Pre-operative diagnosis of thyroid cancer: Clinical, radiological and pathological correlation

AIM: Ultrasonography and fine-needle aspiration biopsy (FNAB) are the mainstays of diagnosing thyroid cancer accurately and reducing the number of diagnostic lobectomies. No benchmark for diagnostic accuracy has been published in the South African context. This single-institution study addresses this deficit. METHODS: The oncology, pathology and surgical records of all patients diagnosed with thyroid carcinoma from 2004 to 2010 at Groote Schuur Hospital, Cape Town, South Africa, were reviewed and data were recorded on a standardised confidential proforma. The findings on pre-operative clinical assessment, ultrasound and FNAB were correlated with the histopathology results. Diagnostic accuracy for thyroid cancer was determined by correlating pre-operative investigations with the final diagnosis. Sensitivity of ultrasound and FNAB were calculated. RESULTS: A total of 109 patients, 79 female and 30 male, were identified. The majority (99, 90.8%) had well-differentiated thyroid cancers (56 papillary, 30 follicular, 10 mixed and 3 Hurtle cell carcinomas). There were 6 anaplastic and 4 medullary carcinomas. Of the 109 patients 38 had a definite pre-operative diagnosis, in 61 a malignant tumour was suspected, and 10 had surgery for benign disease. FNAB was inadequate in 11 cases and the findings indicated a benign lesion in 47, a suspicious lesion in 13 and a malignant lesion in 38 patients diagnosed with thyroid carcinoma. FNAB diagnosed all patients with medullary and anaplastic carcinoma but less than half of those with well-differentiated thyroid carcinoma. Ultrasound scans detected at least one suspicious feature in 44 patients. Microcalcification was the most common sign. CONCLUSION: The rate of pre-operative diagnosis of well-differentiated thyroid carcinomas in this unit is under 50%, well below international norms. Our standard practice needs to change to include ultrasound-guided FNAB and standardised reporting of high-resolution ultrasound and cytology, before reassessment of our diagnostic accuracy

Breast-conserving therapy for breast carcinoma: Margins, re-excision and recurrence rates

Background: Breast-conserving therapy (BCT) is a wide local excision of the tumour usually followed by radiation treatment to the breast. It is the mainstay treatment for carefully selected patients with early breast cancer. There has not been a formal audit to review BCT outcomes in our unit. Objectives: To determine excision margins, re-excision and local recurrence rates. Methods: A histopathological and oncology records’ review of BCT patients from 01 January 2006 to 31 December 2010. The health faculty’s ethics committee granted approval. Data points accrued included age, histological tumour size, nodal status, tumour type, oestrogen receptor status, lymphovascular invasion, volume of specimen, margin status, management of involved or close margins, radiotherapy, ipsilateral breast recurrence rate and duration of follow-up. Results: A total of 192 patients had BCT. The mean age is 53 years. A median of 229.5 cm3 volume of specimen was excised. Infiltrating ductal carcinoma was the commonest histological type at 79.1%. The resection margin status: positive margins rate 15.1%, close margin rate 8.3% (≤ 1 mm), 35.9% (1 mm–5 mm), 23.4% (6 mm–10 mm) and 17.2% (> 10 mm). Overall, 27 (14.0%) patients underwent a second procedure, 16 (8.3%) patients had re-excision and 10 (5.2%) patients had a mastectomy. At a median follow-up of 60 months, a total of 11 (6.8%) patients had recurrence. Median time to recurrence is 39 months. Conclusion: Positive and close margin re-excision and local recurrence rates in our unit are acceptable and comparable to other units in South Africa and internationally

Collaboration is key to strengthening surgical research capacity in sub-Saharan Africa

The paucity of research in areas of greatest clinical need must be addressed urgently. We propose a model of collaboration in an era of information systems and emerging mobile health technology that has had significant success across the UK and has shown early encouraging results in South Africa (SA). We foresee that recent examples of surgical research collaboratives in SA will continue to promote regional, national and international ‘hub-and-spoke’ models and ultimately increase the South-South collaboration that is urgently needed to diffuse the skills and knowledge required to address the unmet surgical need in sub-Saharan Africa

Collaboration is key to strengthening surgical research capacity in sub-Saharan Africa

Background. GlobalSurg-1 was a multicentre, international, prospective cohort study conducted to address the global lack of surgical outcomes data. Six South African (SA) hospitals participated in the landmark surgical outcomes study. In this subsequent study, we collated the data from these six local participants and hypothesised that the location of surgery was an independent risk factor for an adverse outcome following emergency intraperitoneal surgery.Methods. Participating hospitals contributed 30-day outcomes data of consecutive emergency intraperitoneal surgical operations performed during a 2-week period between July and November 2014. The six heterogeneous hospital cohorts were compared by categorical confounders. The primary outcome measure was in-hospital mortality; secondary outcome measures were in-hospital morbidity and length of stay of >14 days. The unadjusted association between hospital and adverse outcome and the univariate association between categorical confounders and adverse outcome were tested. Significant associations were further tested by a multivariate stepwise forward logistic regression model built for each outcome of interest.Results. Six hospitals (designated 1 - 6) contributed outcomes data for 169 operations. The mean age of the patients was 34.9 years (range 9 - 82), 116 (68.6%) were male, and the majority (37.2%) presented as a result of trauma. Hospital 5 was associated with 76-fold increased odds of in-hospital death and 58-fold increased odds of a major in-hospital complication, and hospital 3 was associated with 3-fold increased odds of any in-hospital complication. The final model predicting in-hospital death had a receiver operating characteristic curve statistic of 0.8892.Conclusion. The hospital is an independent risk factor for risk-adjusted adverse outcomes following emergency intraperitoneal surgery in SA

An autologous dendritic cell vaccine polarizes a Th-1 response which is tumoricidal to patient-derived breast cancer cells.

Breast cancer remains one of the leading causes of cancer-associated death worldwide. Conventional treatment is associated with substantial toxicity and suboptimal efficacy. We, therefore, developed and evaluated the in vitro efficacy of an autologous dendritic cell (DC) vaccine to treat breast cancer. We recruited 12 female patients with stage 1, 2, or 3 breast cancer and matured their DCs with autologous tumour-specific lysate, a toll-like receptor (TLR)-3 and 7/8 agonist, and an interferon-containing cocktail. The efficacy of the vaccine was evaluated by its ability to elicit a cytotoxic T-lymphocyte response to autologous breast cancer cells in vitro. Matured DCs (≥ 60% upregulation of CD80, CD86, CD83, and CCR7) produced high levels of the Th1 effector cytokine, IL12-p70 (1.2 ng/ml; p < 0.0001), compared to DCs pulsed with tumour lysate, or matured with an interferon-containing cocktail alone. We further showed that matured DCs enhance antigen-specific CD8 + T-cell responses to HER-2 (4.5%; p < 0.005) and MUC-1 (19%; p < 0.05) tetramers. The mature DCs could elicit a robust and dose-dependent antigen-specific cytotoxic T-lymphocyte response (65%) which was tumoricidal to autologous breast cancer cells in vitro compared to T-lymphocytes that were primed with autologous lysate loaded-DCs (p < 0.005). Lastly, we showed that the mature DCs post-cryopreservation maintained high viability, maintained their mature phenotype, and remained free of endotoxins or mycoplasma. We have developed a DC vaccine that is cytotoxic to autologous breast cancer cells in vitro. The tools and technology generated here will now be applied to a phase I/IIa clinical trial

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Post-operative Transient Hypoparathyroidism: Incidence and Risk Factors

Background: There is limited data on the incidence and risk factors for developing postoperative hypoparathyroidism (POHP) in the South African setting. Objectives: This study aims to calculate the incidence of postoperative hypoparathyroidism in a South African tertiary setting, and to compare local risk factors for POHP to international published data. Methods: All patients who underwent a total or completion thyroidectomy at an academic referral center from January 2010 to December 2015 were included. Data reviewed included post-operative parathyroid hormone (iPTH) level, demographics, type of operation and lymphadenectomy, size of thyroid glands resected, final histology, extra capsular extension of carcinomas, number of lymph nodes resected, and the number of parathyroid excised. Results: Postoperatively, 29% of patients were diagnosed with hypoparathyroidism. Overall, there was no association between POHP and age or gender. In patients withbenign histology, size was significantly associated with higher rates of POHP. In patients with thyroid carcinoma, lymphadenectomy and the number of lymph nodes resected were associated with higher rates of POHP. Conclusion: The incidence of immediate postoperative hypoparathyroidism is within international standards. Standardized postoperative follow up is necessary, and strategies to improve POPH such as auto transplantation in locally identified high-risk subgroups should be considered.Key words: Postthyroidectomy, Hypocalcaemia, Hypoparathyroidis