Samuel Trosman

Effect of human papillomavirus on patterns of distant metastatic failure in oropharyngeal squamous cell carcinoma treated with chemoradiotherapy.

IMPORTANCE Important differences exist in the pattern and timing of distant metastases between human papillomavirus-initiated (HPV+) and HPV- oropharyngeal squamous cell carcinoma (OPSCC). However, our understanding of the natural history of distant metastases in HPV+ OPSCC and its implications for surveillance is limited. OBJECTIVE To investigate the rate, pattern, and timing of distant metastases in advanced-stage OPSCC treated definitively with concomitant chemoradiotherapy. DESIGN, SETTING, AND PARTICIPANTS In a retrospective review, we identified 291 patients with pathologically diagnosed stages III to IVB OPSCC and known HPV status from a tumor registry at the Cleveland Clinic. Patients were treated from January 1, 1996, through December 31, 2013. Details of treatment failure and the natural history of the disease were retrieved from the electronic medical records. INTERVENTIONS All patients were treated with definitive concomitant chemoradiotherapy. MAIN OUTCOMES AND MEASURES The primary outcome was the rate and timing of distant metastases. Secondary outcomes included the pattern of distant failure and survival after distant metastases. RESULTS Thirty-seven patients developed distant metastatic disease after definitive treatment, including 28 of 252 patients with HPV+ disease and 9 of 39 patients with HPV- disease. The 3-year projected distant control rate was higher in the HPV+ group (88% vs 74%; P = .01). The median time to develop distant metastases was also longer after the completion of treatment for HPV+ disease compared with HPV- disease (16.4 vs 7.2 months; P = .008). We detected a trend in patients with HPV+ disease for more distant metastatic sites involved than in those with HPV- disease (2.04 vs 1.33 sites; P = .09). Although the lung was the most common distant site involved in HPV+ and HPV- disease (HPV+ group, 23 of 28 patients [82%]; HPV- group, 7 of 9 patients [78%]), the HPV+ group had metastases to several subsets atypical for head and neck squamous cell carcinoma, including the brain, kidney, skin, skeletal muscle, and axillary lymph nodes in 2 patients each and in the intra-abdominal lymph nodes in 3 patients. The rate of 3-year overall survival was higher in the HPV+ group (89.9% vs 62.0%; P < .001), as was the median survival after the occurrence of distant metastases regardless of additional treatment (25.6 vs 11.1 months; P < .001). CONCLUSIONS AND RELEVANCE This retrospective review suggests that distant metastases in patients with HPV+ OPSCC occurs significantly later after completion of chemoradiotherapy than in patients with HPV- disease. Human papillomavirus-initiated OPSCC also appears to involve a greater number of subsites and metastatic sites infrequently seen in head and neck squamous cell carcinoma. Distant metastatic disease in HPV+ OPSCC has unique characteristics and a natural history that may require alternative surveillance strategies.

Multi-institutional study of risk factors for perioperative morbidity following transnasal endoscopic pituitary adenoma surgery

The goal of this study was to identify preoperative risk factors associated with increased perioperative morbidity after endoscopic pituitary surgery.

Factors impacting cerebrospinal fluid leak rates in endoscopic sellar surgery

In patients undergoing transnasal endoscopic sellar surgery, an analysis of risk factors and predictors of intraoperative and postoperative cerebrospinal fluid leak (CSF) would provide important prognostic information.

Successful repair of intraoperative cerebrospinal fluid leaks improves outcomes in endoscopic skull base surgery

The impact of failed cerebrospinal fluid leak (CSF) leak repair in endoscopic skull base surgery has not been adequately studied.

Predictors of distant metastasis in human papillomavirus-associated oropharyngeal cancer: Distant metastases rates in HPV-positive oropharyngeal cancer

Human papillomavirus (HPV)‐positive oropharyngeal cancer is associated with favorable outcomes, prompting investigations into treatment deintensification. The purpose of this study was for us to present the predictors of distant metastases in patients with HPV‐positive oropharyngeal cancer treated with cisplatin‐based chemoradiotherapy (CRT) or cetuximab‐based bioradiotherapy (bio‐RT).

The contemporary utility of intraoperative frozen sections in thyroid surgery

PURPOSE To determine the accuracy of intraoperative frozen section analysis on thyroidectomy specimens stratified by the Bethesda classification scheme and its utility for intraoperative decision-making. STUDY DESIGN Retrospective chart review. METHODS A retrospective review was performed on all patients who underwent thyroidectomy or thyroid lobectomy with intraoperative frozen sections at a tertiary care academic center from 2009 to 2015. RESULTS There were 74 total patients who underwent partial or total thyroidectomy with intraoperative frozen section analysis of a thyroid nodule whom had previously undergone a thyroid fine needle aspiration of the nodule. The sensitivity, specificity, positive predictive value, and negative predictive value for a thyroid frozen section with respect to its prediction for malignancy was 81%, 95%, 98%, and 66%, respectively, with a diagnostic accuracy of 85%. For 37 patients with an indeterminate cytologic diagnosis on fine needle aspiration (Bethesda categories III-V), the sensitivity, specificity, positive predictive value, and negative predictive value for a thyroid frozen section was 81%, 91%, 95%, and 67%, respectively, with a diagnostic accuracy of 84%. False positives and false negatives resulted in 1 completion thyroidectomy for benign pathology and 3 reoperations for malignancy not discovered on frozen section. CONCLUSION While intraoperative frozen sections on thyroid specimens may be helpful if positive, the false negative rate remains high. There appears to be limited value in routine frozen sections to guide clinical management and decision-making in the era of the Bethesda system.

Short-stay hospital admission after free tissue transfer for head and neck reconstruction.

To show that, for patients with few medical comorbidities and at low risk for airway compromise or fistula formation, early discharge after free tissue transfer for head and neck reconstruction is a safe and viable option.

Polysomnography results in pediatric patients with mild obstructive sleep apnea: Adenotonsillectomy vs. watchful waiting.

OBJECTIVE There is a lack of consensus and a paucity of data regarding how to best treat pediatric patients with mild obstructive sleep apnea. The objective of our study was to compare outcomes following adenotonsillectomy vs. observation in children with mild obstructive sleep apnea based on polysomnography results. METHODS A retrospective chart review was performed on children ages 9 months to 9 years with 2 or more polysomnograms completed at a tertiary care academic center. Children diagnosed with mild obstructive sleep apnea (obstructive apnea-hypopnea index 1-5) on polysomnography performed from 1999 to 2013 were included. Patients underwent adenotonsillectomy or watchful waiting for obstructive sleep apnea. The primary outcome was the change in apnea-hypopnea index. RESULTS There were 62 patients who met inclusion criteria for the study; 19 of the 62 patients were obese, while 15 had a craniofacial syndrome or hypotonia. Eighteen patients underwent adenotonsillectomy for mild obstructive sleep apnea while 44 were observed. The mean apnea-hypopnea index of patients after adenotonsillectomy improved from 3.50 (95% Confidence Interval [CI] 2.97-4.03) to 2.69 (95% CI 1.48-3.90), while the mean apnea-hypopnea index of the observation group worsened from 3.09 (95% CI 2.76-3.42) to 5.18 (95% CI 2.46-7.90). Between-group analysis showed significant improvement in the surgery group (p=0.03), with a persistent improvement on multivariate analysis adjusting for baseline apnea-hypopnea index (p=0.05). This difference was seen mostly in non-obese, non-syndromic children (p=0.04). There was no significant difference between groups amongst obese (p=0.25) and syndromic (p=0.36) patients. CONCLUSIONS Adenotonsillectomy leads to a significant improvement in apnea-hypopnea index on follow-up polysomnography over an observational approach, especially in non-obese, non-syndromic children. A prospective, randomized trial is necessary to help determine appropriate treatment strategies for pediatric mild obstructive sleep apnea.

A Charge Comparison of Audiometric Testing in the Pediatric Population

Objective To determine the charges associated with performing combined tympanometry and otoacoustic emissions vs a comprehensive audiogram in the pediatric population and to analyze its implications for future practice. Study Design Retrospective charge analysis. Setting Tertiary care academic center. Subjects and Methods Analysis was performed on 538 pediatric patients who underwent audiometric hearing testing from May through October 2014. Results In total, 401 patients had combined tympanometry and otoacoustic emissions testing and 91 patients underwent a comprehensive audiogram, while 46 patients underwent all 3 tests. The technical and professional charges for combined tympanometry and otoacoustic emissions were

Hypoglossal nerve paralysis results in hypermetabolic activity on positron emission tomography/computed tomography in the contralateral tongue.

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