Wittich, Michelle A. Neben

Soft tissue aneurysmal bone cysts (STABCs) are rare neoplasms histopathologically identical to aneurysmal bone cysts. These benign lesions are characterized by thin, peripheral ossification and no skeletal continuity. STABC may be difficult to distinguish from myositis ossificans (MO) and malignant entities from imaging and fine needle aspiration, due to rarity and overlapping features. We present a case of a STABC occurring in the paraspinal cervical muscles. The imaging, histopathology, molecular analysis, and treatment are discussed. Four other published cases of STABC of the head and neck are reviewed.

Background: Approximately 75% of all head and neck cancer patients are treated with radiotherapy (RT). RT to the oral cavity results in acute and late adverse events which can be severe and detrimental to a patient’s quality of life and function. The purpose of this study was to explore associations between RT dose to a defined oral cavity organ-at-risk (OAR) avoidance structure, provider- and patient-reported outcomes (PROs), opioid use, and hospitalization. Methods: This was a retrospective analysis of prospectively obtained outcomes using multivariable modeling. The study included 196 patients treated with RT involving the oral cavity for a head and neck tumor. A defined oral cavity OAR avoidance structure was used in all patients for RT treatment planning. Validated PROs were collected prospectively. Opioid use and hospitalization were abstracted electronically from medical records. Results: Multivariable modeling revealed the mean dose to the oral cavity OAR was significantly associated with opioid use (p = 0.0082) and hospitalization (p = 0.0356) during and within 30 days of completing RT. Conclusions: The findings of this study may be valuable in RT treatment planning for patients with tumors of the head and neck region to reduce the need for opioid use and hospitalization during treatment.

ObjectiveFailure to recognize symptoms of non‐human papillomavirus‐associated oropharyngeal squamous cell carcinoma (HPV(−)OPSCC) at presentation can delay diagnosis and treatment. We aim to identify patient factors and provider practice patterns that delay presentation and care in HPV(−)OPSCC.MethodsRetrospective review at a tertiary care center. Patients with HPV(−)OPSCC receiving treatment from 2006 to 2016. Patients were excluded if their date of symptom onset or diagnosis was unknown after thorough review of the electronic medical record or their tissue was not tested for HPV or p16. Clinical data, workup, and care timelines were abstracted. Univariate and multivariable linear regressions were performed to determine associations between patient and provider factors and delays in care.ResultsOf 70 included patients, 52 (74%) were male and mean age was 60.5 (SD = 9.0). Median time to diagnosis was 69 days (IQR = 32–127 days), with a median latency of 30 days (IQR = 12–61 days) from symptom onset to first presentation and 19.5 days (IQR = 4–46 days) from the first presentation to diagnosis. Most patients visited at least 2 providers (n = 52, 74%) before diagnosis. Evaluation by 3 or more providers prior to diagnosis was associated with significant delays in diagnosis of nearly a year (357.7 days, p < 0.001) and being treated or prescribed analgesia prior to diagnosis was significantly associated with delays in diagnosis (p = 0.004) on univariate regression analysis.ConclusionsDelays in care related to evaluations by multiple providers and misdiagnosis prolonged time to diagnosis in HPV(−)OPSCC. Improved patient and provider education is necessary to expedite the diagnosis of HPV(−)OPSCC.Level of Evidence4 Laryngoscope, 133:1394–1401, 2023

ObjectiveTo describe and compare rates of metachronous and synchronous second primaries of the contralateral tonsil in patients with primary HPV(+) tonsillar squamous cell carcinoma (SCC).Study DesignRetrospective cohort study.Materials and MethodsThis is a single tertiary care center retrospective case series, from 2006 to 2019, of HPV(+) tonsillar SCC patients who underwent primary surgical resection with unilateral wide‐field tonsillectomy or bilateral tonsillectomy for diagnostic or therapeutic purposes. A metachronous second primary is one diagnosed >6 months after completion of surgical treatment. A synchronous second primary is one diagnosed during bilateral tonsillectomy for unilateral HPV(+) tonsillar SCC. Rates of second primary and patient characteristics were compared using chi‐square tests.ResultsAbout 303 patients underwent unilateral surgical resection +/− adjuvant therapy for HPV(+) tonsillar SCC. One (0.3%) developed a metachronous second primary in the contralateral tonsil 11.9 years following treatment. Fifty‐seven patients with HPV(+) tonsillar SCC underwent bilateral tonsillectomy, and 37/57 (65%) had no clinical signs for contralateral disease. Of these, only 1/37 (2.7%) was incidentally found to have a synchronous second primary. Twenty patients underwent bilateral tonsillectomy due to clinical concern for contralateral disease. Of these, 3/20 (15%) were found to have a synchronous HPV(+) SCC in the contralateral tonsil.ConclusionsThe prevalence of metachronous second primary after appropriate treatment of HPV(+) tonsillar SCC is very low (0.3%) and so is the chance of incidentally discovering a synchronous second primary during bilateral tonsillectomy (2.7%). We do not recommend bilateral tonsillectomy as a part of the routine algorithm in the surgical management of these patients.Level of Evidence3 Laryngoscope, 132:332–338, 2022

Abstract Introduction Polycythemia vera (PV) and Essential thrombocytosis (ET) progress to myelofibrosis (MF). Extramedullary hematopoeisis (EMH) is common in patients with primary or secondary MF, and can occur in the lungs. Pulmonary EMH can cause recurrent pleural effusions, pulmonary hypertension, and right heart failure with symptoms of dyspnea, cough, and fatigue. Low dose single fraction whole lung irradiation (WLI) has been utilized at our institution, and our preliminary report of 4 patients noted symptomatic improvement with no reported acute side effects. Here we report on a larger cohort of 57 patients as well as long term outcomes for 20 of those patients, including the original 4 patients. Methods We performed a retrospective review of 57 patients with myelofibrosis and pulmonary EMH who received single fraction WLI to a dose of 100 cGy at the Mayo Clinic from March 2001 to March 2014. Data related to the following parameters was collected: initial diagnosis, age at initial diagnosis, date of progression to myelofibrosis, initial treatment prior to radiation therapy, whole body bone marrow scan findings if available, and response to WLI. Overall survival was measured using the Kaplan Meier method. Chi-square analysis was used to evaluate predictors of response to WLI. Results The median age at first WLI was 67 years (45-84 years), and 33 patients (58%) were male. Twenty-two patients (39%) had a diagnosis of primary MF, 27 patients (47%) had PV or ET, and 8 patients (14%) had another cause of secondary MF. At the time of WLI, 27 patients (47%) were on supplemental oxygen, and 3 patients (5%) were in the intensive care unit. Hydroxyurea (n=14, 25%), JAK2 inhibitors (n=9, 16%), Anagrelide (n=3, 5%), and Thalidomide and Prednisone (n=3, 5 %) were the most frequent treatments prior to WLI. EMH was confirmed on bone scan in 38 patients (67%). In the remaining 19 patients, a diagnosis of EMH was made based on clinical impression. This included symptoms of dyspnea, cough, and fatigue, echocardiographic findings of pulmonary hypertension, and in some patients recurrent pleural effusions (n=13), positive lymph node biopsy (n=2), or thoracentesis (n=1). Twenty-eight (49%) patients had other active cardiac or pulmonary conditions that likely contributed to their clinical symptoms. These patients were receiving concurrent treatment for their other conditions. In some patients there were multiple coexisting conditions. Clinical improvement occurred in 30 patients (53%). The median time from WLI to symptomatic improvement was 10 days (1-174 days). Twenty-four patients (42%) did not have clinical improvement. Nine patients (16%) had stable symptoms, 15 patients (26%) had progressive symptoms, and 3 patients (5%) had insufficient follow up. In the group of patients with concurrent active cardiac or pulmonary conditions, 15 patients (54%) had clinical improvement following WLI. In the 29 patients who had solitary EMH, 15 (52%) patients had clinical improvement. There was no difference in response rates related to oxygen use at the time of WLI. Six patients (11%) received WLI on multiple occasions. There was no difference in the percentage of patients with positive bone marrow scans (67%) in the 2 groups. The median overall survival was 259 days for all patients. Patients who improved after WLI had a median survival of 325.5 days compared to 122.5 days for patients who did not improve. No new hematologic abnormalities temporally related to WLI were reported. Long term follow up beyond 1 year was available for 20 patients (35%). No patients developed pneumonitis or pulmonary fibrosis that was considered related to WLI. One patient received a diagnosis of an upper esophageal squamous cell carcinoma 6 years after WLI and allogeneic stem cell transplant. Conclusion Our prior study showed WLI is safe and effective in a small number of patients with isolated pulmonary EMH from MF. The current study confirms the long term safety of this approach. Our results suggest WLI may contribute to symptomatic improvement in 1/2 of patients, even in the common clinical situation of multiple coexisting cardiac and pulmonary conditions. Repeat WLI is also well tolerated and can result in symptomatic improvement. We did not find any factors that predicted response to WLI. WLI should be considered in patients who have clinically proven pulmonary EMH and associated symptoms, even in the presence of other conditions, and can be repeated safely. Disclosures No relevant conflicts of interest to declare.