Effect of Mandible and Maxilla Osteotomies on Velar, Oropharyngeal, and Hypopharyngeal Diameter.

PURPOSE: There is a lack of anatomic comparisons between maxillomandibular advancement (MMA) and other bony surgical treatments of obstructive sleep apnea (OSA). Surgical procedures were simulated in cadavers to evaluate their ability to expand the posterior airway space (PAS). MATERIALS AND METHODS: The following bony advancement surgeries were performed on each of 9 cadavers: genioglossal advancement (GGA); genioplasty with advancement of the genioglossus, geniohyoid, and anterior digastric muscles (GPA); bilateral sagittal split osteotomy; Le Fort I maxillary advancement; Le Fort I maxillary anterior impaction osteotomy (LFAI); MMA; MMA plus GPA; and MMA plus LFAI. Bony advancements were performed at increasing distances and change in PAS anteroposterior (AP) diameter was measured at the levels of the velum, oropharynx, and hypopharynx. RESULTS: Change in PAS varied in a linear fashion with advancement surgical maneuvers. GPA led to a greater increase in AP distance at the levels of the oropharynx and hypopharynx compared with GGA. LFAI showed a greater increase in AP distance at the velum compared with MMA. All maxillary movements showed greater AP expansion in the PAS at the velum compared with mandibular advancements. CONCLUSIONS: Static AP expansion of the PAS at the levels of the velum, oropharynx, and hypopharynx occurs in a roughly linear and predictable pattern with different bony surgical procedures used in OSA surgery. MMA alone and MMA plus GPA had the overall greatest effect at all airway levels. GPA had a greater effect on expansion of the oropharynx and hypopharynx compared with GGA.

Addition of Androgen-Deprivation Therapy or Brachytherapy Boost to External Beam Radiotherapy for Localized Prostate Cancer: A Network Meta-Analysis of Randomized Trials.

PURPOSE: In men with localized prostate cancer, the addition of androgen-deprivation therapy (ADT) or a brachytherapy boost (BT) to external beam radiotherapy (EBRT) have been shown to improve various oncologic end points. Practice patterns indicate that those who receive BT are significantly less likely to receive ADT, and thus we sought to perform a network meta-analysis to compare the predicted outcomes of a randomized trial of EBRT plus ADT versus EBRT plus BT. MATERIALS AND METHODS: A systematic review identified published randomized trials comparing EBRT with or without ADT, or EBRT (with or without ADT) with or without BT, that reported on overall survival (OS). Standard fixed-effects meta-analyses were performed for each comparison, and a meta-regression was conducted to adjust for use and duration of ADT. Network meta-analyses were performed to compare EBRT plus ADT versus EBRT plus BT. Bayesian analyses were also performed, and a rank was assigned to each treatment after Markov Chain Monte Carlo analyses to create a surface under the cumulative ranking curve. RESULTS: Six trials compared EBRT with or without ADT (n = 4,663), and 3 compared EBRT with or without BT (n = 718). The addition of ADT to EBRT improved OS (hazard ratio [HR], 0.71 [95% CI, 0.62 to 0.81]), whereas the addition of BT did not significantly improve OS (HR, 1.03 [95% CI, 0.78 to 1.36]). In a network meta-analysis, EBRT plus ADT had improved OS compared with EBRT plus BT (HR, 0.68 [95% CI, 0.52 to 0.89]). Bayesian modeling demonstrated an 88% probability that EBRT plus ADT resulted in superior OS compared with EBRT plus BT. CONCLUSION: Our findings suggest that current practice patterns of omitting ADT with EBRT plus BT may result in inferior OS compared with EBRT plus ADT in men with intermediate- and high-risk prostate cancer. ADT for these men should remain a critical component of treatment regardless of radiotherapy delivery method until randomized evidence demonstrates otherwise.

Association of Presalvage Radiotherapy PSA Levels After Prostatectomy With Outcomes of Long-term Antiandrogen Therapy in Men With Prostate Cancer.

Importance: In men with recurrent prostate cancer, addition of long-term antiandrogen therapy to salvage radiotherapy (SRT) was associated with overall survival (OS) in the NRG/RTOG 9601 study. However, hormone therapy has associated morbidity, and there are no validated predictive biomarkers to identify which patients derive most benefit from treatment. Objective: To examine the role of pre-SRT prostate-specific antigen (PSA) levels to personalize hormone therapy use with SRT. Interventions: Men were randomized to SRT plus high-dose nonsteroidal antiandrogen (bicalutamide, 150 mg/d) or placebo for 2 years. Design, Setting, and Participants: In this secondary analysis of the multicenter RTOG 9601 double-blind, placebo-controlled randomized clinical trial conducted from 1998 to 2003 by a multinational cooperative group, men with a positive surgical margin or pathologic T3 disease after radical prostatectomy with pre-SRT PSA of 0.2 to 4.0 ng/mL were included. Analysis was performed between March 4, 2019, and December 20, 2019. Main Outcomes and Measures: The primary outcome was overall survival (OS). Secondary end points included distant metastasis (DM), other-cause mortality (OCM), and grades 3 to 5 cardiac and neurologic toxic effects. Subgroup analyses were performed using the protocol-specified PSA stratification variable (1.5 ng/mL) and additional PSA cut points, including test for interaction. Competing risk analyses were performed for DM and other-cause mortality (OCM). Results: Overall, 760 men with PSA elevation after radical prostatectomy for prostate cancer were included. The median (range) age of particpants was 65 (40-83) years. Antiandrogen assignment was associated with an OS benefit in the PSA stratum greater than 1.5 ng/mL (n = 118) with a 25% 12-year absolute benefit (hazard ratio [HR], 0.45; 95% CI, 0.25-0.81), but not in the PSA of 1.5 ng/mL or less stratum (n = 642) (1% 12-year absolute difference; HR, 0.87; 95% CI, 0.66-1.16). In a subanalysis of men with PSA of 0.61 to 1.5 (n = 253), there was an OS benefit associated with antiandrogen assignment (HR, 0.61; 95% CI, 0.39-0.94). In those receiving early SRT (PSA ≤0.6 ng/mL, n = 389), there was no improvement in OS (HR, 1.16; 95% CI, 0.79-1.70), an increased OCM hazard (subdistribution HR, 1.94; 95% CI, 1.17-3.20; P = .01), and an increased odds of late grades 3 to 5 cardiac and neurologic toxic effects (odds ratio, 3.57; 95% CI, 1.09-15.97; P = .05). Conclusions and Relevance: These results suggest that pre-SRT PSA level may be a prognostic biomarker for outcomes of antiandrogen treatment with SRT. In patients receiving late SRT (PSA >0.6 ng/mL, hormone therapy was associated with improved outcomes. In men receiving early SRT (PSA ≤0.6 ng/mL), long-term antiandrogen treatment was not associated with improved OS. Future randomized clinical trials are needed to determine hormonal therapy benefit in this population. Trial Registration: ClinicalTrials.gov Identifier: NCT00002874.

Esophagram findings in cervical esophageal stenosis: A case-controlled quantitative analysis.

OBJECTIVE: Cervical esophageal stenosis is often diagnosed with a qualitative evaluation of a barium esophagram. Although the esophagram is frequently the initial screening exam for dysphagia, a clear objective standard for stenosis has not been defined. In this study, we measured esophagram diameters in order to establish a quantitative standard for defining cervical esophageal stenosis that requires surgical intervention. STUDY DESIGN: Single institution case-control study. METHODS: Patients with clinically significant cervical esophageal stenosis defined by moderate symptoms of dysphagia (Functional Outcome Swallowing Scale > 2 and Functional Oral Intake Scale < 6) persisting for 6 months and responding to dilation treatment were matched with age, sex, and height controls. Both qualitative and quantitative barium esophagram measurements for the upper, mid-, and lower vertebral bodies of C5 through T1 were analyzed in lateral, oblique, and anterior-posterior views. RESULTS: Stenotic patients versus nonstenotic controls showed no significant differences in age, sex, height, body mass index, or ethnicity. Stenosis was most commonly at the sixth cervical vertebra (C 6) lower border and C7 upper border. The mean intraesophageal minimum/maximum ratios of controls and stenotic groups in the lateral view were 0.63 ± 0.08 and 0.36 ± 0.12, respectively (P < 0.0001). Receiver operating characteristic analysis of the minimum/maximum ratios, with a <0.50 ratio delineating stenosis, demonstrated that lateral view measurements had the best diagnostic ability. The sensitivity of the radiologists' qualitative interpretation was 56%. With application of lateral intraesophageal minimum/maximum ratios, we observed improved sensitivity to 94% of the esophagram, detecting clinically significant stenosis. CONCLUSION: Applying quantitative determinants in esophagram analysis may improve the sensitivity of detecting cervical esophageal stenosis in dysphagic patients who may benefit from surgical therapy. LEVEL OF EVIDENCE: IIIb. Laryngoscope, 128:2022-2028, 2018.

Novel and specific inhibitors of a poxvirus type I topoisomerase.

Vaccinia DNA topoisomerase (vTopo) is a prototypic pox virus family topoisomerase that shares extensive structural and mechanistic properties with the human type IB enzyme (hTopo) and is important for viral replication. Despite their far-reaching similarities, vTopo and hTopo have surprisingly distinct pharmacological properties. To further exploit these differences, we have developed recently the first high-throughput screen for vTopo, which has allowed rapid screening of a 1990-member small-molecule library for inhibitors. Using this approach, 21 compounds were identified with IC(90) values less than 10 muM, and 19 of these were also found to inhibit DNA supercoil relaxation by vTopo. Four of the most potent compounds were completely characterized and are structurally novel topo I inhibitors with efficacies at nanomolar concentrations. These inhibitors were highly specific for vTopo, showing no inhibition of the human enzyme even at 500- to 2000-fold greater concentrations. We describe a battery of efficient experiments to characterize the unique mechanisms of these vTopo inhibitors and discuss the surprising promiscuity of this enzyme to inhibition by structurally diverse small molecules.