Contralateral nodal failures in oropharyngeal cancers after TORS and unilateral neck management: a retrospective study

Background Report the incidence of contralateral nodal failure rates in well-lateralized oropharyngeal carcinoma treated with upfront surgery and unilateral neck management. Methods Lateralized oropharyngeal carcinomas treated with upfront surgery using transoral robotic surgery (TORS) and unilateral neck management (unilateral neck dissection ± unilateral radiation treatment) were identified. Primary endpoint was contralateral regional control (CRC). Secondary endpoints were local control (LC), and overall survival (OS). Results Thirty-two patients were included. Pathologic T categories included 66% pT1, 31% pT2 and 3% pT3. Nodal diseases comprised 41% N0 and 47% N1 (AJCC 8th). Twenty-three (72%) patients had HPV related tumors. 3-years CRC, LC and OS were 100%, 96% (89–100) and 96% (CI 89–100). One patient developed a second primary with contralateral nodal disease. Only one patient died from another primary cancer. Conclusion In selected patients with lateralized oropharyngeal cancer, treatment with TORS and ipsilateral management of the neck may be oncologically safe without significant risk of contralateral failure. Level of evidence: Level 2. Graphical abstract

Efficiency of control in regional self-government of the Slovak Republic

The importance of high quality public sector control is an obvious fact – without efficient and effective control system, the risk of wasting public funds is critical. The goal of this article was to evaluate efficiency of internal control systems on the level of regional self-administration in the Slovakia. The findings clearly document many problems related to the performance of regional control bodies and on this basis purposes and possible actions are proposed. From the point of view of "fiscal rules", the research, for example, pointed to an exceptionally poor situation in compliance with the rules and conditions of budgetary management in the Bystrica region in the period 2006-2009. The research also proves that one of the key problems of nonconceptual and non-transparent asset management of regions is confusing and disadvantageous asset sales. The quantitative analysis suggests that the efficiency (intensity) of the functioning of regional control systems does not have a direct impact on the monitored output indicators. The implemented DEA also indicates the low effectivity of the internal control systems of the regions. Our findings fully prove that there are no truly efficient systems of external and internal control at the level of self-governing regions in Slovakia. The factor of high autonomy of regions in the financial management and disposal of assets in connection with the identified high degree of failure of the regional control system generates a clear need to strengthen the system of internal control of regions, based on systemic and procedural changes.

Standardized Diagnostic Workup and Patient-Centered Decision Making for Surgery and Neck Dissection Followed by Risk-Factor Adapted Adjuvant Therapy Improve Loco-Regional Control in Local Advanced Oral Squamous Cell Carcinoma

BackgroundStandardized staging procedures and presentation of oral squamous cell carcinoma (OSCC) patients in multidisciplinary tumor boards (MDTB) before treatment and utilization of elective neck dissection (ND) are expected to improve the outcome, especially in local advanced LAOSCC (UICC stages III–IVB). As standardized diagnostics but also increased heterogeneity in treatment applied so far have not been demonstrated to improve outcome in LAOSCC, a retrospective study was initiated.MethodsAs MDTB was introduced into clinical routine in 2007, 316 LAOSCC patients treated during 1991-2017 in our hospital were stratified into cohort 1 treated before (n=104) and cohort 2 since 2007 (n=212). Clinical characteristics, diagnostic procedures and treatment modality of patients were compared using Chi-square tests and outcome analyzed applying Kaplan-Meier plots and log-rank tests as well as Cox proportional hazard regression. Propensity scores (PS) were used to elucidate predictors for impaired distant metastasis-free survival (DMFS) in PS-matched patients.ResultsMost patient characteristics and treatment modalities applied showed insignificant alteration. Surgical treatment included significantly more often resection of the primary tumor plus neck dissection, tracheostomy and percutaneous endoscopic gastrostomy tube use. Cisplatin-based chemo-radiotherapy was the most frequent. Only insignificant improved disease- (DFS), progression- (PFS) and event-free (EFS) as well as tumor-specific (TSS) and overall survival (OS) were found after 2006 as local (LC) and loco-regional control (LRC) were significantly improved but DMFS significantly impaired. Cox regression applied to PS-matched patients elucidated N3, belonging to cohort 2 and cisplatin-based chemo-radiotherapy as independent predictors for shortened DMFS. The along chemo-radiotherapy increased dexamethasone use in cohort 2 correlates with increased DM.ConclusionsDespite standardized diagnostic procedures, decision-making considering clear indications and improved therapy algorithms leading to improved LC and LRC, shortened DMFS hypothetically linked to increased dexamethasone use had a detrimental effect on TSS and OS.

BRAF mutation correlates with worse local–regional control following radiation therapy in patients with stage III melanoma

Background In patients with stage III melanoma, the use of adjuvant radiation therapy (RT) after lymph node dissection (LND) may be currently considered in selected high-risk patients to improve tumor control. Melanomas harbor BRAF mutations (BRAF+) in 40–50% of cases, the majority of which are on the V600E residue. This study sought to compare the clinical outcomes after RT between patients with BRAF+ and BRAF− melanoma. Methods This was a retrospective review of 105 Stage III melanoma patients treated at our institution with LND followed by adjuvant RT from 2006 to 2019. BRAF mutational status was determined on the primary skin or nodal tissue samples from all patients. We compared characteristics of the BRAF+ and BRAF− groups using Fisher’s exact test and Wilcoxon rank sum test and performed univariate and multivariate analysis using Kaplan–Meier estimates, log-rank tests, and Cox proportional hazards modeling with the clinical outcomes of local–regional lymph node control, distant metastasis-free survival (DMFS), recurrence-free survival (RFS), and overall survival (OS). Results Fifty-three (50%) patients harbored a BRAF mutation (92%, pV600E). BRAF+ patients were younger and had primary tumors more commonly found in the trunk vs head and neck compared to BRAF- patients (p < 0.05). The 5 year local–regional control in the BRAF + patients was 60% compared to 81% in the BRAF- patients (HR 4.5, 95% CI 1.3–15.5, p = 0.02). There were no significant differences in 5-year DMFS, RFS, and OS rates between the two BRAF patient groups. The presence of 4 or more positive LNs remained a significant prognostic factor for local–regional lymph node control, RFS, and OS in multivariate analysis. Conclusions Stage III melanoma patients with BRAF mutation treated with adjuvant RT had > 4 times increased risk of local recurrence or regional lymph node recurrence. These results could be useful for adjuvant RT consideration in lymph node positive melanoma patients and supports other data that BRAF mutation confers radiation resistance.

Choice of Levels in Selective Neck Dissection and Its Impact On Regional Control and Survival in 661 Patients With Head and Neck Squamous Cell Carcinoma

Background: Selective Neck Dissection (SND) is the surgical treatment of choice in suspected or manifest nodal positive squamous cell carcinoma of the head and neck (HNSCC). For SND to be successful, treated levels should be selected accordingly. Aim of this study was to identify neck dissection levels that had an impact on the individual prognosis.Methods: We conducted a retrospective review of SND as part of primary treatment of HNSCC. Overall survival (OS) and regional control rates (RCR) were calculated for all patients.Results: 661 patients with HNSCC were included, 644 underwent ipsilateral and 319 contralateral SND. Average follow up was 78.9 ± 106.4 months. 67 (10.1%) patients eventually developed nodal recurrence. Tumor sites were oral cavity (135), oropharynx (179), hypopharynx (118) and larynx (229). Tumor categories pT1 – pT4a, and all clinical and pathological nodal categories were included. Multivariate analysis indicated improved OS rates for patients undergoing SND in ipsilateral levels I and V as well as level III contralaterally. Analysis for tumor origin showed that SND in ipsilateral level I showed a significantly improved OS in HNSCC of the oral cavity.Conclusion: In HNSCC of the oral cavity, ipsilateral level I needs to be included when performing SND.

The Crusades in North Africa

Although Jerusalem was the ultimate target of many of the largest crusading expeditions during the medieval period, North Africa nonetheless played a crucial role in this movement. Following the establishment of the Crusader states at the end of the 11th century, Latin Christians clashed with the Fatimids of Egypt for regional control of the Levant and Nile River delta. This conflict gave way in the 13th century to the “Egyptian strategy,” through which crusaders thought the most likely way to retake Jerusalem was by attacking the rich and fertile lands of the Nile. The crusades of King Louis IX, which were directed at Egypt and Tunis, were motivated in part by the idea that seizing these lands in North Africa would ultimately lead to the reconquest of the Holy Land. Elsewhere in the Mediterranean, crusading fervor reached the shores of North Africa via the Reconquista. Beginning in the 13th century and extending through the early modern period, Christian leaders in Iberia viewed campaigns in northwest Africa as an extension of their earlier repulsion of Muslims from the peninsula. These crusades, which were theorized as dynastic enterprises that served to both spread Christianity and expand the borders of empires, persisted into the 16th century as the papacy marshaled the assistance of European Christian powers against the Ottomans. The response of Muslim dynasties in North Africa to these expeditions was never uniform, as some preferred diplomacy with the aggressing Franks and others conflict. However, there gradually developed in the Islamic world the idea that a persistent jihad against Mediterranean-wide Frankish aggression was an appropriate response. The memory of medieval crusades was a particularly potent one in France, where Louis IX’s expeditions were evoked during France’s conquest of Algeria in the 19th century.

Study on Regional Control of Tourism Flow Based on Fuzzy Theory

In order to solve the problems of poor regional control effect and high control difficulty coefficient of a traditional tourism flow, this paper puts forward the research of a regional control of tourism flow based on fuzzy theory. The capacity of regional tourism is determined by analyzing the factors that influence the regional control of the tourism flow. The regional tourism flow is divided into different time series by automatic clustering algorithm, the same sample data is fused, and the Euclidean distance between traffic is obtained. The regional tourism flow prediction model is constructed according to fuzzy theory. On this basis, the real-time capacity of regional scenic spot flow is calculated, and the regional tourist flow control model is constructed to realize the regional tourist capacity control. The experimental results show that the regional control error of tourism flow is always lower than 0.40, and the difficulty coefficient of control is low, which has certain advantages.