Daniel A. O’Connell

Objective and Subjective Scar Aesthetics in Minimal Access vs Conventional Access Parathyroidectomy and Thyroidectomy Surgical Procedures: A Paired Cohort Study

OBJECTIVE To determine if performing parathyroidectomy surgery through minimal access (MA) incisions has any notable aesthetic or quality-of-life impact on patients compared with conventional access (CON) techniques. DESIGN Paired cohort with (1) a prospective MA incision and scar cohort and (2) a sex- and age-matched (within 3 years) retrospective CON incision and scar cohort. SETTING Tertiary care center. PATIENTS Fifteen patients enrolled in prospective study protocol over a 2-year period; 11 patients met inclusion criteria. A sex- and age-matched retrospective cohort of patients was selected from a patient population undergoing surgical treatment of thyroid neoplastic diseases using a CON approach. Inclusion criteria were use of MA incision for parathyroidectomy and return for long-term follow-up scar assessment. INTERVENTIONS Minimal access parathyroidectomy surgery vs CON thyroidectomy surgical procedures, postoperative follow-up assessment of scar aesthetics by patient and naive viewers, and digital photography and analysis of the surgical incision site. All patients were followed for at least 8 months after surgery. MAIN OUTCOME MEASURES The Patient and Observer Scar Assessment Scale (POSAS), Vancouver Scar Scale, and photographic scar analysis by naive viewers. RESULTS There was no significant difference in scar assessment scale scores between the MA and CON cohorts and no clinically significant difference in overall patient satisfaction with scars between cohorts (POSAS: Patient Scar Assessment Scale, P = .14, and Observer Scar Assessment Scale, P = .79; Vancouver Scar Scale, P = .76). There was increased visibility of scars in the CON cohort to naive viewers. CONCLUSIONS Although they were more readily visible to naive viewers, CON (larger) cervical scars created in parathyroidectomy or thyroidectomy surgery do not translate into decreased patient satisfaction with their scar result. This may indicate a limited quality-of-life benefit in using MA approaches in transcervical surgical procedures.

Swallowing function in patients with base of tongue cancers treated with primary surgery and reconstructed with a modified radial forearm free flap.

OBJECTIVE To report swallowing outcomes and biomechanical properties of the base of the tongue (BOT) and the posterior pharyngeal wall (PPW) in patients who undergo surgical reconstruction with the beavertail modification of radial forearm free flap after primary resection of BOT cancer. DESIGN Prospective cohort study with a 1-year minimum follow-up performed between October 1, 2001, and August 31, 2005. SETTING Tertiary care facility. PATIENTS Patients diagnosed as having primary carcinoma of the BOT were treated with primary surgical resection and reconstruction followed by radiotherapy. Inclusion criteria were collection of videofluoroscopic swallowing study (VFSS) data before and 1 year after surgery. Forty-one patients were treated during a 5-year period, and 20 were included in the final analysis. INTERVENTIONS Reconstruction of BOT defects with the beavertail modification of radial forearm free flap followed by postoperative radiation. MAIN OUTCOME MEASURES Aspiration score, pharyngeal residue score, and biomechanical analysis of BOT and PPW mobility were performed using images from VFSSs. Both the BOT and PPW positions were measured from 2 static bony landmarks. RESULTS Of the 20 patients in the final analysis, 19 (95%) were able to swallow safely at 1 year. Mobility of the BOT after surgery was reduced in all postoperative VFSS data. Anteroposterior dimension or bulk of the BOT was preserved. No significant difference was found in PPW mobility. CONCLUSIONS The beavertail modification of the radial forearm free flap is a good reconstructive option after BOT cancer extirpation. The procedure preserves the bulk of the BOT after cancer treatment and maintains adequate BOT-PPW apposition. This allows structures such as the pharyngeal, oral, and suprahyoid musculature to contract and generate the necessary force to propel the food bolus through the oropharynx, resulting in a safe swallow.

The lip-splitting mandibulotomy: Aesthetic and functional outcomes

To determine the aesthetic and functional outcomes of the most invasive approach to oral cavity/oropharyngeal lesions, the lip-splitting mandibulotomy approach (LSMA), versus the least invasive, the trans-oral approach (TOA). Retrospective paired-cohort study. Thirty-six patients with oral/oropharyngeal cancers treated with primary surgical extirpation, bilateral neck dissections and adjuvant radiation therapy were enrolled. Half underwent LSMA and half TOA. Patients were paired into gender, age and follow-up time matched cohorts. The primary outcome measure was overall patient satisfaction with scar cosmesis assessed with a 10-point Likert scale. Clinician and naïve viewer ratings of disfigurement in addition to the validated Vancouver scar scale (VSS) and patient and observer scar assessment scale (POSAS) were completed. Functional outcomes included lower-lip sensation and movement as well as oral continence assessment. LSMA patients had very high satisfaction and low perceptions of disfigurement with no statistically significant differences between cohorts (p>.05). VSS and POSAS results failed to demonstrate significant differences between groups (p>.05). Naïve observers, however, found the LSMA to be more disfiguring than TOA scars (p=.03). No significant differences in lower-lip sensation to touch, two-point discrimination or temperature distinction were found (p>.05). House-Brackman and movement symmetry scores were significantly indifferent between cohorts (p>.05). Video-fluoroscopic swallowing studies showed no difference in oral continence between cohorts (p>.05). The LSMA provides satisfactory scarring and low self-perception of disfigurement for patients. Moreover, the LSMA does not impact lower-lip sensation, movement or oral continence.

Depression and Survival in Patients With Head and Neck Cancer: A Systematic Review

IMPORTANCE The incidence of depression in patients with head and neck cancer (HNC) is estimated to be as high as 40%. Previous studies have demonstrated an effect of depression on rehabilitation and survival in the posttreatment period. OBJECTIVE To systematically review the relationship between depression and survival in patients with HNC undergoing curative treatment. EVIDENCE REVIEW A search of electronic databases as well as gray literature was undertaken from January 1, 1974, to August 20, 2014, including MEDLINE (via Ovid), EMBASE (via Ovid), CINAHL, EBSCO, PsycINFO (via Ovid), Elsevier Scopus, and Institute for Scientific Information Web of Science Core Collection, using controlled vocabulary and medical subject headings representing HNC, depression, and survival. Articles in these databases were reviewed for inclusion by 2 independent reviewers according to predetermined eligibility criteria and were adjudicated by a third reviewer. The articles were then quantitatively scored using the GRACE (Good Research for Comparative Effectiveness) tool, a validated instrument for assessing the quality of observational studies. Qualitative assessment of each article was then undertaken. FINDINGS A total of 654 references were retrieved across all databases. A review of the abstracts and full texts identified 3 articles, each describing a distinct, single study, including a total of 431 patients, that were eligible for analysis. Scores for the articles as assessed with the GRACE tool ranged from 9 to 11. In each of the 3 studies used in the analysis, the comparison groups were depressed and nondepressed patients as established by a standardized psychiatric assessment tool. Two of the 3 studies demonstrated a statistically significant difference in survival for patients with HNC and depression; however, a sensitivity analysis was not possible due to the incompatible statistical analyses performed in each study. CONCLUSIONS AND RELEVANCE An association between depression and survival in patients with HNC is apparent; however, the strength and etiology of this association is not yet clear. Further directed and multi-institutional study is required to investigate this association and determine appropriate screening and management strategies.

The impact of clinical versus pathological staging in oral cavity carcinoma–a multi-institutional analysis of survival

ObjectivesTo evaluate any disparity in clinical versus pathological TNM staging in oral cavity squamous cell carcinoma (OCSCC) patients and any impact of this on survival.DesignDemographic, survival, staging, and pathologic data on all patients undergoing surgical treatment for OCSCC in Alberta between 1998 and 2006 was collected. Clinical and pathological TNM staging data were compared. Patients were stratified as pathologically downstaged, upstaged or unchanged.SettingTertiary care centers in Alberta, Canada.Main outcome measuresSurvival differences between groups were analyzed using Kaplan-Meier and Cox regression models.ResultsPatients with clinically early stage tumors were pathologically upstaged in 21.9% of cases and unchanged in 78.1% of cases. Patients with clinically advanced stage tumors were pathologically downstaged in 7.9% of cases and unchanged in 92.1% of cases. Univariate and multivariate estimates of disease-specific survival showed no statistically significant differences in survival when patients were either upstaged or downstaged.ConclusionsSome disparity exists in clinical versus pathological staging in OCSCC, however, this does not have any significant impact on disease specific survival.

Correlation of PET-CT nodal SUVmax with p16 positivity in oropharyngeal squamous cell carcinoma

BackgroundThe incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) has been rising in recent years. Given the clinical impact of HPV/p16 positivity in OPSCC, identifying surrogate markers of this disease early in the diagnostic work-up of these patients could improve patient care.MethodsDemographic, pathologic, staging and PET-CT data from patients diagnosed with OPSCC from 2009–2014 were obtained from a prospectively collected provincial cancer registry. Tumor HPV/p16 status was correlated to the maximum standard uptake value (SUVmax) of the primary tumor and cervical nodes. Comparisons of means and multinomial regression models were used to determine associations between p16 status and SUVmax. A diagnostic odds ratio was calculated using a cut off value for predicting HPV/p16 positivity based on nodal SUVmax.ResultsPET-CT and HPV/p16 data was obtained for 65 patients treated surgically for OPSCC. Significantly higher nodal SUVmax was associated with HPV/p16 positive nodes (SUVmax 10.8 vs 7.9). No significant differences were seen between HPV/p16 positive vs negative primary tumor SUVmax (10.3 vs 13.7). In combination with other clinical parameters, higher nodal SUVmax was highly correlated with HPV/p16 positivity.ConclusionElevated nodal SUVmax is a significant predictor of HPV/p16 positive disease.

Predictors of non-diagnostic cytology in surgeon-performed ultrasound guided fine needle aspiration of thyroid nodules

BackgroundFine needle aspiration (FNA) is the standard of care for the diagnostic work-up of thyroid nodules but despite its proven utility, the non-diagnostic rate for thyroid FNA ranges from 6-36%. A non-diagnostic FNA is problematic for the clinician and patient because it can result in repeated procedures, multiple physician visits, and a delay in definitive treatment. Surgeon-performed FNA has been shown to be safe, cost-effective, as accurate as those performed by other clinicians, and has the added benefit of decreasing wait times to surgery. Several studies have examined rates and factors that may be predictive of a non-diagnostic cytology in non-surgeon FNA, but none have evaluated this in surgeon-performed thyroid FNA. If these factors are unique in surgeon-performed vs. non-surgeon performed thyroid FNA, then patients may be more appropriately triaged to FNA by alternate clinicians.ObjectivesThe purpose of this study was to determine the rate and factors predictive of a non-diagnostic FNA in surgeon performed ultrasound-guided FNA of thyroid nodules.MethodsWe conducted a retrospective review of all adult patients who underwent thyroid FNA by a staff, fellow, or resident Otolaryngologist at the University of Alberta between January 2011 and June 2013. Factors analyzed included patient factors, thyroid characteristics, nodule characteristics, and surgeon level of training and experience. Univariate and multivariate binary logistic regression analysis were performed.Results131 patients (180 nodules) were reviewed. The non-diagnostic rate was 23%. Nodules with predominant cystic component, those less than 1 cm, and resident-performed FNA were associated with non-diagnostic cytology (p = 0.001, p = 0.02, p = 0.04 respectively). A cystic nodule was the only independent predictor of non-diagnostic FNA on multivariate analysis (OR = 4.441, 95% CI [1.785-11.045], p = 0.001).ConclusionsThe rate of non-diagnostic thyroid FNA performed by a surgeon with ultrasound guidance is similar to other clinicians. A cystic nodule is a strong independent predictor of non-diagnostic cytology. Non-cystic nodules may particularly benefit from surgeon-performed thyroid FNA due to the high diagnostic rate and potential for earlier definitive management.

Ultrasensitive detection of oncogenic human papillomavirus in oropharyngeal tissue swabs

BackgroundThe incidence of oropharyngeal squamous cell carcinoma (OPSCC) caused by oncogenic human papillomavirus (HPV) is rising worldwide. HPV-OPSCC is commonly diagnosed by RT-qPCR of HPV E6 and E7 oncoproteins or by p16 immunohistochemistry (IHC). Droplet digital PCR (ddPCR) has been recently reported as an ultra-sensitive and highly precise method of nucleic acid quantification for biomarker analysis. To validate the use of a minimally invasive assay for detection of oncogenic HPV based on oropharyngeal swabs using ddPCR. Secondary objectives were to compare the accuracy of ddPCR swabs to fresh tissue p16 IHC and RT-qPCR, and to compare the cost of ddPCR with p16 IHC.MethodsWe prospectively included patients with p16+ oral cavity/oropharyngeal cancer (OC/OPSCC), and two control groups: p16− OC/OPSCC patients, and healthy controls undergoing tonsillectomy. All underwent an oropharyngeal swab with ddPCR for quantitative detection of E6 and E7 mRNA. Surgical specimens had p16 IHC performed. Agreement between ddPCR and p16 IHC was determined for patients with p16 positive and negative OC/OPSCC as well as for healthy control patients. The sensitivity and specificity of ddPCR of oropharyngeal swabs were calculated against p16 IHC for OPSCC.Results122 patients were included: 36 patients with p16+OPSCC, 16 patients with p16−OPSCC, 4 patients with p16+OCSCC, 41 patients with p16−OCSCC, and 25 healthy controls. The sensitivity and specificity of ddPCR of oropharyngeal swabs against p16 IHC were 92 and 98% respectively, using 20–50 times less RNA than that required for conventional RT-qPCR. Overall agreement between ddPCR of tissue swabs and p16 of tumor tissue was high at ĸ = 0.826 [0.662-0.989].ConclusionOropharyngeal swabs analyzed by ddPCR is a quantitative, rapid, and effective method for minimally invasive oncogenic HPV detection. This assay represents the most sensitive and accurate mode of HPV detection in OPSCC without a tissue biopsy in the available literature.

The effects of geography on survival in patients with oral cavity squamous cell carcinoma

OBJECTIVE To assess the survival outcomes of oral cavity squamous cell carcinoma (OCSCC) by differing geographical location. METHODS Demographic, pathologic, treatment, and survival data was obtained from OCSCC patients from 1998-2010 in Alberta, Canada. 554 patients were included from 660 OCSCC patients. Overall, disease-specific, and disease-free survivals were estimated with Kaplan-Meier and Cox regression analyses. Patients were grouped by geographic locations. RESULTS Patients from urban locations had improved overall, disease-specific, and disease-free survival compared to rural locations (p<0.05). Two and five year estimates of overall survival were significantly higher in the urban cohort at 84% and 78%, versus rural with 48% and 44%, respectively (p<0.05). Disease-specific and disease-free survival rates were also superior in the urban group (p<0.05). Diagnosis to treatment time for all 3 geographical groups was not found to be statistically significant (p>0.05). CONCLUSION This study shows that patients with OCSCC living in urban settings have improved survival compared to rural groups.

Metabolic tumour volume as a prognostic factor for oral cavity squamous cell carcinoma treated with primary surgery

BackgroundMetabolic tumour volume (MTV) obtained from pre-treatment 18 F-fluorodeoxydeglucose positron emission tomography with computed tomography (PET-CT) has been validated as an independent predictive factor of outcomes in head and neck cancer patients (HNC) treated with primary chemoradiotherapy (CRT). However its role in patients treated with primary surgery has not yet been studied.ObjectiveTo evaluate the prognostic value of MTV in patients treated with primary surgery for oral cavity squamous cell carcinoma (OCSCC).MethodDemographic and survival data was obtained from patients diagnosed with OCSCC from 2008-2012 in Alberta, Canada. All patients included in the study had PET-CT scan before curative surgical resection. MTV and maximum standardized uptake value (SUVmax) value was delineated from pre-treatment PET-CT scans using Segami Oasis software (Columbus, OH). MTV and SUVmax were divided into intertertile thirds before statistical analysis to allow for in-group comparison of survival.ResultsA total of 80 patients were analyzed using SPSS ver. 20.0 (SPSS Inc, Chicago, IL). Five-year overall, and disease-free survival using Kaplan-Meier curves were 70% and 73% respectively. When the combined SUVmax (tumour primary and locoregional metastasis) was evaluated, it failed to predict overall (HR = 1.0, p = 0.99) or disease-free survival (HR = 1.0, p = 0.227).Conversely an increase in MTV of 17.5 mL (difference between the highest and lowest MTV tertile) was associated with a 12.4 fold increase in risk of disease recurrence (p < 0.001) and an 11.2 fold increase in the risk of death (p < 0.05).ConclusionsThis study shows that MTV is an independent adverse prognostic factor for death and disease recurrence in OCSCC treated with primary surgery.