Effect of margin status and pathological grade in treatment of sinonasal mucoepidermoid carcinoma.

OBJECTIVES: The purpose of this study was to investigate the association of demographic factors, grade, margin status, and treatment modalities for overall survival in patients with sinonasal mucoepidermoid carcinoma (SNMEC). STUDY DESIGN: Retrospective database review. METHODS: The National Cancer Database was queried for patients of all ages with SNMEC between 2004 and 2015. Univariate Kaplan-Meier and multivariate Cox regression analyses were performed to evaluate the association of suspected prognostic factors with overall survival. Subgroup analysis by margin status and grade was performed. RESULTS: A total of 239 patients with SNMEC were included in the analysis. The 5-year overall survival was 63.6%. Prognostic factors associated with decreased survival include age over 70 years (P = .027), sphenoid primary site (P = .002), and advanced-stage malignancy (P = .024). Improved survival was associated with surgery achieving negative margins (P = .001). Adjuvant radiation was associated with improved survival (hazard ratio [HR] = 0.25, P = .015) in the negative-margin group but was not found to be a statistically significant factor in the positive-margin group (HR = 0.66, P = .509). CONCLUSIONS: This investigation is the largest to date to analyze the association of treatment modalities with overall survival in SNMEC and subgroup analysis by histopathologic grade and surgical margin status of treatment outcomes. Surgery remains the mainstay of treatment in patients with SNMEC. However, administration of radiation may confer survival benefit to patients with negative margins. LEVEL OF EVIDENCE: 4 Laryngoscope, 2020.

Survival in low-grade and high-grade sinonasal adenocarcinoma: A national cancer database analysis.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to investigate survival differences between low-grade and high-grade sinonasal adenocarcinoma (SNAC) by examining demographics, tumor characteristics, and treatment modalities. STUDY DESIGN: Retrospective database analysis. METHODS: The National Cancer Database was queried for patients with SNAC between 2004 and 2015. Univariate and multivariate analyses were performed for all cases of SNAC. Subsequent analysis focused on low-grade (grade 1 and grade 2) and high-grade (grade 3 and grade 4) SNAC. RESULTS: A total of 1,288 patients with SNAC were included in the main cohort and divided into low grade (n = 601) and high grade (n = 370). The 5-year overall survival for all patients, low-grade, and high-grade was 54%, 64%, and 38%, respectively. Prognostic factors associated with decreased survival for the main cohort include advanced age (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 1.03-1.06), Charlson-Deyo score (HR: 1.37; 95% CI: 1.05-1.78), grade 2 (HR: 2.21; 95% CI: 1.26-3.86], grade 3 (HR: 3.67; 95% CI: 2.09-6.45), and grade 4 (HR: 3.31; 95% CI: 1.38-7.91). Radiotherapy was associated with improved overall survival for high-grade SNAC (HR: 0.41; 95% CI: 0.24-0.70) but not for low-grade SNAC (HR: 1.05; 95% CI: 0.59-1.85). CONCLUSIONS: This investigation is the largest to date analyzing the association of treatment modalities with overall survival in SNAC. Surgery remains paramount to treatment, with radiotherapy offering additional survival benefit for high-grade SNAC. Administration of chemotherapy was not associated with improved survival. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:E1-E10, 2020.

Treatment modalities in sinonasal mucosal melanoma: A national cancer database analysis.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to investigate the association of demographic factors, tumor stage, and treatment modalities for overall survival in patients with sinonasal mucosal melanoma (SNMM). STUDY DESIGN: Retrospective database review. METHODS: The National Cancer Database was queried for patients of all ages with SNMM between 2004 and 2015. Univariate Kaplan-Meier and multivariate Cox regression analyses were performed to evaluate the association of suspected prognostic factors with overall survival. RESULTS: A total of 1,874 patients with SNMM were included in the analysis. The 5-year overall survival was 24%. Prognostic factors associated with decreased survival include advanced age (hazard ratio [HR]: 1.02, 95% confidence interval [CI]: 1.01-1.03), T4 disease (HR: 1.44, 95% CI: 1.09-1.89), and presence of distant metastases (HR: 3.22. 95% CI: 2.06-5.04). Improved survival was associated with surgical resection only when margins were negative (HR: 0.44; 95% CI: 0.30-0.65). In patients with metastatic disease, administration of immunotherapy (HR: 0.14; 95% CI: 0.04-0.49) was associated with improved survival. Surgical approach, radiotherapy, and chemotherapy were nonsignificant predictors of survival. CONCLUSIONS: This investigation is the largest to date to analyze the association of treatment modalities with overall survival in SNMM. Surgery remains the mainstay of treatment in patients with SNMM. However, administration of immunotherapy may confer survival benefit to patients with metastatic disease. LEVEL OF EVIDENCE: NA Laryngoscope, 130:275-282, 2020.

Heterogeneity in the clinical presentation, diagnosis, and treatment initiation of p16-positive oropharyngeal cancer.

BACKGROUND: Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) has a patient demographic, presentation, and clinical treatment response distinct from HPV-unassociated OPSCC. The heterogeneity in presentation and diagnosis within a patient population with HPV-positive OPSCC and its impact on times to presentation, diagnosis, and treatment have yet to be characterized. PARTICIPANTS: Patients with biopsy-proven p16-positive OPSCC seen and/or treated at our institution between 2008 and 2018. Of 136 patients with OPSCC seen and/or treated at our institution, 101 met criteria for inclusion. METHODS: Patients were grouped by several parameters including presenting symptom category (asymptomatic neck mass, neck mass with primary-site symptoms, or primary-site symptoms without a neck mass), p16 status on fine-needle aspiration (FNA), and date of presentation. Median time intervals between presentation to imaging, biopsy, and treatment were compared within each parameter using the Kruskal-Wallis test with a significance level of 0.05. RESULTS: Sixty-five of the 101 study patients presented with a neck mass. Patients without a neck mass had a longer interval from presentation to imaging than patients with a neck mass (median 4 vs 0 days, p = 0.025). Initial FNA obtained on 61 patients was positive for p16 in 19 patients. Unknown or negative p16 status on FNA was associated with shorter intervals from initial imaging to treatment initiation (39 vs 46.5 days, p = 0.045). Patients presenting in the final three years had a longer interval from presentation to treatment initiation (55 vs 41 days, p = 0.024). CONCLUSION: A neck mass is absent from the clinical picture of a substantial proportion of HPV-associated OPSCC patients. Primary-site symptom category and regional metastasis were not associated with differences in times to diagnosis or treatment initiation at this major referral center. The increased awareness and complexity of treatment decisions related to OPSCC may contribute to the delays in treatment initiation observed in patients with p16-positive FNAs and those who presented in more recent years.

Histopathologic Features of Chronic Sinusitis Precipitated by Odontogenic Infection.

BACKGROUND: Chronic rhinosinusitis (CRS) is a heterogeneous disease process that can arise in the context of odontogenic disease from the maxillary teeth. The histopathologic features of odontogenic CRS (CRSo) have yet to be determined and may have important implications on disease management and need for escalation of therapy. OBJECTIVES: The objectives of this study are to characterize the histopathologic features of CRSo and determine whether the inflammatory profile of CRSo contributes to its recalcitrance to medical therapy and need for surgery in a subset of patients with this disease. METHODS: A structured histopathology report was used to analyze sinus tissue removed during functional endoscopic sinus surgery (FESS). Histopathology variables, Lund-Mackay scores (LMS), and Sinonasal Outcome Test-22 scores were compared among CRSo patients, CRS without nasal polyps (CRSsNP) patients, and CRS with nasal polyps (CRSwNP) patients. RESULTS: Twenty-three CRSo, 38 CRSwNP, and 53 CRSsNP patients who underwent FESS were analyzed. Compared to CRSsNP, CRSo exhibited increased moderate-severe inflammation (73.9% vs 41.5%, P < .009). Compared to CRSwNP, CRSo had decreased squamous metaplasia (0.0% vs 18.4%, P < .03) and decreased fibrosis (26.1% vs 63.2%, P < .005). Eosinophilia was prevalent in CRSo but to a lesser extent than in CRSwNP (39.1% vs 63.2%, P < .05). CRSo cases had significantly lower mean LMS compared to CRSwNP (7.83 ± 2.77 vs12.18 ± 6.77, P < .005). CONCLUSION: CRSo exhibits histopathologic features similar to those of CRSsNP with more severe inflammation. Moreover, eosinophilia, which is not typically considered to coexist with CRSo, was present in a large portion of CRSo patients. These findings may help explain at the inflammatory level why select cases of CRSo may be recalcitrant to medical and dental therapy.

Understanding the Propensity for Chronic Sinusitis in Patients on Immunosuppressive Therapy.

BACKGROUND: Chronic rhinosinusitis (CRS) is a frequently observed condition in patients with immunodeficiency secondary to immunosuppressive medications. The histologic features of CRS among patients undergoing immunosuppressive treatment have yet to be determined and may have important implications on understanding the pathophysiology of the disease process. METHODS: A structured histopathology report was utilized to analyze sinus tissue removed during functional endoscopic sinus surgery (FESS). Histopathology variables, Lund-Mackay score (LMS), and sinonasal outcome test 22 scores were compared among patients with CRS on immunosuppressive therapy (CRSi), CRS without nasal polyps (CRSsNP) patients, and CRS with nasal polyps (CRSwNP) patients. RESULTS: Fifteen CRSi, 36 CRSwNP, and 56 CRSsNP patients undergoing FESS were analyzed. Compared to CRSsNP, CRSi patients exhibited a trend toward increased moderate-severe inflammation (66.7% vs 42.1%, P < .080), increased neutrophil infiltrate (40.0% vs 24.6%, P < .192), and decreased fibrosis (26.7% vs 43.9%, P < .182). Compared to CRSwNP, CRSi patients demonstrated decreased fibrosis (26.7% vs 66.7%, P < .010), decreased eosinophil aggregates (13.3% vs 44.4%, P < .032), and a trend toward fewer eosinophils per high-power field (46.7% vs 66.7%, P < .154). CRSi cases had significantly lower mean LMS (8.20 ± 4.30 vs 12.78 ± 6.56, P < .017) compared to CRSwNP. CONCLUSION: CRSi patients exhibit histopathology and disease severity more similar to CRSsNP with trends toward increased neutrophilia and reduced fibrosis. In the appropriate clinical context, discontinuing or changing a patient's immunosuppressive regimen may be a valid treatment option in patients with CRSi. This study provides initial insight into understanding the propensity for chronic sinusitis in patients undergoing immunosuppressive treatment which may have implications on disease management.

Laryngeal Paraganglioma with Chronic Cough: A Case Report.

Laryngeal paragangliomas are rare lesions originating from paraganglion cells within the supraglottis or subglottis. As per the latest review, only 76 such cases have been reported in the literature. Symptoms typically include dysphonia or dysphagia. We present, to the best of our knowledge, the first known case of laryngeal paraganglioma with chronic cough as the primary complaint. A 77-year-old male presented with chronic cough. Flexible laryngoscopy revealed a supraglottic submucosal mass emanating from the region of the right false vocal cord and aryepiglottic fold. Postcontrast computed tomography scan showed a well-defined intensely enhancing mass arising from the right paraglottic space and bulging into the right pyriform sinus. Biopsies and immunohistochemical markers supported the diagnosis of paraganglioma. A complete submucosal excision of the mass via a right transcervical approach with tracheostomy was performed. Postoperatively, the patient's cough resolved. Laryngeal paragangliomas are rare tumors that are known to present with dysphonia or dysphagia. This is the first case report of a patient presenting with chronic cough as the primary complaint.

Durability of Silicone Airway Stents in the Management of Benign Central Airway Obstruction.

PURPOSE: The literature is devoid of a comprehensive analysis of silicone airway stenting for benign central airway obstruction (BCAO). With the largest series in the literature to date, we aim to demonstrate the safety profile, pattern of re-intervention, and duration of silicone airway stents. METHODS: An institutional database was used to identify patients with BCAO who underwent rigid bronchoscopy with dilation and silicone stent placement between 2002 and 2015 at Rush University Medical Center. RESULTS: During the study period, 243 stents were utilized in 63 patients with BCAO. Pure tracheal stenosis was encountered in 71% (45/63), pure tracheomalacia in 11% (7/63), and a hybrid of both in 17% (11/63). Median freedom from re-intervention was 104 (IQR 167) days. Most common indications for re-intervention include mucus accumulation (60%; 131/220), migration (28%; 62/220), and intubation (8%; 18/220). The most common diameters of stent placed were 12 mm (94/220) and 14 mm (96/220). The most common lengths utilized were 30 mm (60/220) and 40 mm (77/220). Duration was not effected by stent size when placed for discrete stenosis. However, 14 mm stents outperformed 12 mm when tracheomalacia was present (157 vs. 37 days; p = 0.005). Patients with a hybrid stenosis fared better when longer stents were used (60 mm stents outlasted 40 mm stents 173 vs. 56 days; p = 0.05). CONCLUSION: Rigid bronchoscopy with silicone airway stenting is a safe and effective option for the management of benign central airway obstruction. Our results highlight several strategies to improve stent duration.