Identifying Candidate Biomarkers for Pleomorphic Adenoma: A Case-Control Study.

Pleomorphic adenoma (PA) is the most common benign salivary gland tumor. Kallikrein-related peptidases have been identified as biomarkers in many human tumors and may influence tumor behavior. We investigated KLK1-15 messenger ribonucleic acid and proteins in PA specimens to determine a KLK expression profile for this tumor. Fresh frozen PA tissue specimens (n = 26) and matched controls were subjected to quantitative real-time reverse transcription polymerase chain reaction to detect KLK1-15 mRNA. Expression of KLK1, KLK12, KLK13, and KLK8 proteins were then evaluated via immunostaining techniques. Statistical analyses were performed with the level of significance set at P < .05. We observed downregulation of KLK1, KLK12, and KLK13 mRNA expression, and immunostaining studies revealed downregulation of the corresponding proteins. Histologic evidence of capsular perforation was associated with increased KLK1 protein expression. Tumor size was not associated with capsular invasion and/or perforation. This study is the first to detail a KLK expression profile for PA at both the transcriptional level and the protein level. Future work is required to develop clinical applications of these findings.

Multimedia in the informed consent process for endoscopic sinus surgery: A randomized control trial.

OBJECTIVES/HYPOTHESIS: To determine patient recall of specific risks associated with endoscopic sinus surgery and whether an adjunct multimedia education module is an effective patient tool in enhancing the standard informed consent process. STUDY DESIGN: Prospective, randomized, controlled trial. METHODS: Fifty consecutive adult patients scheduled for endoscopic sinus surgery at a rhinology clinic of a tertiary care hospital were recruited for this study. Informed consent was studied by comparing the number of risks recalled when patients had a verbal discussion in conjunction with a 6-minute interactive module or the verbal discussion alone. Early recall was measured immediately following the informed consent process, and delayed recall was measured 3 to 4 weeks after patient preference details were also collected. RESULTS: Early risk recall in the multimedia group was significantly higher than the control group (P = .0036); however, there was no difference between the groups in delayed risk recall. Seventy-six percent of participants expressed interest in viewing the multimedia module if available online between the preoperative and procedural day. Sixty-eight percent of patients preferred having the multimedia module as an adjunct to the informed consent process as opposed to the multimedia consent process alone. CONCLUSIONS: There is an early improvement in overall risk recall in patients who complete an interactive multimedia module, with a clear patient preference for this method. Here we emphasize the well-known challenges of patient education and demonstrate the effectiveness of integrating technology into clinical practice in order to enhance the informed consent process. LEVEL OF EVIDENCE: 1b Laryngoscope, 126:1273-1278, 2016.

Carcinoma of the larynx, metastatic to illeum, presents as ruptured appendicitis: case report and literature review.

OBJECTIVES: Metastasis of laryngeal squamous cell carcinoma (SCC) to the intra-abdominal gastrointestinal tract is exceedingly rare. The objectives of this case report are to describe a case involving a perforated metastasis of a laryngeal SCC to the ileum and to review the literature pertaining to other similar cases. METHODS: A review of patient's chart and a review of the English literature involving malignant SCC of the larynx with metastasis to the small bowel. RESULTS: We describe the case of a 58-year-old man who had failed induction chemotherapy and underwent a laryngopharyngectomy with bilateral neck dissection and pectoralis major flap for a T4N2c laryngeal SCC. Subsequently, the patient was treated with postoperative radiation and cituximab.The patient went on to present with symptoms consistent with a ruptured appendix, supported by ultrasound imaging. The patient was taken to the operating room where a right hemicolectomy was performed. Pathological gross examination confirmed a 4 cm transmural perforation in the terminal ileum. Microscopy demonstrated deposits of metastatic squamous cell carcinoma in the surrounding smooth muscle. Metastatic carcinoma was also found in a separate nodule from the abdominal wall. The patient had an uncomplicated post-operative period, and survived several months thereafter. CONCLUSIONS: Metastasis of laryngeal SCC to the small bowel with perforation is exceedingly rare, but possible. These patients may be successfully managed with resection.

Preoperative concerns of patients undergoing endoscopic sinus surgery.

BACKGROUND: Patient-centered care is recognized as being fundamental to successful medical practice. The effectiveness of patient-centered care has classically been measured by posttreatment outcomes, such as patient compliance and psychosocial responses. Systematic assessment of patient concerns prior to treatment has been limited, to date. Endoscopic sinus surgery (ESS) is an elective procedure for chronic rhinosinusitis that carries a clear, defined set of risks. The objective of this prospective observational study was to determine the concerns of patients undergoing ESS for chronic rhinosinusitis. METHODS: A total of 180 patients undergoing ESS for chronic rhinosinusitis with or without polyposis were recruited at 2 Canadian tertiary care centers. They completed a validated survey assessing their concerns regarding the risks and outcomes of surgery. Data was analyzed using descriptive statistics and analysis of variance. RESULTS: Patients had a low degree of concern prior to undergoing surgery (overall score 2.8/9), though individual variability existed. Subjects felt the greatest level of concern regarding potential need for revision surgery as well as the wait time for surgery. Patients were least concerned about psychological factors (mean = 1.8/9). No differences with respect to age or gender were identified. Mean scores for cerebrospinal fluid leak and orbital injury were 3 and 3.2, respectively. CONCLUSION: Patients' level of concern prior to undergoing elective surgery is generally low. Patients' areas of greatest concern may not align with those perceived by the physician. This study provides insight into patient concerns prior to undergoing elective sinus surgery and emphasizes the importance of the patient-centered approach to care.

Development of a transoral robotic surgery program in Canada.

Due to significant differences in healthcare structure between the United States and Canada, there are unique barriers to adopting new medical technology in Canada. In this article, we describe our experience developing a transoral robotic surgery (TORS) program at Western University. Specifically, we outline the steps that were necessary to obtain institutional and multidisciplinary team approval, financial support, as well as surgeon and allied healthcare personnel training. This experience can potentially be used as a roadmap for other Canadian institutions pursuing a TORS program.

Does HPV type affect outcome in oropharyngeal cancer?

BACKGROUND: An epidemic of human papillomavirus (HPV)-related oropharyngeal squamous cell cancer (OPSCC) has been reported worldwide largely due to oral infection with HPV type-16, which is responsible for approximately 90% of HPV-positive cases. The purpose of this study was to determine the rate of HPV-positive oropharyngeal cancer in Southwestern Ontario, Canada. METHODS: A retrospective search identified ninety-five patients diagnosed with OPSCC. Pre-treatment biopsy specimens were tested for p16 expression using immunohistochemistry and for HPV-16, HPV-18 and other high-risk subtypes, including 31,33,35,39,45,51,52,56,58,59,67,68, by real-time qPCR. RESULTS: Fifty-nine tumours (62%) were positive for p16 expression and fifty (53%) were positive for known high-risk HPV types. Of the latter, 45 tumors (90%) were identified as HPV-16 positive, and five tumors (10%) were positive for other high-risk HPV types (HPV-18 (2), HPV-67 (2), HPV-33 (1)). HPV status by qPCR and p16 expression were extremely tightly correlated (p < 0.001, Fishers exact test). Patients with HPV-positive tumors had improved 3-year overall (OS) and disease-free survival (DFS) compared to patients with HPV-negative tumors (90% vs 65%, p = 0.001; and 85% vs 49%, p = 0.005; respectively). HPV-16 related OPSCC presented with cervical metastases more frequently than other high-risk HPV types (p = 0.005) and poorer disease-free survival was observed, although this was not statistically significant. CONCLUSION: HPV-16 infection is responsible for a significant proportion of OPSCC in Southwestern Ontario. Other high-risk subtypes are responsible for a smaller subset of OPSCC that present less frequently with cervical metastases and may have a different prognosis.

An endonasal approach to the resection of a papillary seromucinous adenocarcinoma of the eustacian tube.

OBJECTIVES: Papillary seromucinous adenocarcinoma of the sinonasal tract is exceedingly rare. The objectives of this case report are to describe a case of papillary seromucinous adenocarcinoma presenting in the nasopharynx and to review the literature pertaining to other similar cases. METHODS: A review of the patient's chart and a review of the English literature were conducted. RESULTS: We describe the case of a 64 year-old woman who presented with a 3-year history of epistaxis and right-sided otitis media with effusion. The patient had been followed for a known nasopharyngeal mass that had twice been biopsied and in both cases was considered a benign mass pathologically. A third biopsy was diagnosed as a low-grade papillary seromucinous adenocarcinoma. The patient was otherwise asymptomatic. The patient was referred to a multidisciplinary cancer clinic at which endoscopic resection was determined to be the preferred treatment modality. A literature review and approach to patients with nasopharyngeal masses will be presented. CONCLUSIONS: Papillary seromucinous adenocarcinoma is a rare tumor that can present in the nasopharynx. We describe the endoscopic surgical management of one such patient that presented to our care.

Transoral robotic total laryngectomy: report of 3 cases.

BACKGROUND: Because of the significant toxicity of chemoradiation regimens, there has been a resurgence of interest in the primary surgical management of head and neck cancer and, in particular, the use of minimally invasive surgery. One such technique is transoral robotic surgery (TORS). We aim to discuss the potential role of TORS in patients requiring total laryngectomy (TL). METHODS AND RESULTS: Three patients underwent TORS-assisted narrow-field TL. Relative data on preoperative, intraoperative, and postoperative management were collated including postoperative complications. CONCLUSIONS: We present 3 cases of transoral robotic surgery (TORS)-assisted TL in patients requiring narrow field laryngectomy without requirement for neck dissection. In reviewing these cases we provide a discussion of pertinent preoperative and intraoperative considerations that can assist in facilitating successful completion of the procedure. In particular, appropriate assessment at the pinsertlinePOLA_Del_Blank_PgPOLA_Shift_FramePORT_rem_fpg_underremovelinetabminilanning endoscopy in addition to a methodical surgical approach are vital to the successful use of the robot in TORS-assisted TL.

A novel tool for the objective measurement of neck fibrosis: validation in clinical practice.

BACKGROUND: Radiotherapy is commonly used to treat neoplasms of the head and neck, and fibrosis is a known side effect. The Cutometer is a device that quantifies properties of the skin. The goal of the study was to validate the Cutometer in normal neck tissues and then quantify fibrosis in radiated necks. METHODS: We performed a prospective study of 251 patients. The elasticity and stiffness parameters were recorded. Control patients were compared to determine the correlation between their left and right sides. Next, the treatment groups were compared using a nonparametric test (Kruskal-Wallis). RESULTS: We found a significant correlation between the left and right sides of the control patients' necks, supporting the view that the Cutometer provides reproducible measurements in the normal neck. Furthermore, the Cutometer demonstrated reduced elasticity in necks treated with radiation, surgery-radiation, and chemoradiation. No significant difference in stiffness was seen. CONCLUSION: The Cutometer may serve as a valuable and valid tool for the measurement of neck skin elasticity. Radiated patients have a quantifiable decrease in their skin elasticity.

Frequent mutations in TP53 and CDKN2A found by next-generation sequencing of head and neck cancer cell lines.

OBJECTIVE: To conduct high-throughput mutational analysis in 6 commonly used head and neck cancer cell lines. Comprehensive mutation analysis of primary head and neck squamous cell carcinoma (HNSCC) tumors has recently been reported, and mutations in the NOTCH receptors, TP53 and CDKN2A, were key findings. Established cell lines are valuable tools to study cancer in vitro. Similar high-throughput mutational analysis of head and neck cancer cell lines is necessary to confirm their mutational profile. DESIGN: DNA was extracted from American Type Culture Collection (ATCC) cell lines Cal27, Detroit562, FaDu, SCC4, SCC15, and SCC25. Cell line identity was confirmed by short tandem repeat (STR) analysis, and human papillomavirus (HPV) infection status was assessed by real-time polymerase chain reaction. A total of 535 cancer-associated genes were sequenced through a limited exome capture on the Illumina HiSeq system. SETTING: London Regional Cancer Program. RESULTS: The identity of the 6 cell lines was confirmed by STR analysis, and all lines tested negative for HPV infection. We achieved an average of 129-fold coverage with paired-end 100 base-pair reads. Sequencing revealed an average of 38 damaging mutations in each cell line (range, 30-45). The TP53 mutations, predicted to confer loss of function, were noted in all cell lines, and damaging CDKN2A mutations were found in all lines except SCC15. CONCLUSIONS: High-throughput sequencing of head and neck cancer cell lines revealed similar mutations to those observed in primary tumors. Thus, these lines reflect the tumor biology of HNSCC and can serve as valuable models to study HNSCC in vitro.

The role of transoral robotic surgery in the management of oropharyngeal cancer: a review of the literature.

Background. Transoral robotic surgery (TORS) is an emerging treatment option for the treatment of head and neck malignancies, particularly for oropharyngeal squamous cell carcinoma (OPSCC). Preliminary studies have demonstrated excellent oncologic and functional outcomes that have led to a resurgence of interest in the primary surgical management of OPSCC. The aim of the present study was to review the evidence base supporting the use of TORS in OPSCC. Methods. Studies evaluating the application of TORS in the treatment of head and neck squamous cell carcinoma (HNSCC), and more specifically OPSCC, were identified for review. Further searches were made of reference lists for complete evaluation of minimally invasive surgery (MIS) in treating OPSCC. Results. Seventeen results relating to the application of TORS in treatment of OPSCC were identified. Further results relating to the role of transoral laser microsurgery (TLM) in OPSCC were included for review. Feasibility, oncologic, and functional data is summarized and discussed. Discussion. Management strategies for patients with OPSCC continue to evolve. Minimally invasive surgical techniques including TORS and TLM offer impressive functional and oncologic outcomes particularly for patients with early T-classification and low-volume regional metastatic disease. Potential exists for treatment deintensification, particularly in patients who are HPV positive.

Ki-67 expression predicts radiotherapy failure in early glottic cancer.

BACKGROUND: Early-stage laryngeal squamous cell carcinoma is managed with radiotherapy or endoscopic surgery. Although cure rates are high, radiation failures often require total laryngectomy for salvage. Biomarkers that can predict tumour radioresistance may be useful in modifying the treatment approach for individual patients. METHODS: Retrospective patient chart review yielded 75 patients with T1-T2 glottic squamous cell carcinoma treated with radiation therapy at the London Health Sciences Centre. Pretreatment tumour biopsies were immunostained for B-cell lymphoma 2 (Bcl-2), Ki-67, and epidermal growth factor receptor (EGFR) to correlate biomarker expression with disease-free survival (DFS). RESULTS: Ki-67 expression was strongly associated with recurrence following radiation and independently predicted poor DFS (hazard ratio 4.86, 95% CI 1.58-15.00; p  =  .006). EGFR and Bcl-2 were not associated with a risk of recurrence. CONCLUSIONS: Ki-67 expression identified a subset of patients with increased risk of local recurrence after radiation therapy. Ki-67 expression can potentially guide improved personalized treatments for patients with early-stage glottic squamous cell carcinomas.

The Western Surgical Concern Inventory-Thyroid: development and initial validation.

OBJECTIVE: Patients considering surgery face many uncertainties and concerns. This investigation sought to develop an objective assessment tool for characterizing the areas of greatest concern among those considering thyroidectomy. STUDY DESIGN: Prospective cohort design. SETTING: Tertiary-care otolaryngology practice. SUBJECTS: Participants included individuals presenting with a thyroid nodule found to be of intermediate risk (15%-20%) of cancer based on fine-needle aspiration (FNA) biopsy and amendable to hemithyroidectomy. METHODS: As part of validating a clinical measure concerning perioperative concerns, patients presenting with thyroid nodules amendable to hemithyroidectomy were voluntarily recruited. Thirty individuals (6 men, 24 women) completed a novel 18-item questionnaire during their initial clinical visit and again 3 days later. Outcome measures included descriptive statistics and test-retest reliability. RESULTS: Individual patients have both general and specific preoperative concerns. A wide range of responses was obtained across the entire spectrum of the survey. The questionnaire demonstrated fair-to-excellent test-retest reliability, with correlation values from 0.467 to 0.954. Between-rater reliability was consistent with intraclass correlation coefficient values of 0.52 to 0.86. No relationship between question order and patient response was identified. Women were found to be more concerned about scar appearance (P = .028), and men were conversely more concerned about resuming daily activities (P = .026). CONCLUSIONS: Patients considering thyroidectomy have concerns that remain stable in the early preoperative period. This is the first study to evaluate preoperative patient concerns and preliminarily establishes the Western Surgical Concern Inventory-Thyroid as a means of ensuring adequate patient counseling and a method of evaluating preoperative patient education.

Detection of circulating tumor cells in advanced head and neck cancer using the CellSearch system.

BACKGROUND: Early detection of circulating tumor cells (CTCs) offers the possibility of improved outcome for patients with head and neck squamous cell cancer (HNSCC). METHODS: Patients with advanced-stage HNSCC (stage III/IV) were tested for CTCs using the CellSearch system (a registered trade name), which has been approved by the U.S. Food and Drug Administration (FDA) for monitoring CTCs in other cancers. RESULTS: CTCs were detected in 6 of 15 patients with advanced-stage HNSCC (range, 1-2 cells/7.5 mL of blood). CTCs were significantly associated with patients with lung nodules >1 cm (p = .04). There was also a suggestion of improved survival in the CTC-negative versus the CTC-positive patients (p = .11). CONCLUSIONS: CTCs can be successfully isolated in patients with advanced-stage HNSCC using the CellSearch system. CTC detection may be important for prognosis, evaluating treatment outcome, and for determining efficacy of adjuvant treatments.

A descriptive analysis of the relationship between quality of life and distress in individuals with head and neck cancer.

PURPOSE: Both short- and long-term outcomes for individuals with head and neck cancer (HNCa) may be influenced by multiple factors. Identification of distress in those with HNCa may provide a critical dimension that influences quality of life (QoL). Consequently, this investigation assessed distress and QoL in those with HNCa. METHODS: This study utilized a cross-sectional, self-report survey design. Participants included 49 adults diagnosed with HNCa. Upon assessment, post-diagnosis time ranged between 3-12 months. All participants completed a validated distress screening measure, the Brief Symptom Inventory 18 (BSI-18), and the EORTC general QoL assessment tool (EORTC-QLQ-C30) and HNCa module (EORTC-QLQ-H&N35). RESULTS: Approximately 22% of participants demonstrated clinically significant distress. Additionally, distress was significantly related to QoL status and specific symptoms. CONCLUSIONS: Screening for distress in those with HNCa may permit early identification of problems that influence QoL outcomes. The ability to identify distress early may also facilitate timely intervention to reduce distress and optimize QoL.

A Pilot Study Comparing HPV-Positive and HPV-Negative Head and Neck Squamous Cell Carcinomas by Whole Exome Sequencing.

Background. Next-generation sequencing of cancers has identified important therapeutic targets and biomarkers. The goal of this pilot study was to compare the genetic changes in a human papillomavirus- (HPV-)positive and an HPV-negative head and neck tumor. Methods. DNA was extracted from the blood and primary tumor of a patient with an HPV-positive tonsillar cancer and those of a patient with an HPV-negative oral tongue tumor. Exome enrichment was performed using the Agilent SureSelect All Exon Kit, followed by sequencing on the ABI SOLiD platform. Results. Exome sequencing revealed slightly more mutations in the HPV-negative tumor (73) in contrast to the HPV-positive tumor (58). Multiple mutations were noted in zinc finger genes (ZNF3, 10, 229, 470, 543, 616, 664, 638, 716, and 799) and mucin genes (MUC4, 6, 12, and 16). Mutations were noted in MUC12 in both tumors. Conclusions. HPV-positive HNSCC is distinct from HPV-negative disease in terms of evidence of viral infection, p16 status, and frequency of mutations. Next-generation sequencing has the potential to identify novel therapeutic targets and biomarkers in HNSCC.

Ketorolac in thyroid surgery: quantifying the risk of hematoma.

OBJECTIVE: Hematoma is a potentially life-threatening complication of thyroid surgery. Ketorolac is a nonsteroidal anti-inflammatory drug with known antiplatelet activity that is used for analgesia. The goal of this study was to determine the risk of hematoma in patients who received ketorolac in thyroid surgery. DESIGN: Retrospective cohort study. SETTING: London Health Sciences Centre. METHODS: A retrospective cohort study was conducted of patients who underwent thyroid surgery between 2002 and 2007. Data were analyzed using the Fisher exact test. MAIN OUTCOME MEASURES: Incidence of postoperative hematoma and perioperative ketorolac administration. RESULTS: Thirteen hematomas occurred in 799 patients. Of the 799, 183 patients received ketorolac (22.9%) and 616 did not. Five in the ketorolac group (2.73%) and eight in the nonketorolac group (1.30%) developed hematomas. The calculated relative risk was 2.10 (95% CI 0.70-6.35). CONCLUSIONS: Although there was an increased incidence of hematomas in the group receiving ketorolac, the difference was not statistically significant. The lack of significance may be due to the low number of hematomas.

Comparison of endoscopic laser resection versus radiation therapy for the treatment of early glottic carcinoma.

OBJECTIVE: Radiation therapy (RT) and transoral laser microsurgery (TLM) are established treatments for early glottic squamous cell carcinoma (SCC). Similar oncologic outcomes have been reported with both modalities, leading physicians to consider other factors when making clinical recommendations. One such factor is voice-related quality of life. This investigation sought to characterize differences in self-reported voice outcomes in patients undergoing RT or TLM for the treatment of Tis or T1a glottic SCC. METHODS: A retrospective cohort study was conducted of all individuals who received either RT or TLM for the treatment of Tis or T1a glottic SCC between 2004 and 2009 at the London Regional Cancer Program. The primary outcome measure was voice-related quality of life, as assessed by the Voice-Related Quality of Life questionnaire (V-RQOL). Secondary outcomes included local control, overall survival, and laryngectomy-free survival. RESULTS: Fifty-seven patients were eligible for this study; 34 received RT and 23 received TLM. Forty (70.2%) of the 57 patients completed the V-RQOL. No statistically significant difference in total V-RQOL score was observed between the RT and TLM cohorts (p  =  .228). There was, however, a trend toward higher scores (ie, less voice disability) in the physical function domain of the V-RQOL for the RT group (90.0%) compared to the TLM group (80.2%) (p  =  .05). No significant differences were observed in recurrence or overall survival between the two groups. CONCLUSION: Both oncologic outcomes and self-rated voice-related quality of life are similar in patients treated with RT and TLM for early glottic carcinoma.

The N3 neck: outcomes following primary chemoradiotherapy.

OBJECTIVE: To study the treatment outcomes of N3 neck disease following primary chemoradiotherapy. DESIGN: Retrospective cohort. SETTING: Tertiary care centre. METHODS: A review was conducted of 25 consecutive patients with N3 neck disease treated with primary platinum-based chemoradiotherapy. A neck dissection (ND) was offered in the event of clinical and/or radiologic evidence of residual disease on follow-up. MAIN OUTCOME MEASURES: Recurrence-free, disease-specific, and overall survival and patterns of failure. RESULTS: A regional complete response (CR) was noted in 48% of the patients. ND was performed in 36% of the cases. The median duration between the end of radiation and ND was 71 days. The recurrence-free survival rates at 1 and 2 years were 73% and 64%, respectively. The 2-, 3-, and 5-year overall survival rates were 66.7%, 52%, and 31.2%, respectively. Disease-specific survival rates were 69.6%, 63.3%, and 50.6%, respectively. Nine patients developed distant recurrence, with one having concurrent local and regional recurrence as well. Patients in the CR group remained free of regional recurrence. Among the initial partial responders, 54% eventually developed distant metastasis compared to 17% in the CR group. CONCLUSION: Patients with N3 disease may be managed with chemoradiotherapy, with ND reserved for salvage. Distant metastasis accounts for most recurrences and for the reduction in survival.

What are thyroidectomy patients really concerned about?

OBJECTIVE: To better appreciate perioperative concerns affecting patients considering thyroidectomy and to understand how they may vary according to patient characteristics. STUDY DESIGN: Cross-sectional analysis. SETTING: Tertiary referral center. SUBJECTS AND METHODS: The authors recruited patients scheduled for thyroid surgery at the McGill University Thyroid Cancer Center. A total of 148 patients completed the 18-item Western Surgical Concern Inventory-Thyroid (WSCI-T) questionnaire. Psychometrics of the WSCI-T were assessed through a principal component analysis with varimax rotation and reliability analyses. Independent-samples t tests and 2-tailed Pearson correlations were ran, identifying areas of elevated concerns and their relationship to gender, age, and surgical procedure (total vs hemithyroidectomy). RESULTS: The principal component analysis revealed the presence of 3 domains of presurgical concerns on the WSCI-T:Surgery-Related Concerns, Psychosocial Concerns, and Daily-Living Concerns. Reliability coefficients for the WSCI-T Total and subscales were satisfactory. Responses on the WSCI-T indicated on average a moderate overall level of concerns before thyroidectomy. Surgery-Related Concerns was the highest domain of concerns, followed by Daily-Living and Psychosocial Concerns, respectively. Patients were mainly worried about the nodule being cancerous, experiencing a change in voice, and surgical complications. Areas of minor concern included being judged or treated differently, becoming depressed, and feeling embarrassed. Women had higher overall levels of concern than men did. Although there were no significant differences in overall levels of concern according to age and surgical procedure, differences were noted at a subscale and item level. CONCLUSION: This study establishes a mean that will permit adequate physician counseling and a better management of patients' perioperative worries.