Mia E. Miller

A novel classification system for perineural invasion in noncutaneous head and neck squamous cell carcinoma: histologic subcategories and patient outcomes

OBJECTIVE The aims of this study were to define a novel classification system of tumor perineural invasion (PNI) with respect to tumor/nerve involvement such as intratumoral (IT), peripheral, or extratumoral (ET) and to determine the prognostic significance of each of these histologic subcategories in patients with noncutaneous head and neck squamous cell carcinoma (HNSCC). STUDY DESIGN This study is a retrospective chart review and histologic analysis of patients with HNSCC in the setting of a tertiary care medical center. METHODS A clinical chart review of 142 patients with HNSCC who underwent primary surgical treatment from January 2004 through December 2007 was performed. Clinical information collected included patient age, sex, alcohol and tobacco use, tumor location, TNM stage, postoperative adjuvant chemotherapy and/or radiation treatment, and patient outcome. For each case, PNI density, the distance of each PNI focus to the tumor edge, and size of the largest nerve involved were measured. Furthermore, PNI was subcategorized as IT, peripheral, or ET. A Cox regression analysis was performed to determine if PNI was related to regional disease recurrence. Kaplan-Meier survival analysis was also performed. RESULTS Among the 142 patients, 37 (26%) had disease progression. The maximum extent of PNI was significantly correlated with disease-free survival on multivariate analysis (P = .019) and was also significantly related to disease-free survival when T stage (P = .017), N stage (P = .021), and T and N stages (P = .02) were added to the Cox regression model. Kaplan-Meier analysis demonstrated a trend toward increased disease-free survival of PNI negative and IT/peripheral PNI compared with ET PNI. CONCLUSION Perineural invasion is correlated with nodal status and T stage and is related to disease-free survival. It can be subcategorized as IT, peripheral, or ET. This novel classification system has important implications with regard to clinical outcome and may help define a cohort of patients that may require more aggressive management.

Positron emission tomography and positron emission tomography-CT evaluation for recurrent papillary thyroid carcinoma: meta-analysis and literature review

Sensitivity and specificity data regarding positron emission tomography (PET) and PET/CT for surveillance of well‐differentiated thyroid cancer does not evaluate subtypes separately. Papillary and follicular thyroid carcinoma may have different characteristics on PET/CT imaging and so should be investigated individually.

Adenoid cystic carcinoma of the airway: a 30-year review at one institution

PURPOSE The purpose of the study was to evaluate the treatment results of adenoid cystic carcinoma (ACC) of the airway at a single institution during a 30-year period. MATERIALS AND METHODS All cases of ACC of the airway over a 30-year period at one tertiary care institution were reviewed retrospectively. The demographics, treatment modalities, pathologic characteristics, and outcomes were evaluated. RESULTS Eleven patients were treated for ACC of the airway with an age range of 25 to 72 years (median, 48 years). Six patients presented with ACC in the larynx, and 5 patients had ACC of the trachea. All patients underwent surgical excision and radiation; 9 of 11 patients had postoperative external beam radiation, 1 patient had preoperative external beam radiation, and the remaining patient had postoperative neutron beam therapy. Four patients with tracheal ACC and none with laryngeal ACC had microscopic or grossly positive margins after surgery (P = .048). Eighty percent of patients had perineural invasion on pathology. Two patients with tracheal ACC had local recurrence of disease, which occurred at 1 and 10 months postoperatively. One patient with laryngeal ACC died of distant metastatic disease at 16 months. Follow-up varied from 4 to 168 months (median, 31 months). CONCLUSIONS We report high disease-free survival rates for ACC of the airway in patients who underwent definitive surgical resection followed by postoperative radiation. There is a higher risk for local recurrence and positive surgical margins with distal tracheal location. Distant disease ultimately determines survival.

Measurable progress in female authorship in otolaryngology.

Objective To identify contemporary trends in female authorship in the otolaryngology literature. Study Design Analysis of 4 otolaryngology journals. Setting All articles published in Annals of Otology, Rhinology and Laryngology, Archives of Otolaryngology–Head and Neck Surgery, Laryngoscope, and Otolaryngology–Head and Neck Surgery in 2008 were reviewed and compared with prior data from 1978, 1988, and 1998. Subjects and Methods Each published article’s authorship panel was examined for the number of authors and each author’s sex, degree, and the subspecialty area of publication. Year-to-year comparisons were conducted for the rates and characteristics of female authorship. Results A total of 544, 629, 713, and 785 articles from 1978, 1988, 1998, and 2008, respectively, were analyzed. From 1998 to 2008, the overall percentage of female authors increased from 14.5% to 22.5% (P < .001). Similarly, the percentage of articles with a female first author increased from 12.9% to 21.3% (P < .001). Whereas previously pediatric otolaryngology had the highest female first author percentage (range, 6.9%-19.4%), in 2008 all other subspecialties demonstrated significant increases in female first author percentages: otology (18.6%), general (22.3%), head and neck (22.2%), plastics (18.9%), and pediatrics (19.4%) (P = .885). A significant number of female first authors continue to be nonphysicians (19.2% in 2008, P < .001). Conclusions Female authorship has shown significant and steady increases in the otolaryngology literature, particularly in the past decade. Increased rates of publication from female otolaryngologists within most subspecialties have resulted in similar rates of publication across the subspecialties.

Squamous cell carcinoma of buccal mucosa: a 40-year review

PURPOSE The aim of this study was to analyze the outcome of surgical therapy for buccal squamous cell carcinoma (SCCA) at a single tertiary care institution during a 40-year period. MATERIALS AND METHODS A retrospective review was performed by examining the records and pathology of 48 patients with buccal SCCA treated at a single tertiary care institution from 1970 to 2009. RESULTS Treatment entailed surgery alone in 18 patients (37.5%) and surgery followed by radiation therapy in 30 patients (62.5%). Composite resection was performed in 17 patients (35.4%), and ipsilateral neck dissections were performed in 37 patients (77.1%). One-year observed actuarial disease-free survival rates were 60%, 46%, 0%, and 40% for T1 through T4, respectively. Univariate analysis revealed increased age as a risk factor for disease recurrence (P = .062), with skin taken and neck dissection not achieving significance (P = .24 and .20, respectively). Multivariate analysis demonstrated age as increasing risk and neck dissection as decreasing risk of recurrence (P = .029 and .023, respectively). CONCLUSIONS We report relatively high disease-free survival rates in patients who underwent aggressive resection and neck dissection. Performance of neck dissection and younger age were associated with a favorable prognosis. Performance of neck dissection may decrease the risk of recurrence in primary SCCA of the buccal mucosa. Although through-and-through resection of skin decreased risk of disease recurrence, this difference is not statistically significant (P = .24).

Analysis of surgical margins in cases of mandibular osteoradionecrosis that progress despite extensive mandible resection and free tissue transfer.

INTRODUCTION Approximately 1 of 4 patients with osteoradionecrosis (ORN) of the mandible develop ongoing disease despite extensive mandible resection to margins determined by the presence of bleeding bone at the time of surgery. OBJECTIVE To determine whether pathologic examination of bony margins in assessing for the presence of necrotic edges is correlated with ongoing ORN. METHODS Resected mandible specimens from 34 patients with severe mandibular ORN were examined histologically for the presence of necrotic margins and compared with clinical outcome of ORN persistence at follow-up. RESULTS Median follow-up was 17.4 months. Eight specimens had histologic evidence of necrotic, nonviable bone at the margins of resections; however, there was no progression of disease among patients in this group. Twenty-six specimens were clear of necrotic margins; however, 8 patients from this group developed persistent disease. CONCLUSIONS Irradiated mandible is susceptible to ORN progression even if clinical and final histopathologic assessments confirm complete resection of necrotic bone margins. Progression of disease in ORN is not related to inadequate resection of necrotic bone.

Intracochlear schwannoma presenting as diffuse cochlear enhancement: diagnostic challenges of a rare cause of deafness

Intracochlear schwannoma is a rare, treatable, cause of unilateral hearing loss. Due to the small size, position, and variable clinical and imaging features, diagnosis presents a significant challenge and is often delayed. We present a case of a patient with an intracochlear schwannoma presenting as a diffuse enhancement of the cochlea, mimicking an infectious or inflammatory process. The absence of focal nodularity in this lesion on multiple high-resolution MRI examinations led to a delay of over 3 years from the patient’s initial presentation to surgical diagnosis. Clinical history and examination, imaging features, pathologic findings, and surgical management options are described.

Endolymphatic hydrops in otologic syphilis: a temporal bone study.

Hypothesis: Endolymphatic hydrops in temporal bones with otologic syphilis directly relates to osteitis, new bone formation, and/or resorption along the course of the endolymphatic system. Background: Ménières disease and otosyphilis both cause progressive endolymphatic hydrops, and the mechanism of hydrops formation in each disease process remains unclear. Traditionally, osteitic changes of the labyrinthine capsule were thought to lead to endolymphatic hydrops in syphilitic temporal bones. More recently, authors have suggested that microgummata and inflammatory change obliterating the endolymphatic duct and sac may cause endolymphatic hydrops in otosyphilis. Methods: This is a histopathologic study of 11 temporal bones from patients with otosyphilis. Gathered data include presence/absence of endolymphatic hydrops of the cochlea, saccule, and utricle; bony changes involving the endolymphatic duct and sac; a description of bony changes throughout the temporal bone; and the degree of atrophy of the organ of Corti, spiral ganglion, and stria vascularis. Results: The presence of osteitic changes surrounding the endolymphatic duct and sac and whether the endolymphatic system was obliterated did not directly correlate with the presence of endolymphatic hydrops in this study. Conclusion: We reject the hypothesis that otologic syphilis is directly related to osteitis, new bone formation, and/or resorption along the course of the endolymphatic duct and sac. Although a change in the endolymphatic system may contribute to the formation of endolymphatic hydrops in otologic syphilis, it is not the only cause. Whether otosyphilis and Ménières disease share a common mechanism of endolymphatic hydrops formation remains unclear, and the relationship between these causes of hydrops should be investigated further.

Temporal bone verrucous carcinoma: outcomes and treatment controversy

Verrucous carcinoma is a rare tumor that presents in the head and neck with the most common sites being the oral cavity and larynx. Fourteen cases of verrucous carcinoma of the temporal bone have been described in literature; this study aims to examine treatment outcomes and discuss the controversy surrounding postoperative radiation. The study design included a literature review along with individual case report in the setting of a tertiary care medical center. Outcome analysis of all cases of verrucous carcinoma of the temporal bone, which are documented in the English literature, and presentation of a single patient report including gross, histologic and radiologic analyses were performed. The longest recorded survival for verrucous carcinoma of the temporal bone occurs in patients treated with surgery alone. Poorer outcomes for patients treated with adjuvant (chemo)radiation may be due to more advanced stage of disease at the time of treatment. Early reports of radiation leading to tumor dedifferentiation or early recurrence are not supported by more recent studies. Whether adjuvant radiation therapy is indicated in verrucous carcinoma of the temporal bone remains controversial.

Tonsillar Squamous Cell Carcinoma Are We Making a Difference

Objective. To analyze outcomes in patients with squamous cell carcinoma (SCCA) of the tonsil from the years 1998 to 2006. To assess factors that may affect disease-specific survival, such as patient characteristics and/or treatment modality. Study Design and Setting. National Cancer Institute’s Surveillance Epidemiology and End Results (SEER) program. Subjects and Methods. The SEER database was used to perform a population-based cohort analysis for patients diagnosed with SCCA of the tonsil from 1998 to 2006. Disease-specific survival was correlated with sex, age, ethnicity, year of diagnosis, and treatment modality in a univariate Cox proportional hazards analysis and a multiple Cox-regression model with and without interaction effect. Results. Applied inclusion criteria resulted in 8378 patients. Of this patient cohort, 80% were male and 85% were white. The mean patient age at diagnosis was 58.1 years. On univariate and multivariate analyses, ethnicities other than white carried a significantly higher rate of disease-specific death (hazard ratio = 1.71, P < .001). Each additional year of age at the time of diagnosis carried approximately a 4% increase in likelihood of disease-specific death. With each passing year of time at diagnosis, patients carried a decreased risk of disease-specific death (P < .001); this value was significant in all 3 statistical models. Patients who underwent external-beam radiation had a higher likelihood of disease-specific survival with each passing year at time of diagnosis. Conclusion. Population analysis based on the SEER database reveals increased disease-specific survival from tonsillar SCCA in more recent years. This may be because of earlier diagnosis, an increase in less aggressive subtypes of SCCA, and more effective treatment modalities.