Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case-control study.

OBJECTIVES: Pharyngolaryngeal and oesophagogastric cancers present with swallowing symptoms and as such, their clinical evaluation traverses boundaries between different specialties. We studied the incidence and significance of interspecialty cancer referrals (ICRs), that is, pharyngolaryngeal cancers first evaluated by gastroenterology and oesophagogastric cancers first evaluated by otolaryngology. DESIGN: A subset analysis of our Integrated Aerodigestive Partnership's audit dataset, of all ICR patients, and an equal number of controls matched for age, sex and cancer subsite. MAIN OUTCOME MEASURES: Information about patient age and presenting symptoms was recorded. The relationship between symptoms and ICR risk was examined with binary logistic regression. Referral-to-diagnosis latency was compared between ICR and control patients with unpaired Student's t test. Cox regression was used to identify independent predictors of overall survival. RESULTS: Of 1130 patients with pharyngolaryngeal and oesophagogastric cancers between 2008 and 2018, 60 diagnoses (5.3%) were preceded by an ICR. Referral-to-diagnosis latency increased from 43 ± 50 days for control patients to 115 ± 140 days for ICR patients (P < .0001). Dysphagia significantly increased the risk of an ICR (odds ratio 3.34; 95% CI 1.30-8.56), and presence of classic gastroesophageal reflux symptoms (heartburn or regurgitation; OR 0.25; 95% CI 0.08-0.83) and "distal" symptoms (nausea/vomiting, abdominal pain or dyspepsia; OR 0.23; 95% CI 0.08-068) significantly reduced the risk. Eleven pharyngolaryngeal cancers (of 26; 42%) were missed by gastroenterology, and eight (of 34; 24%) oesophageal cancers were missed by otolaryngology. An ICR was an independent adverse prognostic risk factor on multivariable analysis (hazard ratio 1.76; 95% CI 1.11-2.73; P < .02; log-rank test). Two systemic root causes were poor visualisation of pharynx and larynx by per-oral oesophago-gastro-duodenoscopy (OGD) for pharyngolaryngeal cancers, and poor sensitivity (62.5%) of barium swallow when it was used to 'evaluate' oesophageal mucosa. CONCLUSIONS: An interspecialty cancer referral occurs in a significant proportion of patients with foregut cancers. It almost triples the time to cancer diagnosis and is associated with a high incidence of missed cancers and diminished patient survival. It is a complex phenomenon, and its reduction requires an integrated approach between primary and secondary care, and within secondary care, to optimise referral pathways and ensure appropriate and expeditious specialist evaluation.

Imaging features of sinonasal tumors on positron emission tomography and magnetic resonance imaging including diffusion weighted imaging: A pictorial review.

INTRODUCTION: Sinonasal inflammatory conditions account for a major component of head and neck pathologies, whereas neoplasms involving the sinonasal region make up only 2-3% of all head and neck lesions. The symptoms of sinonasal tumors are nonspecific; imaging plays a critical role in distinguishing benign and malignant disease and may illustrate characteristic radiological features of specific sinonasal tumors. OBJECTIVE: Aim was to determine the utilization of multimodality imaging, specifically the metabolic information provided by 18-fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT) and diffusivity characteristics seen with diffusion weighted images (DWI) of magnetic resonance imaging (MRI), in a wide range of benign and malignant sinonasal tumors drawn from over 200 sinonasal lesions from our institution and supplemented by the literature. CONCLUSION: In this pictorial essay, we have reviewed common imaging characteristics of frequently encountered in sinonasal tumors and divided them into benign and malignant categories to facilitate creation of focused differential diagnoses.

Impact of Chemoradiation After Supra- or Infrahyoid Cancer on Aerodynamic, Subjective, and Objective Voice Assessments: A Multicenter Prospective Study.

OBJECTIVES: The study aimed to investigate the impact of chemoradiotherapy (CRT) on speech and voice quality according to the anatomic localization of the head and neck cancer. METHODS: Thirty-four patients treated by CRT for advanced suprahyoid (N = 17) or infrahyoid (N = 17) cancer were assessed for speech function, videolaryngostroboscopy, Voice Handicap Index, blinded Grade, Roughness, Breathiness, Asthenia, Strain, and Instability, acoustic measurements, and aerodynamic measurements. Quality of life was evaluated using the European Organization for Research and Treatment of Cancer Head and Neck 35 (EORTC QLQ-H&N35) questionnaire. RESULTS: Patients treated for an infrahyoid tumor presented more severe values of Voice Handicap Index items, dysphonia, breathiness, asthenia, and some acoustic cues (Voice Turbulence Index, Soft Phonation Index, degree of unvoiced segments, and number of unvoiced segments) than patients treated for a suprahyoid tumor. The EORTC QLQ-H&N35 communication item was better in the suprahyoid patient group. CONCLUSIONS: Voice quality impairments associated with CRT are more severe in patients treated for advanced infrahyoid cancer, suggesting the need to develop specific posttherapy management of the dysphonia according to the tumor anatomical localization.

[Extracranial schwannomas of the Head and Neck: Clinical -approach based on 20 cases]. / Extrakranielle Schwannome im Kopf-Hals-Bereich: Klinische Implikationen anhand von 20 Fällen.

Background Schwannomas are rare benign tumors originating from the perineural cells forming the myelin layer in the peripheral nervous system (PNS). While well established therapeutic concepts exist for intracranial schwannomas, there is a lack of consistent clinical standards for extracranial schwannomas. Method This retrospective study describes the clinical pathway of 20 patients with histologically proven extracranial schwannomas of the head and neck. The diagnostic and therapeutic strategies for schwannomas are discussed with special emphasis on localization and functional outcome. Results Extracranial schwannomas of the head and neck region mostly originated from the facial nerve (n = 4), vagal nerve (n = 4) or sympathetic chain (n = 3). Most common symptoms were swelling (n = 12) and pain (n = 3). Preoperative imaging included MRI (n = 13), ultrasound (n = 12) and CT (n = 3). Surgical intervention was performed in 18 cases (n = 14 complete extirpation, n = 3 partial extirpation, n = 1 unknown). Regarding completely extirpated schwannomas of motor nerves (n = 10) severing the nerve of origin was more often required in patients with a preexisting functional deficit (3 out of 4 = 75 %) than in patients without preexisting deficits (2 out of 6 = 33 %). Conclusion Representing rare tumors of the head and neck region mostly originating from the facial nerve, sympathetic chain or caudal cranial nerves extracranial schwannomas require a systematic diagnostic and therapeutic approach. Postoperative functional deficits after complete extirpation must especially be anticipated in patients with a preexisting functional deficit.

[Psychooncological Treatment of Patients with Head and Neck Cancer]. / Psychoonkologische Betreuung von Patienten mit Kopf-Hals-Tumoren.

The aim of psychooncological interventions are to facilitate coping with the disease, to improve the psychological well-being and quality of life of the cancer patients as well as the strengthening of personal and social resources.Apart from general strain going along with oncological diseases and its treatment, patients with head and neck cancer often also suffer from impairment of the most basic human functions (speech, swallowing, food intake).Patients with head and neck cancer are one of the most distressed and burdened groups of cancer patients.Psychooncological interventions apply proven psychological and psychotherapeutic methods and techniques.Psychooncological treatment is based on the close interdisciplinary cooperation of different professional groups.

Systematic review and meta-analysis of venous thromboembolism in otolaryngology-head and neck surgery.

BACKGROUND: The purpose of this study was to present our systematic review and meta-analysis of the data on venous thromboembolism (VTE; deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) in otolaryngology-head and neck surgery (OHNS). METHODS: PubMed and Scopus databases were searched for studies reporting VTE in OHNS. Incidence of VTE and bleeding is reported and meta-analyzed overall and for chemoprophylaxis and squamous cell carcinoma (SCC)/free flap subgroups. RESULTS: A total of 23 studies were included with a total of 618,264 patients. Incidence of VTE was 0.4%. The incidence of bleeding complications was 0.9%. The addition of chemoprophylaxis did not result in a decreased VTE incidence (odds ratio [OR], 0.86), but produced an increased risk of bleeding (OR, 3.78). The overall OR for VTE in SCC/free flap cases was 6.28. CONCLUSION: Chemoprophylaxis may not be necessary in the OHNS non-SCC or free flap patient population and must be balanced against an increased risk of bleeding. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1249-1258, 2017.

Active surveillance management of head and neck paragangliomas: case series and review of the literature.

BACKGROUND: Head and neck paragangliomas are rare. They are usually slow-growing, benign, non-catecholamine secreting tumours, traditionally treated with surgical excision. Complications of surgical excision include lower cranial nerve palsies, stroke and death. METHOD: A retrospective case note analysis was conducted of patients with head and neck paragangliomas treated with a watch-and-scan policy from March 2003 to September 2015, and the relevant literature was reviewed. RESULTS: Fifteen head and neck paragangliomas were identified. None of the patients developed a new lower cranial nerve palsy or progression of their presenting hearing loss during the follow-up period. Five patients displayed an increase in maximum linear dimension of 4 mm over an average of 57.4 months. A review of the literature showed that a watch-and-surveillance scan policy is evolving as a treatment option for head and neck paragangliomas without malignant risk factors. CONCLUSION: Readily available surveillance scanning in head and neck paragangliomas enables the monitoring of head and neck paragangliomas, which may allow for avoidance of major surgery.

Residue influences quality of life independently of penetration and aspiration in head and neck cancer survivors.

OBJECTIVES/HYPOTHESIS: Dysphagia is one of the most significant side effects of the treatment of head and neck cancer. Residue and aspiration are two indicators of dysphagia, but aspiration is historically the only indicator of interest, because it may impact health outcomes. Clinicians have anecdotally used residue as another marker of swallowing dysfunction, but it is understudied. This project investigated the impact of aspiration versus residue on function and quality of life (QoL) in these patients. STUDY DESIGN: Observational study. METHODS: A total of 168 head and neck cancer survivors with moderate to severe dysphagia were enrolled in a randomized clinical trial comparing two swallow therapy interventions. Data at time of entry were used for the current study. A modified barium swallow study was done to compute Penetration-Aspiration Scale (PAS) scores, percentage oral residue, and percentage pharyngeal residue with three bolus consistencies (5 mL thin, nectar, and pudding). The Performance Status Scale (PSS) and the Head Neck Cancer Inventory (HNCI) questionnaires were administered. Data were analyzed to determine associations between aspiration and residue estimates with function and QoL scores. RESULTS: Worsening aspiration and residue estimates were all correlated with decreased scores on the PSS functional scales (r = -0.190 to -0.324, P ≤ .031). However, only increasing residue estimates were significantly related to decreased patient-perceived QoL on the HNCI (r = -.178 to -.194, P < .046). This effect was more pronounced with oral versus pharyngeal residue. CONCLUSIONS: In this group of head and neck cancer survivors, penetration/aspiration and residue show independent effects. PAS affects functional status only, but residue affects both functional status and QoL. This study supports that residue should be considered a primary measurement of swallowing function and be a target for identification, treatment, and evaluation of swallowing. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:1615-1621, 2017.

[Head and Neck Cancer in Pregnancy - Recommendations for Diagnosis and Therapy With Case Report]. / Kopf-Hals-Krebs in der Schwangerschaft ­ Empfehlungen zu Diagnostik und Therapie mit Fallbericht.

Objective: The diagnosis of cancer in pregnancy is rare, but might become more relevant even for head and neck cancer patients due to a shift of age of primipara towards the last third of reproductive years. Unsureness exists about the risk and benefit of diagnostic and therapeutic cancer modalities for the unborn and established recommendations are still missing. But, according to recent data, even multimodal therapeutic approaches (e. g. surgery, radiation, chemotherapy) seem possible in face of pregnancy and should be traded against the risk of prematurity. Material and Methods: Our findings are discussed on the basis of a case report of a pregnant woman with advanced carcinoma of the outer ear canal and therapy options are formulated. Results: Sufficient performed diagnostic modalities do not reach imperilling uterus dosages. A growing number of case reports und studies did not detect any developmental disadvantage of children of prenatal exposed mothers by radiation or chemotherapy, whereas long-term impairments of premature infants are proven. Conclusion: In cancer in pregnancy, an immediate start of well-established therapy modalities like surgery and/or cisplatin-based chemoradiation seems to be possible without unjustifiable risks for the unborn.

A 14-year-old boy with extranodal natural killer cell lymphoma of the nose, nasopharynx, larynx, and trachea in remission 6years after primary diagnosis. A longitudinal case report.

Nasal type extranodal natural killer/T-cell lymphoma (ENKTL) is a rare lymphoma in the USA and Europe but endemic in East Asia and in areas of South and Central America. Clinically natural killer cell lymphomas are divided into three categories; nasal, non-nasal and aggressive lymphoma/leukemia subtypes. ENKTL, nasal type occurs in the nose and can extend to the upper aero-digestive tract as reported in this longitudinal case study. This is a longitudinal report of progress of a 14-year-old boy with ENKTL originating in the nasal cavity with subsequent extension and recurrence in the contralateral nose, nasopharynx, larynx and trachea presenting with varying degrees of respiratory problems and eventually, respiratory distress. Caregiver refusal of stem cell transplantation prompted an alternative diagnostic and therapeutic approach. Clinical course with recurrences, extensions and remissions over 6years with tailored endoscopic surgical treatment and radiochemotherapy is documented to present a guide in the multidisciplinary management of this rare disease.

Can Oxidative Stress Parameters Be Used as Biomarkers for the Discrimination of Malignant Head and Neck Tumors.

OBJECTIVE: In this study the authors have investigated oxidative stress parameters in sera and tissues, and evaluated their significance for the differentiation of malignant and benign tumors. METHODS: The study included 104 patients who were operated for head and neck tumors, and 45 healthy volunteers. Group 1 (n = 56) consisted of patients with malignant, Group 2 (n = 48) consisted of patients with benign tumors, and Group 3 (n = 45) was the control group. While both tissue and plasma samples were collected from groups 1 and 2, only plasma samples were collected from Group 3. Plasma and tissue levels of oxidative status were determined by using an automated measurement method. RESULTS: Serum analysis revealed that total oxidant status (TOS) and oxidative stress index (OSI) values of Group 1 were significantly higher than those of Groups 2 and 3, and total antioxidant status (TAS) values of Group 1 were significantly lower than those of Groups 2 and 3. TAS values of Group 2 were lower than those of Group 3, but the difference was not statistically significant. Biochemical tissue analysis revealed that TOS and OSI values of Group 1 were significantly higher than those of Group 2, while TAS values of Group 1 were significantly lower than those of Group 2. CONCLUSIONS: There is a significant difference between the total oxidative stress parameters of malignant and benign head and neck tumors. The authors think that total oxidative stress parameters can be used as a practical, cheap, and easy method for discriminating malignant tumors from benign tumors.

[Mucosal Melanoma of the Head and Neck]. / Schleimhautmelanome des Kopf-Hals-Bereichs.

Primary mucosal malignant melanoma of the head and neck is a rare tumor entity with poor clinical outcome. Its growth pattern is characterized by an infiltrative and local destructive behavior. So far no risk factors could be identified. There are practically no early symptoms of the disease, as intermitting nose bleeding or nasal obstruction typically occur in advanced stage. The standard of care remains radical tumor resection with adjuvant radiation in cases of close margin resection. Other therapeutic options like the use of interferon, antibodies or conventional chemotherapeutics have not demonstrated significant clinical benefit so far. Current efforts to investigate the biological and genomic characteristics of these tumors have been constrained by its low incidence. In order to better characterize this rare tumor entity and to establish effective novel targeted therapies it will be necessary to establish an interdisciplinary and multicentric task force.

Characteristics of Human Papillomavirus-Associated Head and Neck Cancers in a Veteran Population.

IMPORTANCE: The US veteran population represents a unique cohort of patients in whom human papillomavirus (HPV)-related head and neck squamous cell carcinoma (HNSCC) has yet to be investigated. OBJECTIVE: To investigate the incidence and characteristics of HPV-positive HNSCC within the veteran population. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review including patients with HNSCC diagnosed between January 1, 2010, and November 15, 2013, from the VA Greater Los Angeles Healthcare System. Data were collected between November 16, 2013, and June 19, 2014, and analyzed between June 20, 2014, and March 26, 2015. EXPOSURES: Chemoradiation therapy, radiation therapy, surgery, or no treatment. MAIN OUTCOMES AND MEASURES: We determined HPV positivity by p16 testing. Demographic and clinicopathologic information and overall survival were extracted from medical records. RESULTS: We identified 150 patients with the diagnosis of HNSCC. Sixty-nine patients had HPV-positive tumors (46%), and 65 (43%) had HPV-negative tumors (16 did not have HPV testing). Age at diagnosis ranged from 44 to 94 years (mean, 64.6 [SD, 8.0] years), and median (interquartile range) follow-up was 16.7 (8.7-27.3) years. Tumor location differed significantly between the 2 groups, with an HPV-positive predominance in the oropharynx (43 of 57 [75%]; P < .001). The HPV-positive patients were more likely to be treated primarily with combined chemoradiation therapy than radiation therapy or surgery (P < .001). T4 tumors had a nearly 9 times greater rate of mortality compared with T1 tumors (HR, 8.52 [95% CI, 2.60-18.40; P < .001); N3 disease was associated with 7.18 times greater mortality (HR, 7.18 [95% CI, 1.99-12.26]; P < .001) compared with N1 disease; and M1 disease was associated with 6.0 times greater mortality (HR, 5.99 [95% CI, 2.59-13.81]; P < .001). There were 42 total deaths during follow-up, 25 in the HPV-negative group and 17 in the HPV-positive group, with a nonsignificantly higher overall survival among HPV-positive patients independent of alcohol or tobacco use history (P = .09). CONCLUSIONS AND RELEVANCE: Previous studies have found that the proportion of HPV-positive HNSCC in the general population ranges between 20% and 75%. Although the incidence of HPV-positive HNSCC in the Veterans Affairs population is comparable, these patients have unique risk factors and demographic characteristics that may suggest different prognostic factors for HPV-positive HNSCC in this population. Nonetheless, HPV-positive tumors still seem to portend a better overall prognosis regardless of alcohol or tobacco history among the Veterans Affairs population.