An assessment of racial differences in epidemiological, clinical and psychosocial factors among head and neck cancer patients at the time of surgery.

OBJECTIVE: Racial disparities have been well characterized and African American (AA) patients have 30% lower 5-year survival rates than European Americans (EAs) for head and neck squamous carcinoma (HNSCC). This poorer survival can be attributed to a myriad of different factors. The purpose of this study was to characterize AA-EA similarities and differences in sociodemographic, lifestyle, clinical, and psychosocial characteristics in HNSCC patients near the time of surgery. METHODS: Setting: Single tertiary care center. Participants: Thirty-nine newly diagnosed, untreated HNSCC patients (n = 24 EAs,n = 15 AAs) who were to undergo surgery were recruited. Study Design: Cross-sectional study Sociodemographic, lifestyle factors, and disease factors (cancer site, AJCC clinical and pathologic stage, and HPV status)were assessed. Risk factors, leisure time, quality of life and social support were also assessed using validated questionnaires. Exposures: EA and AA patients were similar in the majority of sociodemographic factors assessed. AAs had a higher trend toward pathologically later stage disease compared to EAs and significantly increased time to treatment. RESULTS: EA and AA patients were similar in the majority of sociodemographic factors assessed. AAs had a higher trend toward pathologically later stage disease compared to EAs. AAs also had significantly increased time to treatment (P = 0.05). The majority of AA patients (62%) had later stage pathologic disease. AA were less likely to complete high school or college (P = 0.01) than their EA counterparts. Additionally, AAs were more likely to report having a gap in health insurance during the past decade (37% vs. 15%). CONCLUSIONS: This preliminary study demonstrates a similar profile of demographics, clinical and psychosocial characteristics preoperatively for AAs and EAs. Key differences were AAs tending to have later pathologic stage disease, educational status, delays in treatment initiation, and gaps in health insurance.

Inhibition of mTOR Signaling and Clinical Activity of Rapamycin in Head and Neck Cancer in a Window of Opportunity Trial.

PURPOSE: We studied the impact of mTOR signaling inhibition with rapamycin in head and neck squamous cell carcinoma (HNSCC) in the neoadjuvant setting. The goals were to evaluate the mTOR pathway as a therapeutic target for patients with advanced HNSCC, and the clinical safety, antitumor, and molecular activity of rapamycin administration on HNSCC. PATIENTS AND METHODS: Patients with untreated stage II-IVA HNSCC received rapamycin for 21 days (day 1, 15 mg; days 2-12, 5 mg) prior to definitive treatment with surgery or chemoradiation. Treatment responses were assessed clinically and radiographically with CT and FDG-PET. Pre- and posttreatment biopsies and blood were obtained for toxicity, immune monitoring, and IHC assessment of mTOR signaling, as well as exome sequencing. RESULTS: Sixteen patients (eight oral cavity, eight oropharyngeal) completed rapamycin and definitive treatment. Half of patients were p16 positive. One patient had a pathologic complete response and four (25%) patients met RECIST criteria for response (1 CR, 3 PR, 12 SD). Treatment was well tolerated with no grade 4 or unexpected toxicities. No significant immune suppression was observed. Downstream mTOR signaling was downregulated in tumor tissues as measured by phosphorylation of S6 (P < 0.0001), AKT (P < 0.0001), and 4EBP (P = 0.0361), with a significant compensatory increase in phosphorylated ERK in most patients (P < 0.001). Ki67 was reduced in tumor biopsies in all patients (P = 0.013). CONCLUSIONS: Rapamycin treatment was well tolerated, reduced mTOR signaling and tumor growth, and resulted in significant clinical responses despite the brief treatment duration, thus supporting the potential role of mTOR inhibitors in treatment regimens for HNSCC.

Availability of patient-centered cancer support services: A statewide survey of cancer centers.

The Institute of Medicine recommended in their landmark report "From Cancer Patient to Cancer Survivor: Lost in Transition" that services to meet the needs of cancer patients should extend beyond physical health issues to include functional and psychosocial consequences of cancer. However, no systems exist in the US to support state-level data collection on availability of support services for cancer patients. Developing a mechanism to systematically collect these data and document service availability is essential for guiding comprehensive cancer control planning efforts. This study was carried out to develop a protocol for implementing a statewide survey of all Commission on Cancer (CoC) accredited cancer centers in South Carolina and to implement the survey to examine availability of patient support services within the state. We conducted a cross-sectional survey of CoC-certified cancer centers in South Carolina. An administrator at each center completed a survey on availability of five services: 1) patient navigation; 2) distress screening; 3) genetic risk assessment and counseling, 4) survivorship care planning; and 5) palliative care. Completed surveys were received from 16 of 17 eligible centers (94%). Of the 16 centers, 44% reported providing patient navigation; 31% reported conducting distress screening; and 44% reported providing genetic risk assessment and counseling. Over 85% of centers reported having an active palliative care program, palliative care providers and a hospice program, but fewer had palliative outpatient services (27%), palliative inpatient beds (50%) or inpatient consultation teams (31%). This was a small, yet systematic survey in one state. This study demonstrated a practical method for successfully monitoring statewide availability of cancer patient support services, including identifying service gaps.

Intramuscular myxoma of the paraspinal muscles: A case report and systematic review of the literature.

Intramuscular myxoma (IM) is a rare mesenchymal tumor of the head and neck region. The current study reports a case of a 45-year-old man who presented with a painless neck mass. Imaging showed involvement of the levator scapulae and scalene muscles. Core needle biopsy was consistent with intramuscular myxoma. Surgical excision was performed and follow-up for 30 months showed no recurrence. The present study includes a systematic review of head and neck IMs, with a summary of the clinical and demographic parameters of all reported cases in the head and neck region. Surgery was curative in 28 of the 29 published cases, as well as in the current case (96.7%), with the lone recurrent tumor cured following re-resection. Females constituted 57% of the cases and the mean age was 49.7±20.4 years. Although uncommon, IM should be considered in the differential diagnosis of deep neck masses, and surgical excision is the treatment of choice with a low risk of recurrence.

Hyperbaric oxygen therapy for the treatment of radiation-induced xerostomia: a systematic review.

OBJECTIVE: Radiation-induced xerostomia is one of the most common morbidities of radiation therapy in patients with head and neck cancer. However, in spite of its high rate of occurrence, there are few effective therapies available for its management. The aim of this study was to assess the efficacy of hyperbaric oxygen on the treatment of radiation-induced xerostomia and xerostomia-related quality of life. STUDY DESIGN: PubMed, Google Scholar, and the Cochrane Library were searched for retrospective or prospective trials assessing subjective xerostomia, objective xerostomia, or xerostomia-related quality of life. To be included, patients had to have received radiation therapy for head and neck cancer, but not hyperbaric oxygen therapy (HBOT). RESULTS: The systematic review initially identified 293 potential articles. Seven studies, comprising 246 patients, qualified for inclusion. Of the included studies, 6 of 7 were prospective in nature, and 1 was a retrospective study; and 2 of the 7 were controlled studies. CONCLUSIONS: HBOT may have utility for treating radiation-induced xerostomia refractory to other therapies. Additionally, HBOT may induce long-term improvement in subjective assessments of xerostomia, whereas other therapies currently available only provide short-term relief. The strength of these conclusions is limited by the lack of randomized controlled clinical trials.

Calcium Hydroxylapatite Injection for Persistent Velopharyngeal Insufficiency after Sphincter Pharyngoplasty.

BACKGROUND: The role of calcium hydroxylapatite injection pharyngoplasty after failed sphincter pharyngoplasty surgery has not previously been described. We report our technique of injecting calcium hydroxylapatite into the pharyngoplasty site to add bulk to specific areas of the velopharyngeal port. METHODS: A retrospective review of children undergoing calcium hydroxylapatite injection pharyngoplasty for persistent velopharyngeal insufficiency after sphincter pharyngoplasty was performed. Our surgical technique is described. Outcome measures included postoperative perceptual assessment of resonance, improvement in phoneme-specific nasometry scores, and rate of revision surgery. RESULTS: Fourteen patients were included in the study. Improvement in hypernasality on perceptual assessment was noted in the majority of children (85.7%). The rate of achievement of normal resonance on perceptual analysis was 35.7%. A significant decrease in nasometry scores was noted for the following phonemes: /pa/, /sa/, /sha/, and /pi/. There were no intraoperative complications or immediate postoperative complications associated with calcium hydroxylapatite injection. CONCLUSIONS: Our early experience suggests that calcium hydroxylapatite injection after failed sphincter pharyngoplasty is a safe, minimally invasive technique with favorable short-term results.

Melanotic Neuroectodermal Tumor of Infancy: A Systematic Review.

Melanotic neuroectodermal tumor of infancy (MNTI) is a rare tumor, usually diagnosed within the first year of age, with a predilection for the maxilla. Although the tumor is usually benign, its rapidly growing nature and ability to cause major deformities in surrounding structures necessitate early diagnosis and intervention. It is important that medical and dental specialists are prepared to make the diagnosis and proceed with appropriate intervention. The authors performed a systematic review of the 472 reported cases from 1918 through 2013 and provided a comprehensive update on this rare entity that can have devastating effects on young patients. This investigation uncovered age at diagnosis as an important prognostic indicator, because younger age correlated with a higher recurrence rate. The authors also present a case report of a 5-month-old girl diagnosed with MNTI and review her clinical presentation and imaging and histopathologic findings.

Facial nerve monitoring during parotidectomy: a systematic review and meta-analysis.

OBJECTIVES: To determine the effectiveness of intraoperative facial nerve monitoring (FNM) in preventing immediate and permanent postoperative facial nerve weakness in patients undergoing primary parotidectomy. DATA SOURCES: PubMed-NCBI database from 1970 to 2014. REVIEW METHODS: A systematic review and meta-analysis of the literature was conducted. Acceptable studies included controlled series that evaluated facial nerve function following primary parotidectomy with or without FNM (intraoperative nerve monitor vs control). Primary and secondary end points were defined as immediate postoperative and permanent facial nerve weakness (House-Brackmann score, ≥2), respectively. RESULTS: After a review of 1414 potential publications, 7 articles met inclusion criteria, with a total of 546 patients included in the final meta-analysis. The incidence of immediate postoperative weakness following parotidectomy was significantly lower in the FNM group compared to the unmonitored group (22.5% vs 34.9%; P = .001). The incidence of permanent weakness was not statistically different in the long term (3.9% vs 7.1%; P = .18). The number of monitored cases needed to prevent 1 incidence of immediate postoperative facial nerve weakness was 9, given an absolute risk reduction of 11.7% This corresponded to a 47% decrease in the incidence of immediate facial nerve dysfunction (odds ratio, 0.53; 95% CI, 0.35 to 0.79; P = .002). CONCLUSION: In primary cases of parotidectomy, intraoperative FNM decreases the risk of immediate postoperative facial nerve weakness but does not appear to influence the final outcome of permanent facial nerve weakness.

The association between T-stage and clinical nodal metastasis In HPV-positive oropharyngeal cancer.

PURPOSE: To evaluate the association between T-stage and primary tumor subsite with clinical nodal metastasis in HPV-positive oropharyngeal squamous cell carcinomas. STUDY DESIGN: Retrospective medical record review. MATERIALS AND METHODS: A retrospective analysis of all previously untreated patients with HPV-positive oropharyngeal squamous cell carcinoma evaluated by the senior author in a tertiary-care center over a 5-year period was performed. Medical records were evaluated for HPV status, clinical T-stage, clinical nodal stage, and anatomic location of primary oropharyngeal subsite. RESULTS: 83% (59/71) of patients presented with clinical nodal disease. T-stage was not associated with the absence of regional disease (cN0) in tonsillar complex or base of tongue cancers. However, early T1/T2 tonsillar complex cancers were less likely to present with cN2c disease compared to T3/T4 lesions (0% vs. 18-33%, p=0.03). Further, base of tongue cancers were more likely to present with cN2c disease compared to tonsillar complex tumors (35% vs. 7%, p=0.01). CONCLUSION: In HPV-positive tonsillar complex cancers, T-stage does not appear to predict the presence of clinical nodal metastasis (N0 vs. N1-N3), but may predict the extent of metastasis when present. This association does not appear to affect base of tongue cancers. Further, base of tongue cancers have a greater incidence of cN2c disease compared to tonsillar complex cancers.

Ultrasound-Guided Needle Localization during Open Parotid Sialolithotomy.

OBJECTIVES: Our objective is to describe a novel operative technique for localization of parotid sialolithiasis, demonstrate the feasibility of the technique, and discuss its indications. STUDY DESIGN: Prospective study. SETTING: Tertiary-level academic center. SUBJECTS AND METHODS: Patients with symptomatic parotid sialolithiasis who had failed prior sialendoscopic extraction underwent ultrasound needle localization and open sialolithotomy. Data were prospectively collected. Independent variables included size of and location of sialoliths. RESULTS: Eleven patients were treated using transcutaneous ultrasound-guided needle placement and injection of methylene blue prior to external sialolithotomy. Follow-up ranged from 6 to 12 months. Ten (91.9%) patients had stones within the proximal one-third of the ductal lumen, and 1 (9.1%) had stones present within both the proximal one-third and middle one-third of the ductal lumen. The average surgical time was 53 ± 10.8 minutes. The average sialolith length was 7.6 ± 2 mm. The average sialolith width was 6 ± 1.9 mm. All 11 (100%) cases were successful for stone retrieval. Ten (91%) patients had complete symptom resolution, and 1 (9.1%) patient had partial resolution of symptoms. No patients had major complications. Three (27.3%) patients had minor complications. CONCLUSION: After failing a purely endoscopic approach, sialoliths of the parotid gland pose a problem for precise localization and treatment. Ultrasound has been demonstrated to be reliable for identifying sialoliths. We propose a novel technique and assert that ultrasound-guided needle localization is a reliable aid to effective external parotid sialolithotomy, especially for larger stones >4 mm that are not amenable to sialendoscopic retrieval.

Management of radiotherapy-induced salivary hypofunction and consequent xerostomia in patients with oral or head and neck cancer: meta-analysis and literature review.

OBJECTIVE: To analyze the efficacy of various treatment options for radiation-induced hyposalivation in patients with head and neck cancer. STUDY DESIGN: A literature review and meta-analysis was performed on all appropriate literature identified via MEDLINE/PubMed. RESULTS: Fourteen articles were identified that met inclusion criteria for review, and 8 articles qualified for inclusion in the meta-analysis. The available literature addressed both objective and subjective responses of hyposalivation, xerostomia, or both to cholinergic agonists (such as pilocarpine and cevimeline), salivary substitutes, hyperbaric oxygen, and acupuncture. CONCLUSIONS: This analysis indicated that cholinergic agonists were more effective in treating radiation-induced hyposalivation compared with salivary substitutes, hyperbaric oxygen, and acupuncture. However, other treatment modalities, such as salivary substitutes and hyperbaric oxygen, were also found to subjectively improve patients' perception of xerostomia.

Initial symptoms in patients with HPV-positive and HPV-negative oropharyngeal cancer.

IMPORTANCE This study addresses the most common initial symptoms of oropharyngeal squamous cell carcinoma (OPSCC) and investigates differences between human papillomavirus (HPV)­positive vs HPV-negative tumors. OBJECTIVES To analyze the most common initial symptoms in patients with OPSCC and to determine if any differences in initial symptoms occur between HPV-positive and HPV-negative tumors. DESIGN, SETTING, AND PATIENTS Retrospective single-institution review of medical records of previously untreated patients with OPSCC diagnosed from January 1, 2008, toMay 20, 2013, who were evaluated by 1 physician (the senior author, T.A.D.) at the Medical University of South Carolina. MAIN OUTCOMES AND MEASURES We determined the most common initial symptoms of OPSCC and analyzed differences between HPV-positive and HPV-negative tumors. RESULTS Neck mass (in 39 patients [44%]) and sore throat (in 29 patients [33%]) comprised the most common initial symptoms in OPSCC. Patients who were HPV-positive were more likely to initially notice a neck mass than HPV-negative patients (51% vs 18%; P = .02), whereas HPV-negative patients were more likely to notice sore throat (53%vs 28%; P = .09), dysphagia (41% vs 10%; P = .05), or odynophagia (24%vs 6%; P = .04). CONCLUSIONS AND RELEVANCE This study provides preliminary evidence supporting neck mass and sore throat as the initial symptoms of patients with OPSCC. Patients who were HPV-positive more commonly complained of a neck mass as the initial symptom, whereas HPV-negative patients more commonly had symptoms related to the primary tumor site, including sore throat, dysphagia, and/or odynophagia.

Salivary gland transfer to prevent radiation-induced xerostomia: a systematic review and meta-analysis.

Salivary gland transfer (SGT) has the potential to prevent radiation-induced xerostomia. We attempt to analyze the efficacy of SGT in prevention of xerostomia and maintenance of salivary flow rates after radiation treatment (XRT). Systematic review and meta-analysis. Primary endpoint was efficacy of SGT in prevention of radiation-induced xerostomia. Secondary endpoint was change from baseline of unstimulated and stimulated salivary flow rates after XRT. Seven articles, accruing data from 12 institutions, met inclusion criteria. In a total of 177 patients at mean follow-up of 22.7months, SGT prevented radiation-induced xerostomia in 82.7% (95% CI, 76.6-87.7%) of patients. Twelve months after XRT, unstimulated and stimulated salivary flow rates rose to 88% and 76% of baseline values, respectively. In comparison to control subjects twelve months after XRT, SGT subjects' unstimulated (75% vs. 11%) and stimulated (86% vs. 8%) salivary flow rates were drastically higher in SGT patients. Salivary gland transfer appears to be highly effective in preventing the incidence of xerostomia in patients receiving definitive head and neck radiation therapy.