Accuracy of Ultrasonography-Guided Fine-Needle Aspiration in Detecting Persistent Nodal Disease After Chemoradiotherapy

IMPORTANCE: Few patients with persistent adenopathy following chemoradiotherapy (CRT) for head and neck squamous cell carcinoma harbor viable disease. Improved selectivity for surgical salvage is needed to prevent unnecessary salvage neck dissection. OBJECTIVE: To determine whether ultrasonography-guided fine-needle aspiration (FNA) can be used to identify viable cancer cells in the lymph nodes of patients with persistent radiographic adenopathy following CRT. DESIGN, SETTING, AND PARTICIPANTS: A pilot study included patients undergoing preoperative ultrasonography-guided FNA of lymph nodes considered suspicious on radiography prior to planned neck dissection at a quaternary care facility from February 28, 2011, to March 18, 2013. Data analysis was performed from April 28 to December 24, 2013. Patients treated for head and neck squamous cell carcinoma with CRT who were determined to have persistent neck disease on a 6-week posttreatment computed tomographic scan of the neck and scheduled for salvage neck dissection were considered candidates for this pilot study. All patients enrolled in the study underwent ultrasonography-guided FNA of the suspicious lymph nodes within 2 weeks of the planned neck dissection. The cytopathologist reading the samples was blinded to the patient's identity. EXPOSURES: Fine-needle aspiration with a 23- to 25-gauge needle following CRT. MAIN OUTCOMES AND MEASURES: The accuracy of ultrasonography-guided FNA cytologic results was compared with the standard of surgical pathologic examination of neck dissection specimens. RESULTS: Fourteen patients (11 [79%] men; mean [SD] age, 57.8 [11.2] years) were enrolled in this pilot study; data were collected on 17 lymph nodes. Among these 14 patients with incomplete radiographic clinical response, 17 lymph node aspirations were performed. Ultrasonography-guided FNA identified squamous cell carcinoma in the aspirates of 4 (80%) of the 5 nodes with squamous cell carcinoma identified on pathologic testing and confirmed the absence of disease in the remaining 12 (71%) lymph nodes. The statistical analysis of these results revealed a sensitivity of 80%; specificity, 100%; positive predictive value, 100%; and negative predictive value, 92.3%. The diagnostic accuracy of ultrasonography-guided FNA at detecting residual persistent cancer was 88%. CONCLUSIONS AND RELEVANCE: This pilot study suggests that ultrasonography-guided FNA may be a feasible ancillary diagnostic imaging tool to imaging to assess patients with radiographic persistent disease prior to consideration of salvage neck dissection

Endoscopic Resection of Sinonasal Malignancy: A Systematic Review and Meta-analysis

OBJECTIVES: The use of endoscopic approaches for sinonasal malignancy resection has increased, but survival data are limited secondary to disease rarity and new surgical technique. Here we present a systematic review and meta-analysis of endoscopic endonasal resection of sinonasal malignancy. DATA SOURCES: MEDLINE, PubMed Central, NCBI Bookshelf, Cochrane Library, clinicaltrials.gov, National Guideline Clearinghouse. REVIEW METHODS: PRISMA/MOOSE guidelines were followed. MeSH terms were "endoscopic" AND ("esthesioneuroblastoma" OR "sinonasal adenocarcinoma" OR "squamous cell carcinoma" OR "sinonasal undifferentiated carcinoma"). For studies in which individual-level data were available, results were obtained by direct pooling. For studies in which only summary Kaplan-Meier curves were available, numerical data were extracted, traced, and aggregated by fitting a Weibull model. RESULTS: Of 320 studies identified, 35 case series were included (n = 952 patients), with 15 studies analyzed via aggregate modeling and 20 studies analyzed via direct pooling. Two- and 5-year survival rates for patients in aggregate modeling were 87.5% and 72.3%, respectively (mean follow-up: 32.9 months). Two- and 5-year survival for patients in direct pooling were 85.8% and 83.5%, respectively (mean follow-up: 43.0 ± 19.5 months). Significant overall survival difference was found between low- and high-grade cancers (P = .015) but not between low- and high-stage cancers (P = .79). CONCLUSION: Overall 2- and 5-year survival rates are comparable and sometimes greater than those from open craniofacial resection. Survival rates significantly differ by cancer grade but not stage. Journals and investigators should be encouraged to publish retrospective and prospective case series with staged survival updates based on established guidelines

The Endoscopic Endonasal Approach to the Hypoglossal Canal: The Role of the Eustachian Tube as a Landmark for Dissection

IMPORTANCE: Improvements in endoscopic technology and reconstructive techniques have made the endoscopic endonasal approach (EEA) a viable option to approach ventromedial lesions in the region of the hypoglossal canal. Prior to contemplating this surgical corridor, a thorough understanding of anatomic relationships and landmarks is essential to safely approach this region of the posterior skull base through an EEA. OBJECTIVE: To describe the surgical technique and anatomic landmarks in the EEA to the hypoglossal canal through referencing nasopharyngeal and posterior skull base anatomy. DESIGN, SETTING, AND PARTICIPANTS: Study of latex-injected cadaveric heads at the North Carolina Eye Bank Multidisciplinary Surgical Skills Laboratory at the University of North Carolina. INTERVENTIONS: An EEA to the hypoglossal canal was carried out bilaterally in 5 embalmed, latex-injected cadaver heads. MAIN OUTCOMES AND MEASURES: Cadaveric measurements of anatomic landmarks and relationships in the approach were obtained using a 10-cm surgical ruler and were reported as mean distances. Additionally, high-quality endoscopic images demonstrating the operative technique and anatomic relationships were obtained. RESULTS: The distance between the lacerum segment of the internal carotid arteries, the superolateral boundary, was 23.6 mm (SD, 11.8 mm). The distance between the anterolateral edge of the occipital condyles, the inferolateral boundary, was 19 mm (SD, 0.80 mm). The supracondylar groove was identified in the same anteroposterior plane as the nasopharyngeal orifice of the eustachian tube, and the anterior-most edge of the occipital condyle was 14 mm (SD, 0.82 mm) from the posterosuperior edge of the salpingopharyngeal fold. Additionally, the transtubercular corridor was on the same plane as the superior edge of the torus tubarius in the anteroposterior axis. The distance to the hypoglossal canal from midline was 10 mm, which was found after completing drilling in the transcondylar and transtubercular corridors. Last, the hypoglossal nerve rootlets were identified entering the canal 6 mm inferiorly and 8 mm laterally from the vertebrobasilar junction. CONCLUSIONS AND RELEVANCE: The eustachian tube and other elements of nasopharyngeal anatomy are fixed landmarks that provide important points of reference when approaching the hypoglossal canal through an EEA. A thorough understanding of these anatomic relationships is vital in safely navigating this direct, surgical corridor to the posterior fossa

Association of Cervical Effacement With the Rate of Cervical Change in Labor Among Nulliparous Women

OBJECTIVE: To assess the association of cervical effacement with the rate of intrapartum cervical change among nulliparous women. METHODS: We conducted a secondary analysis of a prospective trial of intrapartum fetal pulse oximetry. For women who had vaginal deliveries, interval-censored regression was used to estimate the time to dilate at 1-cm intervals. For each given centimeter of progressive cervical dilation, women were divided into those who had achieved 100% cervical effacement and those who had not. The analysis was performed separately for women in spontaneous labor and those who were given oxytocin. RESULTS: A total of 3,902 women were included in this analysis, 1,466 (38%) who underwent labor induction, 1,948 (50%) who underwent labor augmentation (combined for the analysis), and 488 (13%) who labored spontaneously. For women in spontaneous labor, the time to dilate 1 cm was shorter for those who were 100% effaced starting at 4 cm of cervical dilation (P=.01 to <.001). For women who received oxytocin, the time to dilate 1 cm was shorter for those who were 100% effaced throughout labor (P<.001). CONCLUSION: The rate of cervical dilation among nulliparous women is associated with not only the degree of cervical dilation, but also with cervical effacement. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00098709

Prediction of Spontaneous Preterm Birth Among Nulliparous Women With a Short Cervix

To evaluate whether demographic and sonographic factors associated with spontaneous preterm birth (sPTB) among nulliparous women with a cervical length (CL) < 30 mm could be combined into an accurate prediction model for sPTB

Haptoglobin Phenotype, Preeclampsia Risk and the Efficacy of Vitamin C and E Supplementation to Prevent Preeclampsia in a Racially Diverse Population

Haptoglobin's (Hp) antioxidant and pro-angiogenic properties differ between the 1-1, 2-1, and 2-2 phenotypes. Hp phenotype affects cardiovascular disease risk and treatment response to antioxidant vitamins in some non-pregnant populations. We previously demonstrated that preeclampsia risk was doubled in white Hp 2-1 women, compared to Hp 1-1 women. Our objectives were to determine whether we could reproduce this finding in a larger cohort, and to determine whether Hp phenotype influences lack of efficacy of antioxidant vitamins in preventing preeclampsia and serious complications of pregnancy-associated hypertension (PAH). This is a secondary analysis of a randomized controlled trial in which 10,154 low-risk women received daily vitamin C and E, or placebo, from 9-16 weeks gestation until delivery. Hp phenotype was determined in the study prediction cohort (n = 2,393) and a case-control cohort (703 cases, 1,406 controls). The primary outcome was severe PAH, or mild or severe PAH with elevated liver enzymes, elevated serum creatinine, thrombocytopenia, eclampsia, fetal growth restriction, medically indicated preterm birth or perinatal death. Preeclampsia was a secondary outcome. Odds ratios were estimated by logistic regression. Sampling weights were used to reduce bias from an overrepresentation of women with preeclampsia or the primary outcome. There was no relationship between Hp phenotype and the primary outcome or preeclampsia in Hispanic, white/other or black women. Vitamin supplementation did not reduce the risk of the primary outcome or preeclampsia in women of any phenotype. Supplementation increased preeclampsia risk (odds ratio 3.30; 95% confidence interval 1.61-6.82, p<0.01) in Hispanic Hp 2-2 women. Hp phenotype does not influence preeclampsia risk, or identify a subset of women who may benefit from vitamin C and E supplementation to prevent preeclampsia

Extramedullary Hematopoiesis in the Sinonasal Cavity: A Case Report and Review of the Literature

Approximately 1 in 600 African-Americans are homozygous for the sickle cell gene.1 This commonly inherited hematologic disorder causes sickling of red blood cells (RBCs), prompting rapid hemolysis. A common clinical manifestation of sickle cell disease (SCD) is chronic anemia. The body responds by increasing hematopoiesis. RBC production classically occurs in the bone marrow of the long bones, pelvis, spine, and sternum. With chronically elevated erythropoietin levels, organs such as the spleen and liver help augment the body’s RBC supply. These organs are areas of fetal erythropoiesis that do not typically contribute to physiologic RBC production in adults. Other, less commonly involved organs that have been documented as sites of extramedullary hematoposesis (EMH) include lymph nodes, paravertebral regions, intra-spinal canal, pre-sacral region, nasopharynx, and paranasal sinuses

Cytokine Gene Polymorphisms and Length of Gestation

To estimate whether there is an association between length of gestation and gene polymorphisms that effect transcription of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), or interleukin-1β (IL-1β)