Patterns of dysphagia and acute toxicities in patients with head and neck cancer undergoing helical IMRT±concurrent chemotherapy

Publication date: January 2017
Source:Oral Oncology, Volume 64
Author(s): Laura B. Moroney, Jennifer Helios, Elizabeth C. Ward, Jane Crombie, Leesa F. Wockner, Clare L. Burns, Ann-Louise Spurgin, Claire Blake, Lizbeth Kenny, Brett G.M. Hughes
BackgroundThere is limited prospective data reporting the extent of treatment related toxicities associated with helical Intensity Modulated Radiotherapy (H-IMRT) for head and neck cancer (HNC). The study aim was to investigate severity, peak incidence and recovery patterns of dysphagia and related toxicities in patients undergoing H-IMRT±chemotherapy to examine when patients are experiencing symptoms requiring supportive clinical care.MethodsProspective study of 212 patients undergoing H-IMRT. Dysphagia and associated acute toxicities were monitored weekly during treatment and at weeks 2, 4 and 12 post treatment using the CTCAE v4, Functional Oral Intake Score and National Dysphagia Diet Descriptors.Results75% experienced Grade 2–3 dysphagia. Over 70% had grade 2–3 dysguesia, xerostomia, and thick saliva, and >50% experienced grade 2–3 pharyngeal mucositis, oral mucositis, and nausea. 13% patients declined to NBM requiring complete enteral nutrition, 25% required enteral nutrition but maintained some form of oral intake. Symptoms peaked in final week of treatment, consistently improving thereafter, with the majority better than baseline by 12 weeks post-treatment. Concurrent chemotherapy at least doubles the odds of experiencing most symptoms excepting xerostomia, taste and fluid level.ConclusionDespite advancements in radiation techniques, results confirm a high proportion of HNC patients experience dysphagia and related toxicities requiring supportive care during H-IMRT. Patients receiving H-IMRT alone experience a lower incidence of symptoms compared with those receiving concurrent chemotherapy. The data confirms the ongoing need for active on treatment monitoring with implications for the timing and intensity of patient support services.



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Oral extramedullary plasmacytoma in a HIV positive patient

Publication date: Available online 25 November 2016
Source:Oral Oncology
Author(s): Premalatha Shetty, Flora D. Lobo, R. Arvind, Sameep S. Shetty




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Tenosynovial giant cell tumors of the temporomandibular joint and lateral skull base: Review of 11 cases

Objectives

To elucidate the clinical behavior, treatment, and outcomes of tenosynovial giant cell tumors (TGCT) involving the temporomandibular joint (TMJ) and adjacent temporal bone.

Study Design

Retrospective case series with histopathologic review.

Methods

A retrospective chart review was performed identifying and collecting data from all cases of TGCT involving the TMJ and adjacent temporal bone that were treated at the authors' center between January 1960 and December 2015.

Results

Eleven histopathologically confirmed cases met inclusion criteria. The median age at diagnosis was 49 years, eight patients were men, and the median follow-up was 116 months. Computed tomographic (CT) imaging revealed a lytic expansile mass centered on the TMJ. Magnetic resonance imaging (MRI) most commonly exhibited hypointense signal on precontrast T1- and T2-weighted sequences and variable postcontrast enhancement. The median delay in diagnosis was 24 months, and the most common presenting symptoms were hearing loss and pain. All patients underwent surgical resection, eight receiving gross total removal, one receiving near total removal, and two patients from early in the series receiving subtotal resection with neoadjuvant or adjuvant radiation. Histopathological review of surgical specimens revealed chondroid metaplasia in seven tumors. Eight of nine cases receiving gross total or near total resection have no evidence of recurrence to date.

Conclusions

TGCT of the TMJ and temporal bone are rare and locally aggressive tumors that commonly present with nonspecific symptoms. A careful review of CT and MRI followed by early biopsy is critical in establishing an accurate diagnosis and facilitating appropriate treatment. TGCT of the TMJ more commonly contain chondroid metaplasia when compared to TGCT at other anatomic locations. Gross total resection is achievable in most cases and offers long-term cure. Radiation may be considered for recurrent disease or adjuvant therapy following subtotal resection.

Level of Evidence

4. Laryngoscope, 2016

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Outcomes following laryngectomy refusal after insufficient response to induction chemotherapy

Objective

To review patients who refused a total laryngectomy and were treated with radiotherapy (RT) after insufficient response to induction chemotherapy in a larynx preservation protocol for advanced-stage cancer of the larynx and to compare their outcomes with good responders.

Study Design

Retrospective cohort study.

Methods

Eighty-six patients treated with induction chemotherapy followed by RT were included in the analysis: 75 good responders and 11 insufficient responders who refused surgery. We compared overall survival (OS), disease-free survival (DFS), and laryngo-esophageal dysfunction-free survival (LEDFS) of the cohort populations in univariate and multivariate analyses.

Results

The median follow-up was 44 months. The 2-year and 5-year survival rates were respectively 72.2% and 58.8% for OS, 62.8% and 49.4% for DFS, and 59.5% and 44.3% for LEDFS. No survival endpoint was significantly decreased among insufficient responders, contrary to what we expected. When we focused on patients with an initially fixed larynx, the recovery of larynx mobility after induction chemotherapy was not associated with OS (P = 0.6055), DFS (P = 0.459), or LEDFS (P = 0.7403).

Conclusion

To the best of our knowledge, our study is the first patient treatment evaluation focused on subjects who refused a total laryngectomy after insufficient response to induction chemotherapy in a larynx preservation protocol for advanced-stage cancer of the larynx. Surprisingly, these patients treated with RT in our cancer center did not experience decreased functional and oncologic outcomes compared to good responders. Further studies will explore the relevance of response criteria and their evaluation methods.

Level of Evidence

4. Laryngoscope, 2016

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Antibiotics in eosinophilic chronic rhinosinusitis: Rethinking maximal antimicrobial medical therapy

Objectives/Hypothesis

Eosinophilic chronic rhinosinusitis (eCRS) has recently been recognized as a CRS subtype characterized by inflammation rather than chronic infection. Consequently, the role of antibiotics as a component of maximal medical therapy for eCRS has been called into question. The purpose of this study was to investigate whether the use of antibiotics, which lack any secondary anti-inflammatory properties, are useful in the treatment of eCRS.

Study Design

Prospective individual cohort study.

Methods

Institutional review board–approved, prospective study of 39 patients presenting with chronic rhinosinusitis (CRS). In all patients, Lund-Kennedy endoscopy scores, Lund-Mackay computed tomography scores, and Sino-Nasal Outcome Test-22(SNOT-22) scores were obtained before and after treatment with amoxicillin–clavulanic acid twice a day (625 mg) for 4 weeks. Patients were subsequently stratified into eCRS and non-eCRS groups based on having over 10 eosinophils per high-power field by histopathological examination. The efficacy of antibiotic therapy was compared between groups using the nonparametric Mann–Whitney U test.

Results

Within the non-eCRS group (n = 14), there was a significant improvement in both the Lund-Mackay score (P = .002) and SNOT-22 score (P < .001) but not the endoscopy score. Among the eCRS patients (n = 25), the Lund-Mackay score was similarly improved (P = .007); however, there was no significant improvement in the endoscopy or SNOT-22 scores.

Conclusions

The use of antibiotics without independent anti-inflammatory properties have limited efficacy in patients with eCRS. The concept of maximal medical therapy using antibiotics must continue to evolve in the setting of new evidence for inflammatory subtypes of CRS.

Level of Evidence

2b. Laryngoscope, 2016

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CD44 induces FOXP3 expression and is related with favorable outcome in breast carcinoma

Abstract

We studied the relationship between CD44 and Forkhead box P3 (FOXP3) gene expression in cell lines and breast carcinomas and their association with clinicopathological variables and patient outcome. We assessed messenger RNA (mRNA) expression of CD44 and FOXP3 by quantitative real-time PCR and determined the number of FOXP3+ Tregs by immunohistochemistry in 264 breast cancer specimens. CD44 was stimulated with hyaluronan treatment, and the accompanying changes in FOXP3 mRNA expression in breast cancer cell lines representing breast cancer subtype were assessed. We found that lower CD44 expression correlated with the presence of necrosis, lymph-vascular invasion, grade 3 tumors, and aggressive phenotype (HER2 and basal-like). FOXP3 mRNA correlated positively with CD44 mRNA expression and Treg content. Moreover, stimulation of CD44 expression by hyaluronan in cell lines increased FOXP3 expression, which supports that their regulation is associated. Survival analysis revealed that low CD44 expression is associated with higher frequency of recurrence. Our findings indicate that CD44 has a regulatory role in FOXP3 expression and is associated with good prognostic factors in breast cancer.

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Dermatological content of UK undergraduate curricula: where are we now?

Abstract

Given its impact, prevalence and especially its prominence in primary care ¹, the importance of all medical graduates developing knowledge and awareness of skin disease ought to go without saying. Yet a previous audit of undergraduate teaching against the recommendations of the British Association of Dermatologists (BAD) identified important omissions in the courses of some medical schools ². We recently undertook a survey of all medical schools in the UK and Ireland to investigate whether this had changed. The benchmark for course content derived from the BAD recommendations for undergraduates.

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