S. Mark Taylor

Transoral laser microsurgery versus radiation therapy for early glottic cancer in Canada: Cost analysis

OBJECTIVE There is debate over whether radiation therapy or transoral laser microsurgery (TLM) is the superior treatment for early glottic cancer. Both offer similar cure rates and posttherapy quality of life. One factor that could decide the optimum therapy is cost. Several studies in Europe and the United States show that TLM is the most cost-effective treatment. The goal of this study was to conduct the first cost analysis in Canada on the treatment of early glottic cancer comparing radiation therapy and TLM. DESIGN AND METHODS The study was conducted retrospectively. TLM and radiation therapy were broken down into individual components, and then the price for each component was summed. SETTING The study was conducted at the Queen Elizabeth II Health Science Centre in Halifax, Nova Scotia. MAIN OUTCOME MEASURES The main outcome measure was total cost. RESULTS It was found that radiation therapy was approximately four times more expensive than TLM. CONCLUSIONS This study suggests that TLM should be the preferred treatment option for treating early glottic cancer in Canada as it is the most economical and has been shown in previous studies to be as effective as radiation therapy in both cure rates and quality of life.

Is preoperative ultrasonography accurate in measuring tumor thickness and predicting the incidence of cervical metastasis in oral cancer

The need for elective neck dissection in patients with early stage oral cancer is controversial. A preoperative predictor of the risk of subclinical nodal metastasis would be useful. Studies have shown a strong correlation between histological tumor depth and the risk of nodal metastasis. To determine if preoperative ultrasonography is an accurate measure of tumor depth in oral carcinoma. To assess if preoperatively measured tumor depth predicts an increased risk of subclinical metastatic neck disease and thus the need for elective neck dissection. Twenty one consecutive patients with biopsy proven squamous cell carcinoma of the tongue/floor of mouth were analyzed prospectively. Each patient received a preoperative ultrasonography to assess tumor depth which was compared to histological measures. Univariate analysis was used to correlate tumor thickness and T stage with neck metastasis. There was a significant correlation between the preoperative ultrasonography and histological measures of tumor depth (correlation coefficient 0.981, P<0.001). The overall rate of lymph node metastasis was 52%. The rate of metastasis was 33% in N0 necks. In the group with tumors<5mm in depth, the neck metastatic rate was 0%, as compared with 65% in the group 5mm. Using univariate analysis tumor depth and T stage were significant predictors of cervical metastasis (P=0.0351 and P=0.0300, respectively). Preoperative ultrasonography is an accurate measure of tumor depth in oral carcinoma. Tumor thickness is a significant predictor of nodal metastasis and elective neck dissection should be considered when this thickness is 5mm.

Hyperparathyroidism–jaw tumor syndrome

Hyperparathyroidism–jaw tumor (HPT‐JT) syndrome is a rare autosomal dominant multiple tumor syndrome characterized by hyperparathyroidism due to single or multiple‐gland parathyroid tumor(s). Since it was first described in 1990, the genetics underlying the syndrome have been elucidated and typical clinical presentations are becoming clarified as literature describing this rare entity amasses.

The Effectiveness of Modified Cottle Maneuver in Predicting Outcomes in Functional Rhinoplasty

Objective. To assess the outcomes of functional rhinoplasty for nasal valve incompetence and to evaluate an in-office test used to select appropriate surgical techniques. Methods. Patients with nasal obstruction due to nasal valve incompetence were enrolled. The modified Cottle maneuver was used to assess the internal and external nasal valves to help select the appropriate surgical method. The rhinoplasty outcomes evaluation (ROE) form and a 10-point visual analog scale (VAS) of nasal breathing were used to compare preoperative and postoperative symptoms. Results. Forty-nine patients underwent functional rhinoplasty evaluation. Of those, 35 isolated batten or spreader grafts were inserted without additional procedures. Overall mean ROE score increased significantly (P < 0.0001) from 41.9 ± 2.4 to 81.7 ± 2.5 after surgery. Subjective improvement in nasal breathing was also observed with the VAS (mean improvement of 4.5 (95% CI 3.8–5.2) from baseline (P = 0.000)). Spearman rank correlation between predicted outcomes using the modified Cottle maneuver and postoperative outcomes was strong for the internal nasal valve (Rho = 0.80; P = 0.0029) and moderate for the external nasal valve (Rho = 0.50; P = 0.013). Conclusion. Functional rhinoplasty improved subjective nasal airflow in our population. The modified Cottle maneuver was effective in predicting positive surgical outcomes.

Serum microRNA profiling to distinguish papillary thyroid cancer from benign thyroid masses

ObjectivesPapillary thyroid cancer (PTC) is increasing in incidence. Fine needle aspiration is the gold standard for diagnosis, but results can be indeterminate. Identifying tissue and serum biomarkers, like microRNA, is therefore desirable. We sought to identify miRNA that is differentially expressed in the serum of patients with PTC.MethodsSerum miRNA was quantified in 31 female thyroidectomy patients: 13 with benign disease and 18 with PTC. qPCR results were compared for significant fold-changes in 175 miRNAs, against a pooled control.Results128 miRNA qualified for analysis. There were identifiable fold-changes in miRNA levels between benign and control, and between PTC and control. There were statistically significant fold changes in the level of four miRNAs between benign and PTC: hsa-miR-146a-5p and hsa-miR-199b-3p were down-regulated, while hsa-let7b-5p and hsa-miR-10a-5p were up-regulated.ConclusionsMicroRNA is differentially expressed in the serum of patients with PTC. Serum miRNA has the potential to aid in thyroid cancer diagnosis.

Rates of thyroid malignancy by FNA diagnostic category.

BackgroundFine needle aspiration (FNA) of thyroid nodules is a cornerstone of surgical decision making in thyroid cancer. The most widely utilized system for reporting thyroid FNA results is the Bethesda System, which includes predicted malignancy rates for each FNA category. To date there have been few studies to determine whether these predictions are widely applicable.MethodsAll thyroid FNA results at the Queen Elizabeth II Health Science Centre from 2006–2010 were included in this study. The results were tabulated by FNA category and the health records were reviewed to determine whether the patient went on to have surgery and the result of surgical histopathology. Rates of malignancy were calculated and compared to published values.ResultsA total of 1491 thyroid FNAs were included in the study, representing 1117 individual patients with available health records. The majority of these FNAs were Benign, but the proportion of Unsatisfactory FNAs was higher than predicted while Malignant and Suspicious for Malignancy were lower than predicted. Surgery was performed on 388 patients and 110 were positive for malignancy (28%). The malignancy rate for each FNA category was higher than predicted based on literature values.ConclusionsThe proportions of FNA diagnoses and the rates of malignancy for each FNA category at our institution were not consistent with predicted values. It is important for clinicians to base their surgical recommendations on institution specific malignancy rates, not solely on literature values.

The Double Hatchet Flap A Workhorse in Head and Neck Local Flap Reconstruction

A double triangular flap, or hatchet flap, with a partial cutaneous pedicle, has great versatility for facial reconstruction, yet there has been little published discussion regarding the potential applications and/or modifications of the flap. A total of 483 cutaneous malignant neoplasms have been excised and repaired by the senior author (C.C.M.) using a modified bilateral hatchet flap; 366 of the neoplasms were located in the head and neck region. The flap has been used to reconstruct defects in the scalp, eyebrow, lower eyelid, nasal tip, cheek, chin, arms, and torso, with no cases of flap loss. The design of the flap and our modification will be discussed in detail, along with a description of 4 representative cases.

Serum biomarkers of papillary thyroid cancer

ObjectiveTo identify serum biomarkers of papillary thyroid cancer.MethodsProspective analysis was performed of banked tumor and serum specimens from 99 patients with thyroid masses. Enzyme-linked immunosorbent assay (ELISA) was employed to measure levels of five serum proteins previously demonstrated to be up-regulated in papillary thyroid cancer (PTC): angiopoietin-1 (Ang-1), cytokeratin 19 (CK-19), tissue inhibitor of metalloproteinase-1 (TIMP-1), chitinase 3 like-1 (YKL-40), and galectin-3 (GAL-3). Serum levels were compared between patients with PTC and those with benign tumors.ResultsA total of 99 patients were enrolled in the study (27 men, 72 women), with a median age of 54 years. Forty-three patients had PTC and 58 cases were benign tumors. There were no statistically significant differences when comparing all five different biomarkers between PTC and other benign thyroid tumors. The p-values were 0.94, 0.48, 0.72, 0.48, and 0.90 for YKL-40, Gal-3, CK19, TIMP-1, and Ang-1, respectively.ConclusionSerum levels of four of the five proteins were elevated in patients with thyroid masses relative to normal values. However, the difference between benign and PTC was not significant. Two of the markers (Gal-3 & TIMP-1) displayed a greater potential difference, which may warrant further investigation. This study suggests that other serum markers should be sought. This is the first study to investigate potential serum biomarkers based on over-expressed proteins in thyroid cancer versus benign pathology.

Eyelid and brow asymmetry in patients evaluated for upper lid blepharoplasty

IntroductionIn evaluation for blepharoplasty, patients often desire improved cosmesis and/or correction of visual field deficits. However, patients are usually unaware of eyelid or brow asymmetry. Furthermore, the prevalence of eyelid and brow asymmetry is infrequently reported in the medical literature.PurposeTo determine the prevalence of brow and eyelid asymmetry in patients evaluated for upper lid blepharoplasty.MethodsOne hundred consecutive patients evaluated for upper lid blepharoplasty were included in the study. Standard pre-operative photographs were taken of all patients using consistent background and photographic equipment. Two of the authors (KM & AM) independently recorded the margin pupil (MPD), central eyebrow (CED), nasal eyebrow (NED) and temporal eyebrow (TED) distances. To test the inter-observer reliability, the senior author (SMT) recorded the same measurements for 10% of randomly selected patients. We calculated 95% confidence intervals to compare symmetry between the right and left sides.ResultsOne hundred patients (94 female, mean age 57.7) were included in the study. The average MPD, CED, NED and TED distances were 0.55  mm (95% CI 0.45-0.65), 1.77  mm (95% CI 1.47-2.07), 1.34  mm (95% CI 1.14-1.54), and 1.78  mm (95% CI 1.50-2.06), respectively. Ninety-three percent of patients had at least one asymmetric measurement of greater than 1  mm. Seventy-five percent of patients studied had at least one measurement greater than 2  mm while 37 percent had at least one greater than 3  mm.ConclusionBrow and eyelid asymmetry is common in patients being evaluated for upper lid blepharoplasty. The facial plastic surgeon should identify and document facial asymmetry pre-operatively, and discuss it with prospective blepharoplasty patients. This will improve informed consent and patient expectations.

Metastatic acinic cell carcinoma of the parotid gland with ectopic ACTH syndrome.

A62-year-old woman presented with a 12-year history of a painless parotid mass enlarging over the last year. The patient elected to postpone surgery until the tumor became a local wound care problem, with the infestation of maggots. Her past medical history included hypertension, occasional reflux, anemia, and obesity. She was a nonsmoker and rarely sought medical attention. She was on no medications and had no known drug allergies. On examination, there was a conspicuous right parotid tumor 7 cm in greatest dimension. Laterally, it penetrated the full thickness of the right pretragal skin. She had a thick neck with no cervical adenopathy. Otoscopic exam, facial nerve function, and the remainder of the head and neck exam were normal. CT of the head and neck from August 2002 (Fig 1) demonstrated a heterogeneous ill-defined exophytic mass of the parotid measuring 7 cm in maximum dimension with extension into the masseter muscle, and with associated right-sided retromandibular lymphadenopathy. A right total parotidectomy with sacrifice of the facial nerve and right facial sling was performed. The facial nerve was sacrificed due to direct tumor invasion. A forearm free flap was used to reconstruct the facial skin. The surgical pathology was consistent with an acinic cell carcinoma measuring 6 cm in diameter. There was lymphovascular and perineural invasion. Soft-tissue resection margins were positive microscopically. Half the neck nodes removed were positive for malignancy, and there was invasion of the skin and extraglandular soft tissue.