Faculty Bibliography

OBJECTIVE:To analyze the patterns of care and survival of cutaneous angiosarcomas of the head and neck. STUDY DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:National Cancer Database. METHODS:The National Cancer Database was queried to select patients with cutaneous angiosarcoma of the head and neck between 2004 and 2015. For survival analysis, patients were included only if they received definitive treatment and complete data. Prognostic factors were analyzed by univariate and multivariable Cox regression. RESULTS:< .001) predicted worse overall survival. CONCLUSION/CONCLUSIONS:Angiosarcoma of head and neck is a rare malignancy that affects the elderly. Surgical treatment with negative margins is associated with improved survival. Even with curative-intent multimodality treatment, the survival of patients aged ≥75 years is limited.

OBJECTIVE:We conducted a quality improvement project to increase the rate of discharges before noon (DBN) in the otolaryngology department at a tertiary care center. METHODS:Based on a Plan-Do-Study-Act framework, monthly discharge data and observed-to-expected (O:E) length of stay were collected and shared with the department members monthly. A target of 43% DBN was predetermined by the center (Plan). The following interventions were implemented (Do): discharge planning starting at the time of admission, focus on early attending-to-resident team communication, placement of discharge order prior to rounding, and weekly reminders to the entire department. RESULTS:Discharges were monitored for 3 years. For the year prior to this study, a minority of patients were discharged before noon (12 months: 75 of 190, 36%). During the first 6 months of monitoring (Study), no significant improvement was identified (34 of 95, 36%). After interventions, performance significantly improved (31 months: 250 of 548, 68%). The performance was consistently above the predetermined target of 43%. During the study time, O:E length of stay remained below the predetermined target (O:E ratio, 0.90; hospital target, 0.93). DISCUSSION/CONCLUSIONS:Comprehensive discharge planning beginning at the time of admission, weekly reminders, and improved communication (Act) can help to prioritize DBN and increase the percentage of discharges before noon. IMPLICATIONS FOR PRACTICE/CONCLUSIONS:By utilizing a quality improvement framework, significant improvements in timely discharge can be achieved and sustained with changes in workflow and departmental culture. These changes can be achieved without increases in resources or prolonging the length of stay.

The incidence of thyroid cancer in Graves'Disease (GD) patients is estimated to be low. However, it is unclear what impact the recent rise in the incidence of thyroid cancers has had in this population. Furthermore, it is not clear if these cancers behave more aggressively than cancers in the general population. We investigated the incidence of malignancy and its features in a contemporary cohort of GD patients treated by surgery. All patients who underwent thyroidectomy for GD in our center were reviewed from 2013-2018. Demographics, clinicopathologic features, rate of incidental cancer and outcomes were reviewed. We identified 130 patients with GD who underwent thyroidectomy. Median age was 40.5 (16-80). Majority were female (112, 86%). All but five (4%) were radioactive iodine naive. Thirtyfour (26%) were found to harbor malignancy. While the majority (18, 53%) were papillary microcarcinoma; 12 (34%) had multifocal disease; 10 (29%) had tall cell features, 3 (9%) had positive lymph nodes, and 2 (6%) had extrathyroidal extension. One patient (3%) was diagnosed with follicular carcinoma. No permanent hyperparathyroidism or recurrent laryngeal nerve injury was encountered. With a median follow up of 23 months no recurrences were identified. The risk of incidental malignancy in GD patients was high in our cohort. While the majority were low risk microcarcinomas, a number of patients harbored higher risk tall cell features. Our data suggest that for GD patients who are medically managed, careful surveillance and biopsy of suspicious nodules might be warranted. The outcome of surgical treatment was excellent for controlling both hyperthyroidism and cancer

BACKGROUND:Small cohort studies have suggested oral tongue squamous cell carcinoma (OTSCC) could be associated with worse prognosis in individuals younger than 40. METHODS:We compared the survival of all OTSCC cases in the National Cancer Database under 40 years old with those older than 40, excluding patients over 70. Cox regression and propensity score matched (PSM) survival analyses were performed. RESULTS:A total of 22 930 OTSCC patients were identified. The under 40 group consisted of 2566 (9.9%) cases; 20664 were 40 to 70 (90.1%). Most were male (13 713, 59.8%), stage I-II (12 754, 72.4%), and treated by surgery alone (13 973, 63.2%). Survival in patients under 40 was higher (79.6% vs 69.5%, P < .001). In PSM analysis (n = 2928) controlling for all 10 significant factors in multivariate regression, patients under 40 had a 9% higher 5-year survival (77.1% vs 68.2%, P < .001). CONCLUSION/CONCLUSIONS:Contrary to the prior reports, younger patients with OTSCC did not have worse survival in the National Cancer Database.

OBJECTIVE:Clear cell carcinoma (CCC) is a rare salivary gland malignancy, believed to be generally low grade. We investigated CCC epidemiology and clinical behavior, using the National Cancer Database (NCDB). STUDY DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:NCDB. SUBJECTS AND METHODS/METHODS:All CCCs of the salivary glands were selected between 2004 and 2015. Patient demographics, tumor characteristics, treatments, and survival were analyzed. Cox regression analyses were performed in treated patients. RESULTS:We identified 268 patients with CCC. Median age was 61 (21-90) years. Most were female (145, 54%). The most common site was oral cavity (119, 44%), followed by major salivary glands (68, 25%) and oropharynx (41, 15%). Most tumors were low grade (81, 68%) and stages I to II (117, 60.6%). Nodal (36, 17.5%) and distant metastases (6, 2.4%) were rare. Most were treated by surgery alone (134, 50.0%), followed by surgery and radiotherapy (69, 25.7%). Five-year overall survival (OS) was 77.6% (95% CI, 71.4%-84.2%). In univariate analysis, older age, major salivary gland and sinonasal site, stages III to IV, high grade, and positive margins were associated with worse OS. In multivariate analysis, only high tumor grade (hazard ratio [HR], 5.76; 95% CI, 1.39-23.85; P = .02), positive margins (HR, 4.01; 95% CI, 1.20-13.43; P = .02), and age ≥60 years (HR, 3.45; 95% CI, 1.39-8.55; P = .01) were significantly associated with OS. CONCLUSION/CONCLUSIONS:We report the largest series of clear cell carcinomas of the head and neck. Outcomes are generally favorable following surgical-based treatments. In this series, pathologic tumor grade is associated with worse survival. Routine evaluation and reporting of tumor grade might better guide physicians in recommending appropriate treatments in this rare malignancy.