Characterization of the immune profile of oral tongue squamous cell carcinomas with advancing disease.

We investigated whether a unique immune response was instigated with the development of oral tongue squamous cell carcinomas (OTSCC), with/without nodal involvement, with/without recurrent metastatic disease, or within tumor involved nodes. One hundred and ten formalin-fixed paraffin-embedded samples were collected from a retrospective cohort of 67 OTSCC patients and 10 non-cancerous tongue samples. Targets including CD4, CD8, FOXP3, PD-L1, and PD-1 were analyzed by immunohistochemistry. The Nanostring PanCancer Immune Profiling Panel was used for gene expression profiling. Data were externally validated in the The Cancer Genome Atlas (TCGA) head and neck (HNSCC), melanoma and lung squamous cell carcinoma (LSCC) cohorts. A 24-immune gene signature was identified that discriminated more aggressive OTSCC cases, and although not prognostic in HNSCC was associated with survival in other TCGA cohorts (improved survival for melanoma, P < .001 and worse survival for LSCC, P = .038). OTSCC exhibited concordant gene and immunohistochemical (IHC) features characterized by a TH-2 biased, proinflammatory profile with upregulated B cell and neutrophil gene activity and increased CD4, FOXP3, and PD-L1 expression (P < .001 for all by IHC). Compared to less advanced disease, nodal involvement and recurrent OTSCC did not induce a different immune response although recurrent disease was characterized by significantly higher PD-L1 expression (P = .004 by SP263, P = .013 by 22C3, P = .004 for gene expression). Identification of a gene signature associated with different prognostic effects in other cancers highlights common pathways of immune dysregulation that are impacted by the tumor origin. The significant immunosuppressive signaling in OTSCC indicates primary failure of immune system to control carcinogenesis emphasizing the need for early, combination therapeutic approaches.

A comparative study of extracellular vesicle-associated and cell-free DNA and RNA for HPV detection in oropharyngeal squamous cell carcinoma.

PURPOSE: This study compares the detection sensitivity of two separate liquid biopsy sources, cell-free (cf) DNA/RNA and extracellular vesicle (EV)-associated DNA/RNA (EV-DNA/RNA), to identify circulating Human Papilloma Virus (HPV) DNA/RNA in plasma obtained from patients with oropharyngeal squamous cell carcinoma (OPCSCC). We also report on the longitudinal changes observed in HPV-DNA levels in response to treatment. EXPERIMENTAL DESIGN: A prospective study was conducted that included 22 patients with locally advanced disease and six patients with metastatic OPCSCC. Twenty-three patients had HPV-related OPCSCC defined by p16 immunohistochemistry. Levels of circulating HPV-DNA and HPV-RNA from plasma-derived cf-DNA/RNA and EV-DNA/RNA were quantified using digital droplet PCR. RESULTS: Circulating HPV-DNA was detected with higher sensitivity in cf-DNA compared to EV-DNA at 91% vs. 42% (p = <0.001). Similarly, circulating tumoral HPV-RNA was detected at a higher sensitivity in cf-RNA compared to EV-RNA, at 83% vs. 50% (p = 0.0019). In the locally advanced cohort, 100% (n = 16) of HPV-OPCSCC patients demonstrated a reduction in circulating HPV-DNA levels in cf-DNA following curative treatment, with 81% of patients demonstrating complete clearance to undetectable levels. However, in metastatic HPV-OPCSCC patients (n = 4), HPV-DNA levels did not correlate with treatment response. CONCLUSION: Our study demonstrates that although HPV-DNA/RNA can be detected in EV associated DNA/RNA, cf-DNA/RNA is the more sensitive liquid biopsy medium. As circulating HPV-DNA levels were found to only correlate with treatment response in the locally advanced but not metastatic setting in our small cohort of patients, the use of HPV-DNA as a dynamic biomarker to monitor treatment response requires further evaluation.

Fungal malignant otitis externa treated with hyperbaric oxygen.

OBJECTIVE: To report a case of Aspergillus flavus malignant otitis externa, successfully treated with antifungal agents, surgical debridement, and hyperbaric oxygen treatment. PATIENT: The case was a 77-year-old man with non-insulin dependent diabetes mellitus, who presented with otalgia and purulent otorrhea. Intervention was with surgical debridement, antifungal agents, and hyperbaric oxygen treatment. The main outcome measures were radiological and histological findings. CONCLUSIONS: A. flavus is a rare cause of malignant otitis externa. Aggressive treatment should include surgical debridement, with appropriate antifungal agents and hyperbaric oxygen therapy.

Clear cell chondrosarcoma of the larynx.

Chondrosarcomas represent a group of malignant tumours composed of cells producing cartilage, and clear cell chondrosarcomas (CCC) represent a variant of these. A rare case of a laryngeal CCC is presented. The patient was a 70-year-old man who presented with a 6-week history of throat pain, worsening dysphonia and a lump in the neck. Examination revealed a level 3 neck mass and positron emission tomography imaging revealed a metabolically active right laryngeal mass. Biopsies revealed a cartilaginous neoplasm. The patient underwent total laryngectomy, and the pathology confirmed CCC of the larynx. Chondrosarcomas are the most common type of sarcoma in the larynx but the CCC variant is rare. CCC are usually low-grade tumours affecting long bones, with a male predominance. Less than six cases have been described in the literature affecting the larynx. Management of these malignancies is complete surgical excision given the high risk of local recurrence.

A case of giant ecchordosis physaliphora: a case report and literature review.

OBJECTIVE: To report a case of a giant ecchordosis physaliphora causing local bone remodelling. PATIENTS: A 45 year old man, who presented with sudden sensorineural hearing loss. INTERVENTION: Transpetrosal approach to resect a midline prepontine mass. MAIN OUTCOME MEASURES: Radiological and histological findings. CONCLUSION: The distinction between giant ecchordosis physaliphora and intradural chordoma is questioned and exemplified by our case. It is possible they represent the same entity of disease, which must be distinguished from classical malignant osseous (extradural) chordoma.

Congenital cervical teratomas: diagnostic, management and postoperative variability.

OBJECTIVE: To review the diagnosis, management and outcomes of congenital cervical teratomas presenting to a tertiary referral centre. METHODS: Retrospective chart review of three cases presenting within an 18-month period. RESULTS: Of the three patients in this series, one was diagnosed antenatally. The remaining cases were diagnosed at birth. The antenatally diagnosed patient underwent an EXIT procedure whereby the airway was secured by tracheostomy. This patient subsequently died 30 min after separation from the materno-foetal circulation. Neither of the other two cases had any neonatal respiratory distress, despite having large tumours. Both patients had neonatal surgical excision of the teratomas performed. Both patients had postoperative respiratory distress, requiring intervention. Both patients made a full recovery. No recurrence has been reported. CONCLUSION: The antenatal diagnosis of large congenital cervical teratomas allows for planned intervention by experienced personnel. A successful outcome may not be obtained. All patients that undergo surgical excision of these tumours must be closely observed for post-operative respiratory distress, even in the absence of pre-operative symptoms.

Positron emission tomography-positive thyroid nodules: rate of malignancy and histological features.

BACKGROUND: Thyroid nodules may be incidentally detected on (18) F-FDG-positron emission tomography (PET) scans. Previous reports suggest a high incidence of malignancy in FDG-avid nodules. The aims of this study were to examine the incidence of malignancy in a large cohort and to report on the histological features. The findings suggest that poor prognostic histologic features are often associated with FDG-avid thyroid nodules and this may have clinical implications. METHODS: A retrospective review of prospectively collected data was conducted. A database containing all patients who underwent PET scanning at a single tertiary referral centre from January 2006 to January 2013 was searched to identify those with incidental PET-positive thyroid nodules. Patients with known preexisting thyroid disease were excluded from analysis. The demographics, fine-needle aspiration (FNA) biopsy result and operative histopathology were analysed. RESULTS: A total of 27 851 FDG-PET scans were performed of which 221 found incidental PET-positive thyroid nodules (incidence 0.8%). Fifty-three patients went on to have further investigation and 21 of these were found to have malignant disease (incidence 39.6%). Histopathological examination of 12 malignant nodules revealed an expected rate of poor prognostic features, including poorly differentiated subtype (8.3%), lymphovascular invasion (16.7%), perineural invasion (8.3%) and extrathyroid extension (33.3%). CONCLUSION: Our data indicate that PET-positive thyroid nodules are associated with a high incidence of malignancy. This finding provides strong support for further investigation including FNA biopsy in all surgically suitable patients.

Cervicofacial emphysema and pneumomediastinum following pediatric adenotonsillectomy: a rare complication.

Cervicofacial emphysema and pneumomediastinum are rarely observed sequelae of surgical intervention in the upper aerodigestive tract. It is a potentially life-threatening condition but the majority of cases are self-limiting and benign. Symptoms include chest pain, neck pain, dyspnea and odynophagia. A case occurring after adenotonsillar surgery in a 7-year-old child is presented. This report highlights this unusual complication and its potential to delay the postoperative recovery following adenotonsillectomy.

Graft-versus-host disease-type colitis: an unusual association of malignant thymoma.

We present the case of a patient with a malignant thymoma associated with a graft-versus-host disease-type colitis, of which there has only been a solitary case report in the world literature. Complete surgical resection of the thymoma was achieved; however, the gastrointestinal symptoms persisted.

Oncocytic carcinoma of the parotid gland with facial nerve invasion.

Approximately 3% of all head and neck neoplasms originate in the parotid gland and less than 1% are oncocytic. We present the rare case of a 44-year-old man with oncocytic carcinoma of the parotid gland with facial nerve invasion and discuss the characteristics of this rare entity.

A rare case of bilateral malignant otitis externa and osteomyelitis with lower cranial nerve sequelae.

The authors present the case of a 76-year-old male who presented with right-sided recurrent malignant otitis externa (MOE) and skull-base osteomyelitis. His management involved aggressive antimicrobial therapy and multiple hyperbaric oxygen treatments. After resolution of his right-sided infection, the patient returned a short time later with symptoms and findings consistent with new, left-sided MOE with involvement of the left skull-base. With repeat treatment, the patient is now cured of his infection but poses a challenge to the treating team about future management.

Double fat plane of the radial forearm free flap and its implications for the microvascular surgeon.

OBJECTIVE: The radial forearm free flap (RFFF) is a workhorse in reconstruction of head and neck defects. The superficial cephalic vein is used most commonly for microvascular anastomosis; however, this vein has a variable course in the subcutaneous tissues. We have routinely isolated the cephalic vein within a reliable double fat plane, which has not been previously described. This study demonstrates the consistency of the cephalic vein within this double fat plane using a cadaveric model and our prospective operative experience raising the RFFF. METHOD: Four lightly preserved cadavers and one fresh cadaver were dissected by elevating a RFFF, identifying the double fat plane, and isolating the cephalic vein within this plane. Between August 2006 and April 2008, we prospectively recorded the anatomic location of the cephalic vein in 35 patients who had RFFF surgery. RESULTS: The double fat plane and cephalic vein were identified in all cadaveric dissections. The double fat plane was identified and led to injury-free dissection of the cephalic vein in all 35 patients. DISCUSSION: To our knowledge, this is the first report of the presence of the double fat plane within the subcutaneous tissue of the radial forearm and its use as a consistent landmark in finding the cephalic vein. Our cadaveric studies and operative observations have demonstrated that the double fat plane is a reliable, consistent, and helpful guide for the isolation of the cephalic vein in RFFF surgery.

Transoral laser microsurgery versus radiation therapy for early glottic cancer in Canada: cost analysis.

OBJECTIVE: There is debate over whether radiation therapy or transoral laser microsurgery (TLM) is the superior treatment for early glottic cancer. Both offer similar cure rates and posttherapy quality of life. One factor that could decide the optimum therapy is cost. Several studies in Europe and the United States show that TLM is the most cost-effective treatment. The goal of this study was to conduct the first cost analysis in Canada on the treatment of early glottic cancer comparing radiation therapy and TLM. DESIGN AND METHODS: The study was conducted retrospectively. TLM and radiation therapy were broken down into individual components, and then the price for each component was summed. SETTING: The study was conducted at the Queen Elizabeth II Health Science Centre in Halifax, Nova Scotia. MAIN OUTCOME MEASURES: The main outcome measure was total cost. RESULTS: It was found that radiation therapy was approximately four times more expensive than TLM. CONCLUSIONS: This study suggests that TLM should be the preferred treatment option for treating early glottic cancer in Canada as it is the most economical and has been shown in previous studies to be as effective as radiation therapy in both cure rates and quality of life.

Neck dissection for squamous cell carcinoma of the head and neck.

OBJECTIVES: To investigate the successes and failures of 172 patients receiving neck dissections for squamous cell carcinoma (SCC) managed through a multidisciplinary head and neck clinic and to observe factors in predicting failure (death with head and neck cancer or local regional recurrence) or local regional recurrence alone. STUDY DESIGN: A retrospective, 14-year surgical audit. METHODS: The information from patient medical records was correlated with that of a database. Multivariate analysis was performed with the use of a logistic regression model. RESULTS: The most common site for head and neck SCC was the oral cavity (42%), with 17% of patients having tumors of unknown primary site. The disease-free survival probability was 76.7% at five years. Patients who were older at neck dissection, were nonsmokers, or who did not have radiotherapy to the primary site were more likely to die with head and neck cancer or to have local regional recurrence (P < 0.1). Patients with more radical neck dissections did not have better survival or recurrence outcomes. Lymphatic invasion appears to be the only important factor in predicting local regional recurrence alone (P = 0.1), of which 67% occurred within the first postoperative year. CONCLUSIONS: Patients with smoking-related SCC are likely to have a less aggressive disease. Adjuvant radiotherapy plays an important role in the treatment of patients with head and neck SCC. Follow-up, especially within the first postoperative year, is essential in managing head and neck SCC. Head and neck surgeons can confidently continue their practice away from more radical neck dissections.