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Background Total laryngectomy (TL) as either a primary or salvage treatment strategy remains an effective oncologic operation in the management of laryngeal cancer. Dysphagia is the most common complication following TL and this has a significant impact on patients’ quality of life (QOL). Following removal of the larynx, a number of pharyngeal closure techniques exist. We aimed to evaluate the effect pharyngeal closure techniques have on dysphagia-specific QOL postoperatively. Methods We retrospectively reviewed patients who had undergone TL at our institution (2014–2019). Patients alive at the time of study were invited to complete the MD Anderson Dysphagia Inventory (MDADI). Outcomes were compared among Primary Closure (PC), Pedicled Pectoralis Major Myocutaneous Flap (PMMF) and Free Flap (FF) closure groups. Results There were 27 patients identified for inclusion. Eight patients (30%) underwent PC, 10 patients (37%) had PMMF-assisted closure and 9 patients (33%) underwent FF-assisted closure. Patients within the FF group scored consistently higher MDADI scores across all subscales (emotional, functional, physical, global) as well as composite MDADI score in comparison to the PC and PMMF groups. FF closure was associated with a reduced inpatient length of stay (LOS). Additionally, no significant differences in postoperative morbidity including rates of pharyngo-cutaneous fistula (PCF) were observed between groups. Conclusions We now advocate FF closure for our patients following salvage TL due to the improved dysphagia-specific QOL, reduced inpatient LOS and lack of additional surgical morbidity. Level of evidence, Level III, therapeutic/prognostic study.

Objectives Sinonasal mucosal melanoma (SNMM) is an extremely rare and challenging sinonasal malignancy with a poor prognosis. Standard treatment involves complete surgical resection, but the role of adjuvant therapy remains unclear. Crucially, our understanding of its clinical presentation, course, and optimal treatment remains limited, and few advancements in improving its management have been made in the recent past. Methods We conducted an international multicenter retrospective analysis of 505 SNMM cases from 11 institutions across the United States, United Kingdom, Ireland, and continental Europe. Data on clinical presentation, diagnosis, treatment, and clinical outcomes were assessed. Results One-, three-, and five-year recurrence-free and overall survival were 61.4, 30.6, and 22.0%, and 77.6, 49.2, and 38.3%, respectively. Compared with disease confined to the nasal cavity, sinus involvement confers significantly worse survival; based on this, further stratifying the T3 stage was highly prognostic (p Conclusions We present findings from the largest cohort of SNMM reported to date. We demonstrate the potential utility of further stratifying the T3 stage by sinus involvement and present promising data on the benefit of immune checkpoint inhibitors for recurrent, persistent, or metastatic disease with implications for future clinical trials in this field.

BACKGROUND: Considering the pandemic's mode of transmission, the impact on quality of life (QOL) is likely to be exaggerated among healthcare workers (HCWs) who treat head and neck diseases (hHCWs). METHODS: A cross-sectional self-reported QOL assessment was undertaken between July and September 2020 using the World Health Organization Quality of Life instrument sent out to hHCWs. Factors that predicted a poorer QOL were identified using regression models and mediation analysis. RESULTS: Responses from 979 individuals across 53 countries were analyzed with 62.4% participation from low- and middle-income countries. The physical domain had the highest mean scores of 15 ± 2.51, while the environmental domain was the lowest (14.17 ± 2.42). Participants from low- and middle-income countries had a significantly worse physical (p < 0.001) and environmental (p < 0.001) domains, while a low coronavirus disease 2019-related mortality significantly impacted the environmental domain (p-0.034). CONCLUSION: QOL-related issues among hHCWs are a vexing problem and need intervention at an individual and systems level in all parts of the world.

Frailty refers to a patient's reduced capacity to withstand stressors due to a reduction in physiologic reserves. We assessed the impact of frailty on outcomes following head and neck surgery.We performed a systematic review in accordance with the PRISMA guidelines. Meta-analysis was performed using the Mantel-Haenszel method.Fourteen studies incorporating 182 059 patients were included in qualitative synthesis with 15 953 (8.8%) of patients deemed as frail. Meta-analysis incorporating nine studies demonstrated that frailty is associated with an increased 30 day postoperative morbidity (OR 2.74; 95% CI 1.98-3.80; p 0.01) and meta-analysis with six studies suggested increased 30-day mortality (OR 2.94; 95% CI 2.62-3.31; p 0.01). Preliminary meta-analyses between two and five studies suggested that frail patients had reduced overall survival and were more likely to be discharged to a nonhome location or readmitted within 30 days.Frailty appears to be associated with poor short-term outcomes following head and neck surgery and may improve understanding of an individual patient's peri-operative risk.

Oropharyngeal cancer (OPC) remains a significant health burden and about 15–30% of these have been attributed to the human papillomavirus (HPV). Human papillomavirus-related oropharyngeal cancer (HPV OPC) includes tumours which are detected to be p16INK4A positive or have the HPV DNA detected by in situ hybridisation or polymerase chain reaction. HPV OPC is generally believed to have a relatively good prognosis. More recently, there is a recognised pattern of atypical spread in a highly aggressive subset of HPV OPC. These are HPV OPCs which develop distant metastasis or recurrence. This review raises awareness of this subset of HPV OPC and factors associated with poor outcomes. A review of the literature available on HPV OPC was carried out. Studies were sourced from PubMed with searching of relevant headings and sub-headings and cross-referencing. Factors associated with highly aggressive HPV OPC include nodal stage and nodal morphology, alcohol and tobacco use, age and biological characteristics. Treatment options in cases of disease recurrence include salvage resection radiotherapy and/or chemotherapy and management options vary depending on the nature of recurrence and initial treatment. Recent updates in HPV OPC staging have made staging and treatment of tumours more accurate. While HPV OPC overall carries a relatively good prognosis, it is important for clinicians to be aware of potentially highly aggressive cases of HPV OPC and to be aware of factors that should prompt close monitoring.

Background Solid organ transplantation is associated with increased risk of non-melanoma skin cancer. Studies with short follow up times have suggested a reduced occurrence of these cancers in recipients treated with mammalian target of rapamycin inhibitors as maintenance immunosuppression. We aimed to describe the occurrence of skin cancers in renal and liver transplant recipients switched from calcineurin inhibitor to sirolimus-based regimes. Methods We performed a retrospective study of sirolimus conversion within the Irish national kidney and liver transplant programs. These data were linked with the National Cancer Registry Ireland to determine the incidence of NMSC among these recipients. The incidence rate ratio (IRR) for post versus pre-conversion NMSC rates are referred in this study as an effect size with [95% confidence interval]. Results Of 4,536 kidney transplants and 574 liver transplants functioning on the 1 January 1994 or transplanted between 1 January 1994 and 01 January 1994 and 01 January 2015, 85 kidney and 88 liver transplant recipients were transitioned to sirolimus-based immunosuppression. In renal transplants, the rate of NMSC was 131 per 1000 patient years pre-switch to sirolimus, and 68 per 1000 patient years post switch, with adjusted effect size of 0.48 [0.31 − 0.74] (p = .001) following the switch. For liver transplant recipients, the rate of NMSC was 64 per 1,000 patient years pre-switch and 30 per 1,000 patient years post switch, with an adjusted effect size of 0.49 [0.22 − 1.09] (p .081). Kidney transplant recipients were followed up for a median 3.4 years. Liver transplants were followed for a median 6.6 years. Conclusions In this study, the conversion of maintenance immunosuppression from calcineurin inhibitors to mTOR inhibitors for clinical indications did appear to reduce the incidence of NMSC in kidney and liver transplant recipients.

Introduction: olfactory neuroblastoma (ONB) is a rare cancer of the sinonasal region. We provide a comprehensive analysis of this malignancy with molecular and clinical trial data on a subset of our cohort to report on the potential efficacy of somatostatin receptor 2 (SSTR2)-targeting imaging and therapy.Methods: we conducted a retrospective analysis of 404 primary, locally recurrent, and metastatic olfactory neuroblastoma (ONB) patients from 12 institutions in the United States of America, United Kingdom and Europe. Clinicopathological characteristics and treatment approach were evaluated. SSTR2 expression, SSTR2-targeted imaging and the efficacy of peptide receptor radionuclide therapy [PRRT](177Lu-DOTATATE) were reported in a subset of our cohort (LUTHREE trial; NCT03454763).Results: dural infiltration at presentation was a significant predictor of overall survival (OS) and disease-free survival (DFS) in primary cases (n = 278). Kadish-Morita staging and Dulguerov T-stage both had limitations regarding their prognostic value. Multivariable survival analysis demonstrated improved outcomes with lower stage and receipt of adjuvant radiotherapy. Prophylactic neck irradiation significantly reduces the rate of nodal recurrence. 82.4% of the cohort were positive for SSTR2; treatment of three metastatic cases with SSTR2-targeted peptide-radionuclide receptor therapy (PRRT) in the LUTHREE trial was well-tolerated and resulted in stable disease (SD).Conclusions: this study presents pertinent clinical data from the largest dataset, to date, on ONB. We identify key prognostic markers and integrate these into an updated staging system, highlight the importance of adjuvant radiotherapy across all disease stages, the utility of prophylactic neck irradiation and the potential efficacy of targeting SSTR2 to manage disease.

Head and neck paragangliomas (HNPGLs) are rare neuroendocrine tumors typically arising from nonsecretory head and neck parasympathetic ganglia. Historically thought of as aggressive tumors that warranted equally aggressive surgical intervention, evidence has emerged demonstrating that the vast majority of HNPGLs are slow growing and indolent. It is also now recognized that a large proportion of HNPGLs are hereditary with succinate dehydrogenase gene mutations typically implicated. These recent advances have led to significant changes in the way in which clinicians investigate and treat HNPGLs with most now opting for more conservative treatment strategies. However, a proportion of patients present with more aggressive disease and still require nonconservative treatment strategies. Recent studies have sought to determine in which groups of patients the morbidity associated with treatment is justified. We summarize the recent advances in the understanding and management of these tumors and we provide our recommendations regarding the management of HNPGLs.

Background Diagnostic endomyocardial biopsy (EMB) in patients with suspected myocarditis helps to direct therapy and guide prognosis. This study aimed to investigate the correlation between the 2007 clinical guideline indications for EMB and the presence of a diagnostic biopsy result and associated outcomes in patients with suspected myocarditis in a national quaternary referral center in a contemporary cohort. Methods All cases of suspected myocarditis referred to the National Cardiac Transplant Centre who underwent EMB between 2009 and 2019 were identified retrospectively through pathology records. Outcomes including subsequent need for inotrope and/or mechanical circulatory support (MCS), heart transplantation and in-hospital mortality were recorded. Results In total, 25 (68% male, mean age of 45 ± 15 years) EMBs were performed for this indication across this time period, 64% (n = 16) of which demonstrated diagnostic results, the majority (75%, n = 12) identifying acute lymphocytic myocarditis, 13% (n = 2) giant cell, one patient (6.3%) eosinophilic and one (6.3%) an immune checkpoint inhibitor myocarditis. The majority of those with histologically confirmed myocarditis had a Class I or IIa guideline indication for EMB (n = 12, 75%). The remaining 4 patients (25%), either met Class IIb criteria (n = 2) or would not have been accounted for in this guideline. The majority of patients requiring inotropes and/or MCS (n = 9/11), and/or heart transplant (n = 3/4), or who later died (n = 4/5) were in the diagnostic biopsy group. Conclusions In this 10-year National referral sample, 75% of patients with histologically confirmed myocarditis had a Class I or IIa indication for EMB, reinforcing the usefulness of traditional guidelines in this contemporary era. However, 25% of patients with a subsequent confirmed histological diagnosis had either none or a less well-established indication for EMB, highlighting the need for clinical suspicion outside of accepted clinical scenarios.

Background Head and neck cancer (HNC) is associated with significant morbidity and mortality, especially when high stage disease is present. The epidemiology and prognosis of HNC has changed considerably over the last 20 years. Aims This study aimed to examine the epidemiological trends in HNC patients over a prolonged period in Ireland. Methods We conducted a retrospective cohort study using 20 years of cancer registry data provided by the National Cancer Registry of Ireland. Baseline characteristics and survival statistics were thereby generated. Results 10,148 patients were identified. There is a growing population of young ( 85 years) HNC patients; 48.15% of the population was elderly (> 65 years). Oral cavity (29.8%) and laryngeal cancer (28.1%) remain the most prevalent subsites, though oral cavity cancer prevalence declined from 35.9% in 1994 to 27.5% in 2014. Oropharyngeal cancer prevalence increased from 13.6 to 22.2% over the same period. Overall 5-year survival has improved significantly to 56.8% in 2010 but there remains a disparity between the elderly and adult cohorts (42.0% vs 60.7%). 5-year survival for hypopharyngeal and oropharyngeal cancers has improved from 11.8% and 33.3% to 22.2% and 44.8%, respectively, while laryngeal and oral cavity cancer survival remains approximately stable at 58.7% and 61.5%, respectively. Conclusion HNC survival in Ireland has improved in line with increasing recognition of the value of multidisciplinary assessment, subspecialisation in cancer care, and targeted therapies based on tumour subsites. Survival in the elderly cohort remains poor despite increasing recognition of the challenges such cases pose.

Background The current COVID-19 pandemic has placed enormous strain on healthcare systems worldwide. Understanding of COVID-19 is rapidly evolving. Pneumonia associated with COVID-19 may lead to respiratory failure requiring mechanical ventilation. The rise in patients requiring mechanical ventilation may lead to an increase in tracheostomies being performed in patients with COVID-19. Performing tracheostomy in patients with active SARS-CoV-2 infection poses a number of challenges. Methods These guidelines were written following multidisciplinary agreement between Otolaryngology, Head and Neck Surgery, Respiratory Medicine and the Department of Anaesthetics and Critical Care Medicine in the Royal College of Surgeons in Ireland. A literature review was performed and a guideline for elective tracheostomy insertion in patients with COVID-19 proposed. Conclusion The decision to perform tracheostomy in patients with COVID-19 should be undertaken by senior members of the multidisciplinary team. Steps should be taken to minimise risks to healthcare workers., Highlights • Tracheostomy tube insertion in patients with COVID-19 presents a new set of challenges. • The importance of training and planning during this time cannot be overstated. • Steps should be taken to minimise risks to healthcare workers.

Introduction Diagnostic endomyocardial biopsy (EMB) in patients with myocarditis helps to direct therapy and guide prognosis. The original 2007 joint scientific statement provided guideline indications based on unique clinical scenarios, detailing who should undergo this invasive investigation but have not been studied in a contemporary cohort of suspected myocarditis patients. Purpose To investigate the correlation between the clinical guideline indications for EMB and the presence of a diagnostic biopsy result and associated outcomes in patients with suspected myocarditis in a national quaternary referral center. Methods All cases of suspected myocarditis referred to the National Advanced Heart Failure and Transplant Center between 2009–2019 were identified through pathological records. A thorough retrospective chart review was then performed on all patients. Outcomes including need for inotrope or mechanical circulatory support (MCS), heart transplantation and in-hospital mortality were recorded. Results In total, 25 (68% male, mean age of 45 ± 15 years) EMBs were performed for suspected myocarditis between 2009–2019, 64% (n=16) of which demonstrated diagnostic results. Clinical characteristics of those with histologically confirmed myocarditis are represented in figure 1. Regarding pathologic subtypes, 81% (n=13) identified an acute lymphocytic myocarditis, 13% (n=2) giant cell myocarditis and one patient (6.3%) eosinophillic myocarditis. The majority of those with a histologically confirmed myocarditis had a Class I or IIa guideline indication for EMB (n=12, 75%). All patients requiring inotropes and/or MCS (n=9) and/or heart transplant (n=3) were in this group. The remaining 4 patients (25%), of whom three were diagnosed with acute lymphocytic myocarditis and one an immune checkpoint inhibitor (ICI) myocarditis, either met Class IIb criteria (n=2) or would not have been accounted for in this guideline. Four patients (25%) died during the index admission, one of whom was in the latter group (histologically confirmed myocarditis without a 2007 guideline indication). Conclusions In this National referral sample, 75% of patients with suspected myocarditis had a Class I or IIa indication for EMB, reinforcing the usefulness of these guidelines even in a contemporary era. Further, existing guideline indications appeared to identify a sicker group of patients more frequently requiring inotropes, MCS and/or heart transplant. However, in the contemporary era, 25% of patients had either none or a less well established indication for EMB despite a subsequent confirmed histological diagnosis, including a case of immune checkpoint inhibitor myocarditis, which has emerged since the publication of the 2007 guidelines. This highlights the need for clinical suspicion and correlation outside of accepted clinical scenarios.

Introduction Accurate prevalence data for advanced heart failure (HF), reported to range between 2–10% of the chronic HF population, are lacking. Determining the proportion of patients potentially suitable for referral to a specialist advanced HF center is crucial for accurate service planning and resource provision, particularly in the evolving era of durable mechanical circulatory support. Purpose To identify the population of patients potentially eligible for referral for assessment for advanced surgical therapies to the National Advanced HF and Cardiac Transplant center, using a quick one-page prospective survey. Methods A survey comprising 13 potential markers of advanced HF was developed, modified from the 2018 position statement of the Heart Failure Association of the European Society of Cardiology. This was distributed to 26 HF clinic centers nationally. Each center was asked to complete the survey on consecutive patients over a 3-month period who fulfilled the following three criteria: 1) age 3 months duration. Results In all, 21 of 26 HF clinic centers participated in the survey. Across the period of inclusion, 4950 all-comer HF patients were seen in 21 centers. Of these, 375 fulfilled the inclusion criteria, comprising 279 (74.4%) males with a median age of 57 years. In total, 246 (66%) of the completed surveys had one or more potential markers for advanced HF, representing just under 5% of the total all-comer HF population seen across the same time period. Of these, 67 patients (27%) had at least two, 48 (20%) had three and 40 (16%) had ≥ 4 potential markers. The most frequently noted markers were ≥1 hospitalization or unscheduled clinic review (56%), intolerance to renin-angiotensin-aldosterone system inhibitors due to hypotension or renal dysfunction (29%) and intolerance to beta-blockers due to hypotension (27%). Almost one-quarter of patients reported NYHA Class III or IV symptoms (figure 1). Conclusions In this index prospective National survey, approximately 5% of an all-comer routine HF clinic population and two-thirds of a pre-selected HF with reduced EF

Importance The rapidly expanding novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2, has challenged the medical community to an unprecedented degree. Physicians and health care workers are at added risk of exposure and infection during the course of patient care. Because of the rapid spread of this disease through respiratory droplets, health care workers who come in close contact with the upper aerodigestive tract during diagnostic and therapeutic procedures, such as otolaryngologists–head and neck surgeons, are particularly at risk. A set of safety recommendations was created based on a review of the literature and communications with physicians with firsthand knowledge of safety procedures during the COVID-19 pandemic. Observations A high number of health care workers were infected during the first phase of the pandemic in the city of Wuhan, China. Subsequently, by adopting strict safety precautions, other regions were able to achieve high levels of safety for health care workers without jeopardizing the care of patients. The most common procedures related to the examination and treatment of upper aerodigestive tract diseases were reviewed. Each category was reviewed based on the potential risk imposed to health care workers. Specific recommendations were made based on the literature, when available, or consensus best practices. Specific safety recommendations were made for performing tracheostomy in patients with COVID-19. Conclusions and Relevance Preserving a highly skilled health care workforce is a top priority for any community and health care system. Based on the experience of health care systems in Asia and Europe, by following strict safety guidelines, the risk of exposure and infection of health care workers could be greatly reduced while providing high levels of care. The provided recommendations, which may evolve over time, could be used as broad guidance for all health care workers who are involved in the care of patients with COVID-19.

Objectives/Hypothesis: TNM-classification inadequately estimates patient-specific overall survival (OS). We aimed to improve this by developing a risk-prediction model for patients with advanced larynx cancer. Study Design: Cohort study. Methods: We developed a risk prediction model to estimate the 5-year OS rate based on a cohort of 3,442 patients with T3T4N0N+M0 larynx cancer. The model was internally validated using bootstrapping samples and externally validated on patient data from five external centers (n = 770). The main outcome was performance of the model as tested by discrimination, calibration, and the ability to distinguish risk groups based on tertiles from the derivation dataset. The model performance was compared to a model based on T and N classification only. Results: We included age, gender, T and N classification, and subsite as prognostic variables in the standard model. After external validation, the standard model had a significantly better fit than a model based on T and N classification alone (C statistic, 0.59 vs. 0.55, P

IMPORTANCE: Existing data suggest that nonmelanoma skin cancer (NMSC) is more common in renal transplant recipients than in maintenance dialysis patients. However, whether the risk of NMSC varies as the treatment modality for end-stage kidney disease (ESKD) changes between dialysis and transplantation is not well described. OBJECTIVE: To determine whether the incidence of NMSC is attenuated during periods of graft loss with a return to dialysis in those who receive multiple kidney transplants. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of data from recipients of kidney transplants from the Irish National Kidney Transplant Service database, linked with the Irish Cancer Registry, from 1994 to 2014. All analysis took place between January 10, 2018 and March 31, 2018. Standardized incidence ratios (SIRs) were calculated for NMSC incidence in comparison with the general population using Irish census data as the denominator. Incidence of NMSC was calculated with modality of treatment for ESKD varying over time; incidence rates and rate ratios associated with dialysis intervals were calculated using Poisson regression; and disease was defined according to International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes for cancer diagnosis. EXPOSURES: Kidney transplantation. MAIN OUTCOMES AND MEASURES: Incidence rates per 1000 patient-years and incident rate ratios of NMSC after kidney transplant. RESULTS: Data from the records of 3821 deceased or living donor kidney transplant recipients were assessed; 2399 (62.8%) male and 1422 (37.2%) female recipients; mean (SD) age at time of first data recorded, 41.9 (16.0) years. A total of 3433 recipients were included who had a functioning transplant on January 1, 1994, or received a transplant after that date up to December 31, 2014: 3215 received 1 transplant, 522 a second kidney transplant, and 84 had 3 or more kidney transplants. Periods of treatment with a functioning transplant were associated with a higher incidence of NMSC diagnosis than periods of graft failure: adjusted incidence rate ratio (aIRR), 2.19 (95% CI, 1.56-3.07), P

Purpose Antifungal prophylaxis in heart transplantation is not universally prescribed in our institution. We reviewed the incidence of invasive fungal diseases (IFD) in heart transplants, risk factors, and diagnostic yield of culture and nonculture-based testing for IFD. Methods A 5-year retrospective audit of heart transplant recipients in a national transplant centre from 2015 to 2019 was conducted. Proven and probable IFD were identified based on host factors, clinical features and mycological evidence outlined by the updated EORTC/MSGERC definitions. Results The incidence of proven or probable IFD was 14% (11/77) with 207 median days (IQR 54.5-306) post-transplant to diagnosis. 4 (36%) cases occurred 0.05). Of the 7 with rejection, median time from transplant to 1st rejection was 17 days (IQR11-51), and 1st rejection to IFD was 125 days (IQR 44-191). 45% (5/11) with IFD had required post-operative renal replacement therapy. 45% had neutrophils Conclusion Antifungal surgical prophylaxis could have prevented 1 IFD. A cohort of high-risk heart transplant recipients may benefit from antifungal prophylaxis.

This study aims to determine the survival impact of patient characteristics and treatment options associated with the early stage oral cavity squamous cell carcinoma, OCSCC. The methods are analysis of Irish cancer database examining T1/2, N0, and M0 cases of OCSCC from 1997 to 2007 inclusive. In total, 397 cases were identified. Anterolateral tongue accounted for 52.9 % of cases. Increased age at diagnosis and smoking are independent prognostic survival indicators associated with poorer outcomes. Surgery as the initial intervention was associated with significantly better survival outcomes, while surgery and adjuvant radiotherapy significantly worse outcomes. Surgical intervention is recommended as the first-line treatment in the early stage OCSCC in combination with elective neck dissection.

Background Anaplastic thyroid cancer has a median survival between 1.2 and 10 months. The purpose of our study was to evaluate the outcomes of patients with anaplastic thyroid cancer in Ireland. Methods We carried out a retrospective analysis of the Irish National Cancer Database for patients with anaplastic thyroid cancer between 2000 and 2010. Results Of a total of 64 patients (40 women, 24 men), the median age was 69 years, and 29.7% of the patients had distant metastases. The overall median survival was 2.3 months and the 1, 2, and 5-year survival was 12.5%, 6.25%, and 4.69%, respectively. On univariate analysis age, sex, metastases at diagnosis, and multimodality treatment were statistically significant indicators of prognosis, and metastases at diagnosis remained statistically significant on multivariate analysis. Conclusion These results correlate with the American Thyroid Association (ATA) guidelines, in which, when possible, multimodality therapy offers a survival advantage to a select group of patients. Novel therapies may offer the greatest hope for these patients. © 2016 Wiley Periodicals, Inc. Head Neck, 2016

Purpose To determine overall survival outcomes and outcomes according to gender and era of transplantation, for cardiac transplant recipients in the Republic of Ireland and compare these against international published registry data. Methods A retrospective registry was created of all heart transplants performed in the National Heart and Lung Transplant Centre, Dublin between 1985 and 2019. Kaplan Meier analysis and log rank comparison testing were performed for overall mortality as well as subgroup analyses. This data was then compared to international figures published annually by the ISHLT. Results Overall survival: Median survival was 13.27 years in comparison to 10.9 years internationally over a similar time period. Gender differences: 22.4% of transplants were in females. Median survival in males was 13.9 years and 12.07 years in females (p=0.028). Internationally, median survival was 10.7 years for males and 11.7 years for females. Decade transplanted: Median survival increased from 10.25 years for transplants performed in the 1980s to 15.03 years for those performed 2000-2009 (p=0.034) with survival curves suggesting improved survival for those transplanted after 2010. This compares favourably to ISHLT data: 10.5 years (1992-2001) and 12.4 years (2002-2008). One year survival: This increased from 69.5% for transplants performed in the 1980s, 78% for 1990-1999; 81% for 2000-2009 and 89% for 2010-2019. Conditional on survival to 1 year: Overall median survival was 16.07 years. This has increased from 12.9 years for transplants performed in the 1980s to 18.27 years for those performed 2000-2009 (p=0.069). Conclusion Survival rates post cardiac transplantation in the Republic of Ireland have increased significantly from the beginning of the program in 1985 and compare favourably to international registry data. Based on data since 2000, 1 year survival is now 89%; median survival is at least 15 years and conditional on surviving to 1 year, median survival is at least 18.27 years.

Purpose Identify the prevalence and associates of ISHLT grade ≥2R acute cellular rejection (≥2CR) and its impact on survival post heart transplantation in a well-phenotyped, modern era Irish cohort all of whom receive induction therapy. Methods Retrospective analysis of 88 patients who underwent heart transplantation between 2014 and 2019 (mean age 49.8 ± 13.02 years; female 29.5%). Data was collected on recipient and donor anthropometrics, HLA profile, panel reactive antibodies (PRAs) ischaemia time, cytomegalovirus (CMV) serostatus and endomyocardial biopsy results over a median follow up of 2.04 years (IQR 3.18). Kaplan Meier survival, univariate and multivariate cox regression analysis were performed. Results Standard immunosuppression was with basiliximab induction, a calcineurin inhibitor, steroid and antimetabolite. All-cause mortality at 1 year was 14%. In those patients surviving to first biopsy (n=82), 55% experienced at least 1 episode of ≥2CR at a median time of 53.5 days (IQR 149) and cumulative survival was reduced in this group (p=0.04). More than 1 episode of ≥2CR was not associated with an incremental mortality risk. Intermediate-high risk CMV serostatus was independently associated with increased mortality on multivariate analysis (HR 3.16; 95%CI 1.04-9.65; p=0.04) but not with an increased risk of ≥2CR. There was no association between ischaemic time, PRAs, other recipient/donor matching characteristics, number of HLA mismatches or mismatches confined to any of the 6 HLA subclasses on survival or development of ≥2CR. Conclusion In a modern era Irish cohort where induction therapy is standard, patients who experienced ≥1 episode of ≥2CR post transplant had reduced survival. Intermediate-high risk CMV serostatus was the only independent associate of increased mortality but not for ≥2CR. Further work in an extended cohort will focus on understanding the mechanisms underpinning rejection in this contemporary population and its consequences.

Objective Solid organ transplant recipients are at increased risk of cancer compared to the general population. To date, this risk in Ireland has not been investigated. We conducted a national registry study of cancer incidence following solid organ transplantation. Methods National centers for solid organ transplantation supplied their respective registry databases to cross-reference with episodes of malignancy from the National Cancer Registry Ireland (NCRI) between 1994 and 2014. Standardized incidence of cancer post-transplant was compared to the general population by means of standardized incidence ratios (SIRs), and between solid organ transplant types by incidence rate ratios. Results A total of 3346 solid organ transplant recipients were included in this study. Kidney transplant recipients constituted the majority of participants (71.2%), followed by liver (16.8%), heart (6.4%), and lung (5.6%) transplants. The most common cancers within the composite of all transplant recipients included the following (SIR [95% CI]): squamous and basal cell carcinoma (20.05 [17.97, 22.31] and 7.16 [6.43, 7.96], respectively), non-Hodgkin lymphoma (6.23 [4.26, 8.59]), and renal cell carcinoma (3.36 [1.96, 5.38]). Conclusions This study reports the incidence of cancer following solid organ transplantation in Ireland. These results have significant national policy implications for surveillance, and early diagnosis in this patient group.

Background Device Infection is a recognised complication of cardiac implantable electronic device (CIED) insertion. Reported incidence of CIED infection vary widely, and range from 1.0% for pacemakers to up 9.5% for cardiac resynchronisation defibrillators (CRT-d). The risk of infection is 2–4-fold higher for CIED replacement. CIED infection is associated with significant patient morbidity and mortality rate of up to 27% at 2 years. Recently an antibacterial pouch (Tyrx TM, Medtronic) has been developed. This absorbable pouch elutes rifampicin and minocycline from a monofilament polypropylene mesh. Use of the TYRX pouch has been associated with reduced CIED infection. Real-world data on the efficacy of the envelope remains limited. Methods We performed an retrospective review of the CIED infection rate for all devices implanted with a Tyrx TM pouch from September 2015 to October 2017 in our institution. Patient or procedural factors known to increase the risk of infection were documented in each case. Results 63 patients had CIEDs implanted along with a Tyrx TM pouch during the period under review. 14 (22%) were female. The average age at implant was 64 years±13. Five patients had chronic kidney disease (eGFR Conclusion Our study included many patients with factors associated with increased infection rate. Over a mean follow-up period of >1 year, no patients with a CIED implanted along with a TyrxTM antibacterial pouch had CIED pocket infection. Though the numbers under review were small, our results compare very favourably with previously published rates of CIED infection, and lend further support to the use of antibacterial pouches to reduce the risk of device infection.

Purpose Post transplant malignancy is a common long term complication due to immunosuppression. The aim of this study was to assess the incidence, type of malignancies and evaluate risks associated with development of malignancy in heart transplant recipients at our institution Methods Patients transplanted from March 1998 to March 2018 were included in the study. Data was collected from patient's medical records retrospectively. Skin cancers were not included and patients with pre-transplant malignancy were excluded from the study. Results Of 229 patients, 11% (n=25) patients developed malignancy, 96% (n=24) were male and 4%(n=1) were females. The median time from transplant to diagnosis of malignancy was 9.32 years (0.9-18.1yrs) and the mean age at diagnosis was 66.8± 7.25 years. Most common malignant neoplasm was Lung Cancer (39%, n=9) followed by Colorectal (17%, n=4) and Prostate cancer (9%, n=3). Kaplan Meir survival rate for patients without malignancy post transplant was 18.2 years and with malignancy was 12.1 years. Patient's transplanted after 55 years or above were at higher risk of developing malignancy with p value reaching statistical significance(p=0.006) Conclusion Post transplant malignancy is a common long term complication affecting patient's survival post transplantation. Lung cancer is the most common sold organ malignancy. Patients transplanted after 55 years of age or above are relatively at higher risk for developing malignancy. Early intervention by aggressive screening is required to diagnose malignancy.

Background:This study was undertaken to determine the optimum approach to screening for head and neck cancer based on international experiences.Objective:To determine whether or not head and neck cancer is suitable for screening, and, if so, what the ideal approach should be.Methods:An electronic search of online databases up to and including May 2014 was conducted. Key search terms included ‘head and neck’, ‘cancer’, ‘screening’, ‘larynx’, ‘oropharynx’ and ‘oral’.Results:Subset analysis of high-risk cohorts showed statistically significant improvements in early detection of head and neck cancer via screening.Conclusion:Current levels of public awareness regarding head and neck cancers are suboptimal, despite increased incidence and mortality. Scheduled and opportunistic screening, coupled with efforts to enhance education and health behaviour modification, are highly recommended for pre-defined, high-risk, targeted populations. This can enable early detection and therefore improve morbidity and mortality.

BACKGROUND Despite advantages in terms of cancer control and organ preservation, the benefits of chemotherapy and radiation therapy (CTRT) may be offset by potentially severe treatment-related toxicities, particularly in older patients. The objectives of this study were to assess the types and frequencies of toxicities in older adults with locally or regionally advanced head and neck squamous cell carcinoma (HNSCC) who were receiving either primary CTRT or radiation therapy (RT) alone. METHODS With Surveillance, Epidemiology, and End Results cancer registry data linked with Medicare claims, patients who were 66 years old or older with locally advanced HNSCC, were diagnosed from 2001 to 2009, and received CTRT or RT alone were identified. Differences in the frequency of toxicity-related hospital admissions and emergency room visits as well as feeding tube use were examined, and controlling for demographic and disease characteristics, this study estimated the impact of chemotherapy on the likelihood of toxicity. RESULTS Among patients who received CTRT (n = 1502), 62% had a treatment-related toxicity, whereas 46% of patients who received RT alone (n = 775) did. When the study controlled for demographic and disease characteristics, CTRT patients were twice as likely to experience an acute toxicity in comparison with their RT-only peers. Fifty-five percent of CTRT patients had a feeding tube placed during or after treatment, whereas 28% of the RT-only group did. CONCLUSIONS In this population-based cohort of older adults with HNSCC, the rates of acute toxicities and feeding tube use in patients receiving CTRT were considerable. It is possible that for certain older patients, the potential benefit of adding chemotherapy to RT does not outweigh the harms of this combined-modality therapy. Cancer 2015. © 2015 American Cancer Society. Cancer 2015;121:2083–2089. © 2015 American Cancer Society.

The purpose of this review is to highlight the benefits of gender-neutral and the nonavalent human papillomavirus vaccination. Human papillomavirus infection is the most commonly sexually transmitted disease and is known to cause several types of cancers, including cervical, vulvar, vaginal, penile, oropharyngeal, anal, and rectal. 5% of cancers every year are attributable to human papillomavirus infection, with cervical cancer the most common and oropharyngeal cancer estimated to surpass the incidence of cervical cancer by 2020. PubMed and MEDLINE were searched using the following search terms: [(human papillomavirus OR HPV) AND (vaccine OR vaccination)] AND [(gardasil OR gardasil9 OR cervarix OR quadrivalent OR nonavalent OR ninevalent) OR (gender neutral OR male)]. There are currently three different types of human papillomavirus vaccinations and range in cover from four to nine different strains known to cause human disease. Most countries currently only supply vaccination to females; however, recent data point towards both a personal benefit as well as a cost-effective population-based benefit with gender-neutral vaccination. Data from female vaccination only have shown the vaccine to be effective in preventing premalignant cervical lesions, and are believed to have the same effect for other human papillomavirus cancers. Male vaccination not only provides personal benefit but also has a “herd effect” for females by preventing the propagation of the virus. Gender-neutral vaccination provides significant cost-effective benefits for preventing human papillomavirus-related diseases, and this effect is further enhanced by the use of the nonavalent vaccine.

TNM-classification inadequately estimates patient-specific overall survival (OS). We aimed to improve this by developing a risk-prediction model for patients with advanced larynx cancer.Cohort study.We developed a risk prediction model to estimate the 5-year OS rate based on a cohort of 3,442 patients with T3T4N0N+M0 larynx cancer. The model was internally validated using bootstrapping samples and externally validated on patient data from five external centers (n = 770). The main outcome was performance of the model as tested by discrimination, calibration, and the ability to distinguish risk groups based on tertiles from the derivation dataset. The model performance was compared to a model based on T and N classification only.We included age, gender, T and N classification, and subsite as prognostic variables in the standard model. After external validation, the standard model had a significantly better fit than a model based on T and N classification alone (C statistic, 0.59 vs. 0.55, P.001). The model was able to distinguish well among three risk groups based on tertiles of the risk score. Adding treatment modality to the model did not decrease the predictive power. As a post hoc analysis, we tested the added value of comorbidity as scored by American Society of Anesthesiologists score in a subsample, which increased the C statistic to 0.68.A risk prediction model for patients with advanced larynx cancer, consisting of readily available clinical variables, gives more accurate estimations of the estimated 5-year survival rate when compared to a model based on T and N classification alone.2c. Laryngoscope, 128:1140-1145, 2018.

Objectives/Hypothesis Primary curative treatment of advanced laryngeal cancer may include surgery or chemoradiation, although recommendations vary and both are associated with complications. We evaluated predictors and trends in the use of these modalities and compared rates of complications and overall survival in a population-based cohort of older adults. Study Design Retrospective population-based cohort study. Methods Using Surveillance Epidemiology and End Results (SEER) cancer registry data linked with Medicare claims, we identified patients over 65 with advanced laryngeal cancer diagnosed 1999 to 2007 who had total laryngectomy (TL) or chemoradiation (CTRT) within 6 months following diagnosis. We identified complications and estimated the impact of treatment on overall survival, using propensity score methods. Results The proportion of patients receiving TL declined from 74% in 1999 to 26% in 2007 (P