Comparative cost of transoral robotic surgery and radiotherapy (IMRT) in early stage tonsil cancer.

PURPOSE: To compare treatment costs and cost-effectiveness for transoral robotic surgery (TORS) and definitive intensity-modulated radiotherapy (IMRT) in managing early stage tonsil cancer. MATERIALS AND METHODS: Direct treatment costs for surgery and IMRT were calculated from SEER-Medicare data for a cohort with clinically early stage (cT1/2N0) p16+ tonsillar squamous cell carcinoma from Kaiser Permanente Southern California Health Plan between 2012 and 2017. A Markov decision tree model with a 5-year time horizon was then applied to the cohort which incorporated costs associated with treatment, surveillance, and recurrence. RESULTS: IMRT cost up to $19,000 more (35%) than TORS in direct treatment costs. When input into the Markov model, TORS dominated IMRT with lower cost and better effectiveness over a range of values. CONCLUSION: TORS is a more cost-effective treatment method than IMRT in early stage (cT1/2N0) tonsil cancer.

An evolution in demographics, treatment, and outcomes of oropharyngeal cancer at a major cancer center: a staging system in need of repair.

BACKGROUND: In this retrospective review, the authors examined demographic/clinical characteristics and overall survival in patients with squamous cell carcinoma of the oropharynx at a tertiary cancer center, and they report the characteristics that influenced any observed survival trends over time. METHODS: The study included 3891 newly diagnosed, previously untreated patients who presented at the authors' institution between 1955 and 2004. RESULTS: Over time, patients presented at younger ages and were more likely to have base of tongue or tonsil tumors and to be never-smokers or former smokers. Patients who were diagnosed between 1995 and 2004 were almost half as likely to die as those who were diagnosed before 1995 (hazard ratio, 0.6; 95% confidence interval, 0.6-0.8). In both multivariable and recursive partitioning survival analyses, the TNM staging system predicted the survival of patients who received treatment before 1995 but did not predict the survival patients treated during the period from 1995 to 2004. CONCLUSIONS: Survival among patients with squamous cell carcinoma of the oropharynx improved substantially over the past 50 years. The main contributing factors were changes in clinical characteristics, in particular surrogates for positive human papillomavirus status. The current TNM staging system for squamous cell carcinoma of the oropharynx is inadequate. The incorporation of human papillomavirus status and perhaps smoking status into the TNM system is encouraged.

[Gated single photon emission computed tomography (SPECT) and radionuclide ventriculography for evaluate the left ventricle ejection fraction in heart transplant recipients. Comparative study]. / Comparación de la ventriculografía isotópica de equilibrio y la tomografía computarizada con emisión de fotones individuales (SPECT) sincronizado para evaluar la fracción de expulsión del ventrículo izquierdo en pacientes trasplantados de corazón.

OBJECTIVE: To evaluate which is the best method to determine the left ventricular ejection fraction in heart transplant recipients: radionuclide ventriculography or gated SPECT, compared with echocardiography as the gold standard method. MATERIAL AND METHODS: A prospective, transversal, observational, and open study including all orthotopic heart transplant recipients between January 1, 1993 and December 31, 2010 was realized after signed Informed Consent, and we performed echocardiography, radionuclide ventriculography and gated SPECT in 14 patients. Normal value for left ventricle ejection fraction was considered 50% in all the methods. RESULTS: Fourteen heart transplant recipients were considered for the study. Two patients were excluded because of arrhythmic heartbeat at the time of gated SPECT acquisition and two by being newly transplanted. The mean left ventricle ejection fraction was: echocardiography: 69.9%;gated SPECT: 60%; radionuclide ventriculography: 61.1%. The sensitivity of gated SPECT was 75% and 100% for radionuclide ventriculography. Specificity could not be obtained because our population was very small and there were no false negatives. (All the echocardiography results were over 50%). CONCLUSION: It was concluded that despite our small population, the gated SPECT was a useful tool in the evaluation of heart transplant patients due to its functional and prognostic information, besides offering myocardial perfusion imaging.

Sorafenib inhibits the angiogenesis and growth of orthotopic anaplastic thyroid carcinoma xenografts in nude mice.

Anaplastic thyroid carcinoma (ATC) remains one of the most lethal human cancers. We hypothesized that sorafenib, a multikinase inhibitor of the BRaf, vascular endothelial growth factor receptor-2, and platelet-derived growth factor receptor-beta kinase, would decrease tumor growth and angiogenesis in an orthotopic model of ATC. The in vitro antiproliferative and proapoptotic effects of sorafenib on ATC cell lines were examined. To study the in vivo effects of sorafenib on orthotopic ATC tumors in nude mice, sorafenib was given p.o. at 40 or 80 mg/kg daily. Intratumoral effects were studied using immunohistochemical analysis. The effect of sorafenib on survival of the mice was also studied. Sorafenib inhibited the in vitro proliferation of ATC cell lines. Sorafenib also significantly inhibited tumor angiogenesis via the induction of endothelial apoptosis in an orthotopic model of thyroid cancer. As result, the growth of orthotopic ATC xenografts was reduced and the survival of the test animals was improved. Sorafenib exerts significant antitumor activity in an orthotopic xenograft model of ATC via a potent antiangiogenic effect. The antiangiogenic effects of sorafenib suggest that its use in clinical setting may not depend on the BRAF mutational status of thyroid tumors. Given the lack of curative options for patients with ATC, sorafenib warrants further study as a therapeutic agent against ATC.

Mucoepidermoid Carcinoma: A 23-Year Experience with Emphasis on Low-Grade Tumors with Close/Positive Margins.

Objective Describe outcomes for mucoepidermoid carcinoma by histologic grade and evaluate outcomes for patients with low-grade tumors with close/positive margins after initial surgical resection. Study Design Cohort study. Setting Kaiser Permanente Southern California Medical Group from 1993 to 2016. Subjects and Methods Retrospective review of 154 patients with major and minor salivary gland mucoepidermoid carcinoma of the head and neck. Disease-specific and recurrence-free survival were stratified by tumor grade. Subgroup analysis of recurrence-free survival in patients with low-grade disease with close or positive margins was also performed. Results Five-year recurrence-free and disease-specific survival were excellent for both low- and intermediate-grade tumors, while there was there was a high rate of recurrence and mortality among patients with high-grade tumors. Patients with low-grade tumors with close or positive margins who were observed had no difference in recurrence-free survival compared to those who underwent revision surgery and/or adjuvant radiotherapy. Conclusions High-grade mucoepidermoid carcinoma has poor outcomes despite aggressive treatment. Among patients with low-grade tumors with close or positive margins on initial resection, additional treatment had no impact on survival or recurrence. Observation may be a reasonable alternative to additional treatment in this select group of patients.

Staging Neck Dissection and Transoral Robotic Surgery Treatment Algorithm in Palatine Tonsil Cancer.

Objective This study introduces a treatment algorithm based on staging neck dissection to identify patients with palatine tonsil squamous cell carcinoma who can be effectively treated with single-modality transoral robotic surgery while maintaining quality of life. Study Design Retrospective case series. Setting Kaiser Permanente Southern California Medical Group from 2012 to 2017. Subjects and Methods Patients with early-stage (T1/2) palatine tonsil squamous cell carcinoma with clinically and radiographically N0 necks underwent staging neck dissection. Those with pN2/3 disease or extracapsular extension on final pathology were triaged to definitive chemoradiation treatment. Patients with confirmed pN0/1 necks without extracapsular extension were treated definitively with transoral robotic surgery. Results Nineteen patients with cN0 disease underwent selective neck dissection. All were p16 positive. Of these, 14 had pathologically confirmed N0/1 necks without extracapsular extension and were treated with primary surgical resection via transoral robotic surgery. Clear margins were obtained on all patients. There were no significant intra- or postoperative complications. No patients required gastrostomy tube or tracheostomy placement. Mean and median follow-up was 28 months with no recurrences to date. Conclusion Up-front staging neck dissection accurately triages low-risk patients, determining candidates for single-modality definitive treatment with transoral robotic surgery. This approach provides excellent survival outcomes and minimal morbidity and maintains quality of life among appropriately selected patients with palatine tonsil cancer.

Surgical approaches to the hypoglossal canal.

OBJECTIVE: To describe and illustrate three distinct surgical approaches that permit exposure and resection of extradural, intradural, and transdural lesions involving the hypoglossal canal. STUDY DESIGN: Case series. SETTING: University medical center. PATIENTS: Four patients with lesions of the hypoglossal canal were reviewed to illustrate our philosophy when selecting a surgical approach to the hypoglossal canal. INTERVENTIONS: Three separate surgical approaches were used to approach lesions involving various segments of the hypoglossal canal. MAIN OUTCOME MEASURES: Initial clinical presentation, tumor type, treatment course, complications and functional outcomes of hearing, lower cranial nerves, and great vessels. RESULTS: A modified pre- and postauricular infratemporal fossa approach was used to permit the complete resection of an extradural hypoglossal canal schwannoma. The far lateral approach was used to remove a posterior fossa meningioma that involved the intradural hypoglossal canal. A transjugular craniotomy was used to resect a jugulotympanic paraganglioma with transdural hypoglossal canal involvement. Postoperatively, there were no major complications. However, one patient had cerebrospinal fluid rhinorrhea that resolved with lumbar subarachnoid drainage and another had a pseudomeningocele that resolved spontaneously. Dysphagia was not observed in any patient and all were discharged within 1 week of surgery. All patients are free of recurrence by clinical and radiographic examination with at least 2 years of follow-up. CONCLUSIONS: Lesions of the hypoglossal canal can be safely and effectively resected using the appropriate skull base approach. The three skull base approaches described herein provide access to selected portions of the hypoglossal canal and allow for preservation of hearing, the lower cranial nerves, and great vessels.

Socioeconomic Factors Affect Outcomes in Well-Differentiated Thyroid Cancer.

OBJECTIVES: The effects of socioeconomic status (SES) on the incidence of well-differentiated thyroid cancer (WDTC) are well researched. However, the association between SES and outcomes is not delineated. Our objective was to determine if SES affected outcomes of WDTC. STUDY DESIGNS: Retrospective database review. SETTING: Tertiary care medical center. SUBJECTS AND METHODS: The Henry Ford Virtual Data Warehouse Tumor Registry was used to identify cases of WDTC. Socioeconomic data were obtained through the 2010 US Census: median household income, percentage below poverty line, median household size, percentage rent versus own property, and general demographics. Survival was the primary outcome. Disease-specific survival was also calculated. Cox proportional hazards were calculated and a multivariate analysis performed. RESULTS: There were 1317 patients with WDTC. In multivariable analysis, median household income (hazard ratio [HR]: 0.85, 95% confidence interval [95% CI]: 0.79-0.91), household size (HR: 1.49, 95% CI: 1.09-2.14), younger age (HR: 1.97, 95% CI: 1.74-2.23), and female sex (HR: 0.50, 95% CI: 0.37-0.69) were significantly associated with survival. Controlling for stage revealed percentage below poverty line (stage I, HR: 0.51, 95% CI: 1.34-1.78; stage IV, HR: 1.28, 95% CI: 1.04-1.57) and median household income (HR: 0.84, 95% CI: 0.71-0.99) to be significant factors in survival. Median household income was a statistically significant variable for disease-related death (HR: 0.82, 95% CI: 0.69-0.96) CONCLUSIONS: Along with effects on incidence, lower SES correlates with worse survival in WDTC. This suggests that a patient's economic background, with younger age and female sex, influences one's outcomes with regard to both overall and disease-specific death.

Pilot study of a novel population of head and neck cancer patients in the CRN.

Head and neck cancers are challenging to study because of their relatively low incidence. A large, novel population of patients with head and neck cancers that has not been previously studied and distinct from the referral populations has been identified. The National Cancer Institute-funded Health Maintenance Organization Cancer Research Network is a consortium of 15 nonprofit research centers based in large, vertically integrated health care delivery organizations across the United States. They represent a geographically, racially, and socioeconomically diverse population. These community-based organizations provide care to approximately 10 million individuals and 57,692 patients with head and neck cancer. This pilot study and preliminary analysis seeks to demonstrate the potential this network holds as a resource for clinical cancer research and to identify it as a unique resource that allows for more detailed queries than are currently available to researchers.

Sinonasal adenocarcinoma: a 16-year experience at a single institution.

BACKGROUND: Adenocarcinoma is a rare tumor of the sinonasal tract. The purpose of this study was to characterize a single institution's experience with this malignancy. METHODS: Retrospective review was performed of patients with adenocarcinoma of the sinonasal tract from 1993 to 2009. Demographic data, disease presentation, treatment, and survival rates were collected and evaluated. RESULTS: We identified 66 patients with sinonasal adenocarcinoma; 48 were men and 18 women. Average age at time of diagnosis was 57.1 years (range, 20-88 years), and median follow-up was 55.3 months (range, 1-238 months). The ethmoid sinus (38%) and nasal cavity (36%) were the most common sites of origin. Nasal obstruction (36%), epistaxis (30%), and nasal discharge (21%) were the most common presenting symptoms. Fifty-one percent of patients presented with T1 or T2 tumors. Surgery was the primary form of treatment in 81% of patients. Twenty-six percent of surgical patients underwent an endoscopic tumor resection. Adjuvant radiation was utilized in 50% of patients and chemotherapy in 10%. Recurrence was seen in 24 patients (37%): 29% recurred locally and 7.6% recurred distantly. The overall 5-year survival was 65.9%. Survival was decreased significantly in patients with T4 tumors (p < .05), high-grade histology (p < .05), and sphenoid sinus involvement (p < .05). Survival was not affected by surgical approach between endoscopic and open approaches (p = .76). CONCLUSION: Sinonasal adenocarcinomas are commonly identified in the sinonasal cavity and are associated with a relatively favorable prognosis, despite a substantial local failure rate of 30%. Advanced-stage tumors, sphenoid sinus and skull base invasion, and high-grade histology portend poor prognosis. In our experience, endoscopic resection was not associated with adverse outcomes and suggests that this minimally invasive approach can provide acceptable oncologic outcomes in selected patients.

Single stage management of complex fronto-orbital mucoceles.

Mucoceles arising in the frontal and/or ethmoid sinuses are clinically silent and often involve both the orbit and the anterior cranial fossa extensively. Five patients with advanced mucoceles of the frontal sinus involving the orbitocranial skeleton (OCM), as a result of recurrent sinusitis or trauma, were identified during a 36-month period in a major academic US institution. The range of pathology encountered involved brain herniations, CSF leaks, and extensive orbital involvement. These patients required major reconstructive efforts to restore proper orbital skeletal anatomy and function with the use of multiple calvarial bone grafts. The secondary effects of the pathologic process, such as orbital dystopia, ocular dysfunction, and CSF leak among others, resolved in all patients without further problems. Follow-up by repeat computed tomography and examination scan ranged from 6 weeks to 29 months. Adequate reconstruction of extensive OCMs involves four principles: 1) cranialization of the frontal sinus for adequate intracranial and orbital roof access; 2) complete removal of all mucosal elements from the frontal sinus, orbit, and dura; 3) precise restoration of orbital volume with calvarial bone grafts; and 4) reattachment of the medial canthal ligament to the bone grafts to avoid orbital dystopia. The results of the surgery are gratifying, but long-term follow-up is essential due to the risk of recurrence.