Myoid gonadal stromal tumours are characterised by recurrent chromosome-level copy number gains: molecular assessment of a multi-institutional series.

Myoid gonadal stromal tumours (MGST) represent a rare type of testicular sex cord-stromal tumour that has recently been recognised as a distinct entity by the World Health Organization (WHO) classification of genitourinary tumours. MGSTs affect adult men and have been reported to behave in an indolent fashion. Histologically, MGSTs are pure spindle cell neoplasms that coexpress SMA and S100 protein. Given that the molecular features of these neoplasms remain largely undescribed, we evaluated a multi-institutional series of MGSTs using DNA and RNA sequencing. This study included 12 tumours from 12 patients aged 28 to 57 years. Tumour sizes ranged from 0.6 to 4.3 cm. Aggressive histologic features, such as vascular invasion, necrosis, invasive growth, and atypical mitoses were invariably absent. Mitotic activity was low, with a median of less than 1 mitosis per 10 high power fields (HPF; maximum: 3 mitoses per 10 HPF). Molecular analyses did not identify recurrent mutations or gene fusions. All cases with interpretable copy number variant data (9/10 cases sequenced successfully) demonstrated a consistent pattern of chromosome arm-level and whole-chromosome-level copy number gains indicative of ploidy shifts, with recurrent gains involving chromosomes 3, 6, 7, 8, 9, 11, 12, 14q, 15q, 17, 18q, 20, and 21q. Similar findings have also been recognised in pure spindle cell and spindle-cell predominant sex cord-stromal tumours without S100 protein expression. MGSTs are characterised by ploidy shifts and may be part of a larger spectrum of spindle cell-predominant sex cord-stromal tumours, including cases without S100 protein expression.

What's in a Name? A Cost-Effectiveness Analysis of the Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features' Nomenclature Revision.

Background: The noninvasive subtype of encapsulated follicular variant of papillary thyroid carcinoma (eFVPTC) has been reclassified as noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) in 2016 to reflect the indolent behavior and favorable prognosis of this type of tumor. This terminology change has also de-escalated its management approach from cancer treatment to a more conservative treatment strategy befitting a benign thyroid neoplasm. Objective: To characterize the reduced health care costs and improved quality of life (QOL) from management of NIFTP as a nonmalignant tumor compared with the previous management as eFVPTC. Methods: A cost-effectiveness analysis was performed by creating Markov models to simulate two management strategies for NIFTP: (i) de-escalated management of the tumor as NIFTP involving lobectomy with reduced follow-up, (ii) management of the tumor as eFVPTC involving completion thyroidectomy/radioactive iodine ablation for some patients, and follow-up recommended for carcinoma. The model was simulated for 5 and 20 years following diagnosis of NIFTP. Aggregate costs and quality-life years were measured. One-way sensitivity analysis was performed for all variables. Results: Over a five-year simulation period, de-escalated management of NIFTP had a total cost of $12,380.99 per patient while the more aggressive management of the tumor as eFVPTC had a total cost of $16,264.03 per patient (saving $3883.05 over five years). Management of NIFTP provided 5.00 quality-adjusted life years, whereas management as eFVPTC provided 4.97 quality-adjusted life years. Sensitivity analyses showed that management of NIFTP always resulted in lower costs and greater quality-adjusted life years (QALYs) over the sensitivity ranges for individual variables. De-escalated management for NIFTP is expected to produce ∼$6-42 million in cost savings over a five-year period for these patients, and incremental 54-370 QALYs of increased utility in the United States. Conclusion: The degree of cost savings and improved patient utility of de-escalated NIFTP management compared with traditional management was estimated to be $3883.05 and 0.03 QALYs per patient. We demonstrate that these findings persisted in sensitivity analysis to account for variability in recurrence rate, surveillance approaches, and other model inputs. These findings allow for greater understanding of the economic and QOL impact of the NIFTP reclassification.

A preliminary assessment of guideline adherence and clinical variation in oral cancer treatment: a MarketScan database study.

BACKGROUND: To assess variations in adherence to guideline-recommended processes of care for oral cavity cancer patients. METHODS: Retrospective study using a U.S. healthcare research database (MarketScan). Index diagnoses were considered from 2010 to 2012 with follow-up from 2013 to 2014. Diagnostic and procedure codes were utilized to identify oral cavity patients with a defined treatment modality. Compliance with guideline-recommended processes of care, which included pre-treatment imaging, thyroid-function testing (TFTs), multidisciplinary consultation and gastrostomy-tube insertion rates, were assessed. RESULTS: A total of 2752 patients were identified. Surgery alone was the most common treatment (60.8%), followed by surgery with adjuvant chemoradiotherapy (20.4%) and surgery with adjuvant radiotherapy (18.8%). Head/neck and chest imaging were obtained in 60% and 62.5% of patients respectively. Significant geographical differences in head and neck imaging were observed between North-central (64%), South (58.4%) and West (56.1%) regions (p = 0.026). Differences in chest imaging were also present between North-east (65%) and West (56.8%; p = 0.007). TFTs were obtained in 54.4% of the patients after radiation treatment, and 18.6% of patients had multidisciplinary consultation during the 6 months before and 3 months after initiation of treatment. During the year after treatment initiation, 21.2% of patients underwent G-tube placement, with significantly higher rates in patients receiving triple modality treatment (58%) when compared to surgery plus radiation (27%) and surgery alone (15%; p < 0.01). CONCLUSION: Adherence to evidence-based practices was low based on the database coding. These data suggest a potential to improve adherence and increase the routine use of practices delineated in national clinical practice guidelines. CLINICAL RELEVANCE: This study reflects a suboptimal adherence to guidelines based on the database employed. This study should be considered by healthcare providers and efforts should be maximized to follow the processes of care which have proven to impact on patient's outcomes.

Primary payer status, individual patient characteristics, and hospital-level factors affecting length of stay and total cost of hospitalization in total laryngectomy.

BACKGROUND: Medicaid and uninsured patients anecdotally incur higher cost and length of stay because of nonmedical, discharge-related factors. The purpose of this study was to investigate the association between primary payer and length of stay and cost, controlling for comorbidities and complications, in patients undergoing total laryngectomy. METHODS: The sample included 4128 patients who underwent total laryngectomy in the 2005 to 2010 National Inpatient Sample (NIS). Patients were categorized into 4 subgroups based on payer status: Medicare, Medicaid, uninsured, and private insurance. Using multilevel modeling, we examined differences in length of stay and hospitalization costs. RESULTS: The odds of being in the top quartile of length of stay increased for Medicaid patients by 41% (odds ratio [OR] = 1.41; 95% confidence interval [CI] = 1.03-1.92) compared with privately insured patients. CONCLUSION: After controlling for medical factors, Medicaid patients had increased lengths of stay. Overall costs were highest for those with public insurance, but no difference was seen for the adjusted cost. © 2016 Wiley Periodicals, Inc. Head Neck 39: 311-319, 2017.

Otolaryngology workforce analysis.

OBJECTIVES/HYPOTHESIS: The number of trained otolaryngologists available is insufficient to supply current and projected US health care needs. The goal of this study was to assess available databases and present accurate data on the current otolaryngology workforce, examine methods for prediction of future health care needs, and explore potential issues with forecasting methods and policy implementation based on these predictions. STUDY DESIGN: Retrospective analysis of research databases, public use files, and claims data. METHODS: The total number of otolaryngologists and current practices in the United States was tabulated using the databases of the American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Board of Otolaryngology, American College of Surgeons, Association of American Medical Colleges, National Center for Health Statistics, and Department of Health and Human Services. Otolaryngologists were identified as surgeons and classified into surgical groups using a combination of AMA primary and secondary self-reported specialties and American Board of Medical Specialties certifications. Data gathered were cross-referenced to rule out duplications to assess total practicing otolaryngologists. Data analyzed included type of practice: 1) academic versus private and 2) general versus specialty; and demographics: 1) urban versus rural, 2) patient age, 3) reason for visit (referral, new, established, surgical follow-up), 4) reason for visit (diagnosis), and 5) payer type. RESULTS: Analysis from the above resources estimates the total number of otolaryngologists practicing in the United States in 2011 to be 12,609, with approximately 10,522 fully trained practicing physicians (9,232-10,654) and 2,087 in training (1,318 residents and 769 fellows/others). Based on 2011 data, workforce projections would place the fully trained and practicing otolaryngology workforce at 11,088 in 2015 and 12,084 in 2025 unless changes in training occur. The AAO-HNS Physicians Resource Committee performed an extensive analysis of collated data from multiple sources in 2014 and identified 10,800 practicing otolaryngologists and 2,087 in training. It is estimated that the current attrition rate is approximately 306 otolaryngologists per year. Percentage distribution of office visits by patient age was found to be 20% <15 years old, 7% 15 to 24 years old, 21% 25 to 44 years old, 32% 45 to 64 years old, 11% 65 to 74 years old, and 10% ≥75 years old. Reason for visit was 34% new, 29% chronic, 17% chronic with exacerbation, and 15% pre- or postsurgical follow-up. The top diagnoses consisted of otitis media, chronic sinusitis, and impacted cerumen. Payer mix consisted of 59% private insurance, 19% Medicare, and 12% Medicaid/Children's Health Insurance Program. CONCLUSIONS: Despite past findings and predictions of 8,000 to 8,500 otolaryngologists practicing in the United States, collated data from above resources places the total at 12,887, with 10,800 fully trained and practicing in 2014. This 30% to 50% underestimation of the otolaryngology workforce has an impact on future predictions and resource utilization analysis. Even when this correction is considered, the available trained otolaryngologists required to serve the otolaryngologic health care needs of the US population are still insufficient and understaffed. The impact of an aging population and the estimated 30 to 47 million newly insured citizens under the 2010 Patient Protection and Affordable Care Act are also unprecedented variables that must be considered. Further analysis of differences in physician productivity and geographic population density, and model formation of current otolaryngology workforce utilization, are needed to predict future public health needs. LEVEL OF EVIDENCE: NA Laryngoscope, 126:5-11, 2016.

Effect of Payer Status on Relative Survival of Patients with Laryngeal Cancer.

BACKGROUND: Relative survival (RS) for patients with laryngeal cancer in the US population has yet to be described. Additionally, survival of patients with laryngeal cancer has demonstrated socioeconomic and racial disparities which have not been previously examined through the lens of RS. MATERIALS AND METHODS: Data on 58,814 patients with laryngeal cancer were obtained from the National Cancer Database. Patients were diagnosed between 1998 and 2006, and had at least 5 years of follow-up. Birth-, year-, age-, sex- and race-specific matched life expectancies were used to estimate expected survival. Stage-stratified RS rates were calculated with multiple factors assessed for significance. Excess mortality ratios were estimated in multivariate analysis utilizing Poisson regression. RESULTS: Younger age, African-American race, uninsured or Medicaid insurance, and treatment at an academic center were all significantly associated with stage IV disease. Uninsured and Medicaid patients demonstrated decreased RS when compared to privately insured individuals. Excess mortality was markedly pronounced in the first year for patients over 50 years old with stage II-IV disease, especially for the over 75-year-old cohort. CONCLUSION: Survival disparities for uninsured and Medicaid populations were found, with these patients exhibiting increased excess mortality. Additionally, RS calculations highlight the negative effects of increasing age on survival of patients with laryngeal cancer.

Morbidity, mortality and cost from HPV-related oropharyngeal cancer: Impact of 2-, 4- and 9-valent vaccines.

OBJECTIVE: The incidence of oropharyngeal squamous cell carcinoma (OPSCC) related to human papillomavirus (HPV) is increasing at a dramatic rate, with men affected more commonly than women. Individuals who develop this disease suffer significant morbidity and potential mortality from their cancer and its associated treatment. We aim to evaluate the possible impact that the currently available HPV vaccines will have on this group of cancers. DATA SOURCES: Available peer-reviewed literature, practice guidelines, and statistics published by the Center for Disease Control and Prevention. REVIEW METHODS: Contemporary peer-reviewed medical literature was selected based on its scientific validity and relevance to the impact HPV vaccination may have on the morbidity, mortality and cost resulting from HPV-related OPSCC in the United States. CONCLUSIONS: The incidence of HPV-related OPSCC is increasing at a near epidemic rate in the United States. The cost of treatment of HPV-related OPSCC is high, and the disease and its therapy result in significant morbidity and potential mortality to individuals. Using a cut-off of $50,000/Quality-Adjusted Life Year, expansion of current HPV vaccine indications to include prevention of OPSCC in both men and women should be recommended.

Improvements in survival and disparities for advanced-stage laryngeal cancer.

IMPORTANCE: Laryngeal cancer survival rates have declined over the past 2 decades. Primary surgical therapy may increase survival rates in advanced-stage tumors. OBJECTIVE: To compare survival outcomes for initial surgical treatment of advanced-stage primary tumors in the Louisiana health system with outcomes in the National Cancer Database (NCDB). DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis was conducted at an academic tertiary referral hospital. Patients diagnosed as having laryngeal carcinoma between 1998 and 2007 were identified via a tumor registry. Louisiana State University Health-Shreveport (LSU Health) data and national data from 2000 to 2010 were obtained from the NCDB of the American College of Surgeons. INTERVENTIONS: Treatment of laryngeal cancer. MAIN OUTCOMES AND MEASURES: Age, sex, race/ethnicity, socioeconomic status, laryngeal subsite, stage, primary treatment modality, and observed survival were analyzed and compared. RESULTS: A total of 165 patients treated at LSU Health met the inclusion criteria. One hundred seventeen (70.91%) presented with advanced-stage (III/IV) disease, compared with 46.67% nationwide (P < .01). For stage IV disease our 5-year survival rate was 55.54% (95% CI, 43.35%-66.11%)compared with 31.60% (95% CI, 30.40%-32.90%) nationally (P < .05). Our proportion of uninsured patients was 23.73% vs 5.05% of patients nationally (P < .001), and our patients traveled further distances for care with 60.47% traveling 50 miles or more, compared with 15.87% nationally (P < .001). Sixty-four of the patients with advanced-stage disease (54.70%) underwent primary surgical therapy to include total laryngectomy. Data from the NCDB indicate that the rate of laryngectomy declined from 40% to 60% in the 1980s to 32% in 2007. CONCLUSIONS AND RELEVANCE: Louisiana State University Health-Shreveport treated more uninsured patients with advanced-stage laryngeal cancer compared with national data but demonstrated higher survival rates for those with advanced-stage disease. The results also demonstrate that we have continued a high rate of primary surgical therapy for advanced-stage disease, despite the national trend toward organ preservation. We believe that upfront laryngectomy may explain our higher survival rates for advanced-stage laryngeal cancer.

Mobile teledermatopathology: using a tablet PC as a novel and cost-efficient method to remotely diagnose dermatopathology cases.

: Dermatopathology has relatively few studies regarding teledermatopathology and none have addressed the use of new technologies, such as the tablet PC. We hypothesized that the combination of our existing dynamic nonrobotic system with a tablet PC could provide a novel and cost-efficient method to remotely diagnose dermatopathology cases. 93 cases diagnosed by conventional light microscopy at least 5 months earlier by the participating dermatopathologist were retrieved by an electronic pathology database search. A high-resolution video camera (Nikon DS-L2, version 4.4) mounted on a microscope was used to transmit digital video of a slide to an Apple iPAD2 (Apple Inc, Cupertino, CA) at the pathologist's remote location via live streaming at an interval time of 500 ms and a resolution of 1280/960 pixels. Concordance to the original diagnosis and the seconds elapsed to reaching the diagnosis were recorded. 24.7% (23/93) of cases were melanocytic, 70.9% (66/93) were nonmelanocytic, and 4.4% (4/93) were inflammatory. About 92.5% (86/93) of cases were diagnosed on immediate viewing (<5 seconds), with the average time to diagnosis at 40.2 seconds (range: 10-218 seconds). Of the cases diagnosed immediately, 98.8% (85/86) of the telediagnoses were concordant with the original. Telepathology performed via a tablet PC may serve as a reliable and rapid technique for the diagnosis of routine cases with some diagnostic caveats in mind. Our study established a novel and cost-efficient solution for those institutions that may not have the capital to purchase either a dynamic robotic system or a virtual slide system.