Validity of laryngomalacia classification systems: A multi-institutional agreement study.

OBJECTIVES: To determine the agreement of paediatric otolaryngologists on classifying laryngomalacia (LM). DESIGN: Intra- and interobserver agreement study of two classification systems. SETTING: Three tertiary referral paediatric centres. PARTICIPANTS: Three paediatric otolaryngologists, who were blinded to any clinical details, interpreted the videos of children diagnosed with LM using the Holinger and Olney classifications independently. They rated the videos twice with a washout period of at least 2 weeks. THE MAIN OUTCOME MEASURES: Inter- and intra-observer agreement measured by overall Fleiss kappa and unweighted Cohen's kappa coefficients. The secondary outcome measures were inter- and intra-observer agreement on the individual anatomical subunits of the supraglottis affected by LM, characterised by the subcategories of the classifications. RESULTS: Video records of infants and children <18 years who had an endoscopic diagnosis of LM from 2012 to 2017 were retrospectively chosen for inclusion (n = 73). The overall Fleiss kappa coefficient was 0.25 (95% CI 0.18-0.32) amongst the raters using the Holinger classification and 0.31 (95% CI 0.21-0.42) for the Olney classification. Intra-observer agreement using the Holinger classification was 0.30 (95% CI 0.18-0.42), 0.62 (95% CI 0.23-0.85) and 0.84 (95% CI 0.75-0.94], whilst the Olney classification yielded values of 0.41 (95% CI 0.26-0.56), 0.51 (95% CI 0.29-0.63) and 0.63 (95% CI 0.48-0.78). CONCLUSIONS: The agreement on types of LM between expert observers is modest using the Holinger and Olney classifications. This has significant implications for accurately diagnosing LM and exposes potential obstacles against credible pooling of data and extrapolation of information.

Applications of Synthetic Hybrid-Scale Fiber Matrix in Head and Neck Reconstruction: A Case Series.

Introduction: Patients with head and neck cancer often necessitate complex reconstructions, considering both functional and esthetic concerns. Reconstructions are further complicated by previous radiation therapy and patient co-morbidities, which impair wound healing. A recently introduced synthetic hybrid-scale fiber matrix has been shown to provide durable wound coverage and promote tissue healing as an alternative to traditional biologic allogenic and xenogenic skin substitutes. Case Presentation: Thirteen patients were treated at a single academic hospital between December 1, 2021, and May 1, 2023 with the synthetic matrix in head and neck reconstructions. Reconstructions included exposed muscle, scalp wounds, intra-oral defects, and radial forearm free flap donor sites. Wound sizes ranged from 2 × 2 cm to 18 × 10 cm. Serial photographs were taken to evaluate wound healing at 1, 4, 8, 12, and 16 weeks timepoints after application. Outcomes measured at each timepoint included wound size, presence of granulation tissue, and extent of epithelialization. No hematomas or wound complications were encountered. Complete wound healing was noted between 6 and 12 weeks, dependent on wound size. The synthetic matrix significantly promoted wound healing via early granulation tissue formation and epithelialization, or mucosalization, in all head and neck applications. Scar formation and contracture were acceptable in all cases. Conclusion: The use of synthetic hybrid-scale fiber matrix promotes wound healing and avoids patient morbidity associated with traditional allogenic and biogenic treatments, such as split-thickness skin grafts. This synthetic matrix has been demonstrated to be a valuable asset in the head and neck reconstructive armamentarium.

The effect of insurance status on treatment modality in advanced oral cavity cancer.

BACKGROUND: Insurance status has been shown to impact survival outcomes. We sought to determine whether insurance affects the choice of treatment modality among patients with advanced (T4) oral cavity squamous cell carcinoma. METHODS: This is a retrospective, population-based cohort study using the Survival, Epidemiology, and End Results Program database. The population included all adult (age ≥ 18) patients with advanced (T4a or T4b) oral cavity squamous cell carcinoma diagnosed from 2007 to 2016. The main outcome was the odds of receiving definitive treatment, defined as primary surgical resection. Insurance status was categorized into uninsured, any Medicaid, and insured groups. Univariable, multivariable, and subgroup analyses were performed. RESULTS: The study population consisted of 2628 patients, of whom 1915 (72.9%) were insured, 561 (21.3%) had Medicaid, and 152 (5.8%) were uninsured. The multivariable model showed that patients who were 80 years or older, unmarried, received treatment in the pre-Affordable Care Act (ACA) period, and who were on Medicaid or uninsured were significantly less likely to receive definitive treatment. Insured patients were significantly more likely to receive definitive treatment compared to those on Medicaid or uninsured (OR = 0.59, 95% CI 0.46-0.77, p < 0.0001 [Medicaid vs. Insured]; and OR = 0.48, 95% CI 0.31-0.73 p = 0.001 [Uninsured vs. Insured]), however these differences did not persist when considering only those patients treated following the 2014 expansion of the ACA. CONCLUSIONS: Insurance status is significantly associated with treatment modality among adults with advanced stage (T4a) oral cavity squamous cell carcinoma. These findings support the premise of expanding insurance coverage in the US.

Rate of atypical nodal metastases in surgically treated HPV-associated oropharyngeal squamous cell carcinoma.

BACKGROUND: Understanding of nodal metastasis in patients with HPV+ oropharyngeal squamous cell carcinoma (OPSCC) is warranted. METHODS: Patients with HPV+ OPSCC who underwent neck dissection (ND) between 2016 and 2021 were reviewed. Pathology reports were reviewed for lymph node (LN) metastases. Noncontiguous metastases were defined as pathologic evidence of level II disease with another involved LN in a noncontiguous neck level. Skip metastases were defined as pathologic lymph node(s) in the neck without disease in level II. RESULTS: One hundred and thirty-one patients underwent levels II-IV ND with a mean (SD) LN yield of 33.3 (±13.5). The rate of atypical metastases in both the therapeutic and elective ND cohort was 5%. The noncontiguous and skip metastases were in level IV (n = 2) and level III (n = 4), respectively. CONCLUSIONS: Skip and noncontiguous metastases were rare in patients with HPV+ OPSCC undergoing surgical treatment. Surgeons may consider a selective ND omitting Level IV in select patients with HPV+ OPSCC undergoing surgery.

What Surgeons Need to Know About Gene Therapy for Cancer.

The broad field of gene therapy offers numerous innovative approaches for cancer treatment. An understanding of the different modalities including gene replacement therapy, cancer vaccines, oncolytic viruses, cellular therapy, and gene editing is essential for managing patients with neoplastic disease. As in other areas of oncology, the surgeon plays a pivotal role in the diagnosis and treatment of the disease. This review focuses on what the clinical surgeon needs to know to optimize the benefit of gene therapy for patients with cancer.

EGFR as a biomarker of smoking status and survival in oropharyngeal squamous cell carcinoma.

BACKGROUND: This study aims to investigate EGFR as a prognostic biomarker in oropharyngeal squamous cell carcinoma (OPSCC). METHODS: OPSCC patients from retrospective (1998-2009) and prospective cohorts (2014-2017) were included. Retrospectively collected tumors were used to construct tissue microarrays (TMAs), which were stained with EGFR, p16, DAPI and Pan-cytokeratin, and digitally quantified. EGFR, CDKN2A and HPV E6/7 levels from prospectively collected OPSCC was measured by droplet digital PCR (ddPCR). Biomarkers were compared to patient covariates, factors and survival outcomes. RESULTS: A total of 249 patients were included retrospectively and 64 patients were enrolled prospectively. p16 status (p < 0.001), smoking above 10 pack years (p = 0.04), smoking above 20 pack years (p < 0.001), total EGFR tumor levels (p = 0.016), and high EGFR within high or low Ki67 tumor nuclear staining (p = 0.03) were found to be significant predictors of 5-year disease specific survival (DSS). A Cox proportional hazard model of DSS showed smoking status and eGFR expression to be dependent of each other on predicting 5-year DSS. ddPCR analysis showed a significant association between smoking status and EGFR levels. CONCLUSIONS: Total EGFR tumor levels are predictive of 5-year DSS. EGFR levels correlate with. smoking and could be an objective marker for this disease etiology.

Association of Fludeoxyglucose F 18-Labeled Positron Emission Tomography and Computed Tomography With the Detection of Oropharyngeal Cancer Recurrence.

Importance: No guidelines at present describe when fludeoxyglucose F 18-labeled positron emission tomography and computed tomography (FDG PET-CT) should be used in the initial posttreatment period for evaluation of oropharyngeal squamous cell carcinoma treatment outcome and recurrence. Objective: To compare accuracies of the initial posttreatment PET-CT between primary treatment groups and to define indicators of false-positive findings. Design, Setting, and Participants: This retrospective cohort study identified adults with a new diagnosis of oropharyngeal squamous cell carcinoma who received treatment with curative intent from October 1, 2006, through November 30, 2016, using the Alberta Cancer Registry (n = 380). Patients who underwent PET-CT within 1 year of treatment completion were included (n = 190). Of these, 103 patients (54.2%) had PET-CT findings positive for residual or recurrent disease, and 61 (32.1%) had false-positive findings. Among the 61 patients, 42 (68.9%) had received chemoradiotherapy (CRT) and 19 (31.1%) had primary surgery. Forty-two patients had true-positive findings, indicating a prevalence rate of disease of 22.1%. Data were analyzed from July through October 2017. Exposures: One of 2 primary treatment modalities (surgery with or without adjuvant therapy vs CRT). All patients had posttreatment FDG PET-CT. Main Outcomes and Measures: Primary outcome measures included the diagnostic odds ratio, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET-CT for detecting residual and/or recurrent disease. A multivariate analysis determined indicators of false-positive findings. Discriminative ability was assessed using receiver operating characteristic curve analysis of maximum standardized uptake value (SUVmax) metabolic data. Results: Of the 190 participants, 77.9% were men, with a mean (SD) age at diagnosis of 58.5 (8.5) years. The diagnostic odds ratio was 19.3 (95% CI, 5.7-65.1); pooled sensitivity, 93.3% (95% CI, 80.7%-98.3%); and pooled specificity, 57.9% (95% CI, 49.4%-66.0%). The PPV of detecting disease was 54.7% (95% CI, 38.8%-69.8%) for primary surgery and 31.1% (95% CI, 20.2%-44.4%) for CRT. The NPV was 100% (95% CI, 94.7%-100%) for primary surgery and 96.6% (95% CI, 89.5%-99.1%) for CRT. Multivariate analysis identified treatment type, p16 disease, and smoking status as indicative of false-positive findings. In the receiver operating characteristic curve analysis for primary tumors, the optimal cutoff SUVmax for indicating true- vs false-positive results was 5.1 for surgically treated patients (area under the curve, 0.729; 95% CI, 0.570-0.888) and 5.3 for patients treated with CRT (area under the curve, 0.844; 95% CI, 0.700-0.989). Conclusions and Relevance: The results indicate a higher specificity for FDG PET-CT for initial posttreatment surveillance imaging among patients treated with primary surgery compared with nonsurgical management. Both sets of patients with posttreatment FDG PET-CT findings with an SUVmax greater than 5.0 should undergo close evaluation for possible residual or recurrent disease.