and did not predict improved OS, LRC, DFS, or LEDFS. Thus, for HPSCC, p16 is not a prognostic biomarker. Caution must be taken when extrapolating the prognostic significance of p16 in patients with OPSCC to patients with head and neck SCC of other subsites.

p16, Cyclin D1, and HIF-1α Predict Outcomes of Patients with Oropharyngeal Squamous Cell Carcinoma Treated with Definitive Intensity-Modulated Radiation Therapy

We evaluated a panel of 8 immunohistochemical biomarkers as predictors of clinical response to definitive intensity-modulated radiotherapy in patients with oropharyngeal squamous cell carcinoma (OPSCC). 106 patients with OPSCC were treated to a total dose of 66-70 Gy and retrospectively analyzed for locoregional control (LRC), disease-free survival (DFS), and overall survival (OS). All tumors had p16 immunohistochemical staining, and 101 tumors also had epidermal growth factor receptor (EGFR) staining. 53% of the patients had sufficient archived pathologic specimens for incorporation into a tissue microarray for immunohistochemical analysis for cyclophilin B, cyclin D1, p21, hypoxia-inducible factor-1α (HIF-1α), carbonic anhydrase, and major vault protein. Median followup was 27.2 months. 66% of the tumors were p16 positive, and 34% were p16 negative. On univariate analysis, the following correlations were statistically significant: p16 positive staining with higher LRC (P = 0.005) and longer DFS (P < 0.001); cyclin D1 positive staining with lower LRC (P = 0.033) and shorter DFS (P = 0.002); HIF-1α positive staining with shorter DFS (P = 0.039). On multivariate analysis, p16 was the only significant independent predictor of DFS (P = 0.023). After immunohistochemical examination of a panel of 8 biomarkers, our study could only verify p16 as an independent prognostic factor in OPSCC.

Past and present national tick control programs. Why they succeed or fail

The historical reasons for the introduction of tick control during the nineteenth century are reviewed. Background and concepts for the choice between long-term tick control and tick eradication are compared. Case studies of large-scale tick control or eradication programs in Africa, Australia, the United States, and the Caribbean are used to highlight successes and failures. The main reasons for lack of sustainability, or failure, of programs are discussed. These include the economic constraints that were faced in several African countries, or technical shortcomings such as were perceived as a major problem in Puerto Rico. The successes are generally associated with enforcement of appropriate legislation and good management, such as occurred in Zimbabwe. These case studies are analyzed to identify features that may assist in the implementation of the ongoing tropical bont tick eradication program in the Caribbean. The paper concludes with some practical suggestions for the future, and the need to reassess the economics of control and the potential additional animal health benefits derived from tick control programs.

Eradication and surveillance of the tropical bont tick in the Caribbean. An international approach

The Caribbean Amblyomma program (CAP) is a multidonor funded effort involving several technical organizations and national governments in the eradication of the tropical bont tick. The Food and Agriculture Organization (FAO) is the lead technical agency, providing both technical and administrative support to the CAP Regional Coordination Unit (RCU) based in Barbados. All collaborating agencies, donors, and national representatives are members of the Amblyomma Program Council (APC), the overall governing body of the CAP. In addition to FAO, the other organizations involved are the Caribbean Community (CARICOM), the European Union (EU), the Inter-American Institute for Cooperation on Agriculture (IICA), the International Fund for Agricultural Development (IFAD), and the United States Department of Agriculture (USDA). Several agencies (EU, FAO, IFAD, and USDA) are also major donors. The CAP cooperates with the complementary Plan POSEIDOM Veterinaire Program in the French West Indies. The University of the West Indies (UWI), the International Institute for Biological Control (IIBC), and the Departement d'Elevage et de Medecine Veterinaire des Pays Tropicaux (EM-VT) in Guadeloupe are other collaborators.

The CARICOM/FAO/IICA Caribbean Amblyomma Program

The objective of the Caribbean Amblyomma Program is to eradicate the tropical bont tick (TBT), Amblyomma variegatum, from the Caribbean. Field activities directed to eradication of the TBT were initiated in May 1995 commencing in northern Caribbean islands. Plans have been finalized for the remaining islands to the south to start eradication activities in early 1997. The components of the program include tick control and surveillance, adaptive research, training, communications, and extension. Despite uncertain financial support, substantial progress has been made so far with strong participation by farmers and livestock owners who have been made responsible for the compulsory treatment of all ruminant livestock.

Primary lymphoma of the male urethra

An elderly man presented with urinary outflow obstruction and a smooth mass arising from the bulbar urethra. Biopsy revealed large cell lymphoma, B cell subtype. A literature review revealed no previous cases of undisseminated lymphoma arising within the male urethra. The obstructing mass and symptoms resolved with multiagent chemotherapy.

Bladder pheochromocytoma with ring calcification

A case of a 19-year-old male with a paraganglioma (pheochromocytoma) arising in the prostate and involving the urinary bladder is presented. The radiological studies, including computed tomography, demonstrated ringlike calcification of the tumor, a rare finding that is highly suggestive of the diagnosis of pheochromocytoma. The tumor was excised and found to be malignant at surgery.

Progress towards a program for the eradication of Amblyomma variegatum from the Caribbean

Amblyomma variegatum (Fabricius), the tropical bont tick, is now widely distributed in the Caribbean. Eighteen islands countries are now or were recently infested with the tick. To stop the spread of this tick to other non-infested islands and to the mainland areas of South, Central and North America, a regional eradication program has been proposed and endorsed by the respective governments on each of the Amblyomma variegatum infested islands, including the French government and CARICOM member and associate member countries. The Food and Agriculture Organization of the United Nations (FAO) was requested by CARICOM, on behalf of member and associate member governments to: develop eradication proposals; assist CARICOM member countries to maintain existing Amblyomma tick control programs; advise and assist with the drafting of legislation required for implementation of an eradication program; assist in the identification of funds to implement the eradication program and, if funding was obtained, coordinate the eradication campaign against this tick on all infested islands. The current distribution of the tick and the status of the proposed eradication program in the Caribbean are discussed.

D-Arg-[Hyp3-D-Phe7]-bradykinin, a bradykinin antagonist, reduces mortality in a rat model of endotoxic shock

The kallikrein-kinin system is activated during endotoxic shock, suggesting that bradykinin plays a role in the pathology of this disease. To test this hypothesis, a bradykinin antagonist, D-Arg-Hyp3-D-Phe7-bradykinin (NPC 567), was studied in conscious, chronically catheterized rats undergoing lipopolysaccharide (LPS)-induced endotoxic shock. LPS treatment resulted in an increase in circulating bradykinin from less than 23 pg/ml to 144 +/- 18 pg/ml at 1 hr. Intravenous administration of LPS resulted in a 38% drop in mean arterial pressure at 1 hr which was partially reversed by NPC 567. NPC 567 did not affect the moderate tachycardia observed following LPS. NPC 567 infusion at 8 nmol/kg/min dramatically reduced mortality from 100% to 50% at 24 hr (P less than 0.01). In response to LPS, blood thromboxane B2 (TXB2) rose from less than 200 pg/ml to 2,298 +/- 64 pg/ml, while 6-keto-prostaglandin-F1 alpha (6kPGF1 alpha) rose from 289 +/- 23 pg/ml to 7,927 +/- 822 pg/ml. NPC 567 reduced the rise in 6kPGF1 alpha by 42% (P less than 0.05), without affecting TXB2. In summary, NPC 567 reduced mortality in rats treated with LPS, reduced the rise in 6kPGF1 alpha and partially reversed the hypotensive effects. These results suggest that bradykinin plays a significant role in the pathology of endotoxic shock.

Validation of viscosity measurements for canine hepatic bile

This study developed the validated standards for a known viscosity method by obtaining consistent viscosity measurements with defined precision, reproducibility and sensitivity limits for canine hepatic bile. Size 75 Cannon-Manning semimicro viscometers yielded the most precise viscosity measurements. With the development of proper handling methods for fresh bile samples, a precision defined by a coefficient of variation of less than or equal to +/- 0.3% was obtained. To maintain viscometer constancy, the viscometers must be cleaned with chromic acid after each bile test and pass reproducibility tests using defined distilled water viscosity tests.

Craniopharyngioma intrinsic to the third ventricle

The case of a third ventricular craniopharyngioma in a 57-year-old woman is reported. This lesion is rare, having been previously identified in only eight adults. Intraventricular craniopharyngioma is also unusual in that it is not associated with tumoral calcification or cyst formation, as is frequently seen with the more common suprasellar craniopharyngioma. The role of computed tomography scanning in the diagnosis of this tumor is presented and discussed.

Blastomycosis in a Papanicolaou Smear. Report of a case with possible venereal transmission

An incidental case of cervical blastomycosis discovered by examination of a Papanicolaou smear is reported. Examinations revealed no other focus of blastomycosis in the patient. Since her husband was undergoing treatment for disseminated blastomycosis involving the lungs and prostate at the time the fungus was found, this case may represent venereally transmitted blastomycosis.

Neonatal circumcision

Circumcision is an elective surgical procedure performed on male neonates, but a procedure that may be elected by parents and medical personnel on less than adequate information. In this review paper, the authors explore the history of circumcision as a practice, as well ad the arguments for and against its continuation as a "routine" practice. The authors conclude that the health and social or personal reasons for circumcision may not be based on sound judgments, nor applicable to the general public. Thus there is a strong case made for careful counseling of parents by health education and professional medical staff members of clinics, hospitals, and other health-care settings.