Tristan Tham

Neutrophil-to-lymphocyte ratio as a prognostic indicator in head and neck cancer: A systematic review and meta-analysis

The purposes of this systematic review and meta‐analysis were to investigate the relationship between the neutrophil‐to‐lymphocyte ratio (NLR) and prognosis in head and neck cancer.

Venous Thromboembolism Risk in Head and Neck Cancer: Significance of the Preoperative Platelet-to-Lymphocyte Ratio.

Objective We aimed to investigate the association between the preoperative platelet-to-lymphocyte ratio (PLR) and venous thromboembolism (VTE) in patients with head and neck cancer (HNC) undergoing major surgery. Study Design Retrospective cohort study. Setting Academic tertiary hospital from 2011 to 2017. Subjects and Methods Patients with confirmed HNC undergoing major surgery were included in this study. The preoperative PLR was recorded for all patients. Known VTE risk factors, including Caprini score, age, sex, smoking, body mass index, prior VTE, and anticoagulation, were also recorded. Risk factors were screened in univariate analysis using Wilcoxon’s rank sum test and χ2 test (Bonferroni corrected). Significant covariates were included in a multivariate regression model. Bootstrap techniques were used to obtain credible confidence intervals (CIs). Results There were 306 patients enrolled with 7 cases of VTE (6 deep vein thromboses and 1 pulmonary embolism. On univariate analysis, length of stay (P = .0026), length of surgery (P = .0029), and PLR (P = .0002) were found to have significant associations with VTE. A receiver operator characteristic (ROC) curve was constructed that yielded an area under the ROC of 0.905 (95% CI, 0.82-0.98). Using an optimized cutoff, the multivariate model showed that length of surgery (β 95% CI, 0.0001-0.0006; P = .0056) and PLR (β 95% CI, 5.3256-5.3868; P < .0001) were significant independent predictors of VTE. Conclusion This exploratory pilot study has shown that PLR offers a potentially accurate risk stratification measure as an adjunct to current tools in VTE risk prediction, without additional cost to health systems.

Analysis of bone healing with a novel bone wax substitute compared with bone wax in a porcine bone defect model

Aim: This pilot study describes a novel composite of hydroxyapatite and biodegradable polylactic acid with wax-like handling properties (BoneSeal®). The goal was to compare quantitative measures of bone healing between BoneSeal versus Bone wax. Materials & methods: BoneSeal and Bone wax were introduced into separate defects of a single porcine specimen. After 6 weeks, the defect sites were harvested for analysis. Results: Both groups had similar hemostatic action. The amount of new bone was significantly greater at 6 weeks in the BoneSeal group (38.05%) versus the Bone wax group (11.88%), p = 0.028. Conclusion: In this pilot study, BoneSeal had higher amounts of new bone formation compared with Bone wax.

The lymphocyte-to-monocyte ratio as a prognostic indicator in head and neck cancer: a systematic review and meta-analysis

PurposeThe aim of this systematic review and meta-analysis was to investigate the relationship between the pre-treatment lymphocyte-to-monocyte ratio (LMR) and prognosis in HNC.MethodsPubMed (via the Web), Embase, Scopus, and the Cochrane Library were searched. A systematic review and meta-analysis was done to generate the pooled hazard ratios (HR) for overall survival (OS) and disease-free survival (DFS).ResultsOur analysis included the results of 4260 patients in seven cohorts. The pooled data demonstrated that an elevated LMR was associated with significantly improved OS (HR 0.5; 95% CI 0.44–0.57), and DFS (HR 0.70; 95% CI 0.62–0.80). Of note, there was no detectable heterogeneity in either OS (I2 = 0%) or DFS (I2 = 0%).ConclusionsAn elevated LMR may be an indicator of favorable prognosis in HNC. However, our results should be interpreted with some degree of caution due to the retrospective nature of cohort studies. Further research with high-quality prospective studies is needed to confirm the effect of LMR in HNC prognosis.

The red cell distribution width as a prognostic indicator in upper aerodigestive tract (UADT) cancer: A systematic review and meta-analysis

PURPOSE The aim of this systematic review and meta-analysis was to investigate the relationship between the Red Cell Distribution Width (RDW) and prognosis in upper aerodigestive tract (UADT) cancer. METHODS PubMed (via the web), Embase, Scopus, and the Cochrane Library were searched. A systematic review and meta-analysis was done to generate the pooled hazard ratios (HR) for overall survival (OS), disease specific survival (DSS), and recurrence free survival (RFS). RESULTS Our analysis included the results of 4200 patients in 8 cohorts. The pooled data demonstrated that an elevated RDW was associated with significantly poorer OS (HR: 1.44, 95% CI: 1.13-1.83), RFS (HR: 1.43, 95%CI: 1.13-1.82). The DSS result had high heterogeneity and 95% CI was not pooled. CONCLUSIONS An elevated RDW may be an indicator of poor prognosis in UADT cancers in certain populations. Further research is needed to confirm this effect.

The Temporalis Muscle Flap for Palate Reconstruction: Case Series and Review of the Literature

Introduction  The temporalis myofascial (TM) is an important reconstructive flap in palate reconstruction. Past studies have shown the temporalis myofascial flap to be safe as well as effective. Free flap reconstruction of palate defects is also a popular method used by contemporary surgeons. We aim to reaffirm the temporalis myofascial flap as a viable alternative to free flaps for palate reconstruction. Objective  We report our results using the temporalis flap for palate reconstruction in one of the largest case series reported. Our literature review is the first to describe complication rates of palate reconstruction using the TM flap. Methods  Retrospective chart review and review of the literature. Results  Fifteen patients underwent palate reconstruction with the TM flap. There were no cases of facial nerve injury. Five (33%) of these patients underwent secondary cranioplasty to address temporal hollowing after the TM flap. Three out of fifteen (20%) had flap related complications. Fourteen (93%) of the palate defects were successfully reconstructed, with the remaining case pending a secondary procedure to close the defect. Ultimately, all of the flaps (100%) survived. Conclusion  The TM flap is a viable method of palate defect closure with a high defect closure rate and flap survival rate. TM flaps are versatile in repairing palate defects of all sizes, in all regions of the palate. Cosmetic deformity created from TM flap harvest may be addressed using cranioplasty implant placement, either primarily or during a second stage procedure.

Erratum: The Laparoscopically Harvested Omental Free Flap: A Compelling Option for Craniofacial and Cranial Base Reconstruction

Background Management of craniofacial and cranial base tumors is a challenge due to the anatomic intricacies associated with the calvarium, the pathological diversity of lesions that present, and the potential complications. Clinical outcomes in laparoscopically harvested omentum free flaps for cranial base and craniofacial reconstruction are presented in this paper, in the largest case series to date. Methods A retrospective single‐center experience for over 10 years with laparoscopically harvested omentum flaps used to reconstruct craniofacial and cranial base defects. Results A total of 13 patients underwent craniofacial or cranial base reconstruction using laparoscopically harvested omentum free flaps. The mean patient age was 48 years. The anterior skull base represented the most common site of reconstruction. A total of 12 of the flaps survived (92%), with one flap failure due to infection. All patients demonstrated satisfactory aesthetic and functional outcomes. There were no perioperative or intra‐abdominal complications. Conclusions The laparoscopically harvested omentum free flap is a safe and effective tool in the armamentarium of the reconstructive surgeon. It is the ideal option to treat complex, three‐dimensional subcutaneous defects, such as those encountered in craniofacial and cranial base reconstruction. Its unique angiogenic and immunologic capacity makes it an excellent flap for the previously irradiated and/or infected wound bed.

Detection of HPV16, HPV18, p16, and E6/E7 MRNA in Nasopharyngeal Cancer: A Systematic Review and Meta-Analysis

Introduction Human Papilloma Virus (HPV) associated head and neck cancers, particularly oropharyngeal cancers (OPC), have a superior prognosis to HPV negative cancers. A literature review did not find any studies that analyzed HPV 16, HPV 18 DNA and p16 in the nasopharynx subsite, although it has been reported in the oropharynx. The detection of HPV DNA and p16 in the nasopharynx could have implications for the treatment of NPC. To date no one has reported the detection or concordance rates of HPV associated markers in nasopharyngeal carcinoma (NPC). Methods A literature search was undertaken on Medline, EMBASE, Scopus, and the Cochrane Library to identify studies that used PCR and ISH for detection of HPV DNA and p16 in the nasopharynx. We included studies published between 1992 and 2017 that reported the prognostic impact of HPV DNA and/or p16, treated HPV and p16 as categorical variables with at least 10 patients who tested for p16 and/or HPV16/HPV18 DNA in NPC, irrespective of HPV status. We then collected information from many parameters, and performed a meta-analysis to produce pooled prevalence estimates and explored sources of heterogeneity Results 21 studies published between 1992 and 2017 were selected for meta-analysis, with sample sizes ranging from 10 to 1328. The total (random effects) pooled detection of any HPV marker in NPC patients was 19.7% (95% CI: 12.56 to 28.00). The total (random effects) pooled detection of p16 positivity in NPC patients was 23.98% (95% CI: 14.82 to 34.54). The total (random effects) pooled detection of HPV DNA in NPC patients, detected by ISH, was 14.43% (95% CI: 10.13 to 19.33) and for HPV DNA in NPC patients including E6/E7 was 18.13% (95% CI: 11.45 to 25.94). The total (random effects) pooled detection of HPV DNA in NPC patients was 18.13% (95% CI: 11.45 to 25.94). The total (random effects) pooled detection of EBV positivity in NPC patients was 76.21% (95% CI: 66.40 to 84.80). Heterogeneity was high for all of the results. The attributable fraction of p16+ and HPV DNA+ in NPC is 0.029. The attributable fraction of EBV positive and HPV – in NPC is 0.827. The attributable fraction of EBV negative and HPV – in NPC is 0.0639. The attributable fraction of EBV negative and HPV + in NPC is 0.085. The attributable fraction of EBV positive and HPV + in NPC is 0.023. The attributable fraction of HPV positive and mRNA+ in NPC was 0.115. The attributable fraction of p16 in NPC was 0.123. Discussion This is the first study that contributes to the concordance and detection rates of HPV related markers in NPC. Limitations Most of the studies included were of Asian extraction. Most of the papers also did not test for E6/E7 RNA and therefore we are unsure of the amount of active E6/E7 RNA in NPC.

Investigation of the Relationship between Markers of Systemic Inflammatory Response and Head and Neck Tumor Characteristics

Background Markers of systemic inflammation have been hypothesized to reflect the underlying tumor microenvironment, and have recently been shown to be associated with advanced tumor grade, T and N stages. Aims/Objective The objective of this study was to evaluate the relationship between head and neck cancer (HNC) tumor characteristics and routine pretreatment inflammatory markers: the platelet lymphocyte ratio (PLR), the neutrophil to lymphocyte ratio (NLR), and the lymphocyte to monocyte ratio (LMR). Materials and Methods This is a retrospective cohort study. The tumor characteristics collected were tumor differentiation, T stage, N stage. The relationship between the inflammatory markers and tumor characteristics was analyzed. Results A total of 122 patients were enrolled from 2010-2016. An elevated PLR was found to be significantly associated with advanced T stage (rho=0.191, p=0.00347), and N stage (ANOVA, p=0.005). None of the other inflammatory markers (NLR, LMR) were associated with T stage or N stage. No markers were associated with tumor differentiation. Conclusion and significance We found that an PLR is significantly associated with advanced tumor and nodal stage. We were unable to find any tumor associations with the other inflammatory markers (NLR, LMR).

Neuroradiological and Neuropathological Changes After 177Lu-Octreotate Peptide Receptor Radionuclide Therapy of Refractory Esthesioneuroblastoma

BACKGROUND AND IMPORTANCE Olfactory neuroblastoma, also known as esthesioneuroblastoma (ENB), is a malignant neoplasm with an unpredictable behavior. Currently, the widely accepted treatment is inductive chemotherapy, with or without surgery, followed by radiotherapy. Since data on genetics and molecular alterations of ENB are lacking, there is no standard molecularly targeted therapy. However, ENB commonly expresses the somatostatin receptor (SSTR) that is also expressed by neuroendocrine tumors. Peptide receptor radionuclide therapy (PRRT) using radiolabeled somatostatin analogues, such as 177Lu-octreotate, is an effective treatment for the latter. We present the complex neuroradiological and neuropathological changes associated with 177Lu-octreotate treatment of a patient with a highly treatment-resistant ENB. CLINICAL PRESENTATION A 60-yr-old male presented with an ENB that recurred after chemotherapy, surgery, stereotactic radiosurgery, and immunotherapy. Pathology revealed a Hyams grade 3 ENB and the tumor had metastasized to lymph nodes. Tumor SSTR expression was seen on 68Ga-octreotate positron emission tomography (PET)/computed tomography (CT), suggesting that PRRT may be an option. He received 4 cycles of 177Lu-octreotate over 6 mo, with a partial response of all lesions and symptomatic improvement. Four months after the last PRRT cycle, 2 of the lesions rapidly relapsed and were successfully resected. Three months later, 68Ga-octreotate PET/CT and magnetic resonance imaging indicate no progression of the disease. CONCLUSION We describe imaging changes associated with 177Lu-octreotate PRRT of relapsing ENB. To our knowledge, this is the first report describing neuropathological changes associated with this treatment. PRRT is a promising therapeutic option to improve the disease control, and potentially, the survival of patients with refractory ENB.