Paul W.A. Goodyear

Squamous cell carcinoma of the head and neck outside the oropharynx is rarely human papillomavirus related

The incidence of human papillomavirus (HPV)‐driven disease beyond the oropharynx varies greatly in the reported literature.

IGF-1R expression is associated with HPV-negative status and adverse survival in head and neck squamous cell cancer

Head and neck squamous cell carcinomas (HNSCC) are treated with surgery, radiotherapy and cisplatin-based chemotherapy, but survival from locally-advanced disease remains poor, particularly in patients whose tumors are negative for Human papillomavirus (HPV). Type 1 IGF receptor (IGF-1R) is known to promote tumorigenesis and resistance to cancer therapeutics. Here, we assessed IGF-1R immunohistochemistry on tissue microarrays containing 852 cores from 346 HNSCC patients with primary tumors in the oropharynx (n = 231), larynx (85), hypopharynx (28), oral cavity (2). Of these, 236 (68%) were HPV-negative, 110 (32%) positive. IGF-1R was detected in the cell membrane of 36% and cytoplasm of 92% of HNSCCs; in 64 cases with matched normal tonsillar epithelium, IGF-1R was overexpressed in the HNSCCs (P < 0.001). Overall survival (OS) and disease-specific survival (DSS) were reduced in patients whose tumors contained high membrane IGF-1R [OS: hazard ratio (HR) = 1.63, P = 0.006; DSS: HR = 1.63, P = 0.016], cytoplasmic IGF-1R (OS: HR = 1.58, P = 0.009; DSS: HR = 1.58, P = 0.024) and total IGF-1R (OS: HR = 2.02, P < 0.001; DSS: HR = 2.2, P < 0.001). High tumor IGF-1R showed significant association with high-tumor T-stage (P < 0.001) and HPV-negativity (P < 0.001), and was associated with shorter OS when considering patients with HPV-positive (P = 0.01) and negative (P = 0.006) tumors separately. IGF-1R was independently associated with survival in multivariate analysis including HPV, but not when lymphovascular invasion, perineural spread and T-stage were included. Of these factors, only IGF-1R can be manipulated; the association of IGF-1R with aggressive disease supports experimental incorporation of anti-IGF-1R agents into multimodality treatment programs for HPV-negative and high IGF-1R HPV-positive HNSCC.

Accuracy of magnetic resonance imaging in diagnosing thyroid cartilage and thyroid gland invasion by squamous cell carcinoma in laryngectomy patients

OBJECTIVES We examined the accuracy of magnetic resonance imaging in assessing thyroid cartilage and thyroid gland invasion in patients undergoing total laryngectomy for squamous cell carcinoma, by comparing histopathology results with imaging findings. STUDY DESIGN A retrospective study reviewed histology and magnetic resonance scan results for all total laryngectomies performed between 1998-2008 at University Hospital Aintree, Liverpool. METHODS Pre-operative magnetic resonance images were reviewed independently by two consultant head and neck radiologists masked to the histology; their opinions were then compared with histology findings. RESULTS Eighty-one magnetic resonance scans were reviewed. There were 22 laryngectomy patients with histologically verified thyroid cartilage invasion and one patient with thyroid gland invasion. There were 31 patients with apparent radiological thyroid cartilage invasion pre-operatively (with 17 false positives), giving sensitivity, specificity, and positive and negative predictive values of 64, 71, 45 and 84 per cent, respectively. On assessing thyroid gland invasion, there were nine false positive scans and no false negative scans, giving sensitivity, specificity, and positive and negative predictive values of 100, 89, 10 and 100 per cent, respectively. CONCLUSION Magnetic resonance scanning over-predicts thyroid cartilage and gland invasion in patients undergoing total laryngectomy. Magnetic resonance scans have limited effectiveness in predicting thyroid cartilage invasion by squamous cell carcinoma in laryngectomy patients.

Extensive neck node metastases (N3) in head and neck squamous carcinoma: is radical treatment warranted?

Objective. Head and neck squamous cell carcinoma (HNSCC) patients with N3 neck disease at presentation are the minority. Prognosis for such patients is poor, but there is disagreement about which treatment policy is best adopted. The aim of this study was to identify which groups of patients are best offered radical treatment, examining factors of association, prognosis, and survival. Study Design. Prospective cohort study. Setting. Regional tertiary head and neck cancer unit. Subjects and Methods. Data were collected prospectively from patients treated for HNSCC with N3 nodal disease between 1975 and 2005. The data collected included age, sex, tumor TNM stage, histological grade, treatment, and survival. Odds ratio was used to calculate whether each parameter was statistically significant. Tumor-specific and observed survival curves were also calculated. Results. A total of 275 patients had N3 disease. Multivariate analysis confirmed that advanced disease at the primary site (odds ratio = 4.6, P = .0261) mitigated against curative treatment. Comparison of tumor-specific survival between curative and palliative treatment strategies suggests that aggressive treatment is associated with greatly improved survival (median survival = 1.45 years, 95% confidence interval [CI] = 1.23-1.67 years; 5-year survival = 26.6%, CI = 17.14%-36.06%) compared with those treated palliatively (median survival = 3.18 months, CI = 3.06-3.30 months; no 5-year survivors; P < .0001). Conclusion. A major factor in determining treatment strategies for N3 disease HNSCC is the extent of disease at the primary site. These data suggest that aggressive treatment of the neck improves survival and should be considered in these patients.

Relative expression of vascular endothelial growth factor isoforms in squamous cell carcinoma of the head and neck.

Alternative splicing of the vascular endothelial growth factor (VEGF) gene results in a family of antiangiogenic isoforms (VEGFxxxb), not yet investigated in squamous cell carcinoma of the head and neck (SCCHN). We examined, therefore, the prognostic value of the relative expression of VEGF isoforms in SCCHN.

Is POSSUM predictive of morbidity and mortality in laryngectomy patients

OBJECTIVES To test the validity of the comparative audit tool of POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) against a cohort of 92 consecutive laryngectomies at a major tertiary referral centre for head and neck cancer. The major outcome measurements were 30-day mortality rates, formation of a pharyngo-cutaneous fistula, and length of hospital stay. METHODS By means of a prospective and retrospective case note analysis. RESULTS No significant difference between the mean POSSUM morbidity scores of those patients who did, or did not develop a fistula, was found (p=0.535, 95% C.I. -4.36 to 8.33). No significant correlation was observed between POSSUM predicted morbidity and bed occupancy [r=0.137 (95% C.I. -0.070 to 0.334)]. The Portsmouth POSSUM equation for mortality however did accurately predict the mortality rate (observed to expected ratio of 1.05). CONCLUSION The authors propose that whilst there are many similar factors linked to mortality between cohorts of general surgical and head and neck patients, there are several highly specific risk factors in open surgery of the upper aero-digestive tract in the head and neck which are linked with wound breakdown and morbidity which are omitted from the POSSUM scoring system. The authors warn against the use of this comparative audit tool in its current state for such surgical procedures and recommend the creation of a specific POSSUM for head and neck cancer surgery.

The development of a BAHA program: A review of complications and outcomes, 1991–2002

Abstract Problem: The aim of this study was to evaluate the problems encountered in the development of a Bone Anchored Hearing Aid (BAHA) program in a district general hospital, over a period of 11 years. Patient satisfaction was also assessed. Methods: Patient records and a patients’ database were evaluated retrospectively. Demographics, pre- and postoperative audiogram, surgical technique, and surgical and skin complications were recorded and analyzed. Patient satisfaction was assessed prospectively using a visual analog questionnaire. Results: BAHAs have been fitted to wide age group of patients (ranging from 7 to 80 years). Indications for surgery are congenital abnormalities in children and following mastoid surgery/CSOM (74%) in adults. The remainder is due to chronic otitis externa or otosclerosis. Half of these patients were tertiary referrals. Intially surgery was carried out in 2 stages (43%), Now all are performed in 1 stage with a local skin flap. Complications requiring further surgery (18%) have been due to trauma, primary failure to integrate, or as a result of late infections. Forty-one percent of patients have had no complications, including skin reactions. Review of patient questionnaires showed that 91% express their complete satisfaction with their device. Over 88% use their BAHA every day and for more than 8 hours. Ninety-five percent felt that one-on-one conversation was better with a BAHA. Most were pleased with the cosmetics of the abutment, ease of use of aid, with only 15% expressing difficulty cleaning the abutment. We had no nonusers in the study. Conclusion: Surgical complications were higher than other published data in the early stages of program development. Patient satisfaction was generally high, but improved significantly with the introduction of a multidisciplinary team approach. Significance: The BAHA service has developed steadily over the years. Surgical techniques have improved. Complications, especially skin problems have been reduced by the development of a specialized team approach involving the surgeon, nurse, audiologist, and patient. Support: None reported.

N3 neck node metastasis: Is radical treatment warranted?

O R A LS compared the methylated genes in our samples to that in PubMeth, a cancer methylation database combining text-mining and expert annotation (http://www.pubmeth.org). Of the 441 genes in PubMeth, only 33 of 441 are referenced to head and neck cancer. We matched 74 genes in our samples to the PubMeth database. CONCLUSIONS: The whole-genome methylation approach indicated potential new genes with hypermethylated promoter regions not yet reported in HNSCC. Examination of this comprehensive gene panel in a larger HNSCC cohort should permit the elucidation of HNSCC-specific candidate genes for further validation as biomakers in HNSCC.

Evaluation of Somnoplasty using Snoring Symptom Inventory

Objective To assess whether radiofrequency volumetric tissue reduction of the palate can improve patients’ snoring symptoms and quality of life. Methods A prospective cross-sectional study was undertaken. Over an 18-month period, consecutive habitual snorers without sleep apnoea were asked to complete a validated Snoring Symptoms Inventory (SSI) questionnaire before and 3–6 months after radiofrequency surgical treatment. It contained 25 questions on the impact of snoring symptoms, including social, work, physical and emotional aspects. Most patients underwent 2 operations (Somnoplasty® Somnus device) with a 2-month interval. A scale of 0 (no snoring) to 10(extremely loud snoring) was used to assess partners’ perception of the snoring intensity. Paired T-test was used to compare the mean difference in the SSI before and after surgery. Partners’ scores were analysed with Wilcoxon signed ranks test. Results 26 patients (19 male, 7 female) aged between 33 and 74 (mean=48) were recruited. Preoperative BMI scores ranged from 19 to 35 (mean=28). Pre- and postoperative mean SSI scores were 60.5 (SD 12.3) and 42.8 (SD 17.4). The difference between the 2 means is 17.6 (95% Confidence Interval, 11.0 to 24.2), P<0.0001. The median for pre- and postoperative partners’ scores is 10 and 5 respectively. and the difference is statistically significant (P<0.0001). Conclusions Radiofrequency volumetric tissue reduction can improve habitual snorers’ snoring symptoms, snoring-related quality of life, and partners perception of their snoring. Long-term results of this procedure need to be ascertained with further studies.