[Show abstract][Hide abstract]ABSTRACT: Background
We compared the outcome of patients who received non-image-guided intensity-modulated radiotherapy (IMRT) with those who received helical tomotherapy (HT), a daily image-guided radiotherapy (IGRT), after surgery for oral cavity cancer (OCC).
During the period November 2006 to December 2013, a total of 152 postoperative OCC patients underwent either IMRT (n = 79) or daily IGRT (n = 73) 4 to 6 weeks after surgery. Patients in the IMRT group received 6 MV photon beams to 7 fields and those in the IGRT group received daily fractions of 1.8 or 2 Gy on five consecutive days.
Patients who received daily IGRT had higher 5-year overall survival than those who received IMRT (87 % versus 48 %, p = 0.015). The local progression-free survival rate was also higher in patients who received IGRT (85 % versus 58 %, p = 0.006). More patients in the IGRT group completed the package of overall treatment time in ≤ 13 weeks and completed their course of radiation therapy in ≤ 8 weeks than patients in the IMRT group (89 % versus 68 %, p = 0.002; 84 % versus 58 %, p = 0.001), respectively. The rate of local failure in the primary tumor area was 24.0 % in the IMRT group and 6.8 % in the IGRT group. Among patients with primary local failure, the marginal failure rate was 52.6 % in the IMRT group and 0 % in the IGRT group.
For patients with locally advanced OCC, postoperative IGRT results in better overall survival, better local progression-free survival, less marginal failure and shorter overall treatment time than postoperative non-image-guided IMRT.
[Show abstract][Hide abstract]ABSTRACT: Synchronous second primary tumors (SPTs), especially esophageal squamous cell neoplasia (ESCN), in patients with head and neck squamous cell carcinoma (HNSCC) are not uncommon. Image-enhanced endoscopy (IEE) screening may identify SPTs while there is no evidence to support its benefit. We prospectively recruited an adult cohort with newly-diagnosed HNSCC for IEE screening of upper gastrointestinal (UGI) tract neoplasia. 145 HNSCC patients were recruited. 22 (15.2%) patients had synchronous UGI tract neoplasia, including 20 ESCNs and 2 gastric adenocarcinoma. At a median follow-up of 2.72 (±1.73) years, the 3-year overall survival (OS) rate was 0.71. HNSCC patients with synchronous ESCN/UGI tract neoplasia had poorer prognosis than those without (multivariate analysis, hazard ratio [HR] 2.75/2.79, 95% confidence interval [CI] 1.11~6.82/1.15~6.80, p = 0.03/0.02). HNSCC patients with advanced (stage III&IV) ESCN had worst survivals (p < 0.001). Among those with synchronous ESCNs, hypopharyngeal cancers were associated with poorer prognosis when compared with oral cancers (HR 2.36, 95% CI 1.08~5.15, p = 0.03). IEE screening for UGI SPTs in HNSCC patients could be used for risk stratification and prognosis prediction. HNSCC patients with advanced ESCN had the worst prognosis. Further studies are needed to demonstrate the survival benefits from IEE screening.
[Show abstract][Hide abstract]ABSTRACT: Objectives
To investigate the effect of radiotherapy (RT) on ultrasound-guided fine needle aspiration (USgFNA) and sonographic characteristics in the assessment of cervical lymph nodes (LNs) in oral squamous cell carcinoma (OSCC) patients after primary treatment.
Materials and Methods
88 treated OSCC patients underwent 111 USgFNAs of the neck LNs after US evaluation. Among them, 48 USgFNAs were performed on 40 patients following RT and 63 USgFNAs on 48 patients without previous RT. The results of USgFNA and the US characteristics were compared between these two groups.
USgFNA had a sensitivity of 88.0%, specificity of 91.4%, positive predictive value (PPV) of 88.0%, negative predictive value (NPV) of 91.4% and accuracy of 90.0% in patients without previous RT, and a sensitivity of 97.1%, specificity of 83.3%, PPV of 94.3%, NPV of 90.9% and accuracy of 93.5% in those with previous neck RT. The ranges of the short-axis and long-axis length were 13.3 ± 8.0 mm (mean ± SD) versus 17.8 ± 9.1 mm, and 18.6 ± 9.0 mm versus 24.4 ± 10.9 mm for recurrent LNs from patients with, versus without, previous RT (both ps < 0.05), respectively. 76.5% (26/34) of the recurrent nodes after RT and 48% (12/25) of the recurrent nodes without previous RT exhibited an irregular margin (p < 0.05). Additionally, irradiated recurrent LNs had a significantly decreased percentage of discernable calcification compared with non-irradiated recurrent nodes (48% versus 20.6%, p < 0.05).
RT had influence on sonographic characteristics but no influence on USgFNA in diagnosing recurrent LNs in treated OSCC patients.
[Show abstract][Hide abstract]ABSTRACT: Objective
We evaluate the feasibility of an integrated outpatient-based screening program for oral cancer.
An automated system was used to refer high-risk outpatient patients for oral cavity examination. The outcomes between the screened and concurrent symptomatic cohorts were compared to assess the program's effectiveness in identifying oral cancers.
Among the 38693 candidates flagged as high-risk by our automated referral system, a total of 8037 participants were recruited to our screened cohort. 1,664 subjects were identified with positive lesions and 302 patients received biopsies. Five patients were pathologically diagnosed with oral cancer and 121 with dysplastic precancers. The symptomatic cohort comprised of 157 patients with oral cancers and 61 with precancers. The screening program identified earlier stages of oral cancers than that of the symptomatic cohort.
Automated outpatient-based oral cancer screening programs may be a practicable strategy to identify precancerous lesions or early-stage cancers in high-risk adults.
[Show abstract][Hide abstract]ABSTRACT: Background
Real-time elastography (RTE) and elasticity scoring system is a new diagnostic tool in the evaluation of enlarged cervical lymph nodes (LNs). The aim of the study was to investigate the validity and reliability of two elasticity scoring systems in discriminating cervical lymphadenopathies.
Materials and methods
The study protocol was approved by the institutional review board of the local ethics committee. Ninety-eight consecutive patients underwent ultrasound-guided fine needle aspiration biopsy after conventional ultrasound and RTE evaluation. Elasticity scores were divided into four and five categories according to signal distribution, based on previously determined models. Two independent raters analyzed the elastographic data.
Final histology revealed 60 benign and 38 malignant cervical LNs. In the four-point scoring system, 41/60 benign LNs were classified as score 1 or 2 and 28/38 malignant nodes as score 3 or 4 [sensitivity 73.7%, specificity 68.3%, positive predictive value (PPV) 59.6%, negative predictive value (NPV) 80.4%]. Using the five-point scoring system, 28/60 benign nodes were classified as score 1 or 2 and 31/38 malignant nodes as score 3–5 (sensitivity 79.0%, specificity 45.0%, PPV 47.6%, NPV 80.4%). In the four-point scoring system, rates of concordance between raters (κ = 0.63) and with the same rater (κ = 0.75) were both good with statistical significance (both p < 0.01). With the five-point scoring system, both kappa statistic tests between raters (κ = 0.68) and with the same rater (κ = 0.68) were also good with statistical significance (both p < 0.01).
For qualitative RTE, the four-point scoring system had value similar to the five-point scoring system in predicting malignancy in cervical LNs. Furthermore, the reliability was comparable in both scoring systems. For the purpose of simplified evaluation, we suggested using the four-point scoring system to rate the qualitative RTE in the future.
Full-text Article · Aug 2014 · Journal of Medical Ultrasound
[Show abstract][Hide abstract]ABSTRACT: Background
Real-time ultrasound (US) elastography (USE) assesses lesion stiffness and was reported as markedly accurate in thyroid nodule evaluation. The aim of this study was to validate the effectiveness of head and neck surgeon-performed USE in the evaluation of thyroid nodules.
From January 2011 to November 2013, 308 patients with thyroid nodules who received traditional US, USE, and US-guided cytology were reviewed. The nodules with cytology reports that revealed Bethesda cytology levels of Thy 2, Thy 5, and Thy 6 were collected. The characteristics of traditional US and USE were analyzed.
Univariate analysis revealed that a set of characteristics including a larger transverse diameter, taller-than-wide shape, margins, heterogeneous echotexture, microcalcification, predominately solid echo structure, marked intranodular vascular pattern and USE (an elastography score of III/IV vs. I/II) differed significantly between malignancy and benignity (p < 0.05). Stepwise multivariate logistic regression analysis showed that a taller-than-wide shape, microcalcification, and USE were independent, significant factors in predicting malignant nodular disease (p < 0.05)
The results support the hypothesis that USE is an independent factor in determining malignant thyroid nodules.
Full-text Article · Aug 2014 · Journal of Medical Ultrasound
[Show abstract][Hide abstract]ABSTRACT: To develop magnetic resonance imaging (MRI) indicators to predict trismus outcome for post-operative oral cavity cancer patients who received adjuvant intensity-modulated radiation therapy (IMRT), 22 patients with oral cancer treated with IMRT were studied over a two-year period. Signal abnormality scores (SA scores) were computed from Likert-type ratings of the abnormalities of nine masticator structures and compared with the Mann-Whitney U-test and Kruskal-Wallis one-way ANOVA test between groups. Seventeen patients (77.3%) experienced different degrees of trismus during the two-year follow-up period. The SA score correlated with the trismus grade (r = 0.52, p<0.005). Patients having progressive trismus had higher mean doses of radiation to multiple structures, including the masticator and lateral pterygoid muscles, and the parotid gland (p<0.05). In addition, this group also had higher SA-masticator muscle dose product at 6 months and SA scores at 12 months (p<0.05). At the optimum cut-off points of 0.38 for the propensity score, the sensitivity was 100% and the specificity was 93% for predicting the prognosis of the trismus patients. The SA score, as determined using MRI, can reflect the radiation injury and correlate to trismus severity. Together with the radiation dose, it could serve as a useful biomarker to predict the outcome and guide the management of trismus following radiation therapy.
[Show abstract][Hide abstract]ABSTRACT: The outcome of postoperative high- and intermediate-risk oral cavity cancer (OCC) patients receiving helical tomotherapy (HT) remains limited.
Between November 2006 and November 2012, 53 postoperative high- and intermediate-risk OCC patients treated with HT were enrolled.
The 4-year locoregional, local, and regional control rates were 66%, 76.4%, and 94.3%, respectively. The 4-year locoregional control rates of oral tongue and buccal mucosa cancer were 88.3% and 37.1%, respectively (P=0.012). Eleven (20.8%) patients experienced locoregional failure. In-field failure occurred in six of 53 (11.3%) in the primary area and three of 53 (5.7%) in the regional lymph-node area. No marginal failure was noted. Two of 53 (3.8%) experienced out-of-field failure. The rates of grade 3 dermatitis, mucositis, and dysphagia were 11%, 34%, and 13%, respectively. No grade 3 xerostomia was noted. Grade 2 xerostomia was 33% at month 6 and declined to 0 at month 48. A rate of 56% of grade 2 trismus at month 6 was noted, and declined to around 30% after 2 years. No grade 3 trismus was noted after 2 years.
HT as a postoperative modality provided satisfying results, especially for xerostomia and trismus, and was impressive in high- and intermediate-risk OCC patients receiving postoperative HT.
Full-text Article · Mar 2014 · OncoTargets and Therapy
[Show abstract][Hide abstract]ABSTRACT: Background:
The purpose of this study was to evaluate the pain levels associated with ultrasound-guided fine-needle aspiration biopsy (FNAB) of neck masses.
The pain immediately and 5 minutes after the procedure without use of local anesthesia was evaluated via 100-mm visual analog scale (VAS), 11-point numeric rating scale (NRS), and 4-category verbal rating scale (VRS) in 154 patients.
The mean scores (SDs) for VAS, NRS, and VRS immediately versus 5 minutes after the procedure were 30.5 (24.4) versus 7.3 (13.7), 3.3 (2.2) versus 0.8 (1.6), and 1.3 (0.6) versus 0.3 (0.6), respectively (all ps < .001). Immediately after ultrasound-guided FNAB, the pain scores associated with lymph node aspiration (VAS, 36.7 [25.5]; NRS, 3.9 [2.1]) were significantly higher (both ps < .05) than those associated with thyroid nodule aspiration (VAS, 25.0 [21.2]; NRS, 2.8 [2.0]).
Ultrasound-guided FNAB of thyroid nodules was less painful than that of cervical lymphadenopathy. Most patients tolerated mild transient pain after the procedure without use of local anesthesia. Nevertheless, local anesthesia was necessary for the small subgroup of patients who experienced significant pain.
[Show abstract][Hide abstract]ABSTRACT: The prevalence of esophageal neoplasia in head and neck (H&N) cancer patients is not low; however, routine esophageal surveillance is not included in staging of newly-diagnosed H&N cancers. We aimed to investigate the risk factors for synchronous esophageal neoplasia and the impact of endoscopy on management of H&N cancer patients.
A total of 129 newly diagnosed H&N cancer patients who underwent endoscopy with white-light imaging, narrow-band imaging (NBI) with magnifying endoscopy (ME), and chromoendoscopy with 1.5% Lugol's solution, before definite treatment were enrolled prospectively.
60 esophageal lesions were biopsied from 53 (41.1%) patients, including 11 low-grade, 14 high-grade intraepithelial neoplasia and 12 invasive carcinoma in 30 (23.3%) patients. Alcohol consumption [odds ratio (OR) 5.90, 95% confidence interval (CI) 1.23-26.44], advanced stage (stage III and IV) of index H&N cancers (OR 2.98, 95% CI 1.11-7.99), and lower body mass index (BMI) (every 1-kg/m2 increment with OR 0.87, 95% CI 0.76-0.99) were independent risk factors for synchronous esophageal neoplasia. NBI with ME was the ideal screening tool (sensitivity, specificity, and accuracy of 97.3%, 94.1%, and 96.3%, respectively, for detection of dysplastic and cancerous esophageal lesions). The treatment strategy was modified after endoscopy in 20 (15.5%) patients. The number needed to screen was 6.45 (95% CI 4.60-10.90).
NBI-ME surveillance of esophagus should be done in newly-diagnosed H&N cancer patients, especially those with alcohol drinking, lower BMI, and advanced stage of primary tumor.
Full-text Article · Oct 2013 · BMC Gastroenterology
[Show abstract][Hide abstract]ABSTRACT: The purpose of this study was to examine the dose-response effectiveness of D-methionine (D-met) in rescuing a noise-induced permanent threshold shift (PTS) and cochlear biochemistry following noise exposure. One hour after being exposed to continuous broadband white noise at 105 dB SPL for 6 hr, guinea pigs were treated 5 times at 12-hr intervals with 200, 400, or 600 mg/kg D-met or sterile 0.9% saline (each group, n = 6) by intraperitoneal injection. Six guinea pigs with normal hearing that were not exposed to noise served as control animals. Although administration of D-met 200 mg/kg did not significantly reduce the mean PTS, treatment with D-met 600 mg/kg achieved a complete rescue response. The level of rescue from noise-induced PTS following treatment with 200, 400, or 600 mg/kg D-met was dose-dependent. The attenuation of the noise-induced decreases in the activities of the Na(+), K(+)-ATPase and Ca(2+)-ATPase following treatment with 200, 400, or 600 mg/kg D-met was also dose-dependent. Likewise, D-met-dose-dependent decreases in mean lipid peroxidation and nitric oxide levels were observed in the D-met treated groups. Significant attenuation of increased oxidative stress and decreased ATPase activities were concurrent with the D-met-mediated improvements in noise-induced auditory dysfunction.
[Show abstract][Hide abstract]ABSTRACT: Ultrasound investigations and correct identification of malignant thyroid nodules depend on the experience and qualifications of the investigators; thus, a model that provides better evaluation before needle aspiration is desired. Data from 687 patients with 726 thyroid nodules comprising 65 malignant nodules (61 papillary and 4 follicular carcinoma) and 661 benign nodules were used to construct a predictive model. Presence of micro-calcification, taller-than-wide shape, predominant solid echostructure, and irregular margins were shown to be good independent predictive parameters. A thyroid nodule was predicted as malignant with a score ≥3.3. Internal validation of this predictive tool by the bootstrapping method showed excellent overall model performance.
Article · Jul 2013 · Archives of Oto-Rhino-Laryngology
[Show abstract][Hide abstract]ABSTRACT: Cervical cystic lymph node metastasis as the first and sole manifestation of occult papillary thyroid carcinoma (PTC) is uncommon, and can be mistaken for branchial cleft cyst. The present study reports two cases of PTC initially presenting as upper lateral neck cysts. Ultrasound examination confirmed the presence of occult papillary carcinoma with neck metastasis. The critical importance of ultrasound examination of the soft tissue of the neck for the identification of the clinical manifestations and the imaging features of occult PTC are discussed, with an emphasis on factors that may contribute to misdiagnosis.
Article · Jun 2013 · Journal of Medical Ultrasound
[Show abstract][Hide abstract]ABSTRACT: Importance Vocal polyps are common exophytic laryngeal lesions that usually necessitate microscopic laryngeal surgery under general anesthesia. Office-based indirect laryngoscopic procedures provide an alternative management option and can be performed comfortably under flexible endoscopic guidance. Combining angiolytic potassium titanyl phosphate (KTP) laser treatment and flexible endoscopic polypectomy should alleviate the risks of surgery under general anesthesia and expedite lesion regression.
Objectives To combine angiolytic KTP laser treatment and endoscopic polyp removal and to evaluate the clinical applicability, treatment outcomes, and adverse effects of office-based KTP laser–assisted vocal polypectomy.
Design Case series of KTP laser treatment (n = 16) and KTP laser–assisted polypectomy (n = 20). Patients underwent pretreatment and 2- and 6-week posttreatment evaluation with videolaryngostroboscopy (VLS), maximal phonation time, and a 10-item voice handicap index. Perceptual (GRB [grade, roughness, breathiness] scale) and acoustic analyses were performed before and 6 weeks after treatment.
Setting Tertiary teaching hospital.
Participants Thirty-six outpatients with unilateral hemorrhagic vocal polyps.
Interventions Under local anesthesia, the KTP laser fiber was passed through the working channel of the flexible laryngoscope to photocoagulate the microvasculature of the polyp in all patients. Removal of coagulated vocal polyp using a flexible, endoscopic, blunt-ended grasping forceps immediately after KTP laser application was performed in the polypectomy group.
Main Outcomes and Measures Results of VLS, maximal phonation time, 10-item voice handicap index, and perceptual and acoustic analyses.
Results Six weeks after KTP laser treatment with and without polypectomy, 19 and 12 patients, respectively, experienced complete recovery and much improvement of mucosal wave. Maximal phonation time and the voice handicap index improved significantly 2 weeks after KTP laser with polypectomy (P < .01), whereas significant improvements were noted 6 weeks postoperatively in both treatment groups (P < .05). Acoustic and perceptual analyses also revealed significant improvements in both study groups (P < .05). During follow-up, we did not notice significant adverse effects.
Conclusions and Relevance Potassium titanyl phosphate laser–assisted vocal polypectomy is a safe, practical, and effective alternative option to treat hemorrhagic vocal polyps in the outpatient department, offering comparable but earlier therapeutic effects than KTP laser alone.
Article · Jun 2013 · JAMA Otolaryngology - Head and Neck Surgery
[Show abstract][Hide abstract]ABSTRACT: Emerging literature has documented the effectiveness of intralesional steroid injection as an alternative treatment for benign vocal fold disorders. However, clinical application is frequently limited by the associated technical demands for adequate anesthesia and precise needle placement. This study investigated the applicability and effectiveness of the more practical and less technically demanding method of transnasal endoscopic steroid injection (TESI).
Prospective case series.
This study recruited 30 patients with vocal nodules and polyps. Dexamethasone was injected into the Reinke's space under local anesthesia via the operating channel of a transnasal flexible laryngoscope in an office setting. Treatment outcome were measured before, 1 month after, and 3 months after the injection, using videolaryngostroboscopy (VLS), maximal phonation time (MPT), 10-item voice handicap index (VHI-10), acoustic analysis, and perceptual evaluation.
VLS examinations at 3 months post-treatment demonstrated that vocal lesions of 10 and 19 patients were resolved or reduced, respectively. Objective measurements showed increased MPT and decreased VHI-10 (P < .05 and P < .01, respectively). Acoustic analysis revealed significant decrease in jitter and shimmer (P < .05). Perceptual evaluation using the GRB (grade, roughness, breathiness) scale also showed improved voice quality (P < .01). Treatment outcomes were similar between vocal nodules and polyps (P > .05). Mild vocal hematoma occurred in three patients following TESI, but resolved spontaneously within 1 month.
TESI is a simple and practical office-based treatment modality for benign vocal fold lesions, suitable for most otolaryngologists. Treatment outcomes showed significant subjective and objective improvements that were comparable to the results of other injection procedures reported in the literature.