Colour Doppler and Volume Changes—Anterolateral Thigh Flap: The Sunnybrook Experience

This paper summarizes two recent ALT studies from our institution focusing on the utility of colour flow Doppler's ultrasonography and volumetric changes with radiation. Lastly, we will discuss recommended changes to practice due to the aforementioned studies. Our findings suggest that special care should be made to identify patients at high risk for peripheral arterial disease, and, if the reconstructive surgeon has any concerns, preoperative colour flow Doppler's ultrasonography should be undertaken to better characterize the perforator anatomy and avoid inappropriate flap elevation in patients with silent claudication. Particular detail should be paid to flap thickness especially in patients with increased body habitus. Radiation therapy has on average 20% flap volume-reducing effect, and an overestimation of volume in patients who will be undergoing radiotherapy should lead to the best contour and cosmetic outcomes

Management of oropharyngeal cancer: a cross-sectional review of institutional practice at a large Canadian referral centre

BACKGROUND: Over the years, the treatment of oropharyngeal cancer has changed; in the past, first-line treatment consisted of surgery followed by adjuvant radiotherapy, today however, primary treatment typically involves concomitant chemoradiation, and reserves surgery for salvage. While chemoradiation is the modality of choice for primary management of oropharyngeal cancer, disease characteristics, institutional bias, and patient preferences influence treatment choice. This has lead to variation in the treatment of OPC, and has generated some uncertainly regarding the ideal therapeutic approach. The objective of this study was to describe the treatment of OPC a large Canadian referral center, highlighting trends in treatment choice and outcome. METHODS: This is a cross-sectional retrospective review of clinical practice at Sunnybrook Health Science Centre (Toronto, ON). This investigation documents type of first-line treatment, rates of treatment failure, rates of surgical salvage, and 5-year disease-free survival. This study also asses the therapeutic impact of free-flap reconstruction on the use of a postoperative tracheostomy and/or percutaneous endoscopic gastrostomy tube. RESULTS: The majority of oropharyngeal cancer patients presented with regionally metastatic disease (stage III-IV) and underwent concomitant chemoradiation as first-line treatment. Just over half of patients who failed chemoradiation were eligible for salvage surgery. Forty-six percent of salvage patients recurred at approximately 6 months, and died approximately 12 months following the first sign of disease recurrence. Five-year survival for salvage patients stage II, III, IVA, and IVB was 100%, 54.5%, 53.8%, and 50%, respectively. The incidence of percutaneous endoscopic gastrostomy tubes and tracheostomies was comparable between patients who underwent free-flap reconstruction and patients who did not. CONCLUSION: The modality of choice for first-line treatment of oropharyngeal cancer is concomitant chemoradiation. The moderate failure rate following chemoradiation and the modest survival rate following salvage surgery could indicate that selected patients may benefit from undergoing surgery as first-line treatment. While this study did not show that functional outcomes were better for free-flap patients, it is highly likely that those who received a free-flap did better then they would have had they not undergone reconstructive surgery. More research regarding the therapeutic effects of free-flaps in OPC survivors is needed

Development and validation of a Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN‐HN) in a scarce resource setting: Response to the COVID‐19 pandemic

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163412/2/cncr33114_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163412/1/cncr33114.pd

A Protocol for a Pan-Canadian Prospective Observational Study on Active Surveillance or Surgery for Very Low Risk Papillary Thyroid Cancer

BackgroundThe traditional management of papillary thyroid cancer (PTC) is thyroidectomy (total or partial removal of the thyroid). Active surveillance (AS) may be considered as an alternative option for small, low risk PTC. AS involves close follow-up (including regularly scheduled clinical and radiological assessments), with the intention of intervening with surgery for disease progression or patient preference.MethodsThis is a protocol for a prospective, observational, long-term follow-up multi-centre Canadian cohort study. Consenting eligible adults with small, low risk PTC (< 2cm in maximal diameter, confined to the thyroid, and not immediately adjacent to critical structures in the neck) are offered the choice of AS or surgery for management of PTC. Patient participants are free to choose either option (AS or surgery) and the disease management course is thus not assigned by the investigators. Surgery is provided as usual care by a surgeon in an institution of the patient’s choice. Our primary objective is to determine the rate of ‘failure’ of disease management in respective AS and surgical arms as defined by: i) AS arm – surgery for progression of PTC, and ii) surgical arm - surgery or other treatment for disease persistence or progression after completing initial treatment. Secondary outcomes include long-term thyroid oncologic and treatment outcomes, as well as patient-reported outcomes.DiscussionThe results from this study will provide long-term clinical and patient reported outcome evidence regarding active surveillance or immediate surgery for management of small, low risk PTC. This will inform future clinical trials in disease management of small, low risk papillary thyroid cancer.Registration detailsThis prospective observational cohort study is registered on clinicaltrials.gov (NCT04624477), but it should not be considered a clinical trial as there is no assigned intervention and patients are free to choose either AS or surgery

Predicting complications of major head and neck oncological surgery: an evaluation of the ACS NSQIP surgical risk calculator

Abstract Background The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) universal surgical risk calculator is an online tool intended to improve the informed consent process and surgical decision-making. The risk calculator uses a database of information from 585 hospitals to predict a patient’s risk of developing specific postoperative outcomes. Methods Patient records at a major Canadian tertiary care referral center between July 2015 and March 2017 were reviewed for surgical cases including one of six major head and neck oncologic surgeries: total thyroidectomy, total laryngectomy, hemiglossectomy, partial glossectomy, laryngopharyngectomy, and composite resection. Preoperative information for 107 patients was entered into the risk calculator and compared to observed postoperative outcomes. Statistical analysis of the risk calculator was completed for the entire study population, for stratification by procedure, and by utilization of microvascular reconstruction. Accuracy was assessed using the ratio of predicted to observed outcomes, Receiver Operating Characteristics (ROC), Brier score, and the Wilcoxon signed–ranked test. Results The risk calculator accurately predicted the incidences for 11 of 12 outcomes for patients that did not undergo free flap reconstruction (NFF group), but was less accurate for patients that underwent free flap reconstruction (FF group). Length of stay (LOS) analysis showed similar results, with predicted and observed LOS statistically different in the overall population and FF group analyses (p = 0.001 for both), but not for the NFF group analysis (p = 0.764). All outcomes in the NFF group, when analyzed for calibration, met the threshold value (Brier scores < 0.09). Risk predictions for 8 of 12, and 10 of 12 outcomes were adequately calibrated in the FF group and the overall study population, respectively. Analyses by procedure were excellent, with the risk calculator showing adequate calibration for 7 of 8 procedural categories and adequate discrimination for all calculable categories (6 of 6). Conclusion The NSQIP-RC demonstrated efficacy for predicting postoperative complications in head and neck oncology surgeries that do not require microvascular reconstruction. The predictive value of the metric can be improved by inclusion of several factors important for risk stratification in head and neck oncology

Surgeon-performed ultrasound guided fine-needle aspirate biopsy with report of learning curve; a consecutive case-series study

Abstract Background Fine-needle aspiration biopsy has become the standard of care for the evaluation of thyroid nodules. More recently, the use of ultrasound guided fine-needle aspiration biopsy (UG-FNAB) has improved adequacy of sampling. Now there has been improved access to UG-FNAB as ultrasound technology has become more accessible. Here we review the adequacy rate and learning curve of a single surgeon starting at the adoption of UG-FNAB into surgical practice. Methods UG-FNABs performed at Sunnybrook Health Sciences Centre from 2010 to 2015 were reviewed retrospectively. Nodule characteristics were recorded along with cytopathology and final pathology reports. Chi-square analysis, followed by the reporting of odds ratios with confidence intervals, were used to assess the statistical significance and frequencies, respectively, of nodule characteristics amongst both diagnostic and non-diagnostic samples. A multiple regression analysis was conducted to determine if any nodule characteristic were predictive of adequacy of UG-FNABs. The learning curve was assessed by calculating the eventual adequacy rates across each year, and its statistical significance was measured using Fischer’s Exact Test. Results In total 423 biopsies were reviewed in 289 patients. The average nodule size was 23.05 mm. When examining if each patient eventually received a diagnostic UG-FNAB, regardless of the number attempts, adequacy was seen to increase from 70.8 % in 2010 to, 81.0 % in 2011, 90.3 % in 2012, 85.7 % in 2013, 89.7 % in 2014, and 94.3 % in 2015 (Fischer’s Exact Test, p = 0.049). Cystic (χ2 = 19.70, p <0.001) nodules were found to yield higher rates of non-diagnostic samples, and their absence are predictive of obtaining an adequate biopsy as seen in a multiple regression analysis (p < 0.001) Adequacy of repeat biopsies following an initial non-diagnostic sample was 75.0 %. Conclusions Surgeons are capable of performing UG-FNAB with a learning curve noted to achieve standard adequacy rates. Cystic nodules are shown to yield more non-diagnostic samples in the surgeon’s office