To Pack a Nose: High-Fidelity Epistaxis Simulation Using 3D Printing Technology.

BACKGROUND: Initial management and stabilization of epistaxis is managed by a diverse offset of clinical providers with variable levels of training. OBJECTIVE: To determine the anatomic and clinical fidelity and ease of use of a novel simulator for the training and assessment of epistaxis management skills. STUDY DESIGN: Qualitative Research Study using expert questionnaire's for validation of a newly developed simulator. METHODS: We performed a quasi-experimental intervention with 22 otolaryngology faculty and 10 trainees who independently evaluated the simulator. Data were collected in three phases: phase 1 (preliminary evaluation), phase 2 (final expert evaluation), and phase 3 (trainee evaluation). We designed a three-dimensional (3D) printed model from a de-identified patient computed tomography scan. Artificial blood was circulated through catheters to simulate bleeding from three distinct sites (sphenopalatine, Kiesselbach's plexus, and anterior ethmoid). Four domains were assessed: "Physical and anatomic attributes," "Realism of experience," "Ability to perform tasks," and "Value and clinical relevance." Internal structure and validity were measured with Cronbach's alpha and item outfit mean-square statistics. RESULTS: Results from otolaryngology faculty showed very high median ratings for "Value of the simulator as a training tool" (4.0/4) and high ratings for "Relevance to practice" (4.0/4), and realism of experience (4.0/4). Responses from otolaryngology trainees demonstrated high value for clinical training (4.0/4) and high likelihood to recommend use for future trainees (4.0/4). Confidence in managing epistaxis before (1.0/4) and after (3.0/4) simulator use was statistically improved (P = .03). CONCLUSIONS: Using 3D printing technology, we created a novel simulator for epistaxis management. Preliminary evidence suggests the model is cost-effective, anatomically realistic, relevant to trainees' educational needs, and valuable as a training tool. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:747-753, 2022.

Head and Neck Cancer and Social Media: The Patient Experience and Cancer Survivorship.

OBJECTIVES/HYPOTHESIS: To characterize the head and neck cancer patients' lived experiences with survivorship through Instagram and examine opportunities for health professionals to provide support and outreach specifically targeting these needs. STUDY DESIGN: Descriptive observational study. METHODS: We analyzed key head and neck cancer-related hashtags by querying medical and layman terminology. The top English-language posts for #headandneckcancer underwent further content examination using thematic analysis based in grounded theory for categorization for user engagement (determined by "likes" and comments), type of content, and category of the account that created the post. Of the survivorship posts by patients, the content of posts in top user accounts was further analyzed. RESULTS: There were 11,600 Instagram posts on #headandneckcancer, 1,300 posts on #headandneckcancerawareness, 1,100 posts on #headandneckcancersurvivor, and several thousand posts for additional layman terms. The majority of posts were from patients (65%), with few from head and neck surgeons or medical organizations (26%). User engagement was primarily by nonmedical accounts (95%). Posts by patients discussed medical appointments and treatments (81%), managing treatment effects and symptoms (66%), and cancer screening and prevention (23%). Specific concerns included fatigue (53%), postsurgical cosmetic appearance (27%), and weight and nutrition (34%). CONCLUSIONS: Our study suggests that Instagram accounts can be intimate records of the patient experience, and gaining a better understanding of the daily experience of survivorship may be critical for head and neck surgeons and other oncology providers to provide truly comprehensive cancer care. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1214-E1219, 2021.

Predicting Therapeutic Antibody Delivery into Human Head and Neck Cancers.

PURPOSE: The efficacy of antibody-based therapeutics depends on successful drug delivery into solid tumors; therefore, there is a clinical need to measure intratumoral antibody distribution. This study aims to develop and validate an imaging and computation platform to directly quantify and predict antibody delivery into human head and neck cancers in a clinical study. EXPERIMENTAL DESIGN: Twenty-four patients received systemic infusion of a near-infrared fluorescence-labeled therapeutic antibody followed by surgical tumor resection. A computational platform was developed to quantify the extent of heterogeneity of intratumoral antibody distribution. Both univariate and multivariate regression analyses were used to select the most predictive tumor biological factors for antibody delivery. Quantitative image features from the pretreatment MRI were extracted and correlated with fluorescence imaging of antibody delivery. RESULTS: This study not only confirmed heterogeneous intratumoral antibody distribution in-line with many preclinical reports, but also quantified the extent of interpatient, intertumor, and intratumor heterogeneity of antibody delivery. This study demonstrated the strong predictive value of tumor size for intratumoral antibody accumulation and its significant impact on antibody distribution in both primary tumor and lymph node metastasis. Furthermore, this study established the feasibility of using contrast-enhanced MRI to predict antibody delivery. CONCLUSIONS: This study provides a clinically translatable platform to measure antibody delivery into solid tumors and yields valuable insight into clinically relevant antibody tumor penetration, with implications in the selection of patients amenable to antibody therapy and the design of more effective dosing strategies.

Effect of Medical Scribes on Outpatient Oncology Visits at a Multidisciplinary Cancer Center.

PURPOSE: The use of medical scribes has emerged as a strategy to increase clinic workflow efficiency and reduce physician burnout. While oncology clinics may be ideally suited to scribe integration because of the high burden of documentation, oncology-specific scribe research has been limited. The objective of this study was to determine the effect of scribe integration on clinic workflow efficiency and physician satisfaction and quality of life in outpatient oncology clinics. METHODS: We conducted a retrospective, concurrent qualitative and quantitative analysis of patient visit durations and survey data for 129 attending physicians affiliated with an academic hospital's cancer center between January 2017 and January 2019. Thirty-three physicians were paired with scribes in each physician's individual clinic or clinics. RESULTS: In terms of clinic efficiency, physicians with scribes had a 12.1% decrease in their overall average patient visit duration compared with their own time before receiving a scribe (P < .0001) and spent significantly less time completing charts at the end of the day (P = .04). Compared with their peers, oncologists with scribes showed a 10%-20% decrease in the duration of all patient visits. Scribes also contributed to patient care, as shown by 90% of physicians surveyed who strongly agreed that they spent less time at the computer and more time with patients; 100% of physicians surveyed strongly agreed that scribes improved their quality of life. CONCLUSION: The integration of medical scribes into oncology clinics across several oncologic disciplines has the potential to reduce burnout through increasing physician satisfaction and quality of life, improving patient care, and streamlining clinic workflow.

Outcomes in Head and Neck Resections That Require Multiple-Flap Reconstructions: A Systematic Review.

Importance: Complex head and neck cancer defects that require multiflap reconstructions are technically feasible, but the morbidity and patient outcomes of such large-scale head and neck operations have yet to be systematically reviewed. Objective: To systematically review existing literature to characterize the outcomes of large-scale head and neck resections that require multiple-flap reconstructions (defined as defects that require >1 flap [free, pedicled, or combinations thereof]). Evidence Review: Two authors independently searched PubMed, Embase, and the Cochrane Review databases for English-only texts published on any date. Included studies examined patients who underwent complex head and neck surgical resections that required multiple simultaneous flaps for reconstruction. Included studies reported results on at least one of the following outcomes: functional and aesthetic, patient survival, or cost (estimated by operating room time, length of stay, and/or complications). Methodological Index for Non-Randomized Studies (MINORS) criteria for bias and modified Oxford Centre for Evidence-Based Medicine recommendations were used to assess study quality. Findings: Twenty-four studies published from November 1, 1992, through September 1, 2016, met the final inclusion criteria, with a total of 487 patients (370 male [79.4%]; mean [SD] weighted age, 55.1 [4.1] years). Sixty-two of 250 patients (24.8%) were partially or fully dependent on feeding tubes at follow-up. Twenty-two of 75 patients (29.3%) had poor postoperative oral competence, causing moderate to severe drooling. Nineteen of 108 patients (17.6%) had unintelligible speech. Nine of 64 patients (14.1%) were unsatisfied with their aesthetic outcome. The mean (SD) reported survival was 2.36 (1.39) years. The mean (SD) length of stay was 24.5 (12.2) days in 219 patients. Eighty-eight minor complications (eg, partial flap necrosis, donor site complications) and 185 major complications (eg, surgical reexplorations, flap loss, or cardiopulmonary complications) were reported in 380 patients. Mean (SD) MINORS scores were 16.0 (3.2) for comparison studies and 11.4 (1.8) for noncomparison studies. Conclusions and Relevance: Because of limited patient life expectancies, modest functional and aesthetic outcomes, and significant associated costs, surgeons should weigh the curative potential and palliative benefits for individual patients with a comprehensive view of the overall outcomes of extensive head and neck resections and reconstructions. Realistic expectations should be emphasized during preoperative discussions with patients.

Determination of Tumor Margins with Surgical Specimen Mapping Using Near-Infrared Fluorescence.

For many solid tumors, surgical resection remains the gold standard and tumor-involved margins are associated with poor clinical outcomes. Near-infrared (NIR) fluorescence imaging using molecular agents has shown promise for in situ imaging during resection. However, for cancers with difficult imaging conditions, surgical value may lie in tumor mapping of surgical specimens. We thus evaluated a novel approach for real-time, intraoperative tumor margin assessment. Twenty-one adult patients with biopsy-confirmed squamous cell carcinoma arising from the head and neck (HNSCC) scheduled for standard-of-care surgery were enrolled. Cohort 1 (n = 3) received panitumumab-IRDye800CW at an intravenous microdose of 0.06 mg/kg, cohort 2A (n = 5) received 0.5 mg/kg, cohort 2B (n = 7) received 1 mg/kg, and cohort 3 (n = 6) received 50 mg. Patients were followed 30 days postinfusion and adverse events were recorded. Imaging was performed using several closed- and wide-field devices. Fluorescence was histologically correlated to determine sensitivity and specificity. In situ imaging demonstrated tumor-to-background ratio (TBR) of 2 to 3, compared with ex vivo specimen imaging TBR of 5 to 6. We obtained clear differentiation between tumor and normal tissue, with a 3-fold signal difference between positive and negative specimens (P < 0.05). We achieved high correlation of fluorescence intensity with tumor location with sensitivities and specificities >89%; fluorescence predicted distance of tumor tissue to the cut surface of the specimen. This novel method of detecting tumor-involved margins in surgical specimens using a cancer-specific agent provides highly sensitive and specific, real-time, intraoperative surgical navigation in resections with complex anatomy, which are otherwise less amenable to image guidance.Significance: This study demonstrates that fluorescence can be used as a sensitive and specific method of guiding surgeries for head and neck cancers and potentially other cancers with challenging imaging conditions, increasing the probability of complete resections and improving oncologic outcomes. Cancer Res; 78(17); 5144-54. ©2018 AACR.

Safety of panitumumab-IRDye800CW and cetuximab-IRDye800CW for fluorescence-guided surgical navigation in head and neck cancers.

Purpose: To demonstrate the safety and feasibility of leveraging therapeutic antibodies for surgical imaging. Procedures: We conducted two phase I trials for anti-epidermal growth factor receptor antibodies cetuximab-IRDye800CW (n=12) and panitumumab-IRDye800CW (n=15). Adults with biopsy-confirmed head and neck squamous cell carcinoma scheduled for standard-of-care surgery were eligible. For cetuximab-IRDye800CW, cohort 1 was intravenously infused with 2.5 mg/m2, cohort 2 received 25 mg/m2, and cohort 3 received 62.5 mg/m2. For panitumumab-IRDye800CW, cohorts received 0.06 mg/kg, 0.5 mg/kg, and 1 mg/kg, respectively. Electrocardiograms and blood samples were obtained, and patients were followed for 30 days post-study drug infusion. Results: Both fluorescently labeled antibodies had similar pharmacodynamic properties and minimal toxicities. Two infusion reactions occurred with cetuximab and none with panitumumab. There were no grade 2 or higher toxicities attributable to cetuximab-IRDye800CW or panitumumab-IRDye800CW; fifteen grade 1 adverse events occurred with cetuximab-IRDye800CW, and one grade 1 occurred with panitumumab-IRDye800CW. There were no significant differences in QTc prolongation between the two trials (p=0.8). Conclusions: Panitumumab-IRDye800CW and cetuximab-IRDye800CW have toxicity and pharmacodynamic profiles that match the parent compound, suggesting that other therapeutic antibodies may be repurposed as imaging agents with limited preclinical toxicology data.

Survival and risk factors for progression after resection of the dominant tumor in multifocal, lepidic-type pulmonary adenocarcinoma.

BACKGROUND: It remains unclear whether a dominant lung adenocarcinoma that presents with multifocal ground glass opacities (GGOs) should be treated by local therapy. We sought to address survival in this setting and to identify risk factors for progression of unresected GGOs. METHODS: Retrospective review of 70 patients who underwent resection of a pN0, lepidic adenocarcinoma, who harbored at least 1 additional GGO. Features associated with GGO progression were determined using logistic regression and survival was evaluated using the Kaplan-Meier method. RESULTS: Subjects harbored 1 to 7 GGOs beyond their dominant tumor (DT). Mean follow-up was 4.1 ± 2.8 years. At least 1 GGO progressed after DT resection in 21 patients (30%). In 11 patients (15.7%), this progression prompted resection (n = 5) or stereotactic radiotherapy (n = 6) at mean 2.8 ± 2.3 years. Several measures of the overall tumor burden were associated with GGO progression (all P values < .03) and with progression prompting intervention (all P values < .01). In logistic regression, greater DT size (odds ratio, 1.07; 95% confidence interval, 1.01-1.14) and an initial GGO > 1 cm (odds ratio, 4.98; 95% confidence interval, 1.15-21.28) were the only factors independently associated with GGO progression. Survival was not negatively influenced by GGO progression (100% with vs 80.7% without; P = .1) or by progression-prompting intervention (P = .4). CONCLUSIONS: At 4.1-year mean follow-up, 15.7% of patients with unresected GGOs after resection of a pN0 DT underwent subsequent intervention for a progressing GGO. Some features correlated with GGO growth, but neither growth, nor need for an intervention, negatively influenced survival. Thus, even those at highest risk for GGO progression should not be denied resection of a DT.