Carol M. Bier-Laning

Primary tumor thickness as a risk factor for contralateral cervical metastases in T1/T2 oral tongue squamous cell carcinoma

Contralateral cervical metastases represent an avoidable source of failure in squamous cell carcinoma (SCCa) of the oral tongue. We sought to identify risk factors for the development of contralateral cervical metastases in T1/T2 oral tongue SCCa.

A 25-Year Analysis of Veterans Treated for Tonsillar Squamous Cell Carcinoma

OBJECTIVE To determine the recurrence and survival outcome based on treatment date, type of treatment, stage of disease, and comorbidity and the recurrence and survival differences based on smoking status as a surrogate for human papillomavirus status in veterans treated for tonsillar squamous cell carcinoma (SCC). DESIGN Outcome cohort study. SETTING Tertiary care Department of Veterans Affairs hospital. PATIENTS A consecutive sample from 1981 through 2006 of 683 patients treated for oropharyngeal SCC was screened, and 141 patients with tonsillar SCC without distant metastatic spread and a minimum of 2 years of follow-up were included. MAIN OUTCOME MEASURES Disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). RESULTS Disease-free survival was significantly better in cohort II (treated during or after 1997) compared with cohort I (treated before 1997) (2- and 5-year DFS, 82% vs 64% and 67% vs 48%; P = .02). Disease-specific survival was better in the surgical vs nonsurgical group (2- and 5-year DSS, 77% vs 46% and 67% vs 30%; P < .001), as was the OS (2- and 5-year OS, 66% vs 41% and 45% vs 23%; P = .005). In subjects with early-stage disease, OS and DSS were not different regardless of treatment type. In subjects with late-stage disease treated most recently (time cohort II), there was significantly better DSS in those receiving surgical vs nonsurgical treatment (2-year DSS, 70% vs 43%; P = .045). Nonsmokers had better OS (94 months vs 41 months; P = .001) and lower incidence of recurrence (8% vs 44%; P = .02). CONCLUSION In veterans treated for tonsillar SCC, we advocate the consideration of a treatment plan that includes surgery for patients presenting with advanced-stage SCC of the tonsil, even in patients with notable comorbidities.

Sebaceous Lymphadenoma Identified by Fine Needle Aspiration Biopsy

BACKGROUND Sebaceous lymphadenoma of the parotid gland is a rare benign neoplasm. This is the first reported case of fine needle aspiration biopsy (FNAB) findings for sebaceous lymphadenoma of the parotid gland. CASE A 60-year-old male presented with painless, bilateral parotid swelling noted for 5 months. The swelling was more pronounced on the right. Examination revealed bilaterally prominent parotid glands with diffuse firmness but no discrete masses. There was no evidence of facial nerve dysfunction. Laboratory evaluation was negative for infectious and autoimmune etiologies. Magnetic resonance imaging revealed bilateral cystic parotid masses. FNAB of the right parotid was obtained to assist with preoperative counseling. It revealed lymphoid and salivary gland parenchymal cells. The patient underwent a right superficial parotidectomy. The surgical specimen of the parotid mass confirmed the diagnosis of sebaceous lymphadenoma on the tissue section. The contralateral parotid mass had not been excised at this writing. CONCLUSION This report is the first to describe the FNAB findings of the unusual benign parotid neoplasm sebaceous lymphadenoma. Though the definitive diagnosis of any parotid mass requires tissue, generally obtained via parotidectomy, an FNAB diagnosis can be useful in counseling a patient prior to definitive biopsy.

Candidate Biomarkers for HPV-Negative Head and Neck Cancer Identified via Gene Expression Barcode Analysis

Objectives (1) Reanalyze publicly available genomic data for HPV-negative oral cavity squamous cell carcinoma to look for candidate biomarkers. (2) Evaluate the association of the identified biomarkers with survival. Study Design Retrospective cohort study. Setting Tertiary care. Subjects and Methods Gene expression barcode analysis was applied to an existing publicly available data set of 54 HPV-negative oral cavity squamous cell carcinoma tumor samples to identify candidate genes associated with poor prognosis. Genes identified were evaluated for their association with survival on the basis of univariable and multivariable Cox proportional hazards models. Results Three genes were found to be associated with poor prognosis. The most significant association was seen with spectrin expression. Subjects whose tumors expressed spectrin were 4.60 times more likely (hazard ratio; 95% confidence interval: 1.88-11.25) to die at any given time when compared with those without spectrin (P = .001). On univariable analysis, subjects with late-stage cancer were 6.34 times more likely (hazard ratio; 95% confidence interval: 1.41-28.53; P = .02) to die at any given time, but interestingly, after controlling for spectrin, this effect was attenuated (P = .07). Despite controlling for several possible confounding effects, the effect of spectrin remained hazardous throughout all multivariable models. This was true even after controlling for cancer stage and extracapsular extension (P = .004). Conclusion Our analysis of public genomic data shows promise in identifying biomarkers that may allow clinicians to make more accurate survival predictions. Spectrin is a strong candidate for further biomarker testing.

11q21.1–11q23.3 is a Site of Intrinsic Genomic Instability Triggered by Irradiation

The chromosome location, 11q21‐23, is linked to loss of heterozygosity (LOH) in multiple tumors including those of breast, lung, and head and neck. To examine the process of LOH induction, the H292 cell line (human muco‐epidermoid carcinoma) was irradiated or treated with anti‐CD95 antibody, and individual clones isolated through two rounds of cloning. Regions of LOH were determined by screening a suite of eight polymorphic microsatellite markers covering 11p15‐11q24 using fluorescent primers and genetic analyzer peak discrimination. LOH induction was observed extending through 11q21.1‐11q23.3 in 6/49 of clones surviving 4 Gy and 8/50 after 8 Gy. Analysis of selected clones by Affymetrix 6.0 single nucleotide polymorphism (SNP) arrays confirmed the initial assessment indicating a consistent 27.3–27.7 Mbp deletion in multiple clones. The telomeric border of LOH mapped to a 1 Mbp region of elevated recombination. Whole genome analysis of SNP data indicated that site‐restricted LOH also occurred across multiple additional genomic locations. These data indicate that 11q21.1‐11q23.3, and potentially other regions of this cell line are sites of intrinsic cell‐specific instability leading to LOH after irradiation. Such deletions may subsequently be propagated by genetic selection and clonal expansion.

Can Computed Tomography Characteristics of the Oropharynx in Cancer of Unknown Primary Predict Primary Tumor Site

Objectives: (1) Measure axial and coronal parapharyngeal space area (PPSA) and parapharyngeal mucosal thickness (PMT) in patients who present with cancer of unknown primary (CUP). (2) Determine if PPSA and PMT differences between affected and unaffected sides of the oropharynx were found based on site of primary (tonsil vs base of tongue [BOT]) or body mass index (BMI). Methods: Institutional review board–approved retrospective chart and preoperative computed tomography (CT) review of consecutive patients presenting between 2007-2013 with CUP to a tertiary university hospital. Subjects did not have an identified primary on clinical or imaging examinations including positron emission tomography/CT but did have an identified primary after surgery. Two blinded radiologists reviewed CT scans. Measurements of PPSA and PMT at defined levels in the axial and coronal planes and prediction of the primary site were made. Independent variables were primary tumor site and BMI. Comparisons were made using Student t test. Results: There was no significant difference in PPSA or PMT between the affected and unaffected sides of the oropharynx for the entire group (n = 17, ΔPPSA axial 0 mm2, P = .5; ΔPPSA coronal 16 mm2, P = .2; ΔPMT 0.3 mm, P = .2) or for subgroups based on primary site (tonsil vs BOT) or BMI (≤25, >25). Blinded examiners correctly predicted the primary site in 7/17 (41%) of cases. Conclusions: Differences in axial PPSA and PMT were not useful to predict the primary site in patients with CUP. Although not statistically significant, coronal PPSA in subjects with BMI >25 may be useful in identifying the primary tumor site.

Correlation of Critical Score Models with Outcomes after Tracheostomy in Critically Ill Patients

Objectives: Understand the utility in using the validated outcome prediction models (Sequential Organ Failure Assessment [SOFA] and Logistic Organ Dysfunction System [LODS]) as additional information in making surgical decisions in the specific population of critically ill patients undergoing tracheotomy. Methods: Retrospective chart review of 94 consecutive critically ill patients at a tertiary care Veterans Administration hospital who underwent isolated tracheotomy between January 2006 andJune 2011. Data were collected from the medical charts. Outcome measurements included decannulation, ventilatory status after tracheotomy, and date of death. SOFA and LODS scores were calculated and Students T test was used for statistical analysis. Results: Mortality was expectedly high. Twenty-two point 3 percent of patients died while still inpatients, and 53.2% died within 180 days of tracheotomy. The average time to ventilator independence was 20.1 days, and 28.7% of patients were decannulated. The LODS score was more powerful, showing a significant association with ventilator status 14 days after tracheotomy, death while an inpatient, and death within 90 days of tracheotomy (all P < 0.05). The SOFA score only showed a significant association with death while an inpatient (P < 0.05). Conclusions: This work is the first reported use of the validated LODS and SOFA outcome prediction models in the subset of critically ill patients undergoing tracheotomy. While this patient population is known to have a high mortality rate, the use of objective measurements such as LODS can be useful to help guide clinical decision making, counsel surrogate decision makers, and allocate resources.

R018: A Novel System to Detect Loss of Heterozygosity (LOH)

92% of ANES chief residents have never performed an emergency surgical airway. Residents self-rated their competency to handle an airway emergency on a scale of 1 to 10 (1 ”not competent at all,” 10 ”totally competent”). The most common self-rating is “9” (36%), with 82% of all chief residents rating themselves “8” or higher. Factors correlating to higher self-rated competency include: increased participation in airway emergencies (p 0.001 for OHNS, p 0.01 for ANES), and experience rotating in ANES for OHNS residents (p 0.019). There is a trend towards higher self-ratings for ANES residents who had rotated on an OHNS service (p 0.064). CONCLUSION: OHNS and ANES training in emergency airway management is heterogeneous, unstandardized, and variable in exposure and depth. Resident confidence is high despite limited experience. SIGNIFICANCE: The high confidence–low experience dichotomy likely reflects novice overconfidence and the need to develop novel methods of assessment and feedback in this area. This study supports the recent decision to require an ANES rotation for OHNS interns. SUPPORT: This research is supported by the Section of OHNS, Department of Surgery, University of Chicago Medical Center.