Predisposing, Enabling, and Need Factors Driving Palliative Care Use in Head and Neck Cancer

OBJECTIVE

Characterizing factors associated with palliative care (PC) use in patients with stage III and VI head and neck cancer using Anderson's behavioral model of health service use.

STUDY DESIGN

A retrospective study of the 2004 to 2020 National Cancer Database.gg METHODS: We used multivariate logistic regression to assess the association of predisposing, enabling, and need factors with PC use. We also investigated the association of these factors with interventional PC type (chemotherapy, radiotherapy, surgery) and refusal of curative treatment in the last 6 months of life.

RESULTS

Five percent of patients received PC. "Predisposing factors" associated with less PC use include Hispanic ethnicity (adjusted odds ratio [aOR], 086; 95% confidence interval [CI], 0.76-0.97) and white and black race (vs white: aOR, 1.14; 95% CI, 1.07-1.22). "Enabling factors" associated with lower PC include private insurance (vs uninsured: aOR, 064; 95% CI, 0.53-0.77) and high-income (aOR, 078; 95% CI, 0.71-0.85). "Need factors" associated with higher PC use include stage IV (vs stage III cancer: aOR, 2.25; 95% CI, 2.11-2.40) and higher comorbidity index (vs Index 1: aOR, 1.58; 95% CI, 1.42-1.75). High-income (aOR, 0.78; 95% CI, 0.71-0.85) and private insurance (aOR, 0.6; 95% CI, 0.53, 0.77) were associated with higher interventional PC use and lower curative treatment refusal (insurance: aOR, 0.82; 95% CI, 0.55, 0.67; income aOR, 0.48; 95% CI, 0.44, 0.52).

CONCLUSION

Low PC uptake is attributed to patients' race/culture, financial capabilities, and disease severity. Culturally informed counseling, clear guidelines on PC indication, and increasing financial accessibility of PC may increase timely and appropriate use of this service.

Over-The-Counter Hearing Aids: Trends in Information-Seeking Behavior

Recent Food and Drug Administration approval of over-the-counter (OTC) hearing aids has changed the policy landscape surrounding hearing-assistive technology. Our objective was to characterize trends in information-seeking behavior in the era of OTC hearing aids. Using Google Trends, we extracted the relative search volume (RSV) for hearing health-related topics. The mean RSV in the 2 weeks preceding and following enactment of the FDA's OTC hearing aid ruling were compared using a paired samples t-test. RSV for hearing-related queries increased by 212.5% on the date of FDA approval. There was a 25.6% (p = .02) increase in mean RSV for "hearing aids" before and after the FDA ruling. The most popular searches focused on specific device brands and cost. States with more rural residents represented the highest proportion of queries. Understanding these trends is critical to ensure appropriate patient counseling and improve access to hearing assistive technology.

The Representation of Surgery in Oncology Clinical Trials: 2001 to 2022

BACKGROUND

Surgery is a mainstay of cancer care. Since the advancement of cancer treatment occurs through clinical trials, it is critical to investigate the degree and nature of representation of surgery in oncological clinical trials.

METHODS

This observational analysis used publicly available data from clinicaltrials.gov to investigate non-industry-funded oncological clinical trials in the United States between 2012 and 2022.

RESULTS

From 2012 to 2022, 1,861 (15.7%) of the 11,843 registered oncologic clinical trials were surgical. There was a 43.2% increase in proportional surgical trials and an 18.9% increase in oncology trials over the last two decades. Surgery+diagnostic-technique trials increased from 5.14 to 12.6% (P < 0.001, 95%CI [- 0.097, - 0.052]), surgery+radiation trials increased from 5.24 to 8.1% (P = 0.004, 95%CI [- 0.047, - 0.0088]), surgery+systemic-therapy trials decreased from 34.5 to 29.2% (P = 0.003, 95%CI [0.018, 0.088]), surgery+supportive-therapy trials increased from 8.0 to 11.3% (P = 0.004, 95%CI [- 0.056, - 0.01]) and 'surgery-as-the-variable' trials decreased from 12.0 to 3.5% (P < 0.001, 95%CI[0.065, 0.1]). Systemic therapy with biologics increased from 38.1 to 53.9% (P < 0.001, 95%CI [- 0.22, - 0.091]). Surgery-vs.-no-surgery trials increased from 16.8 to 37.3% (P = 0.001, 95%CI [- 0.32, - 0.078]).

CONCLUSION

Surgical oncology trials increased by 43.2% over the last 10 years. The focus of clinical trials is changing to the encouragement of innovation in more diagnostic and less invasive techniques, and targeted therapies.

Autologous humanized PDX modeling for immuno-oncology recapitulates features of the human tumor microenvironment

BACKGROUND

Interactions between immune and tumor cells are critical to determining cancer progression and response. In addition, preclinical prediction of immune-related drug efficacy is limited by interspecies differences between human and mouse, as well as inter-person germline and somatic variation. To address these gaps, we developed an autologous system that models the tumor microenvironment (TME) from individual patients with solid tumors.

METHOD

With patient-derived bone marrow hematopoietic stem and progenitor cells (HSPCs), we engrafted a patient's hematopoietic system in MISTRG6 mice, followed by transfer of patient-derived xenograft (PDX) tissue, providing a fully genetically matched model to recapitulate the individual's TME. We used this system to prospectively study tumor-immune interactions in patients with solid tumor.

RESULTS

Autologous PDX mice generated innate and adaptive immune populations; these cells populated the TME; and tumors from autologously engrafted mice grew larger than tumors from non-engrafted littermate controls. Single-cell transcriptomics revealed a prominent vascular endothelial growth factor A (VEGFA) signature in TME myeloid cells, and inhibition of human VEGF-A abrogated enhanced growth.

CONCLUSIONS

Humanization of the interleukin 6 locus in MISTRG6 mice enhances HSPC engraftment, making it feasible to model tumor-immune interactions in an autologous manner from a bedside bone marrow aspirate. The TME from these autologous tumors display hallmarks of the human TME including innate and adaptive immune activation and provide a platform for preclinical drug testing.

Abstract NG11: Autologous humanized PDX modeling for immuno-oncology recapitulates the human tumor microenvironment

The immune milieu within tumors, consisting of diverse cell types including adaptive immune cells as well as macrophages, dendritic cells, natural killer and other innate immune cells, is critical to determining cancer outcome. However, the immune tumor microenvironment (TME) has been challenging to model, owing to inherent inter-species differences. While humanized mice can support human immune cells, the hematopoietic stem and progenitor cells (HSPCs) used for transplantation have been largely limited to fetal or neonatal stem cell sources, necessitating allogeneic experiments with limited applicability. We sought to develop a method to pre-clinically model an individual adult cancer patient, capturing the unique features of an individual such as germline genetic determinants of immune function and somatic tumor heterogeneity, and creating an autologous system.

MISTRG6 may be engrafted with low numbers of HSPCs. When engrafted with equivalent numbers of CD34+ cells from human fetal liver (FL), neonatal cord blood (CB), adult mobilized peripheral blood (MPB), or adult bone marrow (BM), MISTRG6 mice harbored greatly increased human hematopoietic cells as a proportion of total hematopoietic cells in peripheral blood compared with NOD-scid-gamma (NSG) and MISTRG mice (p&lt;0.0001). We found that MISTRG6 mice could be engrafted with as few as 1,000 human HSPCs, arguably 100x more efficient than other models, and achieve robust hematopoietic transplantation after 10-12 weeks, indicating the efficiency of this strain in supporting the growth of hematopoietic cells. To better elucidate the mechanism responsible for this enhanced human engraftment, we enumerated human and mouse hematopoietic progenitors in BM of NSG, MISTRG, and MISTRG6 mice. Human progenitors, including CD34+ and CD34+CD38+ cells, were significantly increased in both frequency and absolute numbers in MISTRG and MISTRG6 mice compared with NSG mice (p&lt;0.001), and mouse hematopoietic lin(-)cKit+ (LK) and lin(-)Sca1+cKit+ (LSK) progenitor populations were significantly diminished (p&lt;0.0001), suggesting that the enhanced hematopoietic engraftment observed in MISTRG6 is, in part, a consequence of increased human progenitor frequency and reduced mouse competition.

MISTRG6 allows efficient engraftment of patient derived HSPCs. We sought to apply this improved engraftment prospectively to model individual patients’ TME through collection of BM-derived CD34+ cells from patients under active treatment along with tumor tissue from the same patient. At two cancer centers, we enrolled patients with melanoma, NSCLC, PDAC, and HNSCC to provide BM aspirate, peripheral blood, and tumor tissue. CD34+ cells were isolated from BM aspirates and tumor tissue was utilized to generate PDXs. Overall, 71 patients were enrolled, 46 melanoma, 19 NSCLC, 4 PDAC, 2 HNSCC, ages 22-85, 39% females. These yielded autologous, immune-reconstituted MISTRG6 hosts from 14 melanoma, 5 NSCLC, 2 PDAC, and 1 HNSCC patients. Autologously engrafted MISTRG6 mice displayed the gamut of human immune cells of adaptive and innate types in PB at 7 weeks of age. Notably, this included CD33+ myeloid cells such as CD14+CD16− classical, CD14+CD16+ intermediate, and CD14−CD16+ non-classical monocytes. Moreover, human dendritic cells (DCs), key innate immune cells for initiation of anti-tumor responses were readily detected by flow cytometry in spleens of autologously-engrafted mice, including cDC1, cDC2, and pDC cells.

MISTRG6 mice bearing a patient’s hematopoietic cells support autologous PDX growth. Having achieved successful engraftment of patient hematopoietic systems in MISTRG6 hosts, we next subcutaneously introduced the patient’s matched PDX tumor tissue to generate autologously engrafted PDX mice. For most patients, tumors grown in autologous HSPC-engrafted hosts were significantly larger than in non-engrafted hosts. Multicolor immunofluorescence staining of PDX tumors demonstrated that human immune cells, including CD3+ T cells, CD14+ and HLA-DR+ myeloid cells, penetrated deeply into the tumor and co-localized with tumor cells as well as with other engrafted immune cells. Indeed, HLA-DR+CD14+macrophages and HLA-DR+CD14(-) dendritic cells were present, and direct physical interaction between T cells and macrophages was evident. Using whole-exome sequencing, we found that 225 somatic changes were shared between patient Mel738’s surgical resection sample, two PDX tumors from non-engrafted mice lacking human immune cells, and two PDX tumors from mice with autologous engraftment. 5 additional changes were shared among the tumor samples and absent from the cell line, with 36 additional mutations being specific to the cell line. These data underscore the capacity of the autologous PDX method to recapitulate the somatic heterogeneity that the patient tumor possesses.

Autologous MISTRG6 mice display diverse human immune cell populations and recapitulate an immunosuppressive TME. To fully characterize the autologous MISTRG6 model and investigate mechanisms by which autologous human immune cells enhance tumor growth, we performed single cell transcriptomics on hCD45+-enriched cells from blood and tumor isolated from autologous mice. This revealed 16 distinct cell subtypes, including 3 myeloid, 2 NK cell, 2 CD8 T cell, 3 CD4 T cell, 2 cycling lymphocyte, 1 B cell, and 3 melanoma cell clusters. Subclustering of myeloid cells revealed 9 distinct clusters including 4 monocyte, 4 macrophage, and 1 DC cluster. Comparing CD8 T cells present in blood versus tumor revealed that the most differentially expressed genes (DEGs) found in blood were characteristic of naïve T cells, while genes present in the TME were consistent with activated T cell phenotypes. In addition, sub-clustering revealed 3 distinct CD8 T cell types that included two activated-like populations, with one of these populations also expressing an activated/exhausted program typified by expression of PDCD1, LAG3, and GZMA. Naïve-like T cells were most highly represented in the blood, while activated and activated/exhausted-like genes were more present in the TME.

Inhibiting the actions of human VEGF-A blocks the enhanced tumor growth in autologously engrafted mice. Notably, IPA Upstream Regulator Analysis identified VEGFA, a central player in tumor growth and vascularization, as a key upstream inducer of genes in the TME (FDR p= 5.65 × 10−13). Indeed, expression VEGFA itself was nearly absent in blood but induced in the TME, especially in macrophages and VEGFA targets were highly represented among the DEGs between tumor and blood.To test the relevance of VEGF-A in the TME, we selectively blocked human VEGF-A by treating autologous mice humanized from Mel2 with the anti-hVEGF-A antibody bevacizumab that has high affinity for human VEGF-A yet low affinity for mouse VEGF-A. PDXs grown in untreated autologously engrafted MISTRG6 mice grew significantly larger than those in non-engrafted littermate control hosts (p&lt;0.05). When treated with bevacizumab, the enhanced tumor growth was significantly abrogated, with bevacizumab-treated mice bearing significantly smaller tumors compared with controls (p&lt;0.001).

Future Directions: Thus, these in silico and in vivo results suggest that human VEGF-A production in the autologous TME enhances tumor growth in MISTRG6 PDX models and underscores the utility of the MISTRG6 system for pre-clinical testing of drugs that act on human immune components of the TME. By engrafting mice with bone marrow derived stem cells followed by implantation of tumor derived from the same donor, we have demonstrated that autologous MISTRG6 models recapitulate important features of the human TME, including sufficient immunosuppression to prevent tumor clearance, presence of activated/exhausted T cells, and innate immune cells including DCs, monocytes, NK cells, and macrophages, the latter especially relevant to the production of VEGF-A.

Citation Format: Michael Chiorazzi, Jan Martinek, Bradley Krasnick, Yunjiang Zheng, Keenan Robbins, Rihao Qu, Gabriel Kaufmann, Zachary Skidmore, Laura Henze, Frederic Brösecke, Adam Adonyi, Jun Zhao, Liang Shan, Esen Sefik, Jacqueline Mudd, Ye Bi, S Peter Goedegebuure, Malachi Griffith, Obi Griffith, Abimbola Oyedeji, Sofia Fertuzinhos, Roland Garcia-Milian, Daniel Boffa, Frank Detterbeck, Andrew Dhanasopon, Justin Blasberg, Benjamin Judson, Scott Gettinger, Katerina Politi, Yuval Kluger, A Karolina Palucka, Ryan Fields, Richard A. Flavell. Autologous humanized PDX modeling for immuno-oncology recapitulates the human tumor microenvironment. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr NG11.

Trends in Residency Applicant Volume in Otolaryngology-Head and Neck Surgery and Peer Specialties

OBJECTIVE

To evaluate the 2020 to 2021 Otolaryngology residency application cycle in the context of recent trends.

STUDY DESIGN

Retrospective data analysis.

SETTING

Disruptions caused by the COVID-19 pandemic may significantly alter trends among residency applicants, especially in highly competitive and/or smaller specialties.

METHODS

Applicant and residency statistics from Electronic Residency Application Service (ERAS) and National Residency Matching Program (NRMP) were extracted from the 2016 to 2021 and 2011 to 2021, respectively. Trends in Otolaryngology-Head and Neck Surgery (OHNS) were compared to peer specialties (PS) including Dermatology, Neurological Surgery, Orthopedic Surgery, and Integrated Pathway for Plastic and Reconstructive Surgery (PRS). The ratio of the number of applicants per positions (APP) was used to reflect the degree of competition.

RESULTS

Between 2011 and 2021, the number of OHNS programs and positions expanded less than those of PS and General Surgery. The increase in the APP ratio was significantly greater for OHNS compared to those Dermatology, Orthopedic Surgery, General Surgery and all PGY1 residency positions for both US MD and all applicants (P < .01 for each). OHNS expansion of US MD (P = .046), but not all applicants (P = .169), outgrew that of Neurosurgery.

CONCLUSION

The 2020 to 2021 cycle affected by the COVID-19 pandemic saw a continuation of the recent trend in the expanding OHNS applicant pool. OHNS remains one of the specialties with the highest APP ratio and has observed a significant growth compared to PS since 2018. Understanding and anticipating trends in residency application cycles is critical for designing processes to optimize the best fit between applicants and programs.

NIMG-64. TYPE OF BONY INVOLVEMENT PREDICTS GENOMIC SUBGROUP IN SPHENOID WING MENINGIOMAS

OBJECTIVE

As sphenoid wing meningiomas (SWMs) are associated with varying degrees of bony involvement, we sought to understand potential relationships between genomic subgroup and this feature.

METHODS

Patients treated at Yale-New Haven Hospital for SWM were reviewed. Genomic subgroup was determined via whole exome sequencing, while the extent of bony involvement was radiographically classified as frank tumor invasion (TI), hyperostosis only (HOOs), or both (TI+HO). Among additional clinical variables collected, a subset of tumors was identified as spheno-orbital meningiomas (SOMs). Predictive logistic regression models were developed for genomic subgroups based on pre-operative clinical features.

RESULTS

Among 64 SWMs, 53% had HOO, 9% had TI, and 14% had TI+HO; nine SOMs were identified. Tumors with invasion (i.e., TI or TI+HO) were more likely to be WHO grade II (p: 0.028). Additionally, tumors with invasion were nearly 30 times more likely to harbor NF2 mutations (OR: 27.6; p: 0.004), while hyperostosis only (without frank tumor invasion) were over 4 times more likely to have a TRAF7 mutation (OR: 4.5; p: 0.023). SOMs were a significant predictor of underlying TRAF7 mutation (OR: 10.21; p: 0.004).

CONCLUSIONS

SWMs with invasion into bone tend to be higher grade and are more likely to be NF2 mutated, while SOMs and those with hyperostosis are associated with TRAF7 variants. Pre-operative prediction of molecular subtypes based on radiographic bony characteristics may have significant biological and clinical implications based on known recurrence patterns associated with genomic drivers.

Anesthesia screen use may impact operating room communication practices in otolaryngology

OBJECTIVES

Failures in communication are a leading contributor to medical error. There is increasing attention on cultivating robust communication practices in the Operating Room (OR) to mitigate against patient injury and optimize efficient patient care. Few studies have evaluated how surgical equipment may introduce barriers to team dynamics.

DESIGN

We conducted a pilot observational study to examine the relationship between anesthesia screen drapes (which are used inconsistently) and the frequency of verbal exchanges between surgical and anesthesia members. 25 procedures spanning various procedures in Otolaryngology were covertly observed, 12 of which employed a screen. Verbal exchanges were recorded across three stages of the surgery: pre-procedure (before the draping), procedure (drapes placed throughout) and post-procedure (after the removal of the draping). Speaker and content of the exchange was noted as well as various features about the procedure.

RESULTS

Decreases in rates of exchanges were most pronounced during the procedure stage, although they did not reach significance on T-testing (p = 0.0719). After controlling for attending, table orientation and number of professionals, regression analysis did reveal a statistically significant decrease in rates of verbal exchanges during the procedure in the presence of the anesthesia screen (7.17 (± 6.33) versus 2.23 (± 1.00), p = 0.0318). Differences were also significant among surgeon-initiated and patient-care-related exchanges (p = 0.0168 and p = 0.0432, respectively). Decreases in anesthesiologist-initiated and non-clinical exchanges did not reach significance (p = 0.1530 and p = 0.5120, respectively).

CONCLUSION

This pilot study suggests that anesthesia screens may negatively impact communication practices in the OR.

Otolaryngology Applicant Characteristics and Trends: Comparing OTO-HNS with Peer Specialties

PURPOSE

To evaluate the recent Otolaryngology-Head and Neck Surgery (OTO-HNS) applicant characteristics, to identify which applicant characteristics are associated with successful match into OTO-HNS, and to compare OTO-HNS applicant trends and characteristics to that of peer surgical specialties (PS).

MATERIALS AND METHODS

Data were obtained from official reports by the National Residency Matching Program (NRMP) for OTO-HNS, plastic and reconstructive surgery, orthopedic surgery, neurosurgery, and dermatology from 2006 to 2019. Alpha Omega Alpha (AOA) membership, United States Medical Licensing Examination (USMLE) scores, research productivity, graduation from a top-40 NIH-funded U.S. medical school, and additional graduate degree were recorded. Odds ratios (OR) were calculated to evaluate the relationship between applicant qualifications and match success.

RESULTS

From 2014 to 2018, the OTO-HNS applicant pool shrunk from 443 to 333, representing the largest drop of all PS. Furthermore, OTO-HNS reported the most unfilled positions and highest match rates in 2017 (n = 14; 92.1%) and 2018 (n = 12; 94.6%) among any PS. Despite recent trends, 2019 NRMP data revealed a 38.74% increase in OTO-HNS applicant numbers compared to 2018. AOA membership (OR, 7.3; P = .030), USMLE Step 2 scores between 241 and 260 (OR, 6.5; P = .009), and research productivity (OR, 5.6; P = .005) significantly increased the odds of matching into OTO-HNS.

CONCLUSIONS

Despite recent fluctuations in application trends, OTO-HNS continues to successfully match highly qualified applicants, including applicants with AOA membership, high Step 2 scores, and high research productivity. An understanding of the qualifications used to evaluate residency applicants may be helpful to both applicants and residency programs of OTO-HNS.

Association of Human Papillomavirus Status at Head and Neck Carcinoma Subsites With Overall Survival

Importance

Data are limited on the prognostic value of human papillomavirus (HPV) status for head and neck carcinoma subsites.

Objective

To determine whether HPV positivity at each head and neck subsite is associated with improved overall survival.

Design, Setting, and Participants

This retrospective population-based cohort study used the National Cancer Database to identify patients diagnosed with head and neck squamous cell carcinomas from January 1, 2010, to December 31, 2014. Patients were classified according to the location of their primary malignancy into 1 of the 6 main subsites of the upper aerodigestive tract: oral cavity, oropharynx, nasopharynx, hypopharynx, larynx, and sinonasal tract. Patients were also classified by their HPV status. Data collection for this study took place from January 1, 2010, to December 31, 2014. Data analysis was conducted from August 1, 2017, to September 30, 2017.

Main Outcomes and Measures

The difference in 5-year overall survival between patients with HPV-positive status and those with HPV-negative status in various head and neck carcinoma subsites; the role of HPV status in an unadjusted Cox multivariate regression model.

Results

Of the 175 223 total number of patients identified (129 634 [74.0%] male; 45 589 [26.0%] female; mean [SD] age, 63.1 [11.9] years), 133 273 (76.1%) were ineligible and 41 950 (23.9%) were included in the sample. This sample included 16 644 patients (39.7%) with HPV-positive tumors and 25 306 (60.3%) with HPV-negative tumors. Patients with an HPV-positive status were more likely to be younger, be white, be male, present with local T category tumors, and have poor differentiation on histologic examination. HPV-positive status was associated with survival at 4 tumor subsites: oral cavity (hazard ratio [HR], 0.76; 95% CI, 0.66-0.87), oropharynx (HR, 0.44; 95% CI, 0.41-0.47), hypopharynx (HR, 0.59; 95% CI, 0.45-0.77), and larynx (HR, 0.71; 95% CI, 0.59-0.85). The HPV status was the greatest factor in survival outcome between the HPV-positive and -negative cohorts at the oropharynx subsite (77.6% vs 50.7%; survival difference, 26.9%; 95% CI, 25.6%-28.2%) and hypopharynx subsites (52.2% vs 28.8%; survival difference, 23.4%; 95% CI, 17.5%-29.3%). For the nasopharynx (HR, 1.03; 95% CI, 0.75-1.42) and sinonasal tract (HR, 0.63; 95% CI, 0.39-1.01) subsites, HPV-positive status was not an independent prognostic factor.

Conclusions and Relevance

Human papillomavirus positivity was associated with improved survival in 4 subsites (oropharynx, hypopharynx, oral cavity, and larynx), and the largest survival difference was noted in the oropharynx and hypopharynx subsites. In the nasopharynx and sinonasal tract subsites, HPV positivity had no association with overall survival. Given these results, routine testing for HPV at the oropharynx, hypopharynx, oral cavity, and larynx subsites may be warranted.

Treatment Delays in Primarily Resected Oropharyngeal Squamous Cell Carcinoma: National Benchmarks and Survival Associations

OBJECTIVE

To characterize treatment delays in surgically treated oropharyngeal cancer, identify factors associated with delays, and associate delays with survival.

STUDY DESIGN

Retrospective cross-sectional analysis.

SETTING

Commission on Cancer-accredited institutions.

SUBJECTS AND METHODS

We identified patients in the National Cancer Database with surgically treated oropharyngeal cancer. We characterized the durations of diagnosis-to-treatment initiation, surgery-to-radiation treatment, radiation treatment duration, total treatment package, and diagnosis-to-treatment end intervals as medians. We associated delays with patient, tumor, and treatment factors via multivariable logistic regression analysis and with overall survival by Cox proportional hazards regression.

RESULTS

In total, 3708 patients met inclusion criteria. Median durations of diagnosis-to-treatment initiation, surgery-to-radiation treatment, radiation treatment duration, total treatment package, and diagnosis-to-treatment end intervals were 27, 42, 47, 90, and 106 days, respectively. Medicaid and human papillomavirus (HPV) negativity were associated with delays. Delayed total treatment package and diagnosis-to-treatment end intervals were associated with decreased survival (hazard ratio [HR] = 1.81 [1.29-2.54], P = .001 and HR = 1.97 [1.39-2.78], P < .001, respectively); this was maintained following HPV stratification. Delays in the surgery-to-radiation treatment interval were associated with decreased overall survival in HPV-negative but not HPV-positive patients (HR = 2.05 [1.19-3.52], P = .010 and HR = 1.15 [0.74-1.80], P = .535, respectively). Diagnosis-to-treatment initiation and radiation treatment duration were not associated with overall survival in the overall cohort (HR = 1.21 [0.86-1.72], P = .280 and HR = 1.40 [0.99-1.99], P = .061, respectively); however, following stratification, delayed radiation treatment duration approached significance in HPV-negative but not HPV-positive patients (HR = 1.60 [0.96-2.68], P = .072 and HR = 1.35 [0.84-2.18], P = .220).

CONCLUSION

Treatment durations identified here can serve as national benchmarks and for institutions to compare quality to their peers. Distinct benchmarks should be applied to HPV-negative and HPV-positive patients.

Hypopharyngeal Cancer Treatment Delays: Benchmarks and Survival Association

Objective

To characterize treatment delays in hypopharyngeal cancer, identify factors associated with delays, and associate delays with overall survival.

Study Design

Retrospective cohort.

Setting

Commission on Cancer hospitals nationwide.

Subjects and Methods

We included patients in the National Cancer Database who were treated for hypopharyngeal cancer with primary radiation, concurrent chemoradiation, or induction chemotherapy and radiation. We identified median durations of diagnosis to treatment initiation (DTI), radiation treatment duration (RTD), and diagnosis to treatment end (DTE). We associated delays with patient, tumor, and treatment factors and overall survival via multivariable logistic and Cox proportional hazards regression, respectively.

Results

A total of 3850 patients treated with primary radiation or concurrent chemoradiation were included. Median durations of DTI, RTD, and DTE were 37, 52, and 92 days, respectively. Nonwhite race was associated with delays in DTI (odds ratio [OR] = 0.64; 95% CI, 0.51-0.80; P < .001) and DTE (OR = 0.60; 95% CI, 0.49-0.75; P < .001). Medicaid insurance was associated with delays in DTI (OR = 1.43; 95% CI, 1.07-1.90; P = .015), RTD (OR = 1.39; 95% CI, 1.06-1.83; P = .018), and DTE (OR = 1.48; 95% CI, 1.12-1.97; P = .007). Delays in RTD (hazard ratio [HR] = 1.24; 95% CI, 1.11-1.37; P < .001), not DTI (HR = 0.92; 95% CI, 0.82-1.03; P = .150) or DTE (HR = 1.01; 95% CI, 0.90-1.15; P = .825), were associated with impaired overall survival. We identified 922 patients who received induction chemotherapy. Delays in DTI, RTD, and DTE were not associated with overall survival in this cohort (HR = 1.10; 95% CI, 0.87-1.39; P = 0.435; HR = 1.05; 95% CI, 0.83-1.32; P = 0.686; HR = 1.11; 95% CI, 0.88-1.41; P = 0.377, respectively).

Conclusions

The median durations identified can serve as national benchmarks. Delays during radiation are associated with impaired overall survival among patients treated with primary radiation or chemoradiation but not patients treated with induction chemotherapy.

A Clinical Care Pathway to Reduce ICU Usage in Head and Neck Microvascular Reconstruction

Objective

To design and implement a postoperative clinical care pathway designed to reduce intensive care usage on length of stay, readmission rates, and surgical complications in head and neck free flap patients.

Methods

A postoperative clinical care pathway detailing timelines for patient care was developed by a multispecialty team. In total, 108 matched patients receiving free tissue transfer for reconstruction of head and neck defects in the year before (prepathway), year after (early pathway), and second year after (late pathway) pathway implementation were compared based on postoperative length of stay, 30-day readmission rate, intensive care unit (ICU) admission, and rates of medical/surgical complications.

Results

Median length of stay decreased from 10 to 7.5 and 7 days in the pre-, early, and late-pathway groups, respectively ( P = .012). Readmission rate decreased from 16% in the prepathway group to 0% and 3% in the early and late-pathway groups. The number of patients admitted to the ICU postoperatively decreased from 100% to 36% and 6% in the pre-, early, and late-pathway groups, respectively ( P = .025). The rates of surgical and medical complications were equivalent.

Discussion

This pathway effectively reduced ICU admission, length of stay, and readmission rates, without increasing postoperative complications. These outcomes were sustainable over 2 years.

Implications for Practice

Free flap patients may not require routine ICU admission and may be taken off ventilatory support in the operating room. This effectively reduces costly resource use in this patient population. Similar pathways could be introduced at other institutions.

Pediatric Salivary Cancer: Epidemiology, Treatment Trends, and Association of Treatment Modality with Survival

Objective To characterize the epidemiology of pediatric salivary cancer and associate patient, tumor, and treatment factors with treatment modality and survival. Study Design Cross-sectional analysis. Setting US national database. Subjects and Methods We identified 588 patients 19 years or younger diagnosed with salivary cancer in the National Cancer Database 2004-2013. We characterized patient, tumor, and treatment factors as proportions and associated these factors with treatment modality and overall survival via multivariable logistic regression and multivariable Cox proportional hazards regression, respectively. Results In total, 588 patients were included. Mucoepidermoid carcinoma was identified in 234 of 588 patients (40%) and acinar cell carcinoma in 215 of 588 (37%). Parotid tumors were seen in 504 (86%) of patients. Surgery alone was used to treat 351 (60%) of patients; surgery plus adjuvant radiation was used to treat 145 (25%). Overall 5-year survival was 93%. Controlling for patient and tumor characteristics, treatment with surgery and radiation vs surgery alone was associated with improved overall survival (hazard ratio [HR] = 0.15; 95% confidence interval [CI], 0.02-0.92; P = .041). High tumor grade was associated with decreased overall survival (HR = 33.17; 95% CI, 5.89-186.8; P < .001). Treatment with surgery plus radiation remained associated with improved overall survival in the subset of patients with high tumor grade (HR = 0.12; 95% CI, 0.02-0.64; P = .014). Conclusion Tumor grade is an important predictor of survival in pediatric patients with salivary gland cancer. Surgery plus adjuvant radiation vs surgery alone is associated with improved overall survival and may be considered for high-risk patients, particularly those with high-grade tumors.

Treatment Times in Salivary Gland Cancer: National Patterns and Association with Survival

Objective To characterize treatment times in salivary cancer; associate treatment times with patient, tumor, and treatment characteristics; and examine the association of treatment times and overall survival. Study Design Retrospective cohort. Setting Commission-on-Cancer Accredited Hospitals 2004-2013. Subjects and Methods In total, 5953 patients with salivary cancer included in the National Cancer Database were identified. For each treatment interval, patients in the fourth quartile ("prolonged") were compared to patients in the first and second quartiles ("not prolonged"). Patient, tumor, and treatment characteristics were associated with prolonged times via multivariable binary logistic regression. Prolongation of each interval was associated with overall survival via multivariable Cox proportional hazards regression, controlling for clinically relevant factors. Results Median durations for diagnosis-to-treatment initiation, surgery-to-radiation treatment (RT), RT duration, total treatment package, and diagnosis-to-treatment end were 31, 44, 47, 92, and 110 days, respectively. Race, insurance status, comorbidities, age, T and N stage, facility volume and location, and a facility care transition from diagnosis to initial treatment were associated with prolonged treatment time. Prolonged RT duration was associated with decreased overall survival (OS) (62% vs 75% 5-year OS, HR = 1.26 [95% confidence interval (CI), 1.09-1.47]; P = .002), but prolonged diagnosis-to-treatment initiation, surgery-to-RT, total treatment package, and diagnosis-to-treatment end intervals were not (70% vs 67% 5-year OS, HR = 1.11 [95% CI, 0.92-1.34], P = .284; 72% vs 68%, HR = 0.93 [95% CI, 0.79-1.09], P = .370; 70% vs 70%, HR = 1.00 [95% CI, 0.84-1.20], P = .974; 66% vs 71%, HR = 0.99 [95% CI, 0.84-1.18], P = .920, respectively). Conclusion The median durations identified here can serve as reference points. Radiation therapy duration is associated with overall survival in salivary cancer and could be considered a quality indicator.

Demethylation Therapy as a Targeted Treatment for Human Papillomavirus-Associated Head and Neck Cancer

Purpose: DNA methylation in human papillomavirus-associated (HPV⁺) head and neck squamous cell carcinoma (HNSCC) may have importance for continuous expression of HPV oncogenes, tumor cell proliferation, and survival. Here, we determined activity of a global DNA-demethylating agent, 5-azacytidine (5-aza), against HPV⁺ HNSCC in preclinical models and explored it as a targeted therapy in a window trial enrolling patients with HPV⁺ HNSCC.Experimental Design: Sensitivity of HNSCC cells to 5-aza treatment was determined, and then 5-aza activity was tested in vivo using xenografted tumors in a mouse model. Finally, tumor samples from patients enrolled in a window clinical trial were analyzed to identify activity of 5-aza therapy in patients with HPV⁺ HNSCC.Results: Clinical trial and experimental data show that 5-aza induced growth inhibition and cell death in HPV⁺ HNSCC. 5-aza reduced expression of HPV genes, stabilized p53, and induced p53-dependent apoptosis in HNSCC cells and tumors. 5-aza repressed expression and activity of matrix metalloproteinases (MMP) in HPV⁺ HNSCC, activated IFN response in some HPV⁺ head and neck cancer cells, and inhibited the ability of HPV⁺ xenografted tumors to invade mouse blood vessels.Conclusions: 5-aza may provide effective therapy for HPV-associated HNSCC as an alternative or complement to standard cytotoxic therapy. Clin Cancer Res; 23(23); 7276-87. ©2017 AACR.

A Comparison of Prognostic Ability of Staging Systems for Human Papillomavirus-Related Oropharyngeal Squamous Cell Carcinoma

Importance

The current American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) staging system, developed for human papillomavirus (HPV)-unrelated disease, discriminates poorly when applied to HPV-related oropharyngeal squamous cell cancer (OPSCC), leading to calls for a new staging system.

Objective

To compare the prognostic ability of the AJCC/UICC seventh edition staging system; a recently proposed system, the International Collaboration on Oropharyngeal Cancer Network for Staging (ICON-S); and a novel objectively derived system for HPV-related OPSCC using a national database of patients primarily treated with either radiation or surgery.

Design, Setting, and Participants

In this observational study, patients with HPV-related nonmetastatic OPSCC were identified in the National Cancer Database between 2010 and 2012. Recursive partitioning analysis (RPA) was used to derive the proposed-RPA staging system. The data were analyzed from March to May 2016.

Main Outcomes and Measures

Overall survival was calculated using the Kaplan-Meier method. The performance of the 3 systems was compared using published criteria, and internal validation using bootstrap methods was performed. Survival differences between stage groups were evaluated using the log-rank test.

Results

A total of 5626 patients (86.0% male; median [range] age, 58 [21-90] years) were identified. The median (range) follow-up was 28.5 (0.1-58.8) months. A novel staging system (proposed-RPA) consisting of stage IA, T1-2N0-2a; stage IB, T1-2N2b-3; stage II, T3N0-3; stage III, T4a-bN0-3 resulted in 3-year overall survival rates of 91%, 87%, 81%, and 70%, respectively. This system, as well as the ICON-S, significantly prognosticated for survival when either primary surgery or primary radiation subgroups were examined (log-rank P < .001 for all). The AJCC/UICC system, ICON-S, and proposed-RPA all significantly predicted survival outcomes when analyzed globally (log-rank P < .001 for all). The AJCC/UICC system could not differentiate between survival when stages I and IVA were compared, however (log-rank P = .17). On comparative performance evaluation for survival prediction, the proposed-RPA provided superior prognostication compared with the other systems.

Conclusions and Relevance

We validated the ICON-S staging as prognostic, overall, and in primary radiation therapy and surgery subgroups, but ultimately found that a staging system consisting of stage IA, T1-2N0-2a; stage IB, T1-2N2b-3; stage II, T3N0-3; and stage III, T4a-bN0-3 (with stage IV representing M1 disease) outperformed the others. The proposed-RPA is an alternative staging system that should be evaluated for potential adoption as part of the next AJCC/UICC staging system.

Response to nivolumab in radiation induced, BRCA-2 N372H variant, programed death ligand-1 negative, pleomorphic undifferentiated sarcoma

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Background: Early results from recent studies using immune checkpoint blockade targeting programmed death 1 (PD-1) have suggested that pleomorphic undifferentiated sarcomas may have response rates of over 40%. As of now predictive biomarkers for response and resistance have been incompletely characterized. Methods: A 58-year-old man who received radiation for a head and neck squamous cell cancer, developed a radiation-induced undifferentiated pleomorphic sarcoma (UPS) in his neck in 2014. His sarcoma was resected but recurred in 2015. He received adjuvant radiation after surgical debulking in September 2015 and was found on radiation simulation scan to have new widespread metastatic disease involving liver, lung, and bone. He started treatment on nivolumab in November 2015 and has had a sustained near complete response in all lesions. Results: All sites had a near complete response to nivolumab treatment. Pre treatment tissue analysis revealed no mutations or amplifications in 134 cancer-related genes, on the Oncomine Assay (Life Technologies, Inc.). Normal tissue was noted to be heterozygous for BRCA2 N372H, while the allelic fraction of the 372H variant in the tumor was found to be 85%. Programmed death ligand-1 (PDL-1) immunohistochemistry staining of the tumor tissue was negative. Tumor infiltrating lymphocytes were not noted in the tumor tissue specimen. Conclusions: This patient exhibited a near complete response to all sites of disease, with remaining PET avidity in a single hilar node. The role of the BRCA2 variant and radiation just prior to starting nivolumab is unknown. BRCA2 N372H is a common single nucleotide polymorphism (SNP) in the population with a minor allele frequency of 0.25. Although the effect of the 372H variant on BRCA2 protein structure is predicted to be minimal, population studies have suggested a slightly increased risk of breast and ovarian cancer in homozygotes. It is possible that the radiation treatment to the site of recurrence in the head and neck, resulted in an abscopal effect enhancing the therapeutic effect of nivolumab therapy. Additional testing on his tissue is being done to further investigate the response.

NOTCH1 and SOX10 are Essential for Proliferation and Radiation Resistance of Cancer Stem-Like Cells in Adenoid Cystic Carcinoma

PURPOSE

Although the existence of cancer stem cells (CSC) in adenoid cystic carcinoma (ACC) has been proposed, lack of assays for their propagation and uncertainty about molecular markers prevented their characterization. Our objective was to isolate CSC from ACC and provide insight into signaling pathways that support their propagation.

EXPERIMENTAL DESIGN

To isolate CSC from ACC and characterize them, we used ROCK inhibitor-supplemented cell culture, immunomagnetic cell sorting, andin vitro/in vivoassays for CSC viability and tumorigenicity.

RESULTS

We identified in ACC CD133-positive CSC that expressed NOTCH1 and SOX10, formed spheroids, and initiated tumors in nude mice. CD133(+)ACC cells produced activated NOTCH1 (N1ICD) and generated CD133(-)cells that expressed JAG1 as well as neural differentiation factors NR2F1, NR2F2, and p27Kip1. Knockdowns ofNOTCH1, SOX10, and their common effectorFABP7had negative effects on each other, inhibited spheroidogenesis, and induced cell death pointing at their essential roles in CSC maintenance. Downstream effects ofFABP7knockdown included suppression of a broad spectrum of genes involved in proliferation, ribosome biogenesis, and metabolism. Among proliferation-linked NOTCH1/FABP7 targets, we identified SKP2 and its substrate p27Kip1. A γ-secretase inhibitor, DAPT, selectively depleted CD133(+)cells, suppressed N1ICD and SKP2, induced p27Kip1, inhibited ACC growthin vivo, and sensitized CD133(+)cells to radiation.

CONCLUSIONS

These results establish in the majority of ACC the presence of a previously uncharacterized population of CD133(+)cells with neural stem properties, which are driven by SOX10, NOTCH1, and FABP7. Sensitivity of these cells to Notch inhibition and their dependence on SKP2 offer new opportunities for targeted ACC therapies.

Outcomes for stage IVA squamous cell carcinoma of the oral cavity according to staging subtypes

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Background: Patients with locoregionally advanced squamous cell carcinoma of the oral cavity (SCCOC), defined as stages III to IVB without T4b, are treated similarly and combined for enrollment into most clinical trials. There are several combinations of tumor (T) and lymph node (N) categories for stage IVA. We evaluated the differences in outcomes according to subtypes of patients with stage IVA SCCOC. Methods: The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients with stage IVA SCCOC diagnosed between 1988 and 2007. Patients were subdivided according to tumor (T) and lymph node (N) status. Overall survival (OS) was estimated by the Kaplan-Meier method and compared by using log-rank test. Cox proportional hazard regression models were used for multivariate analyses. Results: Among the 3,904 patients meeting inclusion criteria, most patients underwent surgery, either alone (24%) or with radiation (59%). There was a significant difference in outcomes according to AJCC subsets (T4aN0, T4aN1, T1N2, T2N2, T3N2 and T4N2), with 5-year OS ranging from 15.8% in T4aN2 to 41.3% in T4aN0 (HR 2.3; 95% CI 2.03-2.62, p < 0.001). Since the 5-year OS was similar for patients with T1N2-T2N2 and T3N2-T4aN2, these groups were further subdivided according to the T (T1-2 or T3-4a) and N2 subsets. The 5-year OS was significantly different according to the subgroups, ranging from 11.8% in T3-4aN2c to 37.5% in T1-2N2a (Table). The stage subgroups remained independent predictors for survival after adjusting for age, gender, race and treatment. Conclusions: Stage IVA SCCOC is a heterogeneous disease with significant differences in outcomes according to its subsets. If these findings are confirmed in additional studies, further subdivision of stage IVA may be warranted. [Table: see text]

Role of adjuvant radiation in patients with squamous cell carcinomas of the oral cavity

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Background: Although surgery is the initial treatment of choice for patients with stage III squamous cell carcinoma (SCC) of the oral cavity (OC), the role of adjuvant radiotherapy (RT) remains undefined. We evaluated the differences in outcome according to stage subsets and use of adjuvant RT. Methods: The Surveillance Epidemiology and End Results (SEER) database was queried for patients with SCCOC, treated with surgery (S), RT, or both (SRT); older than 21 years; and diagnosed between 2004 and 2009. Patients with extracapsular lymph node extension or multiple primary cancers were excluded. Overall Survival (OS) rates were estimated by the Kaplan-Meier method and compared using log-rank testing as well as Cox proportional hazards. Results: Among the 1,051 patients meeting eligibility criteria, the most common treatment was SRT (49.1%), followed by S alone (28.9%), and RT alone (22.0%). The 5-year OS ranged from 33.3% in T3N1 to 52.8% in T1N1. Compared to S alone, the addition of RT improved 5-year OS in the entire cohort from 39.5% to 51.1% (HR 0.69, 95% CI 0.54-0.87, p = 0.002). This benefit, however, was significant only for stage T3N0 with a trend towards improvement in the T3N1 group. No significant benefit was observed in T1N1 or T2N1 disease (Table). Conclusions: Stage III SCC of the oral cavity is a heterogeneous disease with significant differences in survival according to its subsets. Adjuvant RT was associated with improved survival for patients with stage T3N0 disease but not T1N1 or T2N1. The benefit of RT in T3N1 cases did not reach statistical significance likely due to the small number of patients. If confirmed in prospective studies, further subdivision of stage III SCC of OC may be necessary, and the indication for RT may be restricted to patients with T3 disease. [Table: see text]

Role of excision repair cross-complementation 1 expression as a prognostic marker for response to radiotherapy in early-stage laryngeal cancer

BACKGROUND

High expression of excision repair cross-complementation 1 (ERCC1) predicts for resistance to platinum-based chemotherapy or chemoradiotherapy. We evaluated the prognostic value of ERCC1 expression in a cohort of laryngeal cancer treated with radiotherapy alone.

METHODS

ERCC1 expression was examined by immunohistochemical analysis of tissue microarrays constructed from 123 patients with stages I-II laryngeal squamous cell carcinoma treated with standard radiotherapy.

RESULTS

ERCC1 expression did not correlate with clinicopathologic risk factors, local control, or overall survival. At 5 years, local control was 75% versus 71% (p = .78) and overall survival was 68% versus 54% (p = .65), for nonexpressors and expressors of ERCC1, respectively. On multivariate analysis, T classification predicted for local control, and T classification and age predicted for overall survival.

CONCLUSIONS

ERCC1 expression did not predict for radiotherapy resistance or worse survival. Therefore, radiotherapy remains an effective treatment in tumors with high ERCC1 expression.

Prognostic significance of the AJCC staging in patients with squamous cell carcinoma of the oropharynx

5529

Background: There have been significant changes in the epidemiology of head and neck squamous cell carcinomas (HNSCC), with an increase in the incidence of oropharyngeal (OP) cancer and opposite effect in other sites. Since the rise in OP cancer incidence is attributed to human papillomavirus (HPV), which is associated with a different biology and clinical behavior, we evaluated whether the current AJCC system retained its prognostic impact in this patient population. Methods: The Surveillance Epidemiology and End Results (SEER) registry was queried for patients with HNSCC diagnosed between 2004 and 2007. Overall survival (OS) was estimated by the Kaplan-Meier method and the Cox model was used to compare the survival curves for each AJCC stage. Patients were grouped into three anatomical locations: oral cavity (OC), larynx (L) and OP. Results: There were 26,520 patients meeting eligibility criteria, including 8622 OP, 7332 OC, and 10566 L. The AJCC staging retained its prognostic significance across all stages for patients with HNSCC of the OC and L. Patients with OP cancer, however, had similar 4-year survival for stages I through IVA, whereas stage IVB and IVC had a significantly decrease survival compared to IVA and IVB respectively (Table). Conclusions: The OS for stages III and IVA OP cancer is similar to those with stages I and II, in an effect that may be attributed to the increased frequency of HPV in this population, rendering the tumors more sensitive to chemotherapy and radiation. Therefore, the AJCC stage in OP cancer may be more useful in guiding the therapy than as a prognostic factor. [Table: see text]

Influence of extracapsular extension on lymph node staging for patients with squamous cell carcinoma of the head and neck

5532

Background: Although extracapsular extension (ECE) is a known poor prognostic factor in head and neck squamous cell carcinoma (HNSCC) and recommended to be collected by the current AJCC manual, it currently does not influence the final stage. We evaluated the prognostic impact of ECE in 4 primary sites. Methods: The Surveillance Epidemiology and End Results (SEER) was queried for patients with squamous cell cancers of the oral cavity (OC), oropharynx (OP), hypopharynx (H) and larynx (L), known ECE status, M0, and diagnosed between 2004 and 2007. Survival curves were estimated by the Kaplan-Meier and compared by Cox proportional hazards models. Results: There were 23,384 patients meeting eligibility criteria, including 14,664 (62.7%) N0, 6483 (27.7%) N+ without ECE (NECE), and 2237 (9.6%) with ECE. ECE was associated with decreased 3-year overall survival (OS), compared to NECE, for all lymph node stages including N1 (52% vs 61%, HR 1.32, p = 0.001), N2a (60% vs 76%, HR 1.82, p<0.001), N2b (44% vs 62%, HR 1.62, p<0.001), N2c (34% vs 47%, HR 1.43, p<0.001), N3 (31% vs 44%, HR 1.38, p=0.012). ECE was also an independent poor prognostic factor for cancer in the OC (HR 1.43, p < 0.001), OP (HR 1.44, p < 0.001), H (HR 1.58, p = 0.01), and L (HR 1.28, p = 0.01). The comparison between ECE and NECE with one additional N degree showed no significant OS difference, except OP N1 and H N2a ECE, where survival was inferior to OP N2a and H N2b NECE respectively (Table). Conclusions: ECE is a significant predictor for poor outcomes in HNSCC, with survival equivalent to one additional degree of N involvement. [Table: see text]

Cervical dedifferentiated liposarcoma with meningothelial-like whorling

Liposarcomas are the most common soft-tissue sarcoma of adults, but rare in the head and neck. Recently, a subtype of dedifferentiated liposarcoma with meningiothelial-like whorls was reported and we present the first description of such a tumor in the head and neck. A 65 year old male underwent a resection of a calcified retroesophageal mass that was in close relation to the left hemithyroid and recurrent laryngeal nerve. It was resected en bloc with the left thyroid lobe. Initial pathologic evaluation suggested the mass was a schwanomma of the recurrent laryngeal nerve, but positive staining for MDM2 and CDK4 indicated the tumor was a dedifferentiated liposarcoma. Further evaluation elucidated the unique meningothelial-like whorls within the tumor. This case demonstrates dedifferentiated liposarcomas do appear in the head and neck. Furthermore, this is the first report in the head and neck of the mengiothelial-like whorling pattern type of dedifferentiated liposarcoma.