Recent Publications by CFE Educators

In the absence of randomized data, the optimal approach to adjuvant radiation therapy in locally advanced thyroid cancer remains unclear. We employed a large retrospective analysis to assess the best available evidence of a potential beneficial impact of intensity-modulated versus 3D-conformal radiotherapy (IMRT vs. 3D-CT). Retrospective analysis of adult thyroid cancer diagnosed between 2004 and 2011 within the National Cancer Database. Among patients treated with radiation therapy (N = 855), the use of IMRT (N = 437) increased among both comprehensive and academic centers (both p  0.001), but not community hospitals (p = 0.43). Receipt of IMRT was associated with adverse clinical factors in multivariable analysis, including positive surgical margins, non-DTC histologies, and nodal metastases (all p  0.001). IMRT use was associated with a significantly higher dose of radiation (60.7 vs. 52.4 Gy, p  0.001). In multivariable analyses, receipt of IMRT demonstrated a trend toward improved overall survival (HR, 0.67; 95 % CI, 0.40-1.10; p = 0.115). This study presents the largest cohort to date examining receipt of IMRT in patients with locally advanced thyroid cancer and demonstrates an association between IMRT, treatment at a tertiary care center, higher total dose, and comparable or superior outcomes compared to patients treated with 3D conformal techniques despite more adverse disease features. In the absence of adequately powered prospective randomized trials, our retrospective analysis provides empirical evidence to support the use in these patients of dose escalation and IMRT, particularly at tertiary care centers.

Cystic dilatation of bulbourethral gland ducts (Cowper's gland syringocele) is a rare abnormality. The condition has been described among pediatric populations, but it is uncommon in adults. It can be asymptomatic or present with obstructive and irritative urinary symptoms. We report a case of a symptomatic imperforate Cowper's syringocele in a young patient that was successfully managed with transurethral unroofing of the cyst.

BACKGROUND

The current study was performed to characterize trends and survival outcomes for chemotherapy in the definitive and adjuvant treatment of hypopharyngeal cancer in the United States.

METHODS

A total of 16,248 adult patients diagnosed with primary hypopharyngeal cancer without distant metastases between 1998 and 2011 were identified in the National Cancer Data Base. The association between treatment modality and overall survival was analyzed using Kaplan-Meier survival curves and 5-year survival rates. A multivariate Cox regression analysis was performed on a subset of 3357 cases to determine the treatment modalities that predict improved survival when controlling for demographic and clinical factors.

RESULTS

There was a significant increase in the use of chemotherapy with radiotherapy both as definitive treatment (P.001) and as adjuvant chemoradiotherapy with surgery (P=.001). This was accompanied by a decrease in total laryngectomy/pharyngectomy rates (P.001). Chemoradiotherapy was associated with improved 5-year survival compared with radiotherapy alone in the definitive setting (31.8% vs 25.2%; log rank P.001). Similarly, in multivariateanalysis, definitive radiotherapy was found to be associated with compromised survival compared with definitive chemoradiotherapy (hazard ratio, 1.51; P.001).

CONCLUSIONS

Survival analysis revealed that overall 5-year survival rates were higher for chemoradiotherapy compared with radiotherapy alone in the definitive setting, but were comparable between surgery with chemoradiotherapy and surgery with radiotherapy. Cancer 2016;122:1853-60. © 2016 American Cancer Society.

BACKGROUND

Experimental studies have shown androgen receptor stimulation to facilitate formation of the TMPRSS2:ERG gene fusion in prostate cell lines. No study has tested whether higher pre-diagnostic circulating sex hormone levels in men increase risk of developing TMPRSS2:ERG-positive prostate cancer specifically.

METHODS

We conducted a nested case-control study of 200 prostate cancer cases and 1057 controls from the Physicians' Health Study and Health Professionals Follow-up Study. We examined associations between pre-diagnostic circulating levels of total testosterone, free testosterone, DHT, androstanediol glucuronide, estradiol, and SHBG and risk of prostate cancer by TMPRSS2:ERG status. TMPRSS2:ERG was estimated by ERG immunohistochemistry. We used multivariable unconditional polytomous logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for risk of ERG-positive (n=94) and, separately, ERG-negative (n=106) disease.

RESULTS

Free testosterone was significantly associated with the risk of ERG-positive prostate cancer (OR: 1.37, 95% CI: 1.05-1.77), but not ERG-negative prostate cancer (OR: 1.09, 95% CI: 0.86-1.38) (Pdiff=0.17). None of the remaining hormones evaluated showed clear differential associations with ERG-positive vs ERG-negative disease.

CONCLUSIONS

These findings provide some suggestive evidence that higher pre-diagnostic free testosterone levels are associated with an increased risk of developing TMPRSS2:ERG-positive prostate cancer.

PURPOSE

Previous studies with small sample sizes have shown a wide range of complication rates and no study has investigated the yield of computed tomography-guided transthoracic core needle biopsies (CTTCB) for coccidioidomycosis. To better assess the safety, accuracy, and risk factors for complications of CTTCB of pulmonary nodules, we conducted a retrospective study at a high-volume academic center in an endemic coccidioidomycosis area.

METHODS

We conducted a retrospective study of 203 patients who underwent CTTCB of pulmonary nodules between December 2010 and May 2013. We collected demographics, clinical, and radiographic data. Each case was reviewed for complications. Diagnostic accuracy was assessed by comparing CTTCB with final diagnoses.

RESULTS

The overall complication rate was 25 %. Pneumothorax accounted for 24 % of complications with 7 % of pneumothoraces requiring chest tube. 1.5 % were complicated by hemoptysis but none required blood transfusions. There was an association between complications and age, presence of emphysema on CT, traversed lung length, and lesion depth. The overall sensitivity of the CTTCB for all types of lung cancer was 93 %, and specificity of 100 %. The positive predictive value of CTTCB for lung cancer was 100 %. The sensitivity and specificity of CTTCB for a coccidiomycosis lung nodule was 83 % with a specificity of 100 % with a PPV of 100 %.

CONCLUSION

Our study demonstrates that CTTCB is a relatively safe method for evaluating lung nodules and highly accurate in evaluating lung nodules due to coccidioidomycosis in an endemic area. The primary risk factors for complications from CTTCB are the presence of emphysema on CT scan, lesion depth, and traversed lung length.

OBJECTIVE

The aim of the present study is to determine if CEACAM6 can be detected in the bile of patients with biliary cancer and can serve as a diagnostic biomarker for cholangiocarcinoma.

SUMMARY BACKGROUND DATA

Distinguishing bile duct carcinoma from other diagnoses is often difficult using endoscopic or percutaneous techniques. The cell surface protein CEACAM6 is over-expressed in many gastrointestinal cancers and may be selectively elevated in biliary adenocarcinoma.

METHODS

Bile from patients with benign biliary disease and cholangiocarcinoma (hilar, intrahepatic and distal) was collected at the time of index operation. The concentration of CEACAM6 was quantified by sandwich enzyme-linked immunosorbent assay (ELISA) and correlated to pathologic diagnosis. Diagnostic capability of CEACAM6 was evaluated by Wilcoxon rank-sum, linear regression, multiple regression, and receiver operating characteristic (ROC) curve analysis.

RESULTS

Bile from 83 patients was analyzed: 42 with benign disease and 41 with cholangiocarcinoma. Patients in the benign cohort were younger, predominantly female, and had lower median biliary CEACAM6 levels than patients in the malignant cohort (7.5 ng/ml vs. 40 ng/ml; p = .001). ROC curve analysis determined CEACAM6 to be a positive predictor cholangiocarcinoma with a CEACAM6 level >14 ng/ml associated with 87.5% sensitivity, 69.1% specificity, and a likelihood ratio of 2.8 (AUC 0.74). Multiple regression analysis suggested elevated alkaline phosphatase and the presence of biliary endoprostheses may influence CEACAM6 levels.

CONCLUSION

Biliary CEACAM6 can identify patients with extrahepatic cholangiocarcinoma with a high degree of sensitivity and should be investigated further as a potential screening tool.

OBJECTIVES/HYPOTHESIS

To prospectively assess symptoms of obstructive sialadenitis before and after sialendoscopy-assisted salivary duct surgery (SASDS) using the chronic obstructive sialadenitis symptoms (COSS) questionnaire to determine and predict impact of interventions.

STUDY DESIGN

Prospective cohort study.

METHODS

Adult patients with chronic obstructive sialadenitis who underwent SASDS were asked to complete the COSS questionnaire and the Short-Form-8 (SF-8) quality-of-life (QOL) survey prior to surgery and 3 months postoperatively. Chronic obstructive sialadenitis symptoms surveys were scored on a scale from 0 to 100.

RESULTS

Forty patients undergoing SASDS, including 54 glands, completed preoperative and postoperative surveys. Overall, the mean COSS score improved from 36.1 (standard error of the mean [SEM] 2.6) preoperatively to 13.5 (SEM 2.4) 3 months postoperatively (p 0.001). Submandibular gland cases had a significant mean score reduction of 27.8 (from 38.1 to 10.3; p 0.005). Parotid gland cases had a significant mean score reduction of 13.6 (from 32.6 to 19.0; p 0.0001). Patients with sialolithiasis-related sialadenitis had greater COSS score improvement after surgery than those with radioactive iodine- or inflammatory-related disease. An improvement in symptoms was seen for 100% and 47% of patients with sialolithiasis and inflammatory etiologies, respectively. The pre- and post-SASDS SF-8 QOL scores were not significantly different.

CONCLUSIONS

Obstructive sialadenitis-related symptoms significantly declined 3 months after SASDS. The COSS questionnaire was able to measure changes in sialadenitis symptoms not captured in the SF-8 QOL survey. This is the first study to prospectively survey sialadenitis-specific symptoms to determine impact of surgical interventions.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1343-1348, 2016.