Faculty Bibliography

OBJECTIVES/HYPOTHESIS:Small cell carcinoma (SmCC) of the head and neck is an extremely rare neuroendocrine malignancy. In this study, we describe the incidence and determinants of survival of patients with SmCC of the head and neck between the years of 1973 and 2012 using the Surveillance, Epidemiology, and End Results database as differed by primary site. STUDY DESIGN:Retrospective, population-based cohort study. METHODS:A total of 237 cases of SmCC of the head and neck were identified, which was divided into sinonasal primaries (n = 82) and all other head and neck primaries (n = 155). Clinicopathologic and epidemiologic variables were analyzed as predictors of overall survival (OS) and disease-specific survival (DSS) based on the Kaplan-Meier method. RESULTS:More than half of sinonasal primaries presented with Kadish stage C or D. On multivariate analysis, surgery was the only independent predictor of improved DSS (P = .008) for sinonasal primaries; in contrast, radiation therapy was a favorable prognosticator for OS (P = .007) and DSS (P = .043) in extrasinonasal sites. Comparison of survival between sinonasal primaries and all other sites demonstrated that sinonasal SmCC had uniformly better OS (P = .002) and DSS (P = .006). CONCLUSIONS:SmCC in the head and neck remains rare, and sinonasal primaries appear to have improved survival compared to other sites. Based on these results, optimal treatment for sinonasal SmCC appears to be surgical therapy, whereas radiation therapy is the preferred treatment for SmCC of other primary sites, particularly the larynx. LEVEL OF EVIDENCE:4. Laryngoscope, 127:1785-1790, 2017.

The purpose of this study was to evaluate the relationship between economic activity and the incidence of high-energy orthopedic trauma. California's Office of Statewide Health Planning and Development patient discharge database was queried to identify monthly orthopedic trauma incidence from 1995 to 2010. Patient inclusion required 1 diagnosis code and 1 associated procedural code for fractures of the femur, tibia, ankle, pelvis, or acetabulum. Data on composite market indices, energy and transportation use, and unemployment were obtained from government sources. Statistical analysis was performed using univariate and multivariate linear regression. The average monthly incidence of orthopedic trauma was 2.92 cases per 100,000 people. Of 15 economic indicators analyzed with univariate regression, 7 variables correlated with trauma incidence to statistical significance. Dow Jones Industrial Average (P=.032), Standard & Poor's 500 (P=.034), vehicle miles driven (P<.001), personal disposable income (P=.033), Coincident Economic Activity Index for California (P=.007), and vehicles purchased (P<.001) were positively correlated with trauma incidence. Unemployment (P<.001) was inversely correlated with trauma incidence. Multivariate regression was used to compute a combination of independent predictors of trauma volume: personal disposable income (P<.001), vehicles purchased (P=.008), and unemployment (P=.005). This combination of variables was used to develop the Crush Index to model the relationship between economic activity and orthopedic trauma volume. The authors show a positive correlation between economic strength and activity and the monthly volume of high-energy orthopedic trauma. The Crush Index serves as a proof of concept that may be useful in guiding preparedness among practitioners and health care system administrators. [Orthopedics. 2017; 40(4):248-255.].

Objectives To analyze the epidemiology and describe the prognostic indicators of patients with primary squamous cell carcinoma of the thyroid. Study Design and Setting Retrospective cohort study based on a national database. Methods The US National Cancer Institute's SEER registry (Surveillance, Epidemiology, and End Results) was reviewed for patients with primary squamous cell carcinoma of the thyroid from 1973 to 2012. Study variables included age, sex, race, tumor size, tumor grade, regional and distant metastases, and treatment modality. Survival measures included overall survival (OS) and disease-specific survival (DSS). Results A total of 199 cases of primary squamous cell carcinoma of the thyroid were identified. Mean age at diagnosis was 68.1 years; 58.3% were female; and 79.4% were white. Following diagnosis, 46.3% of patients underwent surgery; 55.7%, radiation therapy; and 45.8%, surgery with radiation therapy. Kaplan-Meier analysis demonstrated OS and DSS of 16% and 21% at 5 years, respectively. Median survival after diagnosis was 9.1 months. Multivariate Cox regression analysis showed that predictors of OS and DSS included age ( P < .001, P < .001, respectively), tumor grade ( P < .001, P = .001), and tumor size ( P < .001, P = .001). Surgical management was a predictor of OS but not DSS. Conclusion Squamous cell carcinoma of the thyroid is a rare malignancy with a very poor prognosis. Surgical resection confers an overall survival benefit. Age, tumor grade, and tumor size are predictors of OS and DSS.

STUDY DESIGN/METHODS:Retrospective analysis. OBJECTIVE:To determine the epidemiology and prognostic indicators in patients with chondrosarcoma of the osseous spine. SUMMARY OF BACKGROUND DATA/BACKGROUND:Chondrosarcoma of the spine is rare, with limited data on its epidemiology, clinicopathologic features, and treatment outcomes. Therapy centers on complete en bloc resection with radiotherapy reserved for subtotal resection or advanced disease. METHODS:The Surveillance, Epidemiology, and End Results Registry was queried for patients with chondrosarcoma of the osseous spine from 1973 to 2012. Study variables included age, sex, race, year of diagnosis, size, grade, extent of disease, and treatment modality. RESULTS:The search identified 973 cases of spinal chondrosarcoma. Mean age at diagnosis was 51.6 years, and 627% of patients were males. Surgical resection and radiotherapy were performed in 75.2% and 21.3% of cases, respectively. Kaplan-Meier analysis demonstrated overall survival (OS) and disease-specific survival (DSS) of 53% and 64%, respectively, at 5 years. Multivariate Cox regression analysis showed that age (OS, P < 0.001; DSS, P = 0.007), grade (OS, P < 0.001; DSS, P < 0.001), surgical resection (OS, P < 0.001; DSS, P < 0.001), and extent of disease (OS, P < 0.001; DSS, P < 0.001) were independent survival determinants; tumor size was an independent predictor of OS (P = 0.006). For confined disease, age (P = 0.013), decade of diagnosis (P = 0.023), and surgery (P = 0.017) were independent determinants of OS. For locally invasive disease, grade (OS, P < 0.001; DSS, P = 0.003), surgery (OS, P = 0.013; DSS, P = 0.046), and size (OS, P = 0.001, DSS, P = 0.002) were independent determinants of OS and DSS. Radiotherapy was an independent indicator of worse OS for both confined (P = 0.004) and locally invasive disease (P = 0.002). For metastatic disease, grade (OS, P = 0.021; DSS, P = 0.012) and surgery (OS, P = 0.007; DSS, P = 0.004) were survival determinants for both OS and DSS, whereas radiotherapy predicted improved OS (P = 0.039). CONCLUSION/CONCLUSIONS:Surgical resection confers survival benefit in patients with chondrosarcoma of the spine independent of extent of disease. Radiotherapy improves survival in patients with metastatic disease and worsens outcomes in patients with confined and locally invasive disease. LEVEL OF EVIDENCE/METHODS:4.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:To describe the incidence and determinants of survival of patients with nasopharyngeal adenocarcinoma between the years of 1973 to 2012 using the Surveillance, Epidemiology, and End Result (SEER) database. STUDY DESIGN/METHODS:Retrospective cohort study using a national database. METHODS:The SEER registry was utilized to calculate survival trends for patients with nasopharyngeal adenocarcinoma between 1973 and 2012. Patient data was then analyzed with respect to histopathology, age, sex, race, stage, grade, and treatment modalities (surgery and radiation therapy). Overall (OS) and disease-specific survival (DSS) were calculated. RESULTS:A total of 148 cases of nasopharyngeal adenocarcinoma were identified. The cohort was composed of 54.7% males. The mean age at diagnosis was 59.0years. The median OS was 60.6months. 59.4% of cases were treated with surgery, while 64.1% received radiation therapy. OS at 2, 5, and 10years was 63%, 49%, and 36%, respectively. There was no significant difference in OS and DSS between adenocarcinoma of the nasopharynx versus the sinonasal tract (p>0.05). On univariate analysis, younger age, surgery, surgery and radiation, and lower tumor grade were associated with improved OS and DSS, while papillary subtype, lower stage, and no distant metastasis were associated with improved OS alone (all p<0.05). CONCLUSIONS:Nasopharyngeal adenocarcinoma is an extremely rare malignancy with poor prognosis, with the exception of the papillary subtype. Age, grade, and surgical therapy are predictors of survival.

BACKGROUND CONTEXT:Osteosarcoma (OGS) and Ewing sarcoma (EWS) are the two classic primary malignant bone tumors. Due to the rarity of these tumors, evidence on demographics, survival determinants, and treatment outcomes for primary disease of the spine are limited and derived from small case series. PURPOSE:To use population-level data to determine the epidemiology and prognostic indicators in patients with OGS and EWS of the osseous spine. STUDY DESIGN/SETTING:Large-scale retrospective study. PATIENT SAMPLE:Patients diagnosed with OGS and EWS of the spine in the Surveillance, Epidemiology, and End Results (SEER) registry from 1973 to 2012. OUTCOME MEASURES:Overall survival (OS) and disease-specific survival (DSS). METHODS:Two separate queries of the SEER registry were performed to identify patients with OGS and EWS of the osseous spine from 1973-2012. Study variables included age, sex, race, year of diagnosis, tumor size, extent of disease (EOD), and treatment with surgery and/or radiation therapy. Primary outcome was defined as OS and DSS in months. Univariate survival analysis was performed using the Kaplan-Meier method and the log-rank test. Multivariate analysis was performed using Cox proportional hazards regression models. RESULTS:The search identified 648 patients with primary OGS and 736 patients with primary EWS of the spine from 1973 to 2012. Mean age at diagnosis was 48.1 and 19.9 years for OGS and EWS, respectively, with OGS showing a bimodal distribution. The median OS and DSS were 1.3 and 1.7 years, respectively, for OGS, with OGS in Paget's disease having worse OS (0.7 years) relative to the mean (log-rank p=.006). The median OS and DSS for EWS were 3.9 and 4.3 years, respectively. Multivariate cox regression analysis showed that age (OS p<.001, DSS p<.001), decade of diagnosis (OS p=.049), surgical resection (OS p<.001, DSS p<.001), and EOD (OS p<.001, DSS p<.001) were independent positive prognostic indicators for spinal OGS; radiation therapy predicted worse OS (hazard ratio [HR] 1.48, confidence interval [CI] 1.05-2.10, p=.027) and DSS (HR 1.74, CI 1.13-2.66, p=.012) for OGS. For EWS, age (OS p<.001, DSS p<.001), surgical resection (OS p=.030, DSS p=.046), tumor size (OS p<.001, DSS p<.001), and EOD (OS p<.001, DSS p<.001) were independent determinants of improved survival; radiation therapy trended toward improved survival but did not achieve statistical significance for both OS (HR 0.76, CI 0.54-1.07, p=.113) and DSS (0.76, CI 0.54, 1.08, p=.126). CONCLUSIONS:Age, surgical resection, and EOD are key survival determinants for both OGS and EWS of the spine. Radiation therapy may be associated with worse outcomes in patients with OGS, and is of potential benefit in EWS. Overall prognosis has improved in patients with OGS of the spine over the last four decades.

Importance:Squamous cell carcinoma of the lip (lip SCC) composes more than 25% of all oral cancers. Most of the demographic and prognostic indicators for lip SCC are only available through retrospective case series. Objective:To examine the incidence, treatment, overall survival, and disease-specific survival (DSS) of patients with lip SCC. Design, Setting, and Participants:Population-based cohort analysis using the Surveillance, Epidemiology, and End Results database identified patients with lip SCC between January 1, 1973, and December 31, 2012. Main Outcomes and Measures:Overall survival and DSS. Results:A total of 15 832 cases of lip SCC were identified. The cohort was composed of 12 945 men (81.8%) and 2887 women (18.2%). The mean age at diagnosis was 66.1 years. White patients accounted for 98.4% of the cases. Most of the tumors presented in the lower lip (77.8% external and 10.2% mucosal), whereas the external upper lip, mucosal upper lip, and the oral commissure represented 8%, 1%, and 1.2% of all cases, respectively. Of the patients, 91.2% underwent surgical therapy, 7.7% received radiation therapy, and 4.7% received both. Overall survival at 2 years, 5 years, and 10 years was 85.5%, 69.9%, and 50.2%, respectively. Multivariate analysis revealed that age, primary site, T stage, and N stage were determinants of overall survival and DSS. Kaplan-Meier survival analysis showed that SCC of the upper and lower lip had similar overall survival (163.6 months vs 163.8 months) and DSS (418.6 months vs 423.6 months). In contrast, SCC of the oral commissure had significantly lower overall survival (128.5 months) and DSS (286.7 months). Conclusions and Relevance:Our study demonstrates that lip SCC predominantly affects white men in their mid-60s. The determinants of survival for lip SCC include age at diagnosis, primary site, T stage, and N stage. Squamous cell carcinoma of the upper lip and lower lip had similar survival, whereas SCC of the oral commissure was associated with decreased survival.

Successful management of patellar osteochondral lesions has proved difficult, with unreliable outcomes reported using traditional cartilage repair and restoration procedures. Unique considerations for this type of defect include the multiplanar contours of the articular surface of the patella, high compressive and shear forces with knee range of motion that may disrupt graft healing, and the potential need for concomitant surgery to address patellar malalignment and instability. We describe our preferred method for treatment of a symptomatic chondral defect in the setting of recurrent patellar instability using particulated juvenile articular cartilage allograft transplantation and medial patellofemoral ligament reconstruction with semitendinosus allograft. Distinct advantages of this cartilage restoration technique include single-stage restoration of relevant cartilage pathology and the ability to easily contour the graft to the size and shape of the chondral defect.

BACKGROUND:Treatment of patellofemoral instability has evolved as our understanding of the relevant pathoanatomy has improved. In light of these developments, current practice patterns and management trends have likely changed to reflect these advancements; however, this has not been evaluated in a formal study. PURPOSE/OBJECTIVE:To determine nationwide patient demographics, surgical trends, and postoperative complications associated with the operative management of patellar instability surgery. STUDY DESIGN/METHODS:Descriptive epidemiological study. METHODS:A large private-payer database (PearlDiver) comprising patients covered by Humana and United Healthcare insurance policies was retrospectively reviewed using Current Procedural Terminology (CPT) codes to identify patients who underwent surgery for patellar instability. The study cohort was established by querying for patients billed under CPT codes 27420, 27422, or 27427 while satisfying the diagnostic requirement of patellar instability (International Classification of Diseases-9th Revision codes 718.36, 718.86, or 836.3). Patient demographics, surgical trends, concomitant procedures, and postoperative complications were determined. RESULTS:A total of 6190 patients underwent surgical management for patellar instability. Adolescents (age range, 10-19 years) represented 51.5% of cases, and 59.6% were female. The number of patellar instability procedures increased annually over the study period in both the Humana (P = .004, R (2) = 0.76) and United Healthcare (P = .097, R (2) = 0.54) cohorts. The most common concomitant procedures were lateral retinacular release (43.7%), chondroplasty (31.1%), tibial tubercle osteotomy (13.1%), removal of loose bodies (10.5%), osteochondral grafting (9.5%), and microfracture surgery (9.5%). Manipulation under anesthesia was required in 4.6% of patients within 1 year. Patellar fracture within 1 year and infection within 30 days occurred in 2.1% and 1.2% of patients, respectively. CONCLUSION/CONCLUSIONS:Patellar instability surgery has increased over the past decade. This finding may be attributed to growing clinical evidence to support these procedures as well as increased surgeon familiarity and comfort with these specific techniques. We observed an unexpectedly high rate of concomitant lateral retinacular release. Overall, the rates of commonly recognized complications (stiffness, patellar fracture, and postoperative infection) were similar to those observed in smaller case series.