Prognostic Significance Of Extranodal Extension In Hpv (+) Oropharyngeal Carcinoma

Determine the prognostic role of extranodal extension (ENE) among patients with HPV(+) oropharyngeal squamous cell carcinoma (OPSCC) through a systematic review and meta-analysis of institutional studies. Two independent authors searched MEDLINE, EMBASE, Scopus and PubMed databases on 12/03/2019 to identify studies of HPV(+) OPSCC comparing prognostic outcomes stratified by ENE. The I2 statistic was used to determine heterogeneity. Fixed and random effects models were used to determine hazard ratios (HRs) with 95% confidence intervals (CIs). Eighteen observational studies met inclusion criteria, yielding a total of 3,606 HPV(+) OPSCC patients [1,524 ENE(+) and 2,082 ENE(-)] with a median follow-up of 49 months. The presence of pathologic (p) ENE and radiologic (r) ENE were associated with decreased overall survival (pENE HR:1.71 [95% CI: 1.20-2.43] I2=35%; rENE HR:2.64 [95% CI:1.46-4.78] I2=75%) and distant recurrence (pENE HR:3.23 [95% CI:1.25-8.33]; rENE HR:3.83 [95% CI:1.88-7.80] I2=0%). Neither pENE (HR: 0.75, p=0.67, I2=0%) nor rENE (HR: 2.03, p=0.11, I2=0%) were associated with locoregional recurrence. ENE is associated with an increased risk of all-cause mortality and recurrence with distant metastasis in a cohort of patients with HPV(+) OPSCC. These findings may be used to inform exclusion criteria for de-intensification trials and assist in refined risk stratification

Predictors of non-primary auditory and vestibular symptom persistence following surgical repair of superior canal dehiscence syndrome

ObjectivePatients with superior canal dehiscence syndrome (SCDS) can present with a plethora of auditory and/or vestibular symptoms associated with a bony defect of the superior semicircular canal. While surgical repair is a reasonable option for patients with significant localizing symptoms, the degree of clinical improvement will vary among patients and poses challenges in outcome prediction. This study aims to assess the relationship between preoperative and postoperative symptoms and identify predictors of symptom persistence following repair.Study designRetrospective chart review.SettingTertiary neurotology single-institution care center.Main outcome measuresThe primary outcome was to determine the proportion of resolved and persistent primary (most bothersome) and non-primary audiologic and vestibular symptoms following SCD repair. Secondary outcomes included comparison of patient, operative and radiologic characteristics between patients with resolved vs. persistent symptoms. Standardized patient questionnaires including 11 auditory and 8 vestibular symptoms were administered to patients at their preoperative and follow-up visits. Patient pre- vs. postoperative survey results, demographic and clinical characteristics, operative characteristics, audiometric data and cervical vestibular evoked myogenic potential (cVEMP) thresholds were compared via univariate χ2 and multivariate binary logistic regression analyses between those patients reporting full postoperative resolution of symptoms and persistence of one or more symptoms. Radiologic computed tomography (CT) measurements of superior canal dehiscence (SCD) defect size, location, and laterality were also compared between these two groups.ResultsOf 126 patients (132 ears) included in our study, 119 patients (90.2%) reported postoperative resolution (n = 82, 62.1%) or improvement (n = 37, 28.0%) of primary (most bothersome) symptoms, while 13 patients (9.8%) reported persistence of primary symptoms. The median (interquartile range) and range between surgery and questionnaire completion were 9 (4–28), 1–124 months, respectively. Analyzing all symptoms (primary and non-primary) 69 (52.3%) and 68 (51.1%) patients reported complete postoperative auditory and vestibular symptom resolution, respectively. The most likely persistent symptoms included imbalance (33/65/67, 50.8%), positional dizziness (7/20, 35.0%) and oscillopsia (44/15, 26.7%). Factors associated with persistent auditory symptoms included history of seizures (0% vs. 7.6%, p = 0.023), auditory chief complaint (50.0% vs. 70.5%), higher PTA (mean 19.6 vs. 25.1 dB, p = 0.043) and higher cervical vestibular evoked myogenic potential (cVEMP) thresholds at 1000 Hz (mean 66.5 vs. 71.4, p = 0.033). A migraine diagnosis (14.0% vs. 41.9% p < 0.010), bilateral radiologic SCD (17.5% vs. 38.1%, p = 0.034) and revision cases (0.0% vs. 14.0%, p = 0.002) were associated with persistent vestibular symptoms. Neither SCD defect size nor location were significantly associated with symptom persistence (P > 0.05).ConclusionsSurgical repair for SCDS offers meaningful reduction in the majority of auditory and vestibular symptoms. However, the persistence of certain, mostly non-primary, symptoms and the identification of potential associated factors including migraines, PTA thresholds, cVEMP threshold, bilateral SCD, and revision cases emphasize the importance of individualized patient counseling and management strategies