Diagnostic accuracy outcomes of office-based (outpatient) biopsies in patients with laryngopharyngeal lesions: A systematic review.

BACKGROUND: In-office biopsies (IOB) using local anaesthetic for laryngopharyngeal tumours has become an increasingly popular approach since the advent of distal chip endoscopes. Although a wide range of studies advocate use in clinical practice, the widespread application of the procedure is hampered by concerns regarding diagnostic accuracy. OBJECTIVE: To assess the diagnostic accuracy of IOB performed via flexible endoscopy. In addition, to analyse modifiable factors that may affect diagnostic accuracy of IOB. DESIGN: A systematic review following the PRISMA guidelines was conducted. PubMed, EMBASE, the Cochrane Library, Web of Science and CINAHL were used in the literature database search. Quality assessment of included studies was perfomed using the Newcastle-Ottawa Scale. RESULTS: A total of 875 studies were identified, 16 of which were included into the systematic review; 1572 successful biopsies were performed using flexible endoscopy; 1283 cases were accurately diagnosed in the outpatient setting (81.6%) and 289 samples did not provide an accurate diagnosis (18.4%). The median sensitivity of IOB was 73%, and the specificity was 96.7%. Analysis of variable factors did not show any significant differences in method of approach, size of equipment (forceps) and additional lighting system or learning curve. CONCLUSION: IOB are a viable tool for diagnostic workup of laryngopharyngeal tumours. Clinicians should be wary of reported limitations of IOB when benign or pre-malignant diagnoses are made. In cases suspicious of malignancy, confirmatory investigation should be conducted.

An open structure questionnaire on reasons for delay in presentation: a study of patients attending clinic with red flag symptoms of head and neck cancer.

PURPOSE: Reasons for delayed presentation in cancer are reported as patient or professional delays. Studies have examined patient demographic factors associated with presentation delay, but it is currently unknown why patients feel they delayed presenting. METHODS: Questionnaire study of consecutive patients attending an urgent suspicion of cancer clinic at a tertiary referral centre in Glasgow over a 3-month period. RESULTS: 395 patients were included. 53 (13%) patients waited 0-7 days, 164 (41%) patients 1-4 weeks, 139 (35%) 1-12 months and 31 (8%) waited longer than 12 months, before presenting. 8 (3%) did not state length of time before presentation. 123 (31%) patients were not worried about their symptoms. 5 of the 13(38%) patients diagnosed with head and neck cancer, waited up to 12 months. 5 (38%) cancer patients delayed presentation because they were not worried about symptoms. CONCLUSION: Patients with head and neck cancer are not worried about their symptoms and delay their presentation, possibly contributing towards later stage diagnosis.

Total thyroidectomy for Graves' disease-what do our patients think? A qualitative cohort study to evaluate the surgical management of Graves' disease.

INTRODUCTION: Total thyroidectomy for Grave's disease has been covered extensively in literature. There are established risks and side effects of the procedure, but in experienced hands, this is minimised. Studies show the physical complication rate of total thyroidectomy, but not a holistic view. The authors pose the question, "what do our patients really think"? Has there been a significant improvement in quality of life by doing this surgery? METHODS: A cohort of patients who underwent total thyroidectomy for Graves' disease between the dates 2015-2018. A total of 95 patients were identified. The Glasgow Benefit Inventory (GBI) was used to ascertain patient's opinions on their surgery. RESULTS: There were 54 responders, 46 female and 8 male. Average age was 41, with a range 20-81. Average GBI scores were 13.35 (SD 30.16). A general subset had an average score of 19.21 (SD = 32.59), a social subset average was 9.57 (SD = 25.61), and a physical subset was average -6.79 (SD = 37.40). Patients' feedback included positive and negative statements on their feelings surrounding pre-operative communication and post-operative side effects. CONCLUSION: Overall, the GBI scores are positive, thereby showing an improvement in quality of life since having total thyroidectomy for Graves. Pre-operative communication was of paramount importance. It should be made clear to patients that they will require medication after surgery. The majority of patients stated they would prefer to know about "minor" post -operative side effects like weight gain or mood change post op. This highlights the importance of the consenting process- Montgomery Ruling-that clinicians explain the risks involved with surgery according to what the patient would deem a risk. In addition, they must be informed of the non-surgical options available, therefore, surgeons should be able to discuss risks and benefits of radio-iodine and anti-thyroid drugs too.

Outpatient (same-day discharge) versus inpatient parotidectomy: A systematic review and meta-analysis.

BACKGROUND: Parotidectomy is often performed as an inpatient procedure largely due to drain insertion; however, outpatient parotidectomy has increasingly become an attractive alternative for its shorter hospital stays and greater efficiency in cost-effectiveness. OBJECTIVE OF REVIEW: To assess the safety and feasibility of outpatient (or same-day discharge) parotidectomy compared with inpatient parotidectomy. TYPE OF REVIEW: Systematic review of the literature and meta-analysis, in accordance with the PRISMA guidelines. METHODS: Pubmed/Medline, Embase, CINAHL, Google Scholar, Web of Science, The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL) were searched for articles published in English between 01/01/1990 and 05/10/2019. The Newcastle-Ottawa Scale was used for quality assessment and Review Manager 5.3 for meta-analyses. MAIN OUTCOME MEASURES: Primary outcomes assessed were postoperative complications including bleeding/haematoma, surgical site infection, seroma and facial weakness. Secondary outcome was readmission rate. RESULTS: Out of 445 studies identified, 6 were selected for systematic review. The overall quality of evidence was moderate. A total of 3664 patients were included (1646 in the outpatient group and 2018 in the inpatient group). Comparing the outpatient with inpatient cohorts, there were lower complications in outpatient groups though not statistically significant for haematoma (OR = 0.45; 95% CI = 0.11-1.92; P = .28), surgical site infection (OR = 0.88; 95% CI = 0.46-1.69; P = .70), seroma (0.79; 95% CI = 0.21-3.03; P = .74), facial nerve weakness (OR 0.39; 95% CI = 0.14-1.08; P = .07) and hospital readmission (OR 0.58; 95% CI = 0.33-1.04; P = .07). CONCLUSIONS: Outpatient parotidectomy appears to be safe and compares favourably to inpatient procedure in postoperative complication and readmission rates.

Primary thyroid squamous cell carcinoma - a Scottish National Case Series.

AIM: To present our national case series on primary thyroid squamous cell carcinoma (PTSCC) and add to the current literature about this rare and aggressive disease. METHODS: Scottish pathology departments were contacted and asked to provide details of patients with the diagnosis of PTSCC from the last 10 years. Three patients were included. RESULTS: Patients 1, 2 and 3 underwent surgical resection. Patients 1 and 3 went on to receive chemoradiotherapy. Patient 1 received nivolumab. Patient 1 died 10 months following diagnosis. Patient 2 and 3 are currently living with no recurrence, over two years post-diagnosis. CONCLUSION: This case series has demonstrated an unusually good set of outcomes for a classically rapidly progressing disease with poor survival rates. This raises the question whether there is a subgroup of PTSCC associated with better outcomes and lower mortality. A patient-centred approach will give optimal patient management.

Microsatellite alteration and immunohistochemical expression profile of chromosome 9p21 in patients with sporadic renal cell carcinoma following surgical resection.

BACKGROUND: Long-term prognostic significance of loss of heterozygosity on chromosome 9p21 for localized renal cell carcinoma following surgery remains unreported. The study assessed the frequency of deletions of different loci of chromosome 9p along with immunohistochemical profile of proteins in surgically resected renal cancer tissue and correlated this with long-term outcomes. METHODS: DNA was extracted from renal tumours and corresponding normal kidney tissues in prospectively collected samples of 108 patients who underwent surgical resection for clinically localized disease between January 2001 and December 2005, providing a minimum of 9 years follow-up for each participant. After checking quality of DNA, amplified by PCR, loss of heterozygosity (LOH) on chromosome 9p was assessed using 6 microsatellite markers in 77 clear cell carcinoma. Only 5 of the markers showed LOH (D9S1814, D9S916, D9S974, D9S942, and D9S171). Protein expression of p15(INK4b), p16(INK4a), p14(ARF), CAIX, and adipose related protein (ADFP) were demonstrated by immunostaining in normal and cancer tissues. Loss of heterozygosity for microsatellite analysis was correlated with tumour characteristics, recurrence free, cancer specific, and overall survival, including significance of immunohistochemical profile of protein expressions. RESULTS: The main deletion was found at loci telomeric to CDKN2A region at D9S916. There was a significant correlation between frequency of LOH stage (p = 0.005) and metastases (p = 0.006) suggesting a higher LOH for advanced and aggressive renal cell carcinoma. Most commonly observed LOH in the 3 markers: D9S916, D9S974, and D9S942 were associated with poor survival, and were statistically significant on multivariate analysis. Immunohistochemical expression of p14, p15, and p16 proteins were either low or absent in cancer tissue compared to normal. CONCLUSIONS: Loss of heterozygosity of p921 chromosome is associated with aggressive tumours, and predicts cancer specific or recurrence free survival on long-term follow-up.

Prediction of general hospital admission in people with dementia: cohort study.

BACKGROUND: People with dementia are extremely vulnerable in hospital and unscheduled admissions should be avoided if possible. AIMS: To identify any predictors of general hospital admission in people with dementia in a well-characterised national prospective cohort study. METHOD: A cohort of 730 persons with dementia was drawn from the Scottish Dementia Research Interest Register (47.8% female; mean age 76.3 years, s.d. = 8.2, range 50-94), with a mean follow-up period of 1.2 years. RESULTS: In the age- and gender-adjusted multivariable model (n = 681; 251 admitted), Neuropsychiatric Inventory score (hazard ratio per s.d. disadvantage 1.21, 95% CI 1.08-1.36) was identified as an independent predictor of admission to hospital. CONCLUSIONS: Neuropsychiatric symptoms in dementia, measured using the Neuropsychiatric Inventory, predict non-psychiatric hospital admission of people with dementia. Further studies are merited to test whether interventions to reduce such symptoms might reduce unscheduled admissions to acute hospitals.

National survey sampling exercise on current practice in channelled local anaesthetic biopsy in suspected head and neck cancer.

OBJECTIVE: Out-patient channelled endoscopic local anaesthetic biopsy reduces the time to diagnosis and wider use may improve cancer pathway times. This study aimed to assess the practice of ENT surgeons using channelled local anaesthetic biopsy. METHOD: A survey was distributed nationally, containing questions about out-patient local anaesthetic biopsy. RESULTS: In total, 58 responses were returned; only 12 per cent of respondents (n = 7) used general anaesthetic biopsy. The advantages of local anaesthetic biopsy were: the avoidance of general anaesthetic for patients with poor performance scores (95 per cent, n = 55) and faster cancer pathway times (91 per cent, n = 53). Disadvantages were: clinics running late (29 per cent, n = 17) and complications (24 per cent, n = 14). The main barrier to using local anaesthetic was access to channelled flexible endoscopy (38 per cent, n = 22), with 43 per cent (n = 25) reporting they were not using out-patient channelled endoscopes but would be interested in using them. CONCLUSION: Surgeons are interested in using channelled endoscopic local anaesthetic biopsy, but they are limited by access to equipment. Increased use of channelled endoscopes may improve national cancer pathway times and avoid challenging general anaesthetics.

Prospective cohort study assessing patient satisfaction and diagnostic accuracy in channeled endoscope local anesthetic biopsy in the investigation of head and neck cancer.

BACKGROUND: There are delays in the head and neck Urgent Suspicion of Cancer (USOC) pathway. Local anesthetic (LA) biopsy with channeled endoscopes in outpatients can reduce time to diagnosis. METHODS: Questionnaire-based prospective study of LA or general anesthetic (GA) biopsy for investigation of cancer from September 2021 to July 2022. RESULTS: 100% (n = 48) were very satisfied or satisfied with their overall experience. 71% (n = 20) of LA patients reported they would prefer to have a biopsy under LA. LA biopsy was 68% sensitive and 100% specific for cancer diagnosis. 28.6% (8) and 10% (2) of LA and GA patients had palliative MDT outcomes. Median time to diagnosis was 44.5 and 49.0 days for LA and GA biopsy, respectively. CONCLUSION: LA biopsy had a high satisfaction rate and is sensitive for diagnosing cancer. LA biopsy can expedite treatment pathways. LA biopsy should be considered as an option for first line investigation.

A case series of interventions and outcomes in patients with laryngeal squamous cell cancer.

OBJECTIVE: The larynx is the second most prevalent subsite for head and neck cancer. Over half of head and neck cancer patients present with advanced disease. We report our regional practices for palliative intent laryngeal squamous cell cancer (SCC). METHODS: Retrospective analysis of patients with laryngeal SCC treated with palliative intent, discussed at the regional head and neck multidisciplinary team meeting from July 2010 to June 2016. RESULTS: A total of 65 patients were included, of whom 45 per cent had potentially curable disease but were not fit for curative treatment. Nine patients (14 per cent) underwent tracheostomy, with mean survival and hospital stay of 278 and 48 days, respectively. Four patients (6 per cent) underwent debulking surgery with mean survival and hospital stay of 214 and 1 days, respectively. CONCLUSION: All palliative treatment measures offered to patients can have an impact on survival and quality of life. Patients should be at the centre of the decision-making process and counselled on the potential impact of interventions.

A Narrative Review of Flutamide in Juvenile Nasopharyngeal Angiofibroma.

The detection of androgen receptors within Juvenile Nasopharyngeal Angiofibroma (JNA) has prompted investigation of the role of Flutamide. The aim of this review is to evaluate Flutamide as a possible neo-adjuvant treatment for JNA. Literature searches were conducted using MEDLINE, EMBASE and Web of Science. The Joanna Briggs Institute (JBI) checklist was used to assess risk of bias. The Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence was used to stratify the evidence level. Literature searches were conducted using MEDLINE, EMBASE and Web of Science. Flutamide as neo-adjuvant treatment potentially causes a reduction in JNA tumor volume by ≥ 25%. Based on the current limited evidence, Flutamide has a limited role in JNA management and further research is required. Its utilization should only follow discussion with the patient, their families, and within the multidisciplinary team.

Low-Grade Chondrosarcoma of the Posterior Cricoid Plate.

This case report presents an unusual case of chondrosarcoma arising from the cricoid cartilage of the larynx. Although these are commonly low-grade malignancies, this patient attended an outpatient respiratory clinic with acute airway obstruction, and went on to require a total laryngectomy due to the size of their tumour.