Faculty Bibliography

Although many internalized G protein-coupled receptors (GPCRs) continue to signal, the mechanisms and outcomes of intracellular GPCR signaling are uncertain due to the challenges of measuring organelle-specific signals and of selectively antagonizing receptors in intracellular compartments. Herein, genetically encoded biosensors targeted to the plasma membrane and early endosomes were used to analyze compartmentalized signaling of protease-activated receptor 2 (PAR₂); the propensity of nanoparticles (NPs) to accumulate in endosomes was leveraged to preferentially antagonize intracellular PAR₂ signaling of pain. PAR₂ agonists evoked sustained activation of PAR₂, Gαq, and β-arrestin-1 in early endosomes and activated extracellular signal regulated kinase (ERK) in the cytosol and nucleus, measured with targeted biosensors. Fluorescent dendrimer and core-shell polymeric NPs accumulated in endosomes of HEK293T cells, colonic epithelial cells, and nociceptors, detected by confocal microscopy. NPs efficiently encapsulated and slowly released AZ3451, a negative allosteric PAR₂ modulator. NP-encapsulated AZ3451, but not unencapsulated AZ3451, rapidly and completely reversed PAR₂, Gαq, and β-arrestin-1 activation in early endosomes and ERK activation in the cytosol and nucleus. When administered into the mouse colon lumen, fluorescent dendrimer NPs accumulated in endosomes of colonocytes and polymeric NPs accumulated in neurons, sites of PAR₂ expression. Both NP formulations of AZ3451, but not unencapsulated AZ3451, caused long-lasting analgesia and normalized aberrant behavior in preclinical models of inflammatory bowel disease. These results provide evidence that PAR₂ endosomal signaling mediates pain and that nanomedicines that antagonize PAR₂ in endosomes effectively relieve pain. NP-mediated delivery may improve the efficacy of other GPCR antagonists for treatment of diverse diseases.

BACKGROUND:Inferring risk for malignant transformation (MT) in patients with lesions diagnosed as mild or moderate oral epithelial dysplasia (low-grade OED) remains challenging. We developed two models assessing the risk of progression to high-grade OED (severe dysplasia or carcinoma in situ) or OSCC in patients with low-grade OED lesions. METHODS:We included demographic, risk habit and clinical data from participants with low-grade OED lesions enrolled in the BC Oral Cancer Prevention Program's Oral Cancer Prediction Longitudinal study. Cox proportional hazard models were fit to estimate the effects of anatomic site and toluidine blue findings and adjusted for confounders, as both are associated with MT in the literature but without a North American-specific cohort analysis. Our primary model included both variables of interest. A secondary model included only anatomic site since toluidine blue is not in widespread use. RESULTS:Five hundred and thirty-four participants with 605 lesions met final inclusion criteria, with 339 mild and 266 moderate OED at baseline. In the primary model, lesions at a high-risk anatomic site or with positive toluidine blue staining were associated with a 2.6 and 2.4-fold increased risk of progression, respectively. In the second model that did not incorporate toluidine blue, high-risk anatomic site remained a highly associated risk factor (2.7-fold increased risk of progression). CONCLUSION/CONCLUSIONS:Lesion anatomic site is associated with higher risk of MT for the general practitioner, while a specialist with access to toluidine blue results can assume additional risk associated with positive staining. These models may inform decisions for surveillance and intervention for OED.

BACKGROUND:Mutations in DICER1 are uncommon, poorly understood, and infrequently found in thyroid nodules. METHODS:The objective of this study was to investigate category III/IV thyroid nodules according to The Bethesda System for Reporting Thyroid Cytopathology with DICER1 gene mutations detected in fine-needle aspiration cytology samples using ThyroSeq v3 molecular testing, with a focus on an exploration of the clinical and histopathologic outcomes of these nodules. In this multicenter study spanning more than 6 years, nodules were retrospectively analyzed for patient demographics, clinical course, cytologic features, and histopathology, where available. RESULTS:In total, 88 patients with somatic DICER1 mutations were included, with a mean age of 39.6 years and a female predominance. All mutations were in the somatic hotspot region, most commonly at the codon 5437 site. Most excised nodules showed benign histologic features (65.9%). Interestingly, the rate of malignancy was higher in this cohort compared with that in the national average. CONCLUSIONS:DICER1 mutations appear to confer a higher risk of malignancy, but are not associated with any specific cytological or histopathological distinguishing features.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Surgery in NF2-related schwannomatosis (NF2-SWN) vestibular schwannoma (VS) carries a higher risk of facial nerve damage, hearing loss, and partial resection, than in sporadic cases. Radiosurgery is also associated with higher failure compared with sporadic schwannomas. Nowadays, bevacizumab (BEV) is frequently considered in the NF2-SWN population. However, some patients experience progression despite treatment. Among other surgical risks, in BEV-treated patients, hemorrhage and impaired healing are specific considerations. These concerns have led manufacturers to recommend stopping BEV 6 to 8 weeks preoperatively. The aim of our multicentric study was to assess the perioperative bleeding risk and postoperative outcomes in NF2-SWN patients undergoing VS surgery after preoperative BEV treatment. METHODS:Our retrospective analysis included medical and surgical records along with imaging reviews from 4 high-volume tertiary academic referral centers for NF2-SWN and VS. RESULTS:A total of 21 patients met the inclusion criteria. VS had a mean volume of 13.2 ±7.6 cm3 corresponding to 1 KOOS III and 20 KOOS IV. BEV was stopped at a mean of 5.8 ± 4.0 months before surgery with a total mean treatment duration of 33.7 ± 20.7 months and a monthly dose of 10.2 ± 4.1 mg/kg. Intraoperatively, the tumor was assessed to be bloody by the operating surgeons in 7 patients. Late BEV discontinuation and high cumulative dose independently predicted perioperative bleeding and longer surgery duration. No other complication such as wound dehiscence was reported. CONCLUSION/CONCLUSIONS:Our findings suggest that a higher cumulative BEV dose (∼600 mg/kg) and a longer interval between BEV discontinuation and surgery (∼8 months) are associated with a modest but statistically significant increase in intraoperative bleeding risk. Based on these observations, a BEV-free window between 6 weeks and 6 months (depending on the clinical scenario) before tumor resection seems optimal, particularly for patients with high cumulative exposure.

OBJECTIVE:To investigate the impact of resident involvement on pediatric otolaryngology procedure duration and study its financial implications on healthcare delivery. METHODS:A retrospective chart review of all patients who underwent tonsillectomy, adenoidectomy, tonsillectomy and adenoidectomy, nasal cautery, closed nasal reduction, and bilateral myringotomy tube insertion from April 2016 to October 2023 at a tertiary care center. Procedure duration, patient demographics, American Society of Anesthesiology class, body mass index percentile, case schedule time, and surgeon type were collected. The financial investment in trainees was calculated based on the difference in procedure duration between attending physicians and trainees, and the institution's preset value for otolaryngology case revenue. RESULTS:Surgical time was greater for trainees compared to attending physicians in all procedures except for closed nasal reduction. When comparing trainees to attending physicians, surgical time was proportionally prolonged with increase in patient age in bilateral myringotomy tube insertion. Regarding tonsillectomy and adenoidectomy, American Society of Anesthesiology Class I, body mass index greater than 95th percentile and afternoon scheduling were associated with prolonged surgical time. Female sex was associated with increased surgical time when comparing trainees to attending physicians in patients who underwent an adenoidectomy alone. The financial investment was greatest for second year residents, recorded as $616.988 over the study period. CONCLUSION/CONCLUSIONS:Surgical time decreases with surgeon experience for most pediatric otolaryngology procedures. Sex, body mass index, American Society of Anesthesiology class, case schedule time, and age are variables that impact surgical time. Resident training comes with a significant, yet necessary, cost spread over several years.

BACKGROUND:Molecular aberrations have been incorporated into tumour classification guidelines of meningioma. TERT-promoter (TERTp) mutation is associated with worse prognosis and is designated a WHO grade 3 biomarker. However, it remains unclear whether TERTp mutation is context-dependent, with other co-occurring genetic alterations potentially driving its association with prognosis. We sought to characterise the role of TERTp mutation in meningioma and guide TERTp sequencing. METHODS:We identified 1492 patients of all ages who had previously received surgery for meningioma across 14 medical centres in the USA, Canada, and Germany. Patients were eligible if they had post-surgical clinical or radiographical assessment of the resection site, and TERTp status evaluated by Nov 1, 2024. Multi-modal profiling was used to assess TERTp mutation, focal gene alterations-including CDKN2A/B loss-and copy number alterations. An adjusted WHO grade was calculated for TERTp-mutant meningiomas, incorporating all WHO criteria except TERTp status. Kaplan-Meier curves and multivariable Cox proportional hazards models were used to quantify the effect of TERTp mutation on the endpoints of overall survival and recurrence-free survival across adjusted WHO grade and co-occurring molecular alterations. FINDINGS/RESULTS:64 (4·3%) of 1492 meningiomas were TERTp-mutant and 1428 (95·7%) were TERTp-wildtype. Of the TERTp-mutant meningiomas, 33 (51·6%) were from female patients and 31 (48·4%) were from male patients, and the overall median age was 67 years (IQR 60-75). Of the wildtype meningiomas, 965 (67·6%) were from female patients and 463 (32·4%) were from male patients, and the overall median age of the patients was 59 years (IQR 48-70). Data on race was inconsistently reported and thus excluded. The TERTp-mutant patients had a 5-year overall survival (49·4% [95% CI 33·7-72·4]) and 5-year recurrence-free survival (27·6% [95% CI 16·8-45·5]) resembling that of patients with WHO grade 3 TERTp-wildtype tumours (5-year overall survival 32·3% [95% CI 17·2-60·5], p=0·28, 5-year recurrence-free survival 14·3% [5·8-35·2], p=0·28). However, the TERTp-mutant group had heterogenous histological grading and was enriched for aggressive molecular features, with 1p loss present in 44 (77·2%) of 57 profiled tumours and CDKN2A/B loss in 24 (41·4%) of the 58 profiled tumours. Adjusting tumour grade revealed a subset of TERTp-mutant meningiomas that were more molecularly and clinically benign. Among TERTp-mutant tumours, CDKN2A/B loss played a defining role in stratifying tumour behaviour. Multivariable analysis confirmed this, with CDKN2A/B loss being significantly associated with shorter overall survival (HR 3·04 [95% CI 1·67-5·52], p=0·00026) and faster time to recurrence (HR 5·22 [95% CI 3·10-8·79], p<0·0001), while TERTp-mutation did not independently affect overall survival (HR 1·00 [95% CI 0·53-1·87], p=0·99) or recurrence-free survival (1·17 [95% CI 0·75-1·83], p=0·49). Sequencing for TERTp-mutation demonstrated clinical impact only among histologically WHO grade 2 meningiomas. INTERPRETATION/CONCLUSIONS:The indolent behaviour of certain TERTp-mutant meningiomas suggests that TERTp mutation is not sufficient to assign the most aggressive meningioma grade. Instead, TERT sequencing might offer prognostic utility in identifying high-risk cases among WHO grade 2 meningiomas. FUNDING/BACKGROUND:National Institutes of Health, National Institute of Neurological Disorders and Stroke, Friedberg Charitable Foundation, Courtney Meningioma Research Fund, Fleming Meningioma Research Fund, and the Gray Family Foundation.

BACKGROUND AND OBJECTIVE/UNASSIGNED:Intraoperative parathyroid gland recognition is a key step during thyroidectomy to decrease the risk of postoperative hypocalcemia and during parathyroidectomy to distinguish normal and abnormal glands. Current methods for intraoperative identification rely largely upon visual identification. Recent investigation of methods such as near-infrared (NIR) autofluorescence and indocyanine green (ICG) for enhanced recognition have demonstrated steep learning curves. Artificial intelligence (AI) augmentation of all methods of parathyroid gland identification may improve intraoperative recognition rates and ultimately decrease rates of postoperative hypoparathyroidism. This narrative review aims to summarize the status of intraoperative application of AI for parathyroid gland recognition. METHODS/UNASSIGNED:A systematic, comprehensive literature search was conducted using the search terms "artificial intelligence", "deep learning", "surgery", "parathyroid gland", and "parathyroid glands". Inclusion criteria included articles in English with the majority of the article devoted to intraoperative applications of AI on parathyroid gland recognition. Eleven studies were identified and included. KEY CONTENT AND FINDINGS/UNASSIGNED:Eight studies focused on utilizing AI intraoperatively to identify parathyroid glands from surrounding tissues. Three studies focused on using AI to predict abnormal from normal parathyroid glands. Five studies used NIR autofluorescence, two studies used visual recognition during open thyroidectomy, two studies used visual recognition during endoscopic thyroidectomy, one study used NIR autofluorescence with ICG angiography, and one study used coaxial dual-red-green-blue/near-infrared (dual-RGB/NIR) imaging system to identify parathyroid glands. Recall and precision scores for the models ranged from 50-95% and 72-94%, respectively. Four studies compared model performance with that of senior and junior surgeons and found that the models outperformed junior surgeons while performing comparably to senior surgeons. CONCLUSIONS/UNASSIGNED:AI augmentation of intraoperative parathyroid gland recognition demonstrates adequate accuracy results across a range of parathyroid gland recognition methods. Although these models are not currently available for widespread commercial use, the eventual integration into clinical practice may allow for enhanced intraoperative recognition of parathyroid glands, particularly in lower volume centers and for junior level surgeons.

IMPORTANCE/UNASSIGNED:Stage I squamous cell carcinoma (SCC) of the glottic larynx carries a favorable prognosis after treatment with endoscopic surgery or radiation therapy (RT). In addition to tumor control, goals of therapy include preservation of voice quality, swallow function, and breathing. Multidisciplinary consensus guidelines are needed to assist clinicians in treatment selection and the appropriate use of both surgical and radiation-based techniques. OBSERVATIONS/UNASSIGNED:Treatment of clinical T1N0 glottic SCC has evolved over time, with advances in both transoral laser microsurgery and RT designed to become more targeted and reduce the overall treatment burden for patients. When selecting a treatment option, consideration should be given to patient-specific factors, including tumor position/extent, age, and medical and psychosocial factors. This 16-member multidisciplinary American Radium Society (ARS) Head and Neck Cancer Appropriate Use Criteria (AUC) expert panel performed a review of the English-language medical literature from 2000 to 2022 to inform consensus guidelines. Clinical case variants were developed to represent commonly encountered clinical scenarios, and the RAND/UCLA appropriateness method was used to rate the appropriate use of various treatments. The modified Delphi method was used to reach consensus recommendations, which were approved by the ARS Executive Committee and subject to public comment per established ARS procedures. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Given the range of treatment options available, early glottic SCC management should be done in a multidisciplinary fashion including otolaryngologists and radiation oncologists. The ARS Head and Neck AUC expert panel created an appropriate-use consensus document by performing a literature review of the current treatment strategies for stage I glottic SCC, providing recommendations regarding the appropriateness of surgery or RT for various clinical scenarios and highlighting areas of controversy and uncertainty.

OBJECTIVES/OBJECTIVE:The primary objective of this study was to evaluate international practice patterns related to environmental sustainability in pediatric otolaryngology ORs, with a focus on the use of single-use versus reusable supplies. METHODS:An electronic survey was distributed using REDCap to members of an international pediatric otolaryngology WhatsApp group (n = 324). The survey included multiple-choice, Likert-scale, and open-ended questions regarding drape, gown, and glove usage for adenotonsillectomy, ear tube insertion, and laryngoscopy/bronchoscopy procedures, and broader sustainability practices including barriers and enablers. RESULTS:Response rate was 16.0 % (n = 52/324). Respondents were from North America (30.8 %), Europe (25.0 %), Australia/New Zealand (23.1 %), Asia (15.4 %), South America (3.8 %), and Africa (1.9 %). For adenotonsillectomy 61.5 % reported using single-use patient drapes, 61.5 % use single-use table drapes, and 44.2 % use single-use gowns. For ear tube insertions, single-use table drapes (53.8 %) were most frequently reported; single-use patient drapes (38.4 %) and gowns (21.2 %) were less common. For laryngoscopy/bronchoscopy, the majority did not use patient drapes (31.4 %) or gowns (32.7 %), while 62.8 % use single-use table drapes. Top barriers to improving sustainability in the OR were cost (51.9 %) and infection prevention and control (IPAC) practices (44.2 %). Enablers included sufficient technological (46.2 %) and financial (36.6 %) resources, dedicated policies (30.8 %), and supportive leadership (34.6 %). CONCLUSION/CONCLUSIONS:There remains a strong reliance on single-use materials in pediatric otolaryngology ORs globally. Cost, IPAC, education, and leadership are important considerations in sustainability efforts. These findings identify actionable targets for waste reduction and support the need for specialty-specific sustainability interventions.

INTRODUCTION/BACKGROUND:Papillary thyroid cancer (PTC) often follows an indolent course with a favorable prognosis. This has led to evolving guideline-based, low-intensity treatment options for low-risk patients. Recently, the purported benefit of total thyroidectomy (TT) over unilateral lobectomy for PTC with clinical lateral neck nodal metastasis (cN1b) has come into question. MATERIALS AND METHODS/METHODS:A retrospective analysis of the National Cancer Institute's Surveillance, Epidemiology, and End Results database was performed to study patients with PTC with ipsilateral cN1b disease from 1975 to 2020. Kaplan-Meier curves and log-rank tests were used to compare disease-specific survival (DSS) difference between lobectomy and TT at 10 y. Multivariable Cox proportional hazards analysis was performed to determine the independent association of lobectomy versus TT with DSS, correcting for age and lymph node ratio, defined as the ratio of pathologically positive lymph nodes to total number examined. RESULTS:Among 2943 patients (median [interquartile range] age, 45 [26] y), 42 underwent lobectomy and 2901 underwent TT. Unadjusted DSS at 10 y in the lobectomy and TT groups were 51.0% (95% confidence interval, 31.4%-82.8%) and 86.8% (95% confidence interval, 84.8%-88.9%), respectively. On multivariable analysis of all patients, older age (hazard ratio [HR], 1.08; P < 0.001) and male gender (HR, 1.74; P < 0.001) were associated with lower adjusted DSS, whereas treatment with TT (HR, 0.387; P = 0.005) and receipt of radioactive iodine (RAI) (HR, 0.604; P < 0.001) were associated with improved adjusted DSS. In addition, we observed that the magnitude of survival benefit conferred by RAI and TT were reduced with decreasing age (P < 0.001). CONCLUSIONS:This longitudinal cohort study suggests that, while TT is associated with a DSS benefit in most patients with PTC and ipsilateral cN1b disease, this association may not exist in a smaller cohort of younger patients. These findings raise the possibility that unilateral surgical clearance without RAI could offer adequate oncologic outcomes in selected younger individuals; however, further investigation is warranted to confirm these observations and inform clinical decision-making.