Tumour-infiltrating lymphocytes predict for outcome in HPV-positive oropharyngeal cancer.

BACKGROUND: Human papillomavirus (HPV)-positive oropharyngeal cancer (OPSCC) is associated with improved survival compared with HPV-negative disease. However, a minority of HPV-positive patients have poor prognosis. Currently, there is no generally accepted strategy for identifying these patients. METHODS: We retrospectively analysed 270 consecutively treated OPSCC patients from three centres for effects of clinical, pathological, immunological, and molecular features on disease mortality. We used Cox regression to examine associations between factors and OPSCC death, and developed a prognostic model for 3-year mortality using logistic regression analysis. RESULTS: Patients with HPV-positive tumours showed improved survival (hazard ratio (HR), 0.33 (0.21-0.53)). High levels of tumour-infiltrating lymphocytes (TILs) stratified HPV-positive patients into high-risk and low-risk groups (3-year survival; HPV-positive/TIL(high)=96%, HPV-positive/TIL(low)=59%). Survival of HPV-positive/TIL(low) patients did not differ from HPV-negative patients (HR, 1.01; P=0.98). We developed a prognostic model for HPV-positive tumours using a 'training' cohort from one centre; the combination of TIL levels, heavy smoking, and T-stage were significant (AUROC=0·87). This model was validated on patients from the other centres (detection rate 67%; false-positive rate 5.6%; AUROC=0·82). INTERPRETATION: Our data suggest that an immune response, reflected by TIL levels in the primary tumour, has an important role in the improved survival seen in most HPV-positive patients, and is relevant for the clinical evaluation of HPV-positive OPSCC.

Controversies in the management of acute tonsillitis: an evidence-based review.

BACKGROUND: Patients admitted with acute tonsillitis generate a substantial workload for the National Health Service (NHS), placing huge financial pressures on an already overstretched budget. OBJECTIVE OF REVIEW: Due to the difficulty of accurate diagnosis and varying practices across the UK, there exist a number of controversial areas and non-standardised practice. These will be highlighted and tackled within this article. TYPE OF REVIEW AND SEARCH STRATEGY: A literature review, last performed in September 2013, searched PubMed citing variations on the areas of controversies with 'tonsillitis', 'pharyngitis' and 'pharyngotonsillitis' - from 1956 to present with language restrictions. Excluded articles included those regarding sore throat after tonsillectomy and peritonsillar abscess. EVALUATION METHOD: Titles and abstracts were initially screened, and full text of potentially relevant articles obtained. The bibliographies of articles were searched for relevant references. The references were then compiled and reviewed independently by two authors (JB & TB), overseen by the senior author (EK). RESULTS: (i) Diagnosis and investigation: Use of the Centor criteria is inadequate within the secondary care setting. Blood testing is unnecessary in the majority of cases where patients do not require admission, as they are unlikely to change management. (ii) Antibiotics: Antibiotics are likely to be indicated in all those presenting to secondary ENT care, with penicillin being the antibiotic of choice for first-line therapy. (iii) Corticosteroids: Moderate evidence supports the benefit of steroid administration in this patient cohort, advocating a single dose initially followed by reassessment. (iv) Analgesia: Paracetamol and NSAIDs have good evidence of action. Codeine should be used with caution in the paediatric population. (v) Reduced admission rates and early discharge: There is evidence suggesting that a trial of medical therapy prior to admission is beneficial in reducing rates of admission and length of stay. CONCLUSIONS: Management of acute tonsillitis within a secondary care setting largely consists of anecdotal or relatively low-quality evidence. Thus, much evidence from management comes from expert opinion or practice within a primary care setting. Management across the UK can also vary greatly. An evidence-based review of best practice has been presented here, but further evidence will be required in the future examining the significance of corticosteroids and antibiotic administration in this patient cohort specifically, ensuring practice is evidence based and clinically relevant.

Quality of online otolaryngology health information.

OBJECTIVE: Up to 70 per cent of the population search online for medical or health-related information. This study aimed to assess the quality of online health resources available to educate patients on a variety of otolaryngological conditions. METHODS: Two clinicians independently analysed the quality and content of educational websites (patient.co.uk and wikipedia.org) for common and uncommon diagnoses, with cancerresearchuk.org also used to assess two head and neck cancers. RESULTS: Cancerresearchuk.org, followed by patient.co.uk, scored most highly in their ability to inform readers on a selection of otolaryngological conditions. Although wikipedia.org was less likely to include all relevant information and was more difficult to read, it still provided mostly accurate information. CONCLUSION: Where possible, patients should be advised to access professionally maintained health information websites (patient.co.uk and cancerresearchuk.org). However, wikipedia.org can provide adequate information, although it lacks depth and can be difficult to understand.

Future perspectives: United Kingdom National Multidisciplinary Guidelines.

The multidisciplinary management of head and cancer has changed radically in the last decade. This paper provides a glimpse of the emerging surgical and oncological interventions that may play major roles in the treatment paradigms of tomorrow.

Correlation between clinical and MRI assessment of depth of invasion in oral tongue squamous cell carcinoma.

BACKGROUND: Neck metastasis is the most important prognostic factor in oral cavity squamous cell carcinomas (SCC). Apart from the T- stage, depth of invasion has been used as a highly predictable factor for microscopic neck metastasis, despite the controversy on the exact depth cut off point. Depth of invasion can be determined clinically and radio logically. However, there is no standard tool to determine depth of invasion preoperatively. Although MRI is used widely to stage the head and neck disease, its utility in depth evaluation has not formally been assessed. OBJECTIVE: To compare preoperative clinical and radiological depth evaluation in oral tongue SCC using the standard pathological depth. To compare clinical and radiological accuracy between superficial (<5 mm) vs. deep invaded tumor (≥5 mm) METHODS: This prospective study used consecutive biopsy-proven oral tongue invasive SCC that presented to the University health network (UHN), Toronto. Clinical examination, radiological scan and appropriate staging were determined preoperatively. Standard pathology reports postoperatively were reviewed to determine the depth of invasion from the tumor specimen. RESULTS: 72 tumour samples were available for analysis and 53 patients were included. For all tumors, both clinical depth (r = 0.779; p < 0.001) and radiographic depth (r =0.907; p <0.001) correlated well with pathological depth, with radiographic depth correlating slightly better. Clinical depth also correlated well with radiographic depth (r = 0.731; p < 0.001). By contrast, for superficial tumors (less than 5 mm on pathological measurement) neither clinical (r = 0.333, p = 0.34) nor radiographic examination (r = - 0.211; p = 0.56) correlated with pathological depth of invasion. CONCLUSION: This is the first study evaluating the clinical assessment of tumor thickness in comparison to radiographic interpretation in oral cavity cancer. There are strong correlations between pathological, radiological, and clinical measurements in deep tumors (≥5 mm). In superficial tumors (<5 mm), clinical and radiological examination had low correlation with pathological thickness.

Comparison of techniques for identification of peripheral vestibular nystagmus.

OBJECTIVE: To determine the best clinical method for identifying peripheral vestibular nystagmus, by comparing eye movement examination with optic fixation, and with fixation removed using Frenzel's glasses, infra-red video-Frenzel's goggles or an ophthalmoscope, with results of electronystagmography. METHOD: One hundred patients referred for electronystagmography from the audiovestibular medicine clinic at Queen Alexandra Hospital, Portsmouth, were examined immediately before undergoing electronystagmography. RESULTS: Video-Frenzel's goggles were highly effective at detecting peripheral vestibular nystagmus, with a sensitivity of 85 per cent (95 per cent confidence interval, 62.1-96.8 per cent) and a specificity of 65 per cent (53.5-75.3 per cent), compared with electronystagmography. Ophthalmoscopy had comparable sensitivity to Frenzel's glasses (used in the dark), i.e. 26.3 per cent (9.1-51.2 per cent) compared with 31.6 per cent (12.6-56.6 per cent), respectively. Frenzel's glasses as normally used in ENT clinics (i.e. in dim lighting) were ineffective, with a sensitivity of just 10 per cent (1.2-31.7 per cent). CONCLUSION: Video-Frenzel's goggles should be used in all clinics with substantial numbers of balance-impaired patients. Traditional Frenzel's glasses have no place in clinical practice unless formal black-out facilities are available.