Specimen oriented intraoperative margin assessment in oral cavity and oropharyngeal squamous cell carcinoma

OBJECTIVE

Evaluate the oncologic outcomes and cost analysis of transitioning to a specimen oriented intraoperative margin assessment protocol from a tumour bed sampling protocol in oral cavity (OCSCC) and oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

Retrospective case series and subsequent prospective cohort study SETTING: Tertiary care academic teaching hospital SUBJECTS AND METHODS: Retrospective case series of all institutional T1-T2 OCSCC or OPSCC treated with primary surgery between January 1st 2009 - December 31st 2014. Kaplan-Meier survival estimates with log rank tests were used to compare patients based on final margin status. Cost analysis was performed for escalation of therapy due to positive final margins. Following introduction of a specimen derived margin protocol, successive prospective cohort study of T1-T4 OCSCC or OPSCC treated with primary surgery from January 1st 2017 - December 31st 2018. Analysis and comparison of both protocols included review of intraoperative margins, final pathology and treatment cost.

RESULTS

Analysis of our intra-operative tumour bed frozen section protocol revealed 15 of 116 (12.9%) patients had positive final pathology margins, resulting in post-operative escalation of therapy for 14/15 patients in the form of re-resection (7/14), radiation therapy (6/14) and chemoradiotherapy (1/14). One other patient with positive final margins received escalated therapy for additional negative prognostic factors. Recurrence free survival at 3 years was 88.4 and 50.7% for negative and positive final margins respectively (p = 0.048). Implementation of a specimen oriented frozen section protocol resulted in 1 of 111 patients (0.9%) having positive final pathology margins, a statistically significant decrease (p < 0.001). Utilizing our specimen oriented protocol, there was an absolute risk reduction for having a final positive margin of 12.0% and relative risk reduction of 93.0%. Estimated cost avoidance applying the specimen oriented protocol to our previous cohort was $412,052.812017 CAD.

CONCLUSION

Implementation of a specimen oriented intraoperative margin protocol provides a statistically significant decrease in final positive margins. This change in protocol leads to decreased patient morbidity by avoiding therapy escalation attributable only to positive margins, and avoids the economic costs of these treatments.

The abscopal effect in head-and-neck squamous cell carcinoma treated with radiotherapy and nivolumab: a case report and literature review

Introduction

The abscopal effect is a rarely observed outcome of radiotherapy wherein there is a reduction in metastatic disease burden outside of the targeted treatment area. Likely due to an in situ vaccine effect of radiotherapy, the abscopal effect may be augmented by immunotherapy. This report is the first case of the abscopal effect observed in metastatic head-and-neck squamous cell carcinoma (hnscc) treated with concurrent radiotherapy and single-agent nivolumab.

Case Description

An otherwise healthy 57-year-old man underwent craniofacial resection and adjuvant chemoradiotherapy for advanced sinonasal squamous cell carcinoma. Distant metastatic disease developed shortly after primary treatment, and immunotherapy in the form of nivolumab was initiated. Subsequent oligometastatic progression despite immunotherapy prompted palliative radiotherapy to a single metastasis due to pending symptomatology. Post-radiotherapy, the abscopal effect was observed with all distant sites of metastatic disease shrinking. Five months following treatment, a sustained reduction in disease burden has been demonstrated.

Summary

We present the first case of the abscopal effect in a patient with metastatic hnscc treated with palliative radiotherapy concurrent with single-agent nivolumab immunotherapy, and only the third case of the abscopal effect in metastatic head-and-neck cancer. Dual treatment with immunotherapy and radiotherapy may be an important treatment option in the future, mediated through the abscopal effect.

Laryngeal recurrence sites in patients previously treated with transoral laser microsurgery for squamous cell carcinoma

BACKGROUND

The laryngeal framework provides a natural barrier preventing tumour spread to extralaryngeal structures. Transoral laser microsurgery (TLM) for laryngeal squamous cell carcinoma (SCC) may violate these boundaries, altering the pathways of tumor spread for potential recurrences. Our project objective is to describe laryngeal SCC recurrence patterns and overall survival in patients requiring total laryngectomy (TL) after TLM.

METHODS

Patients undergoing TLM for laryngeal SCC requiring salvage TL were identified from a prospective CO2 laser database containing all patients undergoing TLM for head and neck malignancies at the QEII Health Sciences Center in Halifax, Nova Scotia between March 2002 - May 2014. Surgical pathology reports were analyzed for tumor characteristics, extent of recurrence and invasion of local structures. Kaplan-Meier analyses were performed to evaluate overall survival, disease specific survival (DSS) and locoregional control.

RESULTS

Fifteen patients were identified from the database as receiving salvage TL for recurrent disease after initial TLM resection for laryngeal SCC. Final pathology reports demonstrated that 67% (10/15) of patients had thyroid cartilage involvement while 53% (9/15) of patients had cricoid cartilage involvement on salvage TL pathology. 33% (5/15) of patients had perineural invasion and 27% (4/15) had lymphovascular invasion. Mean and median follow-up times were 36.7 months and 26.8 months respectively (range 3.9-112.6). The Kaplan-Meier estimate for overall survival at 36 months was 40% post TL with a standard error (SE) of 13.6%. DSS was 47% (SE 14.2%), and locoregional control was 55% (SE 14.5%) post TL.

CONCLUSIONS

Laryngeal recurrence sites following TLM seem to be consistent with historical data at known laryngeal sites of vulnerability. Treatment with TLM does not predispose patients to a lower rate of locoregional control and overall survival after total laryngectomy and salvage outcomes are consistent with literature values.

FOXO factors and breast cancer: outfoxing endocrine resistance

The majority of metastatic breast cancers cannot be cured and present a major public health problem worldwide. Approximately 70% of breast cancers express the estrogen receptor, and endocrine-based therapies have significantly improved patient outcomes. However, the development of endocrine resistance is extremely common. Understanding the molecular pathways that regulate the hormone sensitivity of breast cancer cells is important to improving the efficacy of endocrine therapy. It is becoming clearer that the PI3K-AKT-forkhead box O (FOXO) signaling axis is a key player in the hormone-independent growth of many breast cancers. Constitutive PI3K-AKT pathway activation, a driver of breast cancer growth, causes down-regulation of FOXO tumor suppressor functions. This review will summarize what is currently known about the role of FOXOs in endocrine-resistance mechanisms. It will also suggest potential therapeutic strategies for the restoration of normal FOXO transcriptional activity.

Destabilizing RET in targeted treatment of thyroid cancers

Metastatic differentiated thyroid cancers (DTC) are resistant to traditional chemotherapy. Kinase inhibitors have shown promise in patients with progressive DTC, but dose-limiting toxicity is commonplace. HSP90 regulates protein degradation of several growth-mediating kinases such as RET, and we hypothesized that HSP90 inhibitor (AUY922) could inhibit RET-mediated medullary thyroid cancer (MTC) as well as papillary thyroid cancer (PTC) cell growth and also radioactive iodine uptake by PTC cells. Studies utilized MTC cell lines TT (C634W) and MZ-CRC-1 (M918T) and the PTC cell line TPC-1 (RET/PTC1). Cell viability was assessed with MTS assays and apoptosis by flow cytometry. Signaling target expression was determined by western blot and radioiodine uptake measured with a gamma counter. Prolonged treatment of both MTC cell lines with AUY922 simultaneously inhibited both MAPK and mTOR pathways and significantly induced apoptosis (58.7 and 78.7% reduction in MZ-CRC-1 and TT live cells respectively, following 1 μM AUY922; P<0.02). Similarly in the PTC cell line, growth and signaling targets were inhibited, and also a 2.84-fold increase in radioiodine uptake was observed following AUY922 administration (P=0.015). AUY922 demonstrates in vitro activity against MTC and PTC cell lines. We observed a potent dose-dependent increase in apoptosis in MTC cell lines following drug administration confirming its anti-tumorigenic effects. Western blots confirm inhibition of pro-survival proteins including AKT suggesting this as the mechanism of cell death. In a functional study, we observed an increase in radioiodine uptake in the PTC cell line following AUY922 treatment. We believe HSP90 inhibition could be a viable alternative for treatment of RET-driven chemo-resistant thyroid cancers.

Utilization of a MAB for BRAF(V600E) detection in papillary thyroid carcinoma

Identification of BRAF(V600E) in thyroid neoplasia may be useful because it is specific for malignancy, connotes a worse prognosis, and is the target of novel therapies currently under investigation. Sanger sequencing is the 'gold standard' for mutation detection but is subject to sampling error and requires resources beyond many diagnostic pathology laboratories. In this study, we compared immunohistochemistry (IHC) using a BRAF(V600E) mutation-specific MAB to Sanger sequencing on DNA from formalin-fixed paraffin-embedded tissue, in a well-characterized cohort of 101 papillary thyroid carcinoma (PTC) patients. For all cases, an IHC result was available; however, five cases failed Sanger sequencing. Of the 96 cases with molecular data, 68 (71%) were BRAF(V600E) positive by IHC and 59 (61%) were BRAF(V600E) positive by sequencing. Eleven cases were discordant. One case was negative by IHC and initially positive by sequencing. Repeat sequencing of that sample and sequencing of a macrodissected sample were negative for BRAF(V600E). Of ten cases positive by IHC but negative by sequencing on whole sections, repeat sequencing on macrodissected tissue confirmed the IHC result in seven cases (suggesting that these were false negatives of sequencing on whole sections). In three cases, repeat sequencing on recut tissue remained negative (including using massive parallel sequencing), but these cases demonstrated relatively low neoplastic cellularity. We conclude that IHC for BRAF(V600E) is more sensitive and specific than Sanger sequencing in the routine diagnostic setting and may represent the new gold standard for detection of BRAF(V600E) mutation in PTC.

Comparison of glove donning techniques for the likelihood of gown contamination. An infection control study

The creation of an optimal environment, whenever major joints are opened or metal is implanted into bone, is important to reduce infection following orthopaedic surgery. Following normal hand washing protocols, it is possible that pathogenic bacteria can remain on the skin. These bacteria may inadvertently be transferred to the surgical gown during the glove donning procedure and therefore contamination of the surgical wound could follow. We aimed to determine whether there is a difference between three differing glove donning techniques, open, closed and scrub staff assisted, in terms of accidental gown contamination, as the optimum method is unknown. Three differing glove donning techniques were assessed using ultra-violet (UV) lotion, applied to the hands after the scrub, to demonstrate patches of contamination on the surgical gowns. Two studies were carried out. An initial pilot study with theatre personnel and the main study by a single surgeon rehearsed in the various techniques. The region and size of contamination patches were documented. In the pilot study 12 out of 13 individuals were seen to have patches of UV fluorescent gown contamination following an observed scrub. In the main study, both the open and closed technique had a 100% gown contamination rate. This was concentrated around the cuff region. There were no contamination patches in the scrub staff assisted technique. Glove donning, using the scrub staff assisted technique can minimise the possibility of gown contamination. This is important in surgical procedures where the results of infection can be devastating.

Embryonic exposure to exogenous alpha- and gamma-tocopherol partially attenuates ethanol-induced changes in brain morphology and brain membrane fatty acid composition

Previous studies demonstrated that embryonic exposure to ethanol (EtOH) promoted a reduction in brain mass, a reduction in brain neuron densities, and a reduction in membrane long-chain polyunsaturated fatty acids (PUFAs) in embryonic chick brains. These EtOH-induced reductions in brain membrane PUFAs may be the result of lipid peroxidation because embryonic exposure to exogenous alpha- or gamma-tocopherol partially attenuated EtOH-induced reductions in membrane PUFAs. In this paper, we report that embryonic exposure to exogenous alpha- or gamma-tocopherol attenuated EtOH-induced decreases in endogenous levels of alpha-tocopherol in both embryonic chick brains and liver. Embryonic exposure to exogenous alpha- or gamma-tocopherol also partially attenuated EtOH-induced reductions in brain neuron densities within the cerebral hemispheres of embryonic chick brains. Finally, embryonic exposure to exogenous alpha- or gamma-tocopherol also partially attenuated EtOH-induced reductions in long-chain PUFAs in 2-day old neonatal chick brains.

Anaesthetic assistants: their role in the development and resolution of anaesthetic incidents

Trained anaesthetic assistants are considered essential for the safe conduct of anaesthesia. Data from 5837 AIMS (Anaesthetic Incident Monitoring Study) reports were evaluated for issues concerning anaesthetic assistants in the generation and resolution of anaesthetic incidents. "Inadequate assistance" as a contributing factor was identified in 187 reports, whilst "skilled assistance" which minimized the incident was present in 808 cases. One hundred and seventy-two reports specifically commented on anaesthetic assistants in the narrative section of the AIMS form. All surgical specialties were represented. In 147 of these reports the assistant actually contributed to or failed to assist with the incident. Although the majority of outcomes from the reports were uneventful, prolonged stay, awareness and ICU admission did ensue in a small number of cases. The most common incidents were related to problems with equipment, communication and inadequate staffing levels (number and/or skill mix). Results from this study have implications for anaesthetic assistant staffing levels and the orientation of course content.

Reiki: a complementary therapy for life

Tom was diagnosed with a very aggressive cancer and received only palliative radiation and medication. At the time of diagnosis, his symptoms suggested that he had a very limited life expectancy. With the Reiki and his intent, he was able to achieve his goal of long-term stability with freedom from immobilizing pain and swelling. Tom's comfort and quality of life improved dramatically, and he is living well with his cancer. Reiki has been associated with dramatic results for many patients. The importance of the patient's intent during Reiki treatments cannot be overemphasized. Some general trends seen with Reiki include: periods of stabilization in which there is time to enjoy the last days of one's life; a peaceful and calm passing if death is imminent; and relief from pain, anxiety, dyspnea and edema. Reiki is a valuable complement in supporting patients in their end-of-life journey, enhancing the quality of their remaining days.

Research to optimise human performance

The need for greater understanding of the factors which limit human movement and functional capacity and for determining effective methods for ensuring optimum performance has led to a wide range of related research studies. This paper draws on some of the research projects pursued or supervised by the author, to show the knowledge gained in aspects of movement capacity, muscle function and the influence of sensory motor deficits on movement and function. The inter-relationship of the many factors influencing functional capacity emphasise the need to think broadly in research. Studies of effectiveness of physiotherapy and collection of data for ergonomic workplace design highlight the importance of both prevention and therapeutic care and demonstrate the contributions which physiotherapists can make through research to optimise human performance.

Suppression of human peripheral blood mononuclear cell function by methadone and morphine

Recent studies have shown that in vitro exposure of peripheral blood mononuclear cells (PBMC) to morphine results in suppressed respiratory-burst activity of monocytes and impaired interferon-gamma (IFN-gamma) production by lymphocytes. To investigate the potential in vivo effect of an opiate on these cell functions, PBMC were obtained from patients maintained on methadone. These freshly isolated mononuclear cells had a significantly impaired capacity to generate superoxide anion (O2-) in response to phorbol myristate acetate (PMA), while production of IFN-gamma by concanavalin A-stimulated cells was intact. After cell culture for 48 h, the defective O2- generating capacity was sustained. Also, culturing PBMC from healthy controls in the presence of methadone or morphine at concentrations as low as 10(-12) M caused significant suppression of PMA-stimulated O2- release. Because reactive oxygen intermediates produced by PBMC may participate in host defense against opportunistic pathogens in AIDS, these results underscore the need for investigations of the biological consequences of opiate-mediated immunosuppression.

Development of a health questionnaire specific for end-stage renal disease

To compare the efficacy of various end-stage renal disease (ESRD) therapies valid and reproducible probes which measure well-being and are specific for ESRD are necessary. Four studies were undertaken to provide and test these probes. (1) 107 dialysis and 119 transplant recipients were interviewed to determine the prevalence of 24 physical symptoms. (2) A questionnaire was devised using 2 new indexes (a symptom scale derived from the first study using 12 symptoms and an affect scale comprising 12 emotions) and 6 indexes previously used in other chronic illnesses. Interobserver and intraobserver reproducibility was satisfactory. (3) Construct validity for the questionnaire was shown by interviewing 97 dialysis and 82 transplant patients in whom we hypothesized that physical well-being would be better in transplant patients. After age matching the transplant group was more active, with a higher objective quality of life and fewer physical symptoms than the dialysis group. (4) 63 stable dialysis, 67 stable transplant, 15 dialysis patients successfully transplanted in the intervening year and 5 failed transplanted patients were reinterviewed 1 year later to assess the responsiveness of the questionnaire. In the group who had recently been successfully transplanted both physical, affect and quality of life scores showed a major improvement following transplant. We conclude that this questionnaire is specific for ESRD, examines physical, psychological, and social well-being, is brief, easily administered, reproducible, has construct validity and is responsive to changes in therapy.

The development of volitional behavior in the toddler years

In order to generate a description of early volitional skills, toddlers' abilities to match their activities to externally defined task standards and to monitor and control activities with respect to outcomes were studied. Children between 15 and 35 months were observed as they engaged in a series of play and clean-up tasks. The results showed that there is a consistent developmental pattern in the extent to which children focus on producing outcomes (rather than on acting for its own sake), the extent to which they monitor, correct, and control activities, and the frequency with which they react to their outcomes with positive affect. These patterns are interpreted in terms of changes in the representation of actions, self-regulation abilities, and the active involvement of the self in actions.

Clinical features and severity of nonspecific symptoms in dialysis patients

Nonspecific symptoms are common in dialysis patients but few methods are available to measure their severity and their response to alteration in dialysis therapy. To determine the clinical features and measure the severity of the most important symptoms in end-stage renal disease (ESRD) patients, 97 dialysis patients were interviewed, 63 of whom were reinterviewed 1 year later. For comparison 82 transplant recipients were also interviewed. The six most important symptoms in dialysis patients (using the product of the patient's perception of severity and prevalence) were tiredness, cramps, pruritus, dyspnea, headaches and joint pain. The symptoms were long-standing, occurred frequently, with little difference in prevalence between hemo- and peritoneal dialysis patients, and were often unrelated to a hemodialysis session. For each symptom, several dimensions of severity were assessed including frequency, duration, effect on sleep, daily living, activity, subjective quality of life and necessity for drug therapy. Often these dimensions did not correlate with patient's perception of severity. For each symptom these items were combined to give an aggregate score with a range 0-10. Interobserver reproducibility for each symptom score was greater than or equal to 0.7 but intraobserver reproducibility was poor for 3 symptoms, because of the fluctuating nature of the symptoms. Construct validity was demonstrated by finding a significantly worse distribution of aggregate scores for tiredness, cramps, pruritus, dyspnea and nausea/vomiting in dialysis compared to transplant patients. Aggregate scores changed little after 1 year's follow-up in stable dialysis patients but significant improvement in the aggregate scores for tiredness, dyspnea and nausea/vomiting were observed in 14 patients after successful transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

The grief-relief process: coping with the life and death of physically and mentally disabled children

Many parents of children with severe physical and mental deficits appear to be in conflict between two ambivalent emotions, wanting to live with their child and needing to be relieved from their child's constant suffering. This internal struggle may become a life-long "grief-relief process" for the parents that is manageable but unresolved. The emotional conflict may result in a subconscious or conscious death wish for the child. The conflict reaches its peak when etiology, surgery, and prognosis are discussed and when the child dies. It has been noted that with the death of the child there may be a rapid movement from grief to a sense of relief. This has been referred to as the "grief-relief phenomenon." Though relief appears soon, the period of bereavement may be long and painful. Consequently, the importance of long-term follow-up has been emphasized. Practical suggestions have been offered to allied health professionals working with these parents on a daily basis. This article has concerned itself primarily with the emotional adjustment of parents to children with severe deficits. The grief-relief phenomenon may also be applicable in relation to other populations, such as elderly or terminally ill patients who are constantly in pain and suffering.

The functional and social significance of orthopedic rehabilitation of mentally retarded patients with cerebral palsy

The 14 outpatients transferred for surgery on the hips and legs also made significant gains, primarily in hygiene and sitting tolerance. Unfortunately, they required two to four times the period of hospitalization of similarly involved nonretarded children. This is an important consideration in the outpatient group, perhaps less so in the previously institutionalized child. In the entire group of patients, including those followed for less than five years, we have had three deaths. Two were due to pneumonia, two months and four months after the hip procedure. One was due to osteosarcoma of the operated femur four years postoperatively.

Preschoolers' understanding of simple object transformations

The ability of 3- and 4-year-old children to reason about the components of event sequences involving simple transformations was tested in 2 experiments. In Experient I children saw picture "stories" of the form object, instrument, and transformed object, with 1 item deleted. They filled in the missing position from 3 choice cards. Children in both groups correctly filled in all positions and therefore could: (1) predict the transformed state of an object, (2) retrieve the initial state of an object, and (3) understand the implicit actions that mediate 2 object states. This was true for transformations that (1) either altered or restored an object, and (2) represented familiar or unusual events. In Experiment II only the instrument item was deleted. Children demonstrated an ability to represent reciprocal transformations (e.g., break-fix); they chose the 2 of 4 instruments that altered and restored the same object. The younger children were less able to describe the events and found it somewhat easier to reason about transformations that altered objects.