A comparison of timing and patterns of treatment failure, and survival outcomes after progression between HPV+ and HPV- patients undergoing chemoradiation for oropharyngeal squamous cell carcinomas

BACKGROUND

We aimed to analyze and compare the timing and patterns of treatment failure, and survival after progression between HPV-positive (HPV+) and HPV-negative (HPV-) patients undergoing chemoradiation for oropharyngeal squamous cell carcinomas (OPSCC).

METHODS

A retrospective review was performed of all patients undergoing primary chemoradiation for OPSCC between 2008 and 2021. Demographic and clinical data were collected. Kaplan-Meier estimates for overall survival (OS), and time to recurrence/metastases (TTR) were compared using the log-rank test, with Cox regression used for multivariable modeling comparing HPV+ and HPV- patients.

RESULTS

HPV- patients developed recurrence or metastases at earlier time points than HPV+ patients (8.8 vs. 15.2 months, p < 0.05), due to earlier local/locoregional recurrence and distant metastases, but not isolated regional recurrences. HPV- distant metastases exclusively occurred in a single organ, most commonly the lungs or bone, while HPV+ metastases frequently had multi-organ involvement in a wide variety of locations (p < 0.05). Once progression (recurrence/metastases) was diagnosed, HPV+ patients experienced superior survival to HPV- patients on univariate and multivariate analysis, largely due to improved outcomes after treatment of local/locoregional recurrences (p < 0.05). There were no differences in survival after isolated regional recurrences or distant metastases.

CONCLUSION

HPV+ OPSCC patients relapse later compared to HPV- patients in local/locoregional and distant sites. HPV+ patients with local/locoregional recurrence experience superior survival after recurrence, which does not hold true for isolated regional recurrences or distant metastases. These data can be useful to inform prognosis and guide treatment decisions in patients with recurrent OPSCC.

The Ansa Hypoglossi: Quantifying Axonal Density of a Donor Nerve for Facial Reinnervation

Background: There are a number of nerve grafting options for facial reanimation and the ansa hypoglossi (AH) may be considered in select situations. Objective: To compare axonal density, area, and diameter of AH with other nerves more usually used for facial reanimation. Methods: AH specimens from patients undergoing neck dissections were submitted in formalin. Proximal to distal cross sections, nerve diameters, and the number of axons per nerve, proximally and distally, were measured and counted. Results: Eighteen nerve specimens were analyzed. The average manual axon count for the distal and proximal nerve sections was 1378 ± 333 and 1506 ± 306, respectively. The average QuPath counts for the proximal and distal nerve sections were 1381 ± 325 and 1470 ± 334, respectively. The mean nerve area of the proximal and distal nerve sections was 0.206 ± 0.01 and 0.22 ± 0.064 mm2, respectively. The mean nerve diameter for the proximal and distal nerve sections were 0.498 ± 0.121 and 0.526 ± 0.75 mm, respectively. Conclusion: The histological characteristics of the AH support clinical examination of outcomes as a promising option in facial reanimation.

Surgical margins of the oral cavity: is 5 mm really necessary?

Background

Squamous cell carcinoma is the most common malignancy of the oral cavity. Primary treatment involves surgical resection of the tumour with a surrounding margin. Historically, the most commonly accepted margin clearance is 5 mm. This distance is controversial, with recent publications suggesting closer margins do not impact local recurrence and survival. The objective of this study is to determine the closest surgical margin that does not impact local recurrence and overall survival.

Methods

A retrospective review of the London Health Sciences Centre Head and Neck Multidisciplinary Clinic between 2010 and 2018 was performed. Demographic data, subsite, tumour staging, treatment modality, margins, and survival outcomes were analyzed. The primary endpoint was local recurrence free survival. Secondary endpoints included recurrence-free survival and overall survival. Descriptive statistics, as well as univariable and multivariable Cox proportional hazards regression modelling were performed for all patients.

Results

Four-hundred and twelve patients were included in the study, with a median follow-up of 3.3 years. On univariable analysis, positive margins and margins < 1 mm were associated with significantly worse local recurrence-free survival, recurrence-free survival, and overall survival (p < 0.05), compared to margins > 5 mm. Patients with surgical margins > 1 mm experienced similar outcomes to those with margins > 5 mm. Multivariable analysis identified age of diagnosis, alcohol consumption, pathological tumour and nodal category as predictors of local recurrence free survival.

Conclusions

Although historical margins for head and neck surgery are 5 mm, similar outcomes were observed for margins greater than 1 mm in our cohort. These findings require validation through multi-institutional collaborative efforts.

Graphical abstract

Transoral robotic surgery for the identification of unknown primary head and neck squamous cell carcinomas: Its effect on the wait and the weight

BACKGROUND

Neck carcinoma of unknown primary (CUP) is a frequent scenario. Transoral robotic mucosectomies (TORM) of pharynx have increased rate of primary identification, but come with cost of treatment delay.

METHODS

We reviewed patients who underwent CUP protocol from 2014 to 2020. Patients with cervical nodes carcinoma and failure to localize a primary source were classified as CUP. We determined primary identification rate and postoperative complications.

RESULTS

We included 65 patients underwent TORM. Surgical approach consisted of lingual and/or palatine tonsillectomies. The primary detection rate was 49.2%. Average weight reduction was 2.5 ± 4.3 kg. The average number of days from consultation to definitive treatment was 52.2 ± 18.3.

CONCLUSION

A systematic approach to patients with CUP showed a promising primary identification rate compared to panendoscopy alone. TORM carries a small risk of complications. The benefits of primary identification must be weighed with the morbidity and delay to definitive treatment.

A prickly situation: an attempted Caterpillar ingestion - case report

Background

Foreign body ingestion is a common problem in pediatrics. Each foreign body can present its’ own unique challenges during removal, and we present the management of an ingested Spotted Tussock Moth (Lophocampa maculata), more commonly known as a caterpillar.

Case presentation

An 18-month-old boy presented to the emergency department with difficulty handling secretions and odynophagia. It was reported he had placed a caterpillar in his mouth and then spat it out. On examination, hundreds of miniscule filaments (setae) were seen embedded in his lips and tongue. Our service was consulted out of concern for airway involvement. The patient was taken to the operating room where a direct laryngoscopy under general anesthesia with spontaneous ventilation was performed to confirm the setae were confined to the anterior tongue and lips. Once we were satisfied the airway was stable, the airway was secured, and we then began to remove the setae. The initial method used was to use Adson-Brown forceps to remove the setae, however this proved difficult and time-consuming given the volume of setae and how thin the setae were. Ultimately, a more effective technique was developed: a 4 × 4 AMD-RITMES® gauze was applied to the mucosa in order to dry up any secretions and then a piece of pink, waterproof BSN medical® tape was applied to the mucosa. After 3 s of contact it was removed. This technique was then repeated and was used to remove the vast majority of the setae.

Conclusion

To our knowledge, we have described the first technique to remove the caterpillar setae from the oral cavity mucosa in a fast, safe and efficient manner.

Exploring polycaprolactone in tracheal surgery: A scoping review of in-vivo studies

INTRODUCTION

Tracheal pathology can be life-threatening if not managed appropriately. There are still some surgical limitations today for certain pathologies, such as in severe tracheomalacia, or when long segments of trachea need to be resected. Poly(ε-caprolactone) (PCL) is a polymer that has recently gained popularity for its use in tracheal surgeries in animal models and in certain human pediatric cases in hopes of addressing these difficult situations. PCL can be 3D printed or manufactured through molds to create tracheal stents, splints, patches and even to reconstruct full circumferential tracheal defects.

OBJECTIVE

To perform a scoping review, and explore insights into the applications of PCL for tracheal surgeries in-vivo.

METHODS

A literature search in Embase, MEDLINE, and BIOSIS was performed to include all articles available prior to December 21, 2018 without any language restrictions. We included all original research that investigated the use of a PCL implant, stent, splint, scaffold, or graft in tracheal surgeries in-vivo. Assessment of all articles were performed by two independent authors prior to inclusion for analysis.

RESULTS

A total of 27 articles were included in the study. All articles were original research studies, primarily consisting of interventional studies (92.4%), there was also 2 case reports (7.4%). Articles were published in the last decade, publications range from 2009 to 2019. The most common animal model used for the tracheal surgeries were the New Zealand rabbits (n = 19, 70%). Two studies (7%) also described the use PCL in a total of 4 human cases. To investigate the PCL reconstructed airways, histology and bronchoscopy were the most commonly implemented methods of analysis in 88.9% and 70.4% respectively. Airway analysis was also done using imaging modalities including CT scan (n = 9, 33.3%), MRI (n = 2, 7.4%), X-ray (n = 1, 3.7%). 17 (62.9%) of the studies used 3D printing processes to create their PCL implants.

CONCLUSIONS

Overall, this review demonstrates the feasibility of PCL in tracheal reconstruction and tracheal stenting/splinting. It highlights common trends and the limitations of the literature thus far on this topic.

Raman Spectroscopy for Inverted Papilloma: A Proof-of-Concept Study

Inverted papillomas are tumors of the sinonasal tract with a propensity to recur. Raman spectroscopy can potentially identify inverted papillomas from other tissue based on biochemical signatures. A pilot study comparing Raman spectroscopy to histopathology for 3 types of sinonasal tissue was performed. Spectral data of biopsies from patients with normal sinonasal mucosa, chronic rhinosinusitis, and inverted papillomas are compared to histopathology using principal component analysis and linear discriminant analysis after data preprocessing. A total of 18 normal, 15 chronic rhinosinusitis, and 18 inverted papilloma specimens were evaluated. The model distinguished normal sinonasal mucosa, chronic rhinosinusitis, and inverted papilloma tissue with an overall accuracy of 90.2% (95% confidence interval, 0.86-0.94). In conclusion, Raman spectroscopy can distinguish inverted papilloma, normal sinonasal mucosa, and chronically rhinosinusitis tissue with acceptable accuracy.

Hemi-transseptal Approach for Pituitary Surgery: A Follow-Up Study

Objectives The hemi-transseptal (Hemi-T) approach was developed to overcome the potential drawbacks of the nasoseptal flap (NSF) in endoscopic endonasal transsphenoidal skull base surgery. In this study, we describe further refinements on the Hemi-T approach, and report long-term outcomes as compared with traditional methods of skull base reconstruction. Design A retrospective case-control study. Setting Montreal Neurological Institute and Jewish General Hospital, Montreal, Canada. Participants Patients who underwent endoscopic endonasal transsphenoidal approach to skull base pathology. Main Outcome Measures Operative time, CSF rhinorrhea, and postoperative nasal morbidity. Results A total of 105 patients underwent the Hemi-T approach versus 40 controls. Operative time was shorter using the Hemi-T technique (180.51 ± 56.9 vs. 202.9 ± 62 minutes; p = 0.048). The rates of nasal morbidity (septal perforation [5/102 vs. 6/37; p = 0.029] and mucosal adhesion [11/102 vs. 10/39 p = 0.027]), fascia lata harvest (21/100 vs. 18/39; p = 0.0028), and postoperative CSF leak rates (7/100 vs. 9/38; p = 0.006) were lower in the Hemi-T group. Conclusion Advantages of the Hemi-T approach over traditional exposure techniques include preservation of the nasal vascular pedicle, shorter operative time, reduced fascia lata harvest rates, and decreased nasal morbidity.

Temporal trend of carpal tunnel release surgery: a population-based time series analysis

BACKGROUND

Carpal tunnel release (CTR) is among the most common hand surgeries, although little is known about its pattern. In this study, we aimed to investigate temporal trends, age and gender variation and current practice patterns in CTR surgeries.

METHODS

We conducted a population-based time series analysis among over 13 million residents of Ontario, who underwent operative management for carpal tunnel syndrome (CTS) from April 1, 1992 to March 31, 2010 using administrative claims data.

RESULTS

The primary analysis revealed a fairly stable procedure rate of approximately 10 patients per 10,000 population per year receiving CTRs without any significant, consistent temporal trend (p = 0.94). Secondary analyses revealed different trends in procedure rates according to age. The annual procedure rate among those age >75 years increased from 22 per 10,000 population at the beginning of the study period to over 26 patients per 10,000 population (p<0.01) by the end of the study period. CTR surgical procedures were approximately two-fold more common among females relative to males (64.9% vs. 35.1 respectively; p<0.01). Lastly, CTR procedures are increasingly being conducted in the outpatient setting while procedures in the inpatient setting have been declining steadily - the proportion of procedures performed in the outpatient setting increased from 13% to over 30% by 2010 (p<0.01).

CONCLUSION

Overall, CTR surgical-procedures are conducted at a rate of approximately 10 patients per 10,000 population annually with significant variation with respect to age and gender. CTR surgical procedures in ambulatory-care facilities may soon outpace procedure rates in the in-hospital setting.

Harassment and discrimination in medical training: a systematic review and meta-analysis

PURPOSE

Harassment and discrimination include a wide range of behaviors that medical trainees perceive as being humiliating, hostile, or abusive. To understand the significance of such mistreatment and to explore potential preventive strategies, the authors conducted a systematic review and meta-analysis to examine the prevalence, risk factors, and sources of harassment and discrimination among medical trainees.

METHOD

In 2011, the authors identified relevant studies by searching MEDLINE and EMBASE, scanning reference lists of relevant studies, and contacting experts. They included studies that reported the prevalence, risk factors, and sources of harassment and discrimination among medical trainees. Two reviewers independently screened all articles and abstracted study and participant characteristics and study results. The authors assessed the methodological quality in individual studies using the Newcastle-Ottawa Scale. They also conducted a meta-analysis.

RESULTS

The authors included 57 cross-sectional and 2 cohort studies in their review. The meta-analysis of 51 studies demonstrated that 59.4% of medical trainees had experienced at least one form of harassment or discrimination during their training (95% confidence interval [CI]: 52.0%-66.7%). Verbal harassment was the most commonly cited form of harassment (prevalence: 63.0%; 95% CI: 54.8%-71.2%). Consultants were the most commonly cited source of harassment and discrimination, followed by patients or patients' families (34.4% and 21.9%, respectively).

CONCLUSIONS

This review demonstrates the surprisingly high prevalence of harassment and discrimination among medical trainees that has not declined over time. The authors recommend both drafting policies and promoting cultural change within academic institutions to prevent future abuse.

Diagnostic Value of FNA-BRAF Mutation Analysis in Papillary Thyroid Cancer: A Systematic Review and Meta-analysis

Objectives:

Fine needle aspiration (FNA) with cytological analysis is an initial step in investigating thyroid nodules. We systematically reviewed the diagnostic value of adding B-type Raf kinase (BRAFV600E) gene mutation analysis to the conventional FNA in the diagnosis of papillary thyroid cancer (PTC).

Methods:

Studies reporting BRAFV600E mutation analysis following FNA for evaluation of thyroid nodules were identified through searching electronic databases (eg, MEDLINE, EMBASE) through 1948-2011, scanning reference lists of relevant studies, and contacting experts. Two independent reviewers screened literature results, abstracted data, and appraised study quality. Meta-analysis of sensitivity and specificity was performed using bivariate random effects models.

Results:

Forty-two studies met our inclusion criteria after screening 787 citations and 117 full-text articles. The included studies enrolled approximately 7,676 patients with 8,196 FNA samples evaluated for BRAFV600E mutation. Bivariate-pooled sensitivity and specificity results from 29 included studies that examined BRAFV600E mutation among cytologically confirmed PTC samples were 72.6% (95% confidence interval [CI] 66.1-78.3%) and 50.8% (95% CI; 32.3-69.1%), respectively. For samples that were diagnosed cytologically as suspicious for PTC, and confirmed by histology as PTC, bivariate-pooled sensitivity and specificity results were 52.1% (95% CI; 36.3-67.4%) and 85.3% (95% CI; 55.2-96.5%), respectively. Eleven studies reported non-diagnostic FNA samples. The pooled sensitivity and specificity results for these samples were 50.5% (95% Cl; 31-69.8%) and 92.9% (95% Cl; 74.2-98.3%), respectively.

Conclusions:

BRAFV600E mutation analysis is associated with increase specificity and moderate increase in the sensitivity of FNA in the diagnosis of papillary thyroid cancer.

Prevalence of harassment and discrimination among residents in three training hospitals in Saudi Arabia

BACKGROUND AND OBJECTIVES

Multiple surveys of medical residents have shown a high incidence of harassment and discrimination in academic health centers. Harassment has a negative effects on residents' health and on their ability to function. No previous study has documented the prevalence of harassment and discrimination among residents in Saudi Arabia. We aimed in this study to assess the prevalence of harassment and discrimination among residents at a tertiary care academic hospitals in Saudi Arabia.

DESIGN AND SETTING

Cross-sectional survey conducted at National Guard Hospitals in Riyadh, Jeddah and Al-Ahsa'a from 27 July to 20 August 2010.

SUBJECTS AND METHODS

The survey included questions on the prevalence of harassment of different types, inlcuding verbal, academic, physical and sexual harassment, as well as discrimination on the basis of gender, region of origin or physical appearance.

RESULTS

Of 380 residents, 213 (56%) returned a completed questionnaire (123 male, 57.8%). At least one of type of harassment and discrimination was reported by 83.6% of respondents. The most frequently reported forms were verbal harassment and gender discrimination (61.5% and 58.3%, respectively). Sexual harassment was commonly reported (19.3%) and was experienced significantly more often by female residents than by male residents (P=.0061).

CONCLUSION

Harassment and discrimination of Saudi residents is common with more than three-quarters reporting having had such an experience. Identification of the risk factors is a necessary first step in clarifying this issue and could be used when planning strategies for prevention.