Incidence of Head and Neck Cancers before and after 9/11 in New York City and New York State.

INTRODUCTION: The incidence of cancers in New York State (NYS) before and after 9/11 including lung, colorectal, and renal cancers has been previously described. To date, the incidence of head and neck cancers (HNCs) before and after 9/11 has not been described. METHODS: Cancers involving the oral cavity and oropharynx; the nose, nasal cavity, nasopharynx, and middle ear; larynx; and thyroid were identified using the New York State Cancer Registry (NYSCR). Age-adjusted incidence and rates per 100,000 residents from 1987 to 2015 were analyzed using joinpoint regression. Trends in incidence using annual percent changes are presented. RESULTS: The overall rate of HNC increased slightly by 0.7% (p < 0.001) from 1987 to 2003 in NYS. From 2003 to 2008, the rate increased by 5.73% (p < 0.001), and from 2008 to 2015, the rate increased by 1.68% (p < 0.001). The rate of thyroid cancer increased by 6.79% (p < 0.001) from 1987 to 2003, by 9.99% (p < 0.001) from 2003 to 2009, and by 2.41% (p = 0.001) from 2009 to 2015. The rate of thyroid cancer was higher in women at all time points. In a subset analysis of HNCs excluding thyroid cancer, the rate decreased by 2.02% (p < 0.001) from 1991 to 2001, followed by a nonsignificant increase of 0.1% (p = 0.515) from 2001 to 2015. The rate of oropharyngeal (OP) cancer significantly increased from 1999 to 2015 (2.65%; p < 0.001). The rate of oral cavity cancer significantly decreased from 1987 to 2003 (1.97%; p < 0.001), with no significant change after 2003. The rate of laryngeal cancer decreased significantly by 2.43% (p < 0.001) from 1987 to 2015, as did the rate of nasal cavity/nasopharyngeal cancer (0.33%; p = 0.03). CONCLUSIONS: In NYS, OP cancer and thyroid cancer rates increased significantly during the study period. The rate of thyroid cancer was higher in women. The rate of combined HNC increased significantly after 9/11 compared to before 9/11; however, in a subset analysis of all HNC patients excluding thyroid cancer, the rate decreased significantly prior to 9/11 and then nonsignificantly increased afterward. This suggests that the increase in thyroid cancer accounts for the increase in combined HNC in NYS. The impact of 9/11 on rates of HNC requires further research.

Viral markers in nasopharyngeal carcinoma: A systematic review and meta-analysis on the detection of p16INK4a, human papillomavirus (HPV), and Ebstein-Barr virus (EBV).

PURPOSE: This study aimed to conduct a meta-analysis to investigate the distribution of EBV and HPV stratified according to histological NPC type. MATERIALS & METHODS: We performed a meta-analysis to produce pooled prevalence estimates in a random-effects model. We also performed calculations for attributable fractions of viral combinations in NPC, stratified according to histological type. RESULTS: There was a higher prevalence of HPV DNA in WHO Type I (34.4%) versus WHO Type II/III (18.4%). The attributable fractions of WHO Type I NPC was predominantly double negative EBV(-) HPV(-) NPC (56.4%), and EBV(-) HPV(+) NPC (21.5%), in contrast to the predominant infection in WHO Type II/III which was EBV(+) HPV(-) NPC (87.5%). Co-infection of both EBV and HPV was uncommon, and double-negative infection was more common in WHO Type I NPC. CONCLUSION: A significant proportion of WHO Type I NPC was either double-negative EBV(-)HPV(-) or EBV(-)HPV(+).

The impact of the COVID-19 pandemic on otolaryngologic emergency department visits at two major NYC hospital systems.

PURPOSE: Since the COVID-19 pandemic began, emergency departments (ED) across the country have seen a significant decrease in patient visits. We aim to evaluate the impact of COVID-19 on ED visits for acute otolaryngologic complaints in New York City, one of the first epicenters of the pandemic in the US. MATERIALS AND METHODS: We conducted a retrospective study of patients who presented to the ED with a primary diagnosis of an acute otolaryngologic complaint between March 1 and May 31 in 2019 and 2020. This was a multicenter study, including two tertiary care hospital systems encompassing Manhattan, Bronx, Queens, and Long Island. RESULTS: A total of 10,162 patients were identified. Significantly fewer patients presented to the ED for acute otolaryngologic complaints in 2020 (7332 vs 2830, p < 0.001). The rate of total otolaryngology-related ED visits was decreased by a factor of 0.635 (95% CI 0.6079 to 0.6634). In a subgroup analysis of each individual diagnosis, there was a significant decrease in rate of ED visits for 13 out of 18 diagnoses, including for life-threatening conditions, such as anaphylaxis. There was no significant difference based on which borough in New York City. Pediatric patients (age 0-17) were more significantly impacted by the pandemic compared to other age groups. CONCLUSION: The COVID-19 pandemic has led to a reduction in the utilization of ED for acute otolaryngologic complaints, including those requiring emergent management, and an even more significant reduction in the pediatric population. Healthcare providers should encourage patients to seek appropriate care, particularly for those illnesses with significant associated morbidity and mortality.

The paralyzing legal costs of facial nerve injury in head and neck tumors.

PURPOSE: Facial nerve paralysis from head and neck tumors can result from disease progression or iatrogenic causes, leading to litigation. The aim of this study was to investigate lawsuits regarding facial paralysis as a consequence of these tumors to understand and better educate physicians behind the reasons for litigation. METHODS: Jury verdict reviews were obtained from the Westlaw database from 1985 to 2018. Gathered data, including verdicts, litigation reasons, defendant specialties, and amounts awarded, were analyzed via Statistical Package for the Social Sciences. RESULTS: Of the 26 lawsuits analyzed, the leading reason for litigation was failure to diagnose (53.8%), followed by iatrogenic injury (34.6%). The average award was $2,704,470. Otolaryngologists were the most common defendants. Defendants that included an otolaryngologist had shorter delays of diagnosis compared to those that did not (p < 0.05). CONCLUSION: Failure to diagnose parotid injury was the leading cause of litigation. In instances where the jury found for the plaintiff, the amount was material. There were equivalent incidences of cases in favor of plaintiffs and defendants.

The effect of race in head and neck cancer: A meta-analysis controlling for socioeconomic status.

PURPOSE: To investigate the association between race and ethnicity and prognosis in head and neck cancers (HNC), while controlling for socioeconomic status (SES). MATERIALS AND METHODS: Medline, Scopus, EMBASE, and the Cochrane Library were used to identify studies for inclusion, from database inception till March 5th 2019. Studies that analyzed the role of race and ethnicity in overall survival (OS) for malignancies of the head and neck were included in this study. For inclusion, the study needed to report a multivariate analysis controlling for some proxy of SES (for example household income or employment status). Pooled estimates were generated using a random effects model. Subgroup analysis by tumor sub-site, meta-regression, and sensitivity analyses were also performed. RevMan 5.3, Meta Essentials, and OpenMeta[Analyst] were used for statistical analysis. RESULTS: Ten studies from 2004 to 2019 with a total of 108,990 patients were included for analysis in this study. After controlling for SES, tumor stage, and treatment variables, blacks were found to have a poorer survival compared to whites (HR = 1.27, 95%CI: 1.18-1.36, p < 0.00001). Subgroup analysis by sub-site and sensitivity analysis agreed with the primary result. No differences in survival across sub-sites were observed. Meta-regression did not identify any factors associated with the pooled estimate. CONCLUSIONS: In HNC, blacks have poorer OS compared to whites even after controlling for socioeconomic factors.

The prognostic effect of anatomic subsite in HPV-positive oropharyngeal squamous cell carcinoma.

BACKGROUND: Since most HPV-associated disease occurs in the tonsillar-related areas (TRA) - palatine and lingual tonsils, the effect of HPV on survival in non-tonsillar oropharyngeal subsites (nTRA) is not well established. The objective of this study was to use a large population-based cohort to investigate the survival impact of HPV in nTRA subsites versus TRA subsites. METHODS: This SEER database study was conducted by stratifying the HPV-positive oropharyngeal cancer cohort into two primary groups, TRA and nTRA. RESULTS: HPV-positive squamous cell cancer was significantly more common in TRAs (73%) compared to nTRAs (31.2%, p < 0.001). After controlling for age, treatment, stage, race, and income, patients with HPV-positive disease in nTRAs had a worse cause-specific survival (CSS) than individuals with HPV-positive disease in TRAs (HR = 2.16, 95% CI 1.20-3.86, p = 0.01). CONCLUSION: Patients with HPV-positive OPSCC in nTRAs had poorer survival outcomes compared to patients with HPV-positive OPSCC in TRAs.

HPV status in patients with nasopharyngeal carcinoma in the United States: A SEER database study.

PURPOSE: To investigate the etiologic and prognostic role of Human Papilloma Virus (HPV) in Nasopharyngeal Carcinoma (NPC). MATERIALS AND METHODS: Patients diagnosed with NPC were identified with the Surveillance, Epidemiology, and End Results (SEER) database. Logistic regression was used to investigate the effect of clinicopathologic predictors on HPV positivity in NPC. Survival analyses were performed with Kaplan-Meier curves and Cox regression models. RESULTS: 180/517 patients (34.8%) with known HPV testing were positive for HPV-associated NPC. East Asians and individuals over 25 were less likely to have HPV-associated NPC, while controlling for AJCC-7 stage and AJCC-7 M stage. According to the survival analysis, cause-specific survival (CSS) did not differ significantly by HPV status throughout the study period, but did differ significantly by HPV ethnicity group. CONCLUSIONS: The clinical implications of HPV in NPC are further elucidated but require more investigation. LEVEL OF EVIDENCE: IV.

Management of the neck after definitive chemoradiation in patients with HPV-associated oropharyngeal cancer: An institutional experience.

PURPOSE: To investigate the multidisciplinary management of patients with Human Papilloma Virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) and an incomplete nodal response on restaging PET/CT after definitive chemoradiation (CRT). MATERIALS AND METHODS: A retrospective chart review was performed of patients diagnosed with node-positive HPV-associated OPSCC from 2012 to 2017, who underwent definitive upfront CRT, and had an incomplete response on post-therapy PET/CT according to NCCN criteria. Post-CRT PET/CT results, management decisions, and clinical outcomes were recorded. RESULTS: Seventy-four patients with node-positive HPV-associated OPSCC were identified; 20 patients with incomplete neck response on PET/CT according to NCCN criteria were included in the final case series. Median follow-up time was 33 months. Patients were managed as follows: 8 underwent observation and surveillance imaging, 6 underwent ultrasound-guided fine needle aspiration (FNA), and 6 had immediate neck dissection. All the observed patients were disease-free at most recent follow-up. None of the patients who underwent immediate neck dissection had residual neck disease on pathological examination; two patients in this group ultimately developed metastatic disease. Among the 6 who underwent FNA, 1 individual had positive pathology, along with residual primary disease, for which the patient underwent salvage surgery. The 5 remaining individuals had negative FNA results, were subsequently observed, and remained free of disease. CONCLUSIONS: This institutional experience supports the notion of a high threshold for neck dissection in this low-risk population; only 1 of 20 patients with suspicious PET/CT findings had residual disease in the neck. Moreover, these patients should be managed by a multidisciplinary tumor board (MTB) since current algorithms do not universally include HPV status. Finally, the use of restaging PET/CT to guide management of the neck can be improved with changes in terminology and consideration of FDG-avidity at the primary site and on pre-therapy scans.

Systemic immune response in squamous cell carcinoma of the head and neck: a comparative concordance index analysis.

PURPOSE: The objective of this study was to investigate the prognostic role of three inflammatory markers: the neutrophil to lymphocyte ratio (NLR), the lymphocyte to monocyte ratio (LMR), and the platelet to lymphocyte ratio (PLR) as prognostic indicators in squamous cell carcinoma of the head and neck (HNSCC). METHODS: Patients with HNSCC treated with primary surgery, with or without adjuvant radiochemotherapy were enrolled. The preoperative NLR, LMR, and PLR were recorded. Confounding variables were also recorded: age, sex, BMI, comorbidities, performance status, AJCC T and N stage and HPV status. Endpoints were overall survival (OS) and event-free survival (EFS). Survival analysis was performed using Kaplan-Meier analysis, and multivariable analysis was performed using Cox proportional hazards regression. Survival models were evaluated using Harrell's concordance index (c-index). RESULTS: NLR (p = 0.2413), PLR (p = 0.1593), and LMR (p = 0.0552) were not significantly associated with OS in the multivariable analysis. With regard to EFS, low LMR (HR = 2.95, 95% CI 1.54-5.65, p = 0.001), high PLR (HR = 2.68, 95% CI 1.42-5.09, p = 0.003), and high NLR (HR = 3.37, 95% CI 1.7-6.69, p < 0.001) were associated with EFS. The multivariable c-index was highest for LMR (0.762), followed by NLR (0.761) and PLR (0.739). CONCLUSION: The LMR, PLR, and NLR were not associated with OS, but were associated with EFS in HNSCC. These markers are easily obtainable, and in the age of individualized patient care and precision medicine, they might represent further risk stratification tools for HNSCC patients.

Is human papillomavirus and p16 expression associated with survival outcomes in nasopharyngeal cancer?: A systematic review and meta-analysis.

INTRODUCTION: Human papillomavirus (HPV) is a known prognostic indicator in oropharyngeal cancer. Not much is known about the prognostic role of HPV in Nasopharyngeal cancer (NPC). Here, we performed a systematic review and meta-analysis of the literature to investigate if HPV status was a prognostic factor for NPC. METHODS: PubMed (via the web), Embase, Scopus, and the Cochrane Library were searched. A systematic review and meta-analysis was done to generate the pooled Hazard Ratios (HR) for Overall Survival (OS). RESULTS: A total of 7 studies from 2014 to 2018, reporting data on 2646 patients (range 43-1328) were included in this meta-analysis. The pooled data showed that HPV/p16 status was not associated with OS in NPC with HR of 0.77 (95% CI: 0.55-1.09, p = 0.14). The test for heterogeneity showed little to no heterogeneity of results (I2 = 4%, p = 0.38). Subgroup analysis showed that in large sample sizes, HPV was significantly associated with survival. CONCLUSION: Despite the finding in the pooled HR, we could not draw a definitive conclusion as to the prognostic significance of HPV in NPC. Recommendations for future research are given.

The red cell distribution width as a prognostic indicator in upper aerodigestive tract (UADT) cancer: A systematic review and meta-analysis.

PURPOSE: The aim of this systematic review and meta-analysis was to investigate the relationship between the Red Cell Distribution Width (RDW) and prognosis in upper aerodigestive tract (UADT) cancer. METHODS: PubMed (via the web), Embase, Scopus, and the Cochrane Library were searched. A systematic review and meta-analysis was done to generate the pooled hazard ratios (HR) for overall survival (OS), disease specific survival (DSS), and recurrence free survival (RFS). RESULTS: Our analysis included the results of 4200 patients in 8 cohorts. The pooled data demonstrated that an elevated RDW was associated with significantly poorer OS (HR: 1.44, 95% CI: 1.13-1.83), RFS (HR: 1.43, 95%CI: 1.13-1.82). The DSS result had high heterogeneity and 95% CI was not pooled. CONCLUSIONS: An elevated RDW may be an indicator of poor prognosis in UADT cancers in certain populations. Further research is needed to confirm this effect.

Evaluation of the prognostic utility of the hemoglobin-to-red cell distribution width ratio in head and neck cancer.

PURPOSE: Hemoglobin is a known prognostic marker in many cancers, including head and neck cancer (HNC). There is some evidence that the red cell distribution width, which is an index of variation in size of red blood cells (RBCs), might be associated with prognosis as well. Recently, a novel prognostic biomarker has been reported-the ratio of the hemoglobin-to-red cell distribution width (Hb/RDW). Our objective was to evaluate the prognostic utility of the pretreatment Hb/RDW in HNC, controlled with known prognostic indices. METHODS: Retrospective cohort study in a tertiary academic hospital setting. Patients diagnosed with HNC treated with curative-intent surgery were eligible. Metastatic disease was excluded. The variables collected were age, sex, BMI, alcohol/tobacco exposure, performance scores, ACE-27, tumor characteristics, adjuvant treatment, and lab values. The primary endpoints were event-free survival (EFS) and overall survival (OS). OS was defined as time from start of treatment to death from any cause, and EFS was defined as time from start of treatment to any progression, recurrence, or death from any cause. Univariate and multivariate survival analysis was performed on the primary endpoints. RESULTS: A total of 205 patients were enrolled from 2010 to 2016. In multivariate analysis, the factors independently associated with EFS were BMI (p = 0.0364), advanced T stage (p = 0.001), and low Hb/RDW ratio (p = 0.017). The factors independently associated with OS were ECOG score (p = 0.042), advanced T stage (p < 0.0001), positive nodes (p = 0.0195), and Hemoglobin (0.0134). CONCLUSION: A low Hb/RDW ratio was associated with poorer EFS (HR = 2.02, 95% CI 1.13-3.61, p = 0.017), but was not associated with OS. This is the first study reporting the prognostic utility of Hb:RDW in head and neck cancer.

The lymphocyte-to-monocyte ratio as a prognostic indicator in head and neck cancer: a systematic review and meta-analysis.

PURPOSE: The aim of this systematic review and meta-analysis was to investigate the relationship between the pre-treatment lymphocyte-to-monocyte ratio (LMR) and prognosis in HNC. METHODS: PubMed (via the Web), Embase, Scopus, and the Cochrane Library were searched. A systematic review and meta-analysis was done to generate the pooled hazard ratios (HR) for overall survival (OS) and disease-free survival (DFS). RESULTS: Our analysis included the results of 4260 patients in seven cohorts. The pooled data demonstrated that an elevated LMR was associated with significantly improved OS (HR 0.5; 95% CI 0.44-0.57), and DFS (HR 0.70; 95% CI 0.62-0.80). Of note, there was no detectable heterogeneity in either OS (I2 = 0%) or DFS (I2 = 0%). CONCLUSIONS: An elevated LMR may be an indicator of favorable prognosis in HNC. However, our results should be interpreted with some degree of caution due to the retrospective nature of cohort studies. Further research with high-quality prospective studies is needed to confirm the effect of LMR in HNC prognosis.

Intra-arterial cetuximab for the treatment of recurrent unresectable head and neck squamous cell carcinoma†.

IMPORTANCE: Management of recurrent head and neck squamous cell carcinoma is a common and challenging clinical problem in head and neck oncology. OBJECTIVE: Here we present the first reported case of super-selective intra-arterial (SSIA) microcatheter based local delivery of cetuximab for head and neck cancer. This technical report describes the techniques used to deliver the SSIA dose of cetuximab, as well as the patient outcome. DESIGN: This technical report is part of an ongoing Phase I Clinical Trial. SETTING: The New York Head and Neck Institute (NYHNI) is a full-service otolaryngology and neurosurgery department at Lenox Hill Hospital, part of the Northwell Health System. The NYHNI serves a diverse patient population with a wide range of head and neck diseases in a tertiary hospital setting. INTERVENTION: SSIA Cetuximab. PARTICIPANT: A patient presents to our clinic with recurrent unresectable squamous cell carcinoma of the nasopharynx. He is recruited into the first cohort of a phase I clinical trial to assess the safety of SSIA cetuximab, dose starting at 100mg/m2. Adjuvant chemo-radiation therapy is also given. MEASURES: Safety, as measured by toxicity of SSIA cetuximab. RESULTS: SSIA Cetuximab has been demonstrated to be a safe and feasible procedure in this technical report. CONCLUSIONS: This case illustrates technical feasibility and a very preliminary assessment of the safety of a novel delivery of a biologic agent for squamous cell carcinoma of the head and neck, which is part of an ongoing phase I clinical trial. TRIAL REGISTRATION: NCT02438995.

Machine Learning Methods in Classification of Prolonged Radiation Therapy in Oropharyngeal Cancer: National Cancer Database.

OBJECTIVE: To investigate the accuracy of machine learning (ML) algorithms in stratifying risk of prolonged radiation treatment duration (RTD), defined as greater than 50 days, for patients with oropharyngeal squamous cell carcinoma (OPSCC). STUDY DESIGN: Retrospective cohort study. SETTING: National Cancer Database (NCDB). METHODS: The NCDB was queried between 2004 to 2016 for patients with OPSCC treated with radiation therapy (RT) or chemoradiation as primary treatment. To predict risk of prolonged RTD, 8 different ML algorithms were compared against traditional logistic regression using various performance metrics. Data was split into a distribution of 70% for training and 30% for testing. RESULTS: A total of 3152 patients were included (1928 prolonged RT, 1224 not prolonged RT). As a whole, based on performance metrics, random forest (RF) was found to most accurately predict prolonged RTD compared to both other ML methods and traditional logistic regression. CONCLUSION: Our assessment of various ML techniques showed that RF was superior to traditional logistic regression at classifying OPSCC patients at risk of prolonged RTD. Application of such algorithms may have potential to identify high risk patients and enable early interventions to improve survival.

Outcomes of Chandelier-Assisted Scleral Buckling in Rhegmatogenous Retinal Detachments: Systematic Review and Meta-analysis.

Purpose: To examine the outcomes of chandelier endoillumination-assisted scleral buckling (chandelier scleral buckling) for rhegmatogenous retinal detachments (RRDs) and compare them with those of standard scleral buckling using indirect ophthalmoscopy. Methods: A literature search was performed on April 15, 2023. Outcomes analyzed included the primary anatomic success rates, surgical duration, and complication rates. A meta-analysis of proportions estimated the pooled success rate of chandelier scleral buckling. In addition, meta-analyses compared the success rates between pseudophakic eyes and phakic eyes having chandelier scleral buckling and compared success rates and surgical duration between standard scleral buckling and chandelier scleral buckling. Results: Thirty studies with 1133 eyes were included. The pooled primary anatomic success rate of chandelier scleral buckling was 91.7% (95% CI, 89.6%-93.6%). In studies comparing success rates between the 2 techniques, there was no significant difference (risk ratio, 1.01; 95% CI, 0.94-1.08; P = .80). The surgical times were significantly shorter with chandelier scleral buckling than with standard scleral buckling (mean difference, -18.83; 95% CI, -30.88 to -6.79; P = .002). There was no significant difference in the success rate between pseudophakic eyes and phakic eyes (risk ratio, 0.99; 95% CI, 0.91-1.08; P = .89). No cases of endophthalmitis were reported. Conclusions: Chandelier endoillumination-assisted scleral buckling may be a promising technique given its high rate of primary anatomic success for RRDs and success rates similar to those of standard scleral buckling. There was no significant difference in the efficacy of chandelier scleral buckling between pseudophakic eyes and phakic eyes.

Diagnosis and Management of Common Presentations of Posttraumatic Nasal Deformity: A Narrative Review.

Posttraumatic nasal deformity (PTND) is a surgical challenge for the otolaryngologist and plastic surgeon. Various classifications and management algorithms have been proposed without reaching much consensus in terms of definition and management. Methods: We present a narrative review aimed to define PTND and consolidate current knowledge regarding its diagnosis, subtypes, and treatment options. Results: This report is a clinical overview of PTND. We also review recent studies that characterize different osteotomy approaches and techniques used for patients with PTND. Conclusions: By providing a summary of the main challenges for PTND, we aim to add context to its variable presentation. We hope this broad overview will reinforce more effective communication between providers and promote patient understanding in order to ensure favorable long-term outcomes.

Preoperative Embolization Techniques in the Treatment of Juvenile Nasopharyngeal Angiofibroma: A Systematic Review.

OBJECTIVE: Preoperative embolization has proven beneficial in the surgical treatment of juvenile nasopharyngeal angiofibromas (JNA). However, the consensus for the best embolization practices remains unclear. This systematic review seeks to characterize the reporting of embolization protocols throughout the literature and to compare differences in surgical outcomes. DATA SOURCES: PubMed, Embase, and Scopus. REVIEW METHODS: Studies investigating embolization in the treatment of JNA from 2002 to 2021 were selected from defined inclusion criteria. All studies underwent a 2-stage blinded screening, extraction, and appraisal process. Embolization material, time to surgery, and embolization route were compared. Embolization complications, surgical complications, and rate of recurrence were pooled. RESULTS: Of 854 studies, 14 retrospective studies with 415 patients met the criteria for inclusion. A total of 354 patients underwent preoperative embolization. A total of 330 patients (93.2%) underwent transarterial embolization (TAE) and 24 patients had a combination of direct puncture embolization and TAE. Polyvinyl alcohol particles were the most used embolization material (n = 264, 80.0%). The most common reported time to surgery was 24 to 48 hours (n = 8, 57.1%). Pooled results showed an embolization complication proportion of 3.16% (95% confidence interval [CI]: 0.96-6.60) (n = 354), a surgical complication proportion of 4.96% (95% CI: 1.90-9.37) (n = 415), and a recurrence proportion of 6.30% (95% CI: 3.01-10.69) (n = 415). CONCLUSION: The current data on JNA embolization parameters and their effect on surgical outcomes remains too heterogenous to provide expert recommendations. Future studies should use uniform reporting to allow for more robust comparisons of embolization parameters, which, in turn, may lead to optimized patient outcomes.