Patients with obstructive sleep apnea (OSA) commonly experience difficulty tolerating positive airway pressure (PAP) therapy. Drug Induced Sedation Endoscopy (DISE) assesses airway characteristics while the patient is sedated and may help guide alternative interventions for OSA. Since DISE is performed in the operating room, its cost is high and its availability limited to the surgeon’s busy schedule. Performing DISE in the bronchoscopy suite may reduce cost and improve access to care while maintaining a low risk for complications. Following training by an ENT physician, a sleep boarded pulmonologist performed DISE in the bronchoscopy suite. Patients with OSA and difficulty tolerating PAP therapy were evaluated for alternative interventions via DISE. A propofol infusion was administered by an anesthesiologist trained on performing DISE and sedation level was tracked via Bispectral IndexTM for a target level of 60–75. Videos of the DISE were recorded for multidisciplinary conference review with ENT and to track patient outcomes following interventions. Baseline polysomnography prior to DISE was reviewed to classify severity of OSA. Complication rates were tracked. Facility costs of DISE in the bronchoscopy suite were compared to those of the operating room. The sleep trained pulmonologist performed 21 DISE procedures in the bronchoscopy suite over a period of ten months. Review of polysomnography prior to DISE demonstrated an average AHI of 34.3+/-15.9 and an average SpO2 nadir 78 +/- 8.3%. No complications were observed during DISE. The facility fee for performing DISE procedures in the operating room was twice as much as the facility fee for performing DISE in the bronchoscopy suite while the operator charges were the same. Based on these findings, performance of DISE in the bronchoscopy suite appears feasible, safe and cost effective. Its performance by the sleep trained pulmonologist may improve access to care and may help identify successful alternative treatments for patients with PAP intolerance. Further studies are needed to identify the training necessary for pulmonary based sleep specialists to become proficient in the procedure. None

Merkel cell carcinomas (MCC) are aggressive, small round blue cell tumors of the skin often found in a head and neck location. Given the frequent cosmetic and functional limitations of head and neck surgery, wide circumferential margins are often difficult to obtain. We hypothesized that postoperative radiation therapy (RT) would reduce the risk of locoregional recurrence and improve survival. A single-institution institutional review board–approved study was performed including 144 patients with MCC of the head and neck without distant metastatic disease treated from 1989 to 2012. Most patients were treated with wide excision (n=140, 97.2%) ± sentinel lymph node biopsy (SLNB) ± neck dissection (LND). Postoperative RT (n=99, 68.9%) was delivered to the primary tumor bed ± draining lymphatics. Patient, tumor, and treatment characteristics were compared based on receipt of RT. Patients were treated with RT to a median total dose of 5000 cGy (range 2,500-6,600 cGy). The primary outcomes were local control (LC), locoregional control (LRC), disease-free survival (DFS), and overall survival (OS). Kaplan-Meier (KM) analyses with log-rank tests and Cox multivariate models were created for the outcomes of interest. Median follow-up of surviving patients was 26 months. Receipt of RT was associated with more advanced nodal status (cN1 status 10.8% vs 2.4% and pN1 status 15.7% vs 11.9%, respectively; P=.003), and a lower median age (76 vs 78, P=.02). On KM univariate analysis, postoperative RT was associated with improved 3-year LC (89.3% vs 67.6%; P=.001), LRC (68.1% vs 28.5%; P<.001), DFS (56.6% vs 20.9%; P<.001), and OS (75.0% vs 65.3%; P=.003). Similarly, on Cox MV analysis, RT was associated with improved LC (hazard ratio [HR] 0.19, 95% confidence interval [CI] 0.07-0.51; P=.001), LRC (HR 0.22, 95% CI 0.11-0.41; P<.001), DFS (HR 0.24, 95% CI 0.14, 0.41; P<.001), and OS (HR 0.41, 95% CI 0.24-0.72; P=.002). The only other variable associated with OS on MV analysis was a tumor size >2 cm (HR 3.21, 95% CI 1.51-6.81; P=.002). A benefit in median LRC time was seen with RT among node-negative patients (n=111, 187 mo vs 10 mo, respectively; P<.001) and node-positive patients (n=33, median not reached vs 6 mo, respectively; P<.001). The 3-year LC rates of patients with negative margins treated with surgery and RT (n=87) compared with patients with positive margins or gross disease treated with definitive RT (n=15) were 88.8% and 92.3%, respectively (P=.88). Similarly, the 3-year regional control rates of node-positive patients treated with LND ± RT (n=25) compared with SLNB positive and definitive RT (n=6) were 79.2% and 100%, respectively (P=.25). RT is associated with improved LC, LRC, DFS, and OS in patients with MCC of the head and neck.

Purpose/Objective(s)Following wide excision of Merkel Cell Carcinoma (MCC), adjuvant radiation therapy (RT) is typically recommended although its influence on overall survival (OS) is uncertain. There also remains controversy as to whether RT can be avoided in selected cases, such as those with negative margins and/or node-negative disease.Materials/MethodsWe reviewed 300 patients treated for non-metastatic MCC from 1989 through 2012 at a single institution. Most patients were treated with wide local excision with or without adjuvant radiation therapy. Median follow-up was 27 months. The median age was 75 years (range 13-96), median pathologic tumor size 1.5 cm (range 0.2-12.5) and the majority of patients were male (70%), with node-negative (70%), head and neck primary (48%), and margin negative (88%) MCC. Patients treated with adjuvant RT were significantly younger (median age 73 vs. 77 years, respectively), more often had involved nodal disease (35% vs. 20%, respectively), and more often were treated with chemotherapy (16% vs. 4%, respectively). The median radiation dose was 5,000 cGy delivered in 25 daily fractions. Clinicopathologic and treatment variables were assessed regarding their role in local control (LC), locoregional control (LRC), disease-free survival (DFS), and OS.ResultsTreatment with adjuvant RT was associated with improved LC (91% vs. 70% at 3-years, respectively; p<0.001), LRC (71.5% vs. 37.8% at 3 years, respectively; p<0.001), DFS (57.0% vs. 30.2% at 3 years, respectively; p<0.001), and OS (73% vs. 66%, respectively; p=0.02). On multivariate analysis, adjuvant RT was independently associated with improved LC (hazard ratio [HR] 0.14, 95% confidence interval [CI] 0.06-0.29, p<0.001), LRC (HR 0.25, 95% CI 0.16-0.39, p<0.001), DFS (HR 0.38, 95% CI 0.27-0.54, p=0.001), and OS (HR 0.62, 95% CI 0.41-0.94, p=0.03). Even patients with negative margins and node-negative disease had significant improvements in LC (93% vs. 82%, respectively, p=0.03) and LRC (75% vs. 52%, respectively, p<0.001) with adjuvant RT.ConclusionAdjuvant RT for MCC was independently associated with improved LC, LRC, DFS, and OS. RT was beneficial regardless of margin status and nodal status. Purpose/Objective(s)Following wide excision of Merkel Cell Carcinoma (MCC), adjuvant radiation therapy (RT) is typically recommended although its influence on overall survival (OS) is uncertain. There also remains controversy as to whether RT can be avoided in selected cases, such as those with negative margins and/or node-negative disease. Following wide excision of Merkel Cell Carcinoma (MCC), adjuvant radiation therapy (RT) is typically recommended although its influence on overall survival (OS) is uncertain. There also remains controversy as to whether RT can be avoided in selected cases, such as those with negative margins and/or node-negative disease. Materials/MethodsWe reviewed 300 patients treated for non-metastatic MCC from 1989 through 2012 at a single institution. Most patients were treated with wide local excision with or without adjuvant radiation therapy. Median follow-up was 27 months. The median age was 75 years (range 13-96), median pathologic tumor size 1.5 cm (range 0.2-12.5) and the majority of patients were male (70%), with node-negative (70%), head and neck primary (48%), and margin negative (88%) MCC. Patients treated with adjuvant RT were significantly younger (median age 73 vs. 77 years, respectively), more often had involved nodal disease (35% vs. 20%, respectively), and more often were treated with chemotherapy (16% vs. 4%, respectively). The median radiation dose was 5,000 cGy delivered in 25 daily fractions. Clinicopathologic and treatment variables were assessed regarding their role in local control (LC), locoregional control (LRC), disease-free survival (DFS), and OS. We reviewed 300 patients treated for non-metastatic MCC from 1989 through 2012 at a single institution. Most patients were treated with wide local excision with or without adjuvant radiation therapy. Median follow-up was 27 months. The median age was 75 years (range 13-96), median pathologic tumor size 1.5 cm (range 0.2-12.5) and the majority of patients were male (70%), with node-negative (70%), head and neck primary (48%), and margin negative (88%) MCC. Patients treated with adjuvant RT were significantly younger (median age 73 vs. 77 years, respectively), more often had involved nodal disease (35% vs. 20%, respectively), and more often were treated with chemotherapy (16% vs. 4%, respectively). The median radiation dose was 5,000 cGy delivered in 25 daily fractions. Clinicopathologic and treatment variables were assessed regarding their role in local control (LC), locoregional control (LRC), disease-free survival (DFS), and OS. ResultsTreatment with adjuvant RT was associated with improved LC (91% vs. 70% at 3-years, respectively; p<0.001), LRC (71.5% vs. 37.8% at 3 years, respectively; p<0.001), DFS (57.0% vs. 30.2% at 3 years, respectively; p<0.001), and OS (73% vs. 66%, respectively; p=0.02). On multivariate analysis, adjuvant RT was independently associated with improved LC (hazard ratio [HR] 0.14, 95% confidence interval [CI] 0.06-0.29, p<0.001), LRC (HR 0.25, 95% CI 0.16-0.39, p<0.001), DFS (HR 0.38, 95% CI 0.27-0.54, p=0.001), and OS (HR 0.62, 95% CI 0.41-0.94, p=0.03). Even patients with negative margins and node-negative disease had significant improvements in LC (93% vs. 82%, respectively, p=0.03) and LRC (75% vs. 52%, respectively, p<0.001) with adjuvant RT. Treatment with adjuvant RT was associated with improved LC (91% vs. 70% at 3-years, respectively; p<0.001), LRC (71.5% vs. 37.8% at 3 years, respectively; p<0.001), DFS (57.0% vs. 30.2% at 3 years, respectively; p<0.001), and OS (73% vs. 66%, respectively; p=0.02). On multivariate analysis, adjuvant RT was independently associated with improved LC (hazard ratio [HR] 0.14, 95% confidence interval [CI] 0.06-0.29, p<0.001), LRC (HR 0.25, 95% CI 0.16-0.39, p<0.001), DFS (HR 0.38, 95% CI 0.27-0.54, p=0.001), and OS (HR 0.62, 95% CI 0.41-0.94, p=0.03). Even patients with negative margins and node-negative disease had significant improvements in LC (93% vs. 82%, respectively, p=0.03) and LRC (75% vs. 52%, respectively, p<0.001) with adjuvant RT. ConclusionAdjuvant RT for MCC was independently associated with improved LC, LRC, DFS, and OS. RT was beneficial regardless of margin status and nodal status. Adjuvant RT for MCC was independently associated with improved LC, LRC, DFS, and OS. RT was beneficial regardless of margin status and nodal status.

Background and Objectives Cigarette smoking is common among cancer patients and is associated with negative outcomes. Electronic nicotine delivery systems (e-cigarettes) are rapidly growing in popularity and use, but there is limited information on their safety or effectiveness in helping individuals quit smoking. Data Sources The authors searched PubMed, Web of Science, and additional sources for published empirical data on safety and use of electronic cigarettes as an aid to quit smoking. Review Methods We conducted a structured search of the current literature up to and including November 2013. Results E-cigarettes currently vary widely in their contents and are sometimes inconsistent with labeling. Compared to tobacco cigarettes, available evidence suggests that e-cigarettes are often substantially lower in toxic content, cytotoxicity, associated adverse effects, and secondhand toxicity exposure. Data on the use of e-cigarettes for quitting smoking are suggestive but ultimately inconclusive. Conclusions Clinicians are advised to be aware that the use of e-cigarettes, especially among cigarette smokers, is growing rapidly. These devices are unregulated, of unknown safety, and of uncertain benefit in quitting smoking. Implications for Practice In the absence of further data or regulation, oncologists are advised to discuss the known and unknown safety and efficacy information on e-cigarettes with interested patients and to encourage patients to first try FDA-approved pharmacotherapies for smoking cessation.

Background and Objectives Cigarette smoking is common among cancer patients and is associated with negative outcomes. Electronic nicotine delivery systems (“e-cigarettes”) are rapidly growing in popularity and use, but there is limited information on their safety or effectiveness in helping individuals quit smoking. Data Sources The authors searched PubMed, Web of Science, and additional sources for published empirical data on safety and use of electronic cigarettes as an aid to quit smoking. Review Methods We conducted a structured search of the current literature up to and including November 2013. Results E-cigarettes currently vary widely in their contents and are sometimes inconsistent with labeling. Compared to tobacco cigarettes, available evidence suggests that e-cigarettes are often substantially lower in toxic content, cytotoxicity, associated adverse effects, and secondhand toxicity exposure. Data on the use of e-cigarettes for quitting smoking are suggestive but ultimately inconclusive. Conclusions Clinicians are advised to be aware that the use of e-cigarettes, especially among cigarette smokers, is growing rapidly. These devices are unregulated, of unknown safety, and of uncertain benefit in quitting smoking. Implications for Practice In the absence of further data or regulation, oncologists are advised to discuss the known and unknown safety and efficacy information on e-cigarettes with interested patients and to encourage patients to first try FDA-approved pharmacotherapies for smoking cessation.

6051 Background: Salvage re-irradiation (ReRT) is a treatment option for squamous cell carcinoma of the head and neck (SCHN) that recurs in a previously irradiated area. ReRT, though toxic, can produce long-term survival, even when tumor is unresectable or poor prognostic feature is present after salvage surgery. The degree to which patient co-morbidities serve as a predictor of survival following re-RT has not been studied to date. Methods: Patients (pts) with SCHN who underwent ReRT with an overlapping target to previous RT during 1998–2007 at our institution were eligible. Co-morbidity burden was assessed by Charlson Index (CI), measuring frequency of co- morbid diseases as score 2–27, and Adult Comorbidity Evaluation-27 (ACE-27), measuring frequency & severity of co-morbid diseases as score 0–3. Results: 69 total pts, including 25 who had salvage surgery, had a median age of 62 yrs. Most common site was oropharynx (48%). Median time since previous RT was 35 mos. Of 41 pts with measurable disease, median tumor bulk was 3 cms. ReRT was delivered at a median of 60 Gy. IMRT/3-D RT was used in 51%; Concurrent chemotherapy, in 78%. Median survival (MS) was 18.3 mos (95% CI 14–30); PFS 13.4 mos. Comorbidity burden by CI showed that 58% of pts had a score >2 (i.e. had ≥1 comorbid disease other than the current cancer). By ACE-27, 20% of pts had a score of 2 or 3 (mod or severe decompensation). Higher co-morbidity scores predicted worse survival. By CI, MS was 30 mos if score ≤2 vs. 14 mos if score >2 (p=0.003). By ACE-27, MS was 19 mos if score 0–1 vs. 12 mos if score 2 or 3 (p=0.004). Using Cox model, this remained significant after adjusting for ReRT dose and tumor bulk, which were also survival predictors (p=0.007, 0.001). Time from previous RT, new primary, IMRT/3-D RT, or salvage surgery were not significant predictors. Grade ≥3 toxicities were 36% at baseline & 68% at follow-ups (dysphagia most common). Late toxicities including trismus, fistula, and soft tissue necrosis occurred in 7, 2, and 4 pts. Conclusions: Co-morbidity burden is a strong, independent predictor of survival among selected pts undergoing salvage ReRT. This information, along with other prognostic factors, may help refine patient selection and improve future treatment outcome. No significant financial relationships to disclose.

OBJECTIVES:We describe a cohort of patients with an unusual presentation of stridor, their evaluation and management, and their outcome. We review the pertinent English-language literature.METHODS:We performed a retrospective review of the records of 12 adolescent patients treated for acute-onset inspiratory stridor at the Departments of Otolaryngology-Head and Neck Surgery and Allergy and Immunology at the University of South Florida and the Department of Speech Pathology at the H. Lee Moffitt Cancer Center and Research Institute. Two additional patients received treatment elsewhere. Demographic, historical, and laboratory data, physical examination findings, and follow-up information were extracted. A review of both the Hillsborough County Department of Health epidemiological report and the English-language literature was performed.RESULTS:Fourteen female patients who attended a local high school developed audible inspiratory noise. Twelve of the 14 were seen at the University of South Florida Ear, Nose and Throat Center. The remaining 2 patients were evaluated by outside otolaryngologists but were included in all reports from the Department of Health. Environmental studies did not find noxious chemical or biological agents in the students' environments to explain the development of the symptoms. Physical and videostroboscopic examination identified two distinct laryngeal findings causing the audible stridor. One involved paradoxical vocal fold movement, and the other, supraglottic mucosal collapse into the airway. All patients underwent rigorous speech pathology intervention and structured treatment with either complete resolution or significant improvement, seen both clinically and on videostroboscopic evaluation.CONCLUSIONS:Audible stridor can arise from numerous disease processes. In the vast majority of presentations it occurs sporadically and on an individual basis. Our cohort is especially unusual because of the sheer number of patients. Our presentation of a case of mass psychogenic illness as the cause of vocal cord dysfunction with additional findings of laryngomalacia within a group of adolescent girls is the first in the English-language literature. The key to the diagnosis is recognition of the disorder and susceptible individuals by using a thorough physical examination with emphasis on the laryngoscopic and videostroboscopic findings. The systematic approach, undertaken by a team including an otolaryngologist, an allergist, a speech pathologist, and an epidemiologist, proved to be effective in the management of this complex disorder and highly unusual situation.