Faculty Bibliography

Importance: Historically, patients with cervical metastases from melanoma of the head and neck were treated with a radical neck dissection. This study evaluates the efficacy of limiting the extent of lymphadenectomy in this high-risk population. Objectives: To determine whether limiting the extent of lymphadenectomy for patients with biopsy-proven melanoma has a negative effect on regional control. Our hypothesis was that performing a more limited lymphadenectomy does not have a negative impact on regional control. Design, Setting, and Participants: A retrospective, single-cohort study was performed using a prospectively collected database of patients with head and neck melanoma with histopathologically positive lymph nodes after modified radical (MRND) or selective neck dissection (SNDs) performed at a high-volume, academic, tertiary care center. Interventions: Lymphadenectomy was performed as clinically indicated. Main Outcomes and Measures: Primary end points were regional recurrence and regional recurrence free survival. Univariable and multivariable analyses were conducted using multiple patient characteristics. Results: Forty-one patients underwent SND or MRND from 2001 through 2010. The median number of positive nodes was 1 (range, 1-16). Twenty-six patients (63%) received adjuvant radiation and 23 patients (56%) received adjuvant immunotherapy or chemotherapy. The median follow-up time was 17 months (range, 1-116 months). Regional control was achieved in 29 patients (71%). Median regional recurrence-free survival was 21 months (range, 1-116 months). Age (hazard ratio [HR], 1.13; 95% CI, 1.01-1.26), total number of nodes examined (HR, 1.05; 95% CI, 1.01-1.10), and number of sentinel lymph nodes examined (HR, 1.45; 95% CI, 1.01-2.09) were all significantly associated with increased recurrence-free survival. Tumor depth, extracapsular spread, number of nodes positive, prior SLNB, extent of lymphadenectomy, and adjuvant therapy were not significant. Conclusions and Relevance: Limiting the extent of lymphadenectomy with frequent use of adjuvant radiation therapy is effective in achieving regional control of head and neck melanoma with cervical metastases.

BACKGROUND: Patients with cystic fibrosis (CF) exhibit a wide range of disease severity, and can be broadly stratified into high-risk and low-risk groups based on cystic fibrosis transmembrane conductance regulator (CFTR) mutation class. Patients with a low-risk genotype are often diagnosed as adults, with milder disease and lower sweat chloride values. The aim of the current study was to better understand radiographic and clinical characteristics of sinus disease in adult CF patients within this risk category. METHODS: Adult CF patients were retrospectively compared to a control group of patients with chronic rhinosinusitis. CF diagnostic testing and pulmonary characteristics were compared between high-risk and low-risk CF groups, and sinus CT findings were compared among all 3 groups. RESULTS: When comparing CF cohorts (n = 25 and 30, respectively), earlier age at diagnosis (p < 0.001), higher sweat chloride values (p < 0.001), lower forced expiratory volume in 1 second (FEV1 ) values (p < 0.001), and a higher prevalence of pulmonary infection with Pseudomonas aeruginosa (p = 0.001) were found in the high-risk genotype group. A significantly increased incidence of sinus hypoplasia/aplasia and bony sclerosis was seen when comparing both CF groups to the control cohort (n = 30), as well as when comparing the high-risk and low-risk CF genotype cohorts. CONCLUSION: The current study describes clinicopathologic findings of sinus disease in adult CF patients in the context of genotype severity. Our data demonstrate that while patients within a low-risk genotype cohort have generally milder lung disease, they retain classic radiographic findings of CF sinus disease that can help raise the index of suspicion for undiagnosed CF.

This report describes a 6-year-old boy with disseminated low-grade astrocytoma and ventriculo-peritoneal shunt, who developed recurrent ascites while receiving sorafenib on a clinical trial. Laboratory analysis of the peritoneal fluid showed no elevation of protein content and no evidence of underlying infection or tumor dissemination. This report highlights ascites as a previously unrecognized adverse reaction to sorafenib in a patient with a ventriculo-peritoneal shunt. We conclude that such patients should be closely monitored for this complication when treated with sorafenib.

BACKGROUND: We present a case report of a trachea-colonic fistula and demonstrate our unique approach to repair, which was efficient and effective. METHODS: The patient was a 50-year-old man who had a congenital tracheoesophageal fistula repair with colonic interposition as a child who now developed a fistula between his colon and trachea. RESULTS: We performed a transtracheal approach, with primary closure of redundant colon mucosa as well as direct repair of the trachea. An inferiorly based sternocleidomastoid muscle flap was interposed between these 2 layers to augment the repair. The patient had an uneventful recovery with an effective reconstitution of the alimentary tract and the airway. CONCLUSION: Tracheo-colonic fistula is an extremely rare pathology, and the scarring that develops after a prior esophagectomy makes a traditional lateral approach very difficult. The transtracheal approach is an effective method to obtain needed exposure in order to carry out the repair. (c) 2013 Wiley Periodicals, Inc. Head Neck, 2014.

PURPOSE/OBJECTIVE:Treatment with cisplatin or cetuximab combined with radiotherapy each yield superior survival in locally advanced squamous cell head and neck cancer (LA-SCCHN) compared with radiotherapy alone. Eastern Cooperative Oncology Group Trial E3303 evaluated the triple combination. EXPERIMENTAL DESIGN/METHODS:Patients with stage IV unresectable LA-SCCHN received a loading dose of cetuximab (400 mg/m(2)) followed by 250 mg/m(2)/week and cisplatin 75 mg/m(2) q 3 weeks ×3 cycles concurrent with standard fractionated radiotherapy. In the absence of disease progression or unacceptable toxicity, patients continued maintenance cetuximab for 6 to 12 months. Primary endpoint was 2-year progression-free survival (PFS). Patient tumor and blood correlates, including tumor human papillomavirus (HPV) status, were evaluated for association with survival. RESULTS:A total of 69 patients were enrolled; 60 proved eligible and received protocol treatment. Oropharyngeal primaries constituted the majority (66.7%), stage T4 48.3% and N2-3 91.7%. Median radiotherapy dose delivered was 70 Gy, 71.6% received all three cycles of cisplatin, and 74.6% received maintenance cetuximab. Median PFS was 19.4 months, 2-year PFS 47% [95% confidence interval (CI), 33%-61%]. Two-year overall survival (OS) was 66% (95% CI, 53%-77%); median OS was not reached. Response rate was 66.7%. Most common grade ≥3 toxicities included mucositis (55%), dysphagia (46%), and neutropenia (26%); one attributable grade 5 toxicity occurred. Only tumor HPV status was significantly associated with survival. HPV was evaluable in 29 tumors; 10 (all oropharyngeal) were HPV positive. HPV(+) patients had significantly longer OS and PFS (P = 0.004 and P = 0.036, respectively). CONCLUSIONS:Concurrent cetuximab, cisplatin, and radiotherapy were well tolerated and yielded promising 2-year PFS and OS in LA-SCCHN with improved survival for patients with HPV(+) tumors.

Traumatic brain injury (TBI), a signature wound of Operations Enduring and Iraqi Freedom, can result from blunt head trauma or exposure to a blast/explosion. While TBI affects sleep, the neurobiological underpinnings between TBI and sleep are largely unknown. To examine the neurobiological underpinnings of this relationship in military veterans, [18F]-fluorodeoxyglucose positron emission tomography (FDG PET) was used to compare mTBI-related changes in relative cerebral metabolic rate of glucose (rCMRglc) during wakefulness, Rapid Eye Movement (REM) sleep, and non-REM (NREM) sleep, after adjusting for the effects of posttraumatic stress (PTS). Fourteen veterans with a history of blast exposure and/or mTBI (B/mTBI) (age 27.5+/-3.9) and eleven veterans with no history (No B/mTBI) (age 27.7+/-3.8) completed FDG PET studies during wakefulness, REM sleep, and NREM sleep. Whole-brain analyses were conducted using Statistical Parametric Mapping (SPM8). Between group comparisons revealed that B/mTBI was associated with significantly lower rCMRglc during wakefulness and REM sleep in the amygdala, hippocampus, parahippocampal gyrus, thalamus, insula, uncus, culmen, visual association cortices, and midline medial frontal cortices. These results suggest that alterations in neurobiological networks during wakefulness and REM sleep subsequent to B/mTBI exposure may contribute to chronic sleep disturbances and differ in individuals with acute symptoms.