Frailty as a Predictor of Postoperative Outcomes among Patients with Head and Neck Cancer.

OBJECTIVES: To understand measures of frailty among preoperative patients and explain how these can predict perioperative outcomes among patients with head and neck cancer. STUDY DESIGN: Retrospective cross-sectional case series with chart review. SETTING: Academic tertiary medical center. SUBJECTS AND METHODS: A retrospective review was performed of patients presenting to an academic hospital following a surgical procedure for a head and neck cancer diagnosis. Charts were queried for preoperative medical diagnoses to calculate 2 frailty scores: the American College of Surgeons National Surgical Quality Improvement Program modified frailty index and the Johns Hopkins Adjusted Clinical Groups frailty index. The American Society of Anesthesiologists classification system was also analyzed as a predictor. Primary outcomes were mortality, 30-day readmission, and length of stay. Perioperative complications and discharge disposition were also evaluated. RESULTS: A total of 410 charts were queried between January 2014 and December 2017. Mortality was 11%; mean ± SD length of stay was 7.4 ± 5.5 days; and the readmission rate was 17%. The modified frailty index score significantly increased the odds of mortality (odds ratio = 1.475, P = .012) and readmission (odds ratio = 1.472, P = .004), the length of stay (relative risk = 1.136, P = .001), and the number of perioperative complications. The American Society of Anesthesiologists classification was also significantly associated with poor outcomes, including readmission, length of stay, and perioperative complications. The Adjusted Clinical Groups index was not a significant predictor of outcomes in this study population. CONCLUSIONS: This study demonstrated a significant increase in poor perioperative outcomes and mortality among patients with head and neck cancer and increased frailty, as measured by the modified frailty index.

Human papillomavirus: the fundamentals of HPV for oral health care providers.

Human papillomavirus (HPV) has become widely known as the causative agent of cervical cancer and some oropharyngeal cancers. The development of HPV vaccines has further piqued public interest. As a result, dentists will have increasing numbers of patients who will inquire about oral HPV infection and its prevention by means of vaccination. Dental professionals must be informed. This review provides an overview of HPV, its association with HIV and oropharyngeal cancer, and information on HPV vaccinations.

Human papillomavirus: the fundamentals of HPV for oral health care providers.

Human papillomavirus (HPV) has become widely known as the causative agent of cervical cancer and some oropharyngeal cancers. The development of HPV vaccines has further piqued public interest. As a result, dentists will have increasing numbers of patients who will inquire about oral HPV infection and its prevention by means of vaccination. Dental professionals must be informed.This review provides an overview of HPV, its association with HIV and oropharyngeal cancer and information on HPVvaccinations.

Human papillomavirus-active head and neck cancer and ethnic health disparities.

OBJECTIVES/HYPOTHESIS: Mortality for black males with head and neck squamous cell carcinoma (HNSCC) is twice that of white males or females. Human papillomavirus (HPV)-active HNSCC, defined by the concurrent presence of high-risk type HPV DNA and host cell p16(INK4a) expression, is associated with decreased mortality. We hypothesized that prevalence of this HPV-active disease class would be lower in black HNSCC patients compared to white patients. STUDY DESIGN: Multi-institutional retrospective cohort analysis. METHODS: Real-time polymerase chain reaction was used to evaluate for high-risk HPV DNA presence. Immunohistochemistry for p16(INK4a) protein was used as a surrogate marker for HPV oncoprotein activity. Patients were classified as HPV-negative (HPV DNA-negative, p16(INK4a) low), HPV-inactive (HPV DNA-positive, p16(INK4a) low), and HPV-active (HPV DNA-positive, p16(INK4a) high). Overall survival and recurrence rates were compared by Fisher exact test and Kaplan-Meier analysis. RESULTS: There were 140 patients with HNSCC who met inclusion criteria. Self-reported ethnicity was white (115), black (25), and other (0). Amplifiable DNA was recovered from 102/140 patients. The presence of HPV DNA and the level of p16(INK4a) expression were determined, and the results were used to classify these patients as HPV-negative (44), HPV-inactive (33), and HPV-active (25). Patients with HPV-active HNSCC had improved overall 5-year survival (59.7%) compared to HPV-negative and HPV-inactive patients (16.9%) (P = .003). Black patients were less likely to have HPV-active disease (0%) compared to white patients (21%) (P = .017). CONCLUSIONS: The favorable HPV-active disease class is less common in black than in white patients with HNSCC, which appears to partially explain observed ethnic health disparities.

Multi-spectral imaging analysis of HSPB1 expression in head and neck squamous cell carcinoma.

The objective of this study was to obtain more accurate quantitation of HSPB1 expression in HNSCC using a novel quantitative protein expression analysis system based on multispectral imaging. The study was a retrospective laboratory study of HNSCC patients treated at tertiary care academic medical center. Archival tissue samples from forty seven patients with HNSCC were subjected to immunohistochemistry using primary antibody to HSPB1. Seven of the patients had early stage cancers (TNM stage I/II) and forty patients had advanced stage cancers (TNM stage III/IV). HSPB1 expression was increased in advanced stage versus early stage cancers. Further investigation of HSPB1 as a potential biomarker for HNSCC is warranted.

Significance of HSPB1 expression in head and neck squamous cell carcinoma: a meta-analysis of published literatures.

OBJECTIVE: HSPB1 functions to prevent stress-induced cellular damage and has is elevated in multiple cancer types. The significance of HSPB1 in HNSCC remains controversial. We sought to perform a meta-analysis of HSPB1 expression to clarify previous findings. STUDY DESIGN: Meta-analysis of all published studies of HSPB1 in HNSCC patients using IHC techniques. METHODS: A literature review was performed on PubMed and Google Scholar search engines using terms HSP27, HSPB1, Heat Shock Proteins, Cancer, Head and Neck Squamous Cell Carcinoma. Additional studies were added by review of manuscript bibliographies. Means and standard deviations for continuous data were obtained for overall HSPB1 expression (in cancer, normal and dysplasia), nodal status and TNM stage. Chi-square and Cochran's Q test were used to test statistical significance. RESULTS: There were 77 studies identified in the context of HSPB1 and cancer in general. Of these, 7 studies (total patients n=347) met inclusion criteria and reported findings in HNSCC using IHC scoring techniques. For the mean difference in HSPB1 expression; cancer vs. normal, cancer vs. dysplasia, and dysplasia vs. normal all showed significance (p<0.0001) however the difference was not homogeneous across studies for cancer vs. dysplasia and normal. The difference was homogeneous for dysplasia vs. normal. There was no significant difference for HSPB1 expression by nodal status or stage. CONCLUSION: HSPB1 is elevated in HNSCC and may be a useful biomarker for this disease.

2D-DIGE proteomic characterization of head and neck squamous cell carcinoma.

OBJECTIVE: Identify proteins that are differentially expressed between head and neck squamous cell cancer (HNSCC) and patient-matched normal adjacent tissue, and validate findings in a separate patient cohort. STUDY DESIGN: Cross-sectional study of surgical specimens. SETTING: Tertiary care academic medical center. SUBJECTS AND METHODS: Laser capture microdissection and two-dimensional difference gel electrophoresis were used previously to establish proteomic profiles for tumor and normal adjacent tissue from 14 patients. Here, significance analysis of microarray was used to rank candidate biomarkers. Spots meeting statistical and biological criteria of significance were analyzed by liquid chromatography and tandem mass spectrometry to obtain protein identifications. The expression pattern of the highest-ranked candidate biomarker (cornulin) was validated in a larger, independent patient cohort (n = 68) by immunohistochemical staining of a tissue microarray. RESULTS: Of 732 spots, 117 (15.9%) met criteria for significance. Identities were obtained for 39 spots, representing 17 different proteins. Four proteins were novel in the context of HNSCC: glutathione synthetase, which was upregulated; and cornulin (squamous epithelial heat shock protein 53), guanylate binding protein 6, and heat shock 70 kDa protein 5 (glucose-regulated protein, 78 kDa), which were downregulated. Cornulin functions in the stress response in normal squamous epithelium, and reduced expression has been proposed as a marker of susceptibility to laryngopharyngeal reflux and other stressors. Loss of cornulin expression was confirmed in an independent HNSCC patient cohort (P < 0.001). CONCLUSIONS: Downregulation of cornulin is a prominent feature of the molecular signature of HNSCC identified by comparative proteomics. Cornulin may represent a link between HNSCC and other pathologies arising in stratified squamous epithelium.

Quantitative analysis of syndecan-1 expression in dysplasia and squamous cell carcinoma of the oral cavity.

INTRODUCTION: Decreased expression of syndecan-1 has been reported in dysplasia and squamous cell carcinoma (SCCA) of the oral cavity and appears to correlate with decreasing histological differentiation and poor clinical outcome. Assays of syndecan-1 expression to date have utilized manual microscopic analysis with qualitative grading of immunohistochemical staining intensity, which may introduce observer bias. We evaluated syndecan-1 expression in dysplasia and squamous cell carcinoma (SCCA) of the oral cavity, using a novel automated cellular imaging system that incorporates both staining intensity as well as the percentage of positively stained cells to yield a quantitative value for syndecan-1 expression. MATERIALS AND METHODS: We performed a quantitative immunohistochemical analysis of syndecan-1 expression using an automated cellular image analysis system. We analyzed specimens from cases of mild dysplasia (N = 55), moderate dysplasia (N = 38), severe dysplasia (N = 25), carcinoma in situ (CIS) (N = 43), and SCCA of the oral cavity (N = 45), using normal mucosal epithelium (N = 21) as a positive control. The SCCA specimens were further subdivided by degree of differentiation. We retrospectively reviewed patient charts to identify tumor stage at diagnosis, recurrence, and disease-specific survival. RESULTS: Syndecan-1 expression was significantly greater in normal controls than in specimens of mild, moderate, or severe dysplasia, CIS, or invasive SCCA (P < .05). Syndecan-1 expression did not differ significantly among specimens of mild, moderate, or severe dysplasia, CIS or SCCA. There was no significant difference in syndecan-1 expression between specimens from patients with no evidence of disease at 3 years follow-up and patients with local, regional, or distant recurrence. CONCLUSIONS: Syndecan-1 expression does not appear to be useful as a marker of differentiation or as a prognostic indicator in dysplasia and SCCA of the oral cavity. The search for a suitable and reliable marker of biological aggressiveness is ongoing.

Classification and management of rhinosinusitis and its complications.

A stepwise evaluation of patients who have CRS allows a management approach that is tailored to each individual patient and to the specific type of disease.

Use of the harmonic scalpel in superficial and total parotidectomy for benign and malignant disease.

OBJECTIVES: Use of the harmonic scalpel in superficial parotidectomy for benign parotid disease has been shown to reduce surgical time as well as intraoperative blood loss. We sought to determine whether similar results could be achieved with the expanded use of the harmonic scalpel in parotidectomy for both benign and malignant disease. STUDY DESIGN: Retrospective review. METHODS: The medical records of all patients undergoing superficial or total parotidectomy from 1999 to 2004 were reviewed. Patients were excluded for a history of bleeding disorder, prior facial nerve weakness, or concurrent neck dissection at the time of parotidectomy. RESULTS: Forty-four patients underwent harmonic scalpel parotidectomy and 41 patients underwent conventional cold knife parotidectomy (control group). Use of the harmonic scalpel was associated with a significant reduction in intraoperative blood loss (38.0 +/- 3.6 mL vs. 66.0 +/- 10.8 mL for controls, P < 0.05) and duration of drainage (31.80 +/- 2.4 h vs. 39.29 +/- 2.21 h for controls, P < 0.05). Use of the harmonic scalpel in superficial parotidectomy (n = 35) compared to controls (n = 37) was associated with a significant reduction in intraoperative blood loss (38.0 +/- 4.23 mL vs. 68.0 +/- 12.0 mL, P < 0.05) and reduced incidence of facial nerve injury (P < 0.05). In patients undergoing total parotidectomy, no significant differences were observed between the harmonic scalpel (n = 9) and control groups (n = 4) in length of surgery, intraoperative blood loss, postoperative drainage, duration of drainage, and facial nerve injury. CONCLUSIONS: Use of the harmonic scalpel in the surgical treatment of parotid disease is safe and confers some advantages over conventional methods of parotid dissection.