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The present study characterizes national trends in the utilization of adjuvant chemotherapy to treat salivary gland malignancies.The National Cancer Database was queried for salivary gland malignancies treated by surgery with radiation in 2004-2019. Proportions of patients receiving adjuvant chemotherapy over the study period were analyzed by linear regression. The impact of chemotherapy on overall survival was assessed using Kaplan-Meier and Cox proportional hazards analyses.Among 15 965 patients meeting inclusion criteria, 2355 (14.8%) received adjuvant chemotherapy. Chemotherapy utilization significantly increased from 4.9% to 16.5% over the study period (p 0.001). No survival benefit was observed with adjuvant chemotherapy on propensity score-matched Kaplan-Meier analysis (HR: 0.98; 95% CI: 0.86-1.11; p = 0.72) or multivariable Cox regression (HR: 0.92; 95% CI: 0.78-1.09; p = 0.34).Adjuvant chemotherapy has been increasingly utilized to treat salivary gland malignancies in recent years. Our findings highlight the importance of obtaining high-quality prospective data regarding the benefit of chemotherapy.

Acinic cell carcinoma (AciCC) is a rare, usually low-grade salivary malignancy. Evidence on rates of lymph node metastases (LNMs) is limited in pediatric patients and varies significantly (4%-45%) in adults. We set out to determine and compare rates of LNMs in pediatric and adult AciCC and to analyze their impact on survival, using the National Cancer Database.Historical cohort study.National Cancer Database.All AciCCs of the major salivary glands with complete clinical and pathologic nodal staging were selected between 2010 and 2016. Patient demographics, tumor characteristics, treatment, and survival were analyzed. Univariable and multivariable regression were performed to determine factors associated with LNMs and survival.We identified 57 (4.6%) pediatric patients (18 years) and 1192 (95.4%) adults with AciCC. Clinical LNMs were rare in pediatric patients (n10) and adults (n = 88, 7.4%). Occult LNMs were uncommon in pediatric patients (n5) and adults (n = 41, 4.6%). Three-year overall survival for pediatric patients was 97.8%. Adults with LNM had worse 3-year overall survival than those without (66.0% vs 96.3%,LNMs in AciCC of the major salivary glands are rare in children and adults. However, high-grade and T3-T4 tumors are associated with an increased risk of LNM. LNM is associated with worse survival.

Venous congestion accounts for most microvascular free tissue flaps failures. Given the lack of consensus on the use of single versus dual venous outflow, the authors present our institutional experience with 1 versus 2 vein anastomoses in microvascular free flap for head and neck reconstruction. A retrospective chart review was performed on all patients undergoing free flaps for head and neck reconstruction at our institution between 2008 and 2020. The authors included patients who underwent anterolateral thigh, radial forearm free flap, or fibula free flaps. The authors classified patients based on the number of venous anastomoses used and compared complication rates. A total of 279 patients with a mean age of 55.11 years (standard deviation 19.31) were included. One hundred sixty-eight patients (60.2%) underwent fibula free flaps, 59 (21.1%) anterolateral thigh, and 52 (18.6%) radial forearm free flap. The majority of patients were American Society of Anesthesiologists classification III or higher (N = 158, 56.6%) and had history of radiation (N = 156, 55.9%). Most flaps were performed using a single venous anastomosis (83.8%). Univariate analysis of postoperative outcomes demonstrated no significant differences in overall complications (P = 0.788), flap failure (P = 1.0), return to the Operating Room (OR) (P = 1.0), hematoma (P = 0.225), length of hospital stay (P = 0.725), or venous congestion (P = 0.479). In our cohort, the rate of venous congestion was not statistically different between flaps with 1 and 2 venous anastomoses. Decision to perform a second venous anastomoses should be guided by anatomical location, vessel lie, flap size, and intraoperative visual assessment.

To analyze clinical outcomes in a series of indeterminate thyroid nodules (ITNs) with repeat fine-needle aspiration (FNA) biopsy and results of genomic classifier.Historical chart review.Tertiary care center.We reviewed FNA samples from subjects with Bethesda III or IV diagnoses from January 2015 to December 2018 at a single institution and selected those with repeat FNA and ThyroSeq testing of the same nodule. Patient demographics, Bethesda classifications, ThyroSeq results, treatment detail, and surgical pathology, when available, were analyzed.Ninety-six patients with cytologic diagnosis of ITN, repeat FNA, and ThyroSeq testing were identified. Following repeat FNA, 55 nodules (57%) remained ITN; 40 (42%) were reclassified as benign; and 1 (1%) was reclassified as suspicious for malignancy. In 31 patients with ThyroSeq analysis accompanying initial and repeat FNA, 26 (84%) had the same result on each, while 5 (16%) tested ThyroSeq positive following an initially negative result (κ = 0.24). Most nodules that were downgraded to Bethesda II on repeat FNA (37/40, 93%) were managed nonsurgically. Patients with ThyroSeq-positive results were treated with surgery more often (25/28, 89%) than patients with ThyroSeq-negative results (11/68, 16%;In this case series, repeat FNA helped patients with ITNs avoid diagnostic surgery through reclassification to benign cytology. The risk of high-risk malignancy in ThyroSeq-positive nodules with repeat indeterminate cytology was low.

Non-squamous cell carcinoma (SCC) malignancies are rare, but well described laryngeal pathologies. However, the epidemiology and clinical behavior of these tumors is not well studied.Retrospective cohort study.Patients diagnosed with non-squamous cell larynx cancer from 2004 to 2017 in the National Cancer Database were selected. Demographic, clinicopathologic factors, treatments, and survival were analyzed. Univariable and multivariable cox regression were performed. Survival was compared with a propensity score-matched (PSM) population of laryngeal SCC patients.A total of 136,235 cases of larynx cancer were identified. After excluding SCC variants, 2,172 (1.6%) patients met inclusion criteria. The most common histology was chondrosarcoma (374, 17.2%), followed by small cell (345, 15.9%), and spindle cell carcinoma (268, 12.3%). The most common treatment was surgery (683, 31.4%) followed by chemoradiation (409, 18.8%) and surgery and adjuvant radiation (288, 13.3%). Overall, 3- and 5-year survival was 67.9% and 59.4%, respectively. In multivariate analysis controlling for age, stage, comorbidity, histology, and treatment modality; chondrosarcoma had the best survival (hazard ratio [HR] 0.11, confidence interval [CI] 0.07-0.19, P .001). In a PSM population, matched for age, stage, comorbidity, and treatments; non-SCC patients had significantly lower survival (51.5% vs. 59.9%, P .001).A diverse range of non-squamous cell malignancies occur in the larynx. In general, these tumors have poor survival, with few exceptions such as chondrosarcoma. While the majority of these histologies undergo surgical-based treatments in other sites, only 53% of patients underwent surgical-based treatment in the larynx. These data could guide clinicians in determining the outcome of treatment in these patients.4 Laryngoscope, 132:1771-1777, 2022.

IMPORTANCE: Genomic classifiers were developed to better guide clinicians in the treatment of indeterminate thyroid nodules (ITNs). To our knowledge, whether there is variation in the diagnostic accuracy of these tests depending on ITN size has not been previously studied. OBJECTIVE: To analyze the diagnostic performance of a genomic classifier in relation to ITN size. DESIGN, SETTING, AND PARTICIPANTS: A case series study with medical records review was conducted including all patients with a cytologic diagnosis of ITN managed with genomic classifier testing and surgery from January 2015 to December 2018 at NYU Langone Health. Demographics, ITN characteristics, genomic profiles, treatment, and final pathologic findings were recorded. Data analysis was conducted from March to April 2021. MAIN OUTCOMES AND MEASURES: The primary aim was to assess the positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity of a genomic classifier test (ThyroSeq) in relation to ITN size (4 cm). The secondary aim was to investigate the risk of cancer associated with genetic signatures. RESULTS: Of the 212 patients with 218 ITNs, 158 (74.5%) were women; median (SD) age was 49 (15.6) years. Genomic classifier results were positive in 173 ITNs (79.4%) treated with surgery. In this group of 173 positive ITNs, 46 (26.6%) were malignant on final pathologic testing. Overall, the observed cancer prevalence in the population was 23.9% (52 ITNs). In 45 ITNs that underwent surgery despite a negative genomic classifier interpretation, 6 (13.3%) were malignant. The PPV of a positive test was 27% and the NPV was 87%. The PPV and NPV findings improved as the ITN size increased (4 cm [n = 33]: PPV, 50%; NPV, 89%). Test specificity was higher in larger ITNs (4 cm: 40%; P = .01). Isolated RAS sequence variations were the most common variant identified in malignant nodules (11 [21.1%] of all ITNs), followed by BRAF variants (7 [13.5%] of all ITNs). CONCLUSIONS AND RELEVANCE: In this case series, the performance of the ThyroSeq test improved for larger ITNs. The risk of cancer in large ITNs with negative test results was low. These data suggest that, in genomic classifier–negative ITNs larger than 4 cm, initial management of thyroid lobectomy may be sufficient.

ImportanceOver time, the American Thyroid Association (ATA) guidelines have increasingly promoted more limited treatments for well-differentiated thyroid cancers.ObjectiveTo determine whether the 2009 and 2015 ATA guidelines were associated with changes in the management of low-risk papillary thyroid carcinomas on a national scale.Design, Setting, and ParticipantsThis historical cohort study used the National Cancer Database. All papillary thyroid carcinomas diagnosed from 2004 to 2019 in the National Cancer Database were selected. Patients with tumors of greater than 4 cm, metastases, or clinical evidence of nodal disease were excluded. Data were analyzed from August 1, 2021, to September 1, 2022.Main Outcomes and MeasuresThe primary aim was to tabulate changes in the rates of thyroid lobectomy (TL), total thyroidectomy (TT), and TT plus radioactive iodine (RAI) therapy after the 2009 and 2015 ATA guidelines. The secondary aim was to determine in which settings (eg, academic vs community) the practice patterns changed the most.ResultsA total of 194 254 patients (155 796 [80.2%] female patients; median [range] age at diagnosis, 51 [18-90] years) who underwent treatment during the study period were identified. Among patients who underwent surgery, rates of TL decreased from 15.1% to 13.7% after the 2009 guidelines but subsequently increased to 22.9% after the 2015 changes. Among patients undergoing TT, rates of adjuvant RAI decreased from 48.7% to 37.1% after 2009 and to 19.3% after the 2015 guidelines. Trends were similar for subgroups based on sex and race and ethnicity. However, academic institutions saw larger increases in TL rates (14.9% to 25.7%) than community hospitals (16.3% to 19.5%). Additionally, greater increases in TL rates were observed for tumors 1 to 2 cm (6.8% to 18.9%) and 2 to 4 cm (6.6% to 16.0%) than tumors less than 1 cm (22.8% to 29.2%).Conclusions and RelevanceIn this cohort study among patients with papillary thyroid carcinomas up to 4 cm, ATA guideline changes corresponded with increased TL and reduced adjuvant RAI. These changes were primarily seen in academic institutions, suggesting an opportunity to expand guideline-based care in the community setting.

PURPOSE/OBJECTIVE(S) Computerized planning and 3D printing of titanium (Ti) plates attached during radical tumor resection allow for patient-specific, personalized solutions for complex osseous reconstructions in locally advanced oral cavity carcinoma. Here, we investigate dose perturbations related to such Ti plates and further interrogate whether the commonly used anisotropic analytical algorithm (AAA) dose calculation algorithm accurately predicts perturbations around Ti plates in comparison to the Boltzmann Solver Acuros XB model (AXB). MATERIALS/METHODS Twenty-three cases of radically resected oral cavity carcinoma, with or without Ti plate reconstruction, followed by VMAT were reviewed with rates of spontaneous osteoradionecrosis (ORN) documented. Clinical treatment plans using AAA (2.5mm dose grid) were retrospectively re-planned with 1mm dose grids on AAA and AXB. Seven consecutive Ti plate reconstructed cases were compared to 16 control cases (postoperative cases without Ti plate) to understand the extent of dose perturbation near reconstructed bone and surrounding tissues using previously established dose metrics, such as maximum plan dose (Dmax) and maxillary/mandibular doses (Dmax, Dmean, V35, V44). Additionally, a 3mm shell was contoured around each plate to directly assess short-range dose perturbance at tissue-to-Ti interfaces. RESULTS Of the 23 patients who underwent oral cavity resection followed by adjuvant VMAT, 4 underwent reconstruction with conventional low-profile Ti plates while 3 cases underwent reconstruction with high-profile custom plates. ORN was observed in 3 patients, all of whom had high profile custom plates. Global Dmax was significantly elevated in AXB 1mm (118.0 ± 3.3%) compared to AAA 2.5mm (109.1 ± 0.8%) and AAA 1mm (113.1 ± 2.0%), with most notable increases in the Ti plate cohort (P < 0.001; Table). Within the AXB 1mm plans, all a priori parameters were significantly higher in the Ti plate vs. no plate cohort (global Dmax: +5.7%, osseous Dmax: +4.9%, osseous Dmean: +10.9%, osseous V35: +13.4%, osseous V44: +15.9%). Furthermore, in the Ti plate population, AXB calculated significantly higher local hot spots within the 3mm shell contoured (115.6 ± 4.4% vs. 107.0 ± 1.7%; P < 0.002). CONCLUSION Using the AAA model with a clinical standard 2.5mm dose grid does not appear to adequately account for dose perturbation at the tissue-to-Ti interface in comparison to the AXB algorithm at a finer dose grid, resulting in a significant underestimation of global and osseous maximum doses. Care should be taken when delivering radiation to patients with high profile Ti plates. The impact of beam entrance restriction and alternative plate designs to minimize the profile of high-Z materials are currently being explored.

Purpose/Objective(s) Lacrimal gland cancer is a rare tumor with little data regarding outcomes and optimal management. We performed a large database analysis using the National Cancer Database (NCDB) to elucidate patterns of care and outcomes for this rare malignancy. Materials/Methods Patients with lacrimal gland cancer diagnosed between 2004 and 2016 were included in analysis. All histologies were included with the exception of malignant melanoma and lymphoma; squamous cell carcinoma was also excluded as it is rarely found in the lacrimal gland, and likely reflects lacrimal duct or sac cancer. Patients without recorded follow up or with less than 6 months of follow up were excluded. Patients were stratified by sex, age, race, Charlson-Deyo comorbidity score, facility type, and pathologic T stage. Patterns of care including treatment with surgery, chemotherapy and/or radiation therapy were noted. Outcomes were analyzed using Kaplan-Meier analysis, and Cox proportional hazards regression was used to study the effect of surgery and radiation therapy on overall survival. Results 460 patients with lacrimal gland cancer were included in the database. Median follow up for all patients was 42.7 months. The most common histology was adenoid cystic carcinoma (185 patients, 40.2%), followed by adenocarcinoma (85, 18.5%). Most patients were of unknown T stage (63.9%). 362 patients (78.7%) underwent surgical resection, 104 (22.6%) received chemotherapy, and 292 (63.5%) underwent radiotherapy. Median overall survival for all patients was 106.8 months (95% CI: 85.3 months - not reached). Variables associated with worse overall survival on univariate analysis included age over 60 (P Conclusion The ideal management for lacrimal gland cancer is still unknown due to the rarity of this tumor. Retrospective study of a large national database suggests that patients who undergo surgical resection may have better outcomes than those who do not, although a benefit for radiotherapy is not apparent. Further data collection is required for this unusual tumor.