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UPMC-Developed Test Increases Odds of Correct Surgery for Thyroid Cancer Patients

PITTSBURGH, July 24, 2014 – The routine use of a molecular testing panel developed at UPMC greatly increases the likelihood of performing the correct initial surgery for patients with thyroid nodules and cancer, report researchers from the University of Pittsburgh Cancer Institute (UPCI), partner with UPMC CancerCenter.

The test, available at the UPMC/UPCI Multidisciplinary Thyroid Center and other diagnostic testing agencies, improved the chances of patients getting the correct initial surgery by 30 percent, according to the study published this month in the Annals of Surgery.

“Before this test, about one in five potential thyroid cancer cases couldn’t be diagnosed without an operation to remove a portion of the thyroid,” said lead author Linwah Yip, M.D., assistant professor of surgery in Pitt’s School of Medicine and UPMC surgical oncologist.  Previously, “if the portion removed during the first surgery came back positive for cancer, a second surgery was needed to remove the rest of the thyroid. The molecular testing panel now bypasses that initial surgery, allowing us to go right to fully removing the cancer with one initial surgery. This reduces risk and stress to the patient, as well as recovery time and costs.”

Cancer in the thyroid, which is located in the “Adam’s apple” area of the neck, is now the fifth most common cancer diagnosed in women.  Thyroid cancer is one of the few cancers that continues to increase in incidence, although the five-year survival rate is 97 percent.

Previously, the most accurate form of testing for thyroid cancer was a fine-needle aspiration biopsy, where a doctor guides a thin needle to the thyroid and removes a small tissue sample for testing. However, in 20 percent of these biopsies, cancer cannot be ruled out. A lobectomy, which is a surgical operation to remove half of the thyroid, is then needed to diagnose or rule-out thyroid cancer. In the case of a postoperative cancer diagnosis, a second surgery is required to remove the rest of the thyroid.

Researchers have identified certain gene mutations that are indicative of an increased likelihood of thyroid cancer, and the molecular testing panel developed at UPMC can be run using the sample collected through the initial, minimally invasive biopsy, rather than a lobectomy. When the panel shows these mutations, a total thyroidectomy is advised.

Dr. Yip and her colleagues followed 671 UPMC patients with suspicious thyroid nodes who received biopsies. Approximately half the biopsy samples were run through the panel, and the other half were not. Patients whose tissue samples were not tested with the panel had a 2.5-fold higher statistically significant likelihood of having an initial lobectomy and then requiring a second operation.

“We’re currently refining the panel by adding tests for more genetic mutations, thereby making it even more accurate,” said co-author Yuri Nikiforov, M.D., Ph.D., professor in the Department of Pathology at Pitt and director of thyroid molecular diagnostics at the UPMC/UPCI Multidisciplinary Thyroid Center. “Thyroid cancer is usually very curable, and we are getting closer to quickly and efficiently identifying and treating all cases of thyroid cancer.”

In 2009, the American Thyroid Association (ATA) revised its guidelines to add that doctors may consider the use of molecular markers when the initial biopsy is inconclusive.

“The ATA is currently revising those guidelines to take into account the latest research, including our findings,” said senior author Sally Carty, M.D., Pitt professor of surgery, co-director of the UPMC/UPCI Multidisciplinary Thyroid Center and recent president of the American Association of Endocrine Surgeons. “The molecular testing panel holds promise for streamlining and eliminating unnecessary surgery not just here but nationwide.”

A previous study led by Dr. Yip showed the panel to be cost-saving when used to help in the diagnosis of thyroid cancer.

Each year, approximately half of the 25,000 patients assessed at UPMC’s Multidisciplinary Thyroid Center are found to have thyroid conditions, and more than 900 thyroid operations are performed by the center’s surgeons. The center aims to provide patients with one-stop evaluation from thyroid experts in a variety of fields, including surgery and endocrinology.

Additional researchers on this study are Laura I. Wharry, M.D., Michaele J. Armstrong, Ph.D., Ari Silbermann, B.S., Kelly L. McCoy, M.D., and Michael T. Stang, M.D., all of the Pitt Department of Surgery; Nobuyuki P. Ohori, M.D., and Marina N. Nikiforov, M.D., all of the Pitt Department of Pathology; Shane O. LeBeau, M.D., Christopher Coyne, M.D., and Steven P. Hodak, M.D., all of the Pitt Department of Endocrinology; Julie E. Bauman, M.D., of the PItt Department of Hematology/Oncology; Jonas T. Johnson, M.D., of the Pitt Department of Otolaryngology; and Mitch E. Tublin, M.D., of the Pitt Department of Radiology.

This study was funded by a grant from UPMC.

Depressive Symptoms Associated With Premature Mortality in Type 1 Diabetes

PITTSBURGH, June 16, 2014 – People with type 1 diabetes have a higher risk of premature death as their number of depressive symptoms increases, a University of Pittsburgh Graduate School of Public Health analysis reveals.

The findings were presented in a press conference at the American Diabetes Association’s 74th Scientific Sessions in San Francisco and used data collected through the Pittsburgh Epidemiology of Diabetes Complications Study, a long-term study of health complications in people with type 1 diabetes.

“Through the 25 years that we’ve been running this study, we’ve found that there’s a lot more to diabetes than high blood sugar,” said senior author Trevor Orchard, M.D., professor of epidemiology at Pitt Public Health. “This link between premature mortality and depression adds to our previous findings, which show that depressive symptomatology predicts cardiovascular disease and demonstrates that doctors need to consider more than adjusting insulin doses when treating type 1 diabetes.”

Lead author Cassie Fickley, M.P.H., C.P.H., analyzed data on 458 study participants with type 1 diabetes who were assessed using the Beck Depression Inventory, a 32-point scale that measures depressive symptoms ranging from loss of appetite to suicidal tendencies. People who score 16 or more points are considered likely to be clinically depressed.

“For every one-point increase on the scale, participants showed a 4 percent increase in risk for mortality, even after controlling for other relevant factors, such as age, gender, smoking, cholesterol levels and high blood pressure,” said Ms. Fickley, a doctoral student in Pitt Public Health’s Department of Epidemiology. “That’s a significant increase and is something we’ll need to explore more to determine if treating depression would translate into lower mortality in people with type 1 diabetes.”

Type 1 diabetes is usually diagnosed in children and young adults and happens when the body does not produce insulin, a hormone that is needed to convert sugar into energy. The disease can lead to nerve, kidney, eye and heart complications but can be controlled with insulin therapy and other treatments.

The Pittsburgh Epidemiology of Diabetes Complications Study is an investigation to document long-term complications of type 1 diabetes among patients at Children’s Hospital of Pittsburgh between 1950 and 1980. Funded by the National Institutes of Health, the study recently was renewed for another five years.

“It is thanks to the volunteers who participate in this study that we are able to make discoveries like this that will contribute to better therapies and life expectancy for children diagnosed with type 1 diabetes today and in the future,” said Dr. Orchard.

Additional authors on this study are Tina Costacou, Ph.D., of Pitt; and Cathy E. Lloyd, Ph.D., of the Open University in the United Kingdom.

Older Age at Onset of Type 1 Diabetes Associated with Lower Brain Connectivity Later in Life

SAN FRANCISCO, March 14, 2014 – Children and adolescents older than age 8 at the onset of type 1 diabetes had weaker brain connectivity when tested later in life relative to those who had earlier ages of diagnosis, University of Pittsburgh Schools of the Health Sciences researchers discovered.

The findings, presented today at the American Psychosomatic Society’s annual meeting, were made by analyzing the brain scans of 44 middle-age adults diagnosed with type 1 diabetes as children.

“Adolescence is a time when the brain matures and makes connections in networks responsible for different functions,” said John Ryan, Ph.D., assistant professor of psychiatry at Pitt. “Further study is needed to determine if and how the onset of type 1 diabetes shortly before or during puberty affects brain function and how better control of the disease at that important time could yield changes in brain function later in life.”

Half the study participants had onset of type 1 diabetes before age 8 and were matched with participants of the same sex and age who were diagnosed after age 8, but before age 17. All were enrolled in the Pittsburgh Epidemiology of Diabetes Complications Study, an ongoing investigation led by Pitt’s Graduate School of Public Health to document long-term complications of type 1 diabetes among patients at Children’s Hospital of Pittsburgh of UPMC between 1950 and 1980.

Type 1 diabetes is usually diagnosed in children and young adults and happens when the body does not produce insulin, a hormone that is needed to convert sugar into energy, and can lead to nerve and organ damage. With insulin therapy and other treatments, the condition can be controlled.

Dr. Ryan noted that his findings were a “snapshot” of scans and tests from one time point, and repeated scans and tests over the next five to 10 years will be critical to determine if the weaker brain connectivity might be linked to cognitive function, and if any predictive markers could be found in the brain scans that might warn of future cognitive impairment.

“The fact that adults with type 1 diabetes are now living longer than ever is certainly a success of treatment advancements, but it also presents an urgent public health problem,” said Caterina Rosano, M.D., M.P.H., senior author of this work and associate professor of epidemiology at Pitt Public Health. “A striking feature of these patients is that they develop brain abnormalities similar to those observed in much older adults without diabetes. It is very possible that older age may amplify the progression of brain abnormalities and possibly lead to a faster cognitive decline than what would be observed because of age alone. We need to rapidly identify and prevent the characteristics of this accelerated brain aging in type 1 diabetics if we want to ensure the highest quality of life for these patients.”

Additional researchers on this project include Howard J. Aizenstein, M.D., Ph.D., Department of Psychiatry, Pitt School of Medicine; and Trevor J. Orchard, M.B.B.Ch., M.Med.Sci., F.A.H.A., F.A.C.E., Department of Epidemiology, Pitt Public Health.

Second Annual Update on the Multidisciplinary Management of Pituitary Tumors

PITTSBURGH, Feb. 27, 2014 – The Second Annual Update on the Multidisciplinary Management of Pituitary Tumors will be held at UPMC Shadyside in Pittsburgh, Pa., on Friday, April 4, 2014.

This conference will cover the most recent advances in the diagnosis and treatment of pituitary tumors, including functioning and nonfunctioning tumors, hypopituitarism, and pituitary adenomas. The role of and advances in surgical and medical therapies for pituitary tumors, and perioperative management of pituitary tumors will also be discussed.

Who Should Attend
This conference is designed for physicians, physicians’ assistants, nurses, and other health care professionals practicing in the areas of Endocrinology and Metabolism, Family Medicine, General Internal Medicine, and Neurosurgery.

Location
UPMC Shadyside, West Wing Auditorium – First Floor, 5230 Centre Avenue, Pittsburgh, PA, 15232

Course Directors
Paul A. Gardner, MD
Associate Professor of Medicine
University of Pittsburgh School of Medicine
Co-Director, Center for Cranial Base Surgery, UPMC

Sue M. Challinor, MD
Associate Professor of Medicine
Division of Endocrinology and Metabolism
University of Pittsburgh School of Medicine

For more information, or to register online, please visit the Center for Continuing Education in the Health Sciences page.

Continuing Medical Education
The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The University of Pittsburgh School of Medicine designates this live activity for a maximum of 6.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Other health care professionals are awarded 0.6 continuing education units (CEUs) which are equal to 6.2 contact hours.

Low Vitamin D Levels During Pregnancy May Increase Risk of Severe Preeclampsia

PITTSBURGH, Jan. 24, 2014 – Women who are deficient in vitamin D in the first 26 weeks of their pregnancy may be at risk of developing severe preeclampsia, a potentially life-threatening disorder diagnosed by an increase in blood pressure and protein in the urine, according to research by the University of Pittsburgh Graduate School of Public Health.

In one of the largest studies to date, researchers studied blood samples collected from 700 pregnant women who later developed preeclampsia in an effort to examine a woman’s vitamin D status during pregnancy and her risk of developing preeclampsia. The full study, funded by the National Institutes of Health (NIH), is available online in the journal Epidemiology, and will publish in the March print issue.

“For decades, vitamin D was known as a nutrient that was important only for bone health,” said lead author Lisa Bodnar, Ph.D., M.P.H., R.D., associate professor in Pitt Public Health’s Department of Epidemiology. “Over the past 10 to 15 years, scientists have learned that vitamin D has diverse functions in the body beyond maintaining the skeleton, including actions that may be important for maintaining a healthy pregnancy.”

Dr. Bodnar and her colleagues also studied blood samples from 3,000 mothers who did not develop preeclampsia. The samples were collected between 1959 and 1965 at 12 U.S. sites enrolled in the Collaborative Perinatal Project. The blood was well-preserved, and researchers were able to test for vitamin D levels decades later.

Scientists controlled for factors that could have affected a woman’s vitamin D status, including race, pre-pregnancy body mass index, number of previous pregnancies, smoking, diet, physical activity and sunlight exposure, which is the body’s primary source of vitamin D.

The researchers found that vitamin D sufficiency was associated with a 40 percent reduction in risk of severe preeclampsia. But there was no relationship between vitamin D and mild preeclampsia. The overall risk of severe preeclampsia in the women sampled was 0.6 percent, regardless of vitamin D status.

“Scientists believe that severe preeclampsia and mild preeclampsia have different root causes,” said senior author Mark A. Klebanoff, M.D., M.P.H., Center for Perinatal Research at The Research Institute at Nationwide Children’s Hospital and the Department of Pediatrics at The Ohio State University College of Medicine. “Severe preeclampsia poses much higher health risks to the mother and child, so linking it with a factor that we can easily treat, like vitamin D deficiency, holds great potential.”

“If our results hold true in a modern sample of pregnant women, then further exploring the role of vitamin D in reducing the risk of preeclampsia would be warranted,” said Dr. Bodnar. “Until then, women shouldn’t automatically take vitamin D supplements during pregnancy as a result of these findings.”

Additional co-authors include: Hyagriv N. Simhan, M.D., Janet M. Catov, Ph.D., James M. Roberts, M.D., and Jill C. Diesel, M.P.H., all of the University of Pittsburgh; and Robert W. Platt, Ph.D., of McGill University.

This research was supported by NIH grant HD 056999.

African-American Women Must Eat Fewer Calories or Burn More to Lose as Much Weight as Caucasians

PITTSBURGH, Dec. 19, 2013 – African-American women may need to eat fewer calories or burn more than their Caucasian counterparts to lose a comparable amount of weight, according to researchers at the University of Pittsburgh School of Medicine in a study published online today in the International Journal of Obesity.

Several studies have suggested that African-American women don’t lose as much weight as Caucasian women in response to the same behavioral interventions of calorie restriction or increased physical activity, said lead investigator, James P. DeLany, Ph.D., associate professor, Division of Endocrinology and Metabolism, Pitt School of Medicine.

“At first, it was thought that perhaps the African-American women didn’t adhere as closely to their calorie prescriptions or that the interventions were not culturally sensitive,” he said. “But even in research projects that were designed to address those possibilities, the difference in weight loss remained.”

Dr. DeLany’s team decided to see if there were metabolic reasons behind the discrepancy by examining body weight changes, energy expenditure, physical activity and energy intake among 39 severely obese African-American and 66 Caucasian women who were participating in a six-month weight loss program of calorie restriction and increased physical activity. They measured body composition and daily energy expenditure at the beginning and end of the intervention period and assessed physical activity levels using multisensor activity monitors. By combining these measures, they obtained objective assessment of intake during the intervention.

The researchers found that the African-American women lost about seven pounds fewer than the Caucasian women, even though their starting body mass index, or BMI, measures were comparable and they followed as closely to the calorie restriction and activity prescriptions. But the African-American women had lower resting metabolic rates and expended less energy daily than the other group.

Calorie prescriptions are typically calculated by determining how many calories are needed to fuel the body’s basic physiological processes and adding the calories needed for other activities. To maintain weight, calorie intake and output should be equal. If more calories are burned than are taken in by eating, weight loss should occur.

“We prescribe how many calories are allowed and how much activity is needed during weight loss interventions based on the premise that people of the same weight have similar metabolic rates,” Dr. DeLany explained. “But to account for their lower metabolic rate, African-American women must further reduce the number of calories they eat or use up more of them with exercise in order to lose the same number of pounds in the same time span as a Caucasian woman of the same weight.”

Other members of the research team are John M. Jakicic, Ph.D., of Pitt School of Education and the Physical Activity and Weight Management Research Center, Division of Endocrinology, Pitt School of Medicine; Jolene B. Lowery, M.D., now of Morehouse College of Medicine; Kazanna C. Hames, Ph.D., now of Mayo Clinic; David E. Kelley, M.D., now of Merck Sharp & Dohme Corp.; and Bret H. Goodpaster, Ph.D., now of Florida Hospital, Orlando.

The study was funded by the Commonwealth of Pennsylvania Department of Health.

Pitt Public Health Findings Suggest Improved Way to Determine Heart Disease Risk in Type 1 Diabetes

PITTSBURGH, Oct. 23, 2013 – Physicians caring for people with type 1 diabetes might be better able to determine their patients’ chances of developing heart disease if they include their levels of protective antioxidants in the assessment, according to a new study from the University of Pittsburgh Graduate School of Public Health.

The study, funded by the National Institutes of Health (NIH), was published today in the November issue of the journal Diabetes Care. It relied on data from “Pittsburgh Epidemiology of Diabetes Complications,” a historical prospective investigation of childhood onset type 1 diabetes cases diagnosed, or seen within one year of diagnosis, at Children’s Hospital of Pittsburgh (now part of UPMC) between 1950 and 1980.

“Currently in clinical practice, physicians assess a patient’s risk factors for developing a disease to determine what, if any, preventative measures to take,” said lead author Tina Costacou, Ph.D., assistant professor of epidemiology at Pitt Public Health. “In our study, we found that the risk of people with type 1 diabetes developing heart disease is better predicted by looking at the ratio of factors representing protection – for example, antioxidants – to those representing harm – for example oxidative stress levels. Currently, doctors most commonly determine heart disease risk by looking at the level of harmful risk factors alone, which may not give an accurate picture of the person’s risk.”

In a statistical analysis over time, it appeared that patients with higher levels of oxidative stress (measured with a urine test) who also had higher levels of a form of the antioxidant vitamin E (measured with a blood test) had a lower risk of developing heart disease compared to those with higher levels of oxidative stress and lower levels of protective antioxidants.

Thus, although both patient groups had higher levels of oxidative stress, they were actually at a different risk of developing heart disease, and only those with the lower levels of antioxidants may need additional treatment to try to prevent heart disease from developing.

“This improved way of determining risk is not necessarily limited to the hypothesis of oxidative stress and antioxidants in terms of heart disease development; it could be expanded to other risk/protective factors and other pathologic conditions. If further supportive data are published, it may one day become possible to better classify a person’s disease risk and individualize treatment based on simultaneous assessment of risk and protective factors,” said Dr. Costacou.

Additional co-authors on this study include Trevor J. Orchard, M.B.B.Ch., M.Med.Sci., Robert W. Evans, Ph.D., and Gerald L. Schafer, M.S., all of Pitt Public Health’s Department of Epidemiology.

This research was supported by NIH grants DK34818 and DK082900.

Retired Night Shift Workers Have Higher Risk of Diabetes, Pitt Study Finds

PITTSBURGH, Oct. 16, 2013 – People who regularly work night shifts in their lifetimes are twice as likely to have diabetes, even if they have retired and returned to a normal, daytime schedule, according to a new study released today in the Journal of Biological Rhythms.

The study complements previous international research that found night shift work is associated with a decrease in metabolic health, impaired glucose metabolism, increased body mass index (BMI), and impaired insulin resistance. In the U.S., a recent Nurses’ Health Study showed a night shift work-related increase in BMI and diabetes risk in working female nurses. The Pitt study is the first to examine the increased risk of diabetes in a large, U.S. sample of retired men and women with varying pre-retirement occupations who are no longer subject to the stresses of night shift work.

“The results are worrisome, given the current epidemic of diabetes and obesity in the U.S.,” said Timothy H. Monk, Ph.D., D.Sc., the study’s lead author and professor of psychiatry at the University of Pittsburgh School of Medicine. “Increasingly, scientific study has confirmed the importance of regular sleep patterns and sufficient sleep in maintaining good health.”

For this study, researchers interviewed more than 1,000 retired night shift workers over 65-years-old living in western Pennsylvania, and divided the respondents into five groups: those who worked night shifts for 0 years, 1 to 7 years, 8 to 14 years, 15 to 20 years and more than 20 years.

The results showed:

  • Both BMI and diabetes rates were higher in retired former night shift workers than in retired former day workers.
  • Night shift retirees were about twice as likely as retired former day workers to be diabetic if they had done night shift work and had a higher BMI.
  • Even when BMI was excluded as a factor, diabetes risk was still higher in retired night shift workers (1.4 times greater risk as opposed to 2 times greater risk).
  • Diabetes risk within the five shift-work-exposed groups did not differ, suggesting that any exposure to night shift work can be associated with increased risk.

“We ought to recognize that there is a health cost to society of exposing large numbers of people to night shift work. Steps should be taken both to encourage day work as an alternative wherever possible, and also to provide education and support for employees who are in occupations that, by their very nature, require work at night.” added Monk.

The authors also recommended that intensive educational campaigns be launched to encourage night shift workers to adopt behavioral strategies regarding diet, exercise and circadian adjustment because of their increased vulnerability to metabolic health problems.

Dr. Monk currently is leading a research study of insomnia in older adults (AgeWise) which is seeking to recruit both seniors with insomnia, as well as those who sleep well. The study is being done through the University of Pittsburgh. Those interested may contact the AgeWise program toll-free at 1-866-647-8283 for more details.

Next Generation Sequencing Test Developed at UPMC Improves Detection of Thyroid Cancer, Reduces Unnecessary Surgeries

PITTSBURGH, Sept. 30, 2013 – A new test for genetic markers that can identify which lumps in the thyroid gland are cancerous and which are harmless – potentially preventing unneeded operations – will make its debut Oct. 1 for patients seeking care at the UPMC/UPCI Multidisciplinary Thyroid Center (MTC).

Growth of a small mass or nodule of the thyroid gland, which is located in the “Adam’s apple” area of the neck, is very common, particularly with aging, said Yuri Nikiforov, M.D., Ph.D., director of thyroid molecular diagnostics at the thyroid center and a professor of pathology at the University of Pittsburgh School of Medicine. The nodule will be benign 90 percent of the time, but an ultrasound-guided biopsy of the suspicious tissue is needed to confirm it is harmless.

“The test we had been using can distinguish between cancerous and benign nodules about 70 percent of the time, but that means the result is uncertain in nearly a third of cases,” Dr. Nikiforov explained. “When that happens, the patient has to have the nodule surgically removed so that more extensive testing can be done. If it turns out to be cancerous, yet another operation might be needed to remove the entire thyroid gland.”

Approximately 100,000 thyroid nodule biopsies done annually yield uncertain results, and most of these patients must undergo follow-up testing and diagnostic surgery, even though the likelihood of having a cancer is very low, he noted.

The new test, called ThyroSeq, was designed and developed by Dr. Nikiforov and his team and uses a technique called next-generation sequencing. This revolutionary technology allows pathologists to simultaneously test for multiple genetic markers using just a few cells collected from the nodule and at low cost. The test detects mutations associated with thyroid cancer in nearly 300 sites of 12 genes in the thyroid cells obtained during the biopsy procedure. UPMC will be the first academic institution in the country where next-generation sequencing technology will be used to improve care for patients with thyroid nodules.

“The ultimate goal of molecular testing is to allow patients to have the initial definitive operation for thyroid cancer and to avoid diagnostic surgery for benign conditions,” said MTC co-director Sally E. Carty, M.D. “The next -generation sequencing test is very exciting, innovative and promising because it’s designed to pick up a much higher percentage of cancers.” Dr. Carty added that the new panel is the same price as the earlier one, which was shown to be cost-effective in a 2012 study led by MTC expert Linwah Yip, M.D.

According to Dr. Nikiforov’s research, ThyroSeq findings suggest that certain gene alteration patterns may be associated with more aggressive cancers, so there is potential to develop tailored treatment approaches for the specific kinds of tumors.

“If we can distinguish aggressive thyroid cancers from cancers that are growing much more slowly and will not metastasize, we might be able to avoid surgery in these low-risk patients in favor of watchful waiting,” said MTC co-director Steven Hodak, M.D. “That’s really the Holy Grail – finding patients both with and without thyroid cancer for whom surgery is unnecessary and not putting them through the expense and risk of surgeries they don’t need.”

Each year, approximately half of the 25,000 patients assessed at the MTC have thyroid conditions and more than 900 thyroid operations are performed by MTC surgeons. The center aims to provide patients with one-stop evaluation from thyroid experts in a variety of fields, including surgery and endocrinology.

Accurately Identifying Neck Tumors Using Robotics Improves Treatment, Survival, Pitt Study Finds

ATLANTA, Sept. 22, 2013 – Using robotic surgery done through the mouth to more accurately identify the cause of lumps in the neck can help physicians to better target more personalized therapies for patients and dramatically improve survival, according to a study led by the University of Pittsburgh’s Umamaheswar Duvvuri, M.D., Ph.D., and encompassing the largest series of patients treated with transoral robotic surgery (TORS) in the U.S.

Dr. Duvvuri, a head and neck and endocrine oncologic surgeon at UPMC and assistant professor of otolaryngology at the University of Pittsburgh School of Medicine, presented the findings today at the American Society for Radiation Oncology’s 55th Annual Meeting in Atlanta.

The number of head and neck cancers, especially those associated with the human papillomavirus, are on the rise. In order to best treat these cancers, doctors need a better mechanism to localize the primary tumor that metastasizes to the neck. Traditionally, these tumors were identified using endoscopy or various scans, but only 30 percent of such cases are accurately found, Dr. Duvvuri said.

“Using TORS, we can remove tissue from the back of a patient’s throat and tongue to get a much more accurate result,” Dr. Duvvuri said. “Doing so triples the chance of identifying the patient’s tumor and improves survival compared to more traditional identification methods.”

In the study, researchers examined 206 head and neck robotic cases performed at UPMC between December 2009 and December 2012. TORS was performed on 22 patients where there was a lump in the neck with unknown origin, also known as occult primary squamous cell carcinoma. Of these 22 patients, the primary tumor was identified in 19 cases.

To determine the impact of identifying the unknown primary tumor on overall survival, researchers matched 69 patients with unidentifed carcinoma (following clinical exam, imaging and surgical evaluation) and 67 patients in which the primary tumor was discovered at the initial surgical evaluation. They found a difference of more than one year in overall survival between undiscovered (8.83 years) and discovered (10.19 years).

Accurately identifying the primary tumor then allows otolaryngologists, radiation oncologists, medical oncologists and others to work together in a multidisciplinary effort on treatment, said Dwight D. Heron, M.D., professor of radiation oncology, otolaryngology and head and neck surgery at Pitt’s School of Medicine, and director of radiation services, UPMC CancerCenter, partner with the University of Pittsburgh Cancer Institute.

“This really allows us to have a more holistic, team approach to cancer care and leads to more personalized treatments for our patients,” Dr. Heron said.

Dr. Duvvuri and his colleagues are working to follow this review of cases with a prospective clinical trial to further understand how TORS can affect treatment and outcomes.

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