Treatment Choices in Managing Bethesda III and IV Thyroid Nodules: A Canadian Multi-institutional Study.

OBJECTIVE: Patient-centered decision making is increasingly identified as a desirable component of medical care. To manage indeterminate thyroid nodules, patients are offered the options of surveillance, diagnostic hemithyroidectomy, or molecular testing. Our objective was to identify factors associated with decision making in this population. STUDY DESIGN: This is a retrospective cross-sectional study of patients with Bethesda III and IV thyroid nodules. SETTING: Multi-institutional. METHODS: Factors of interest included age, sex, socioeconomic status (SES), nodule size, institution, attending surgeon, surgeon payment model, and hospital type. Our outcome of interest was the initial management decision made by patients. RESULTS: A total of 956 patients were included. The majority of patients had Bethesda III nodules (n = 738, 77%). A total of 538 (56%) patients chose surgery, 413 (43%) chose surveillance, and 5 (1%) chose molecular testing. There was a significant variation in management decision based on attending surgeon (proportion of patients choosing surgery: 15%-83%; P≤.0001). Fee-for-service surgeon payment models (odds ratio [OR], 1.657; 95% CI, 1.263-2.175; P < .001) and community hospital settings (OR, 1.529; 95% CI, 1.145-2.042; P < .001) were associated with the decision for surgery. Larger nodule size, younger patients, and Bethesda IV nodules were also associated with surgery. CONCLUSION: While it seems appropriate that larger nodules, younger age, and higher Bethesda class were associated with decision for surgery, we also identified attending surgeon, surgeon payment model, and hospital type as important factors. Given this, standardizing management discussions may improve patient-centered shared decision making.

Quality Indicators of Central Compartment Neck Dissection in Thyroid Surgery.

OBJECTIVES: Quality metrics are an increasingly important means of improving patient care. Variability in the number of lymph nodes removed during central compartment lymph node dissection (CCLND) at the time of thyroidectomy has not been studied. STUDY DESIGN: A retrospective cohort study was performed using American College of Surgeons National Quality Improvement Program (ACS-NSQIP) data. SETTING: Centers in North America and worldwide contributing data to ACS-NSQIP and performing thyroidectomy on adults in inpatient and outpatient settings were included. SUBJECTS AND METHODS: Adult patients undergoing thyroidectomy with or without CCLND were included. Outcomes of interest were number of nodes removed during CCLND and risks of postoperative hypocalcemia. RESULTS: In total, 6108 patients met inclusion criteria (1565 with CCLND). The median number of lymph nodes removed during CCLND was 2. There was no statistically significant association between postoperative hypocalcemia and CCNLD, regardless of number of nodes removed. However, we were underpowered to detect this association based on the overall low nodal yield of many CCLNDs performed. CONCLUSION: In many cases where CCLND is documented as part of thyroidectomy, very few lymph nodes are removed. Our ability to draw conclusions regarding the effect of CCLND on postoperative hypocalcemia is restricted due to the limited nature of many CCLNDs performed.

Intraoperative Primary Tumor Identification and Margin Assessment in Head and Neck Unknown Primary Tumors.

OBJECTIVE: Surgical management of the unknown primary head and neck squamous cell carcinoma (UP HNSCC) remains controversial due to challenging clinical diagnosis. This study compares positron emission tomography-computed tomography (PET-CT) findings with intraoperative identification of primary tumors and compares intraoperative frozen-section margins to final histopathology. In addition, adjuvant therapy indications are provided. STUDY DESIGN: Prospective cohort study. SETTING: Academic university hospital. SUBJECTS AND METHODS: Sixty-one patients with UP HNSCC were included. Patients received PET-CT, followed by oropharyngeal transoral laser microsurgery (TLM). Margins were assessed intraoperatively using frozen sections and afterward by final histopathology. Adjuvant treatment was based on final histopathology. RESULTS: The sensitivity of localizing the primary tumor with PET-CT was 50.9% with a specificity of 82.5%. The primary tumor was found intraoperatively on frozen sections in 82% (n = 50) of patients. Five more tumors were identified on final histopathology, leading to a total of 90% (n = 55). Of the 50 intraoperatively found tumors, 98% (n = 49) had negative margins on frozen sections, and 90% (n = 45) were truly negative on final histopathology. Eighteen patients (29.5%) avoided adjuvant treatment. CONCLUSION: PET-CT localized the primary tumor in fewer than half the cases. This protocol identified 90% of primary tumors. Intraoperative frozen-section margin assessment has shown potential with a specificity of 92% compared to final histopathology. As a result, adjuvant therapy was avoided in almost one-third of our patients.

Does Socioeconomic Status Affect Stage at Presentation for Larynx Cancer in Canada's Universal Health Care System?

OBJECTIVE: Diagnosis of laryngeal cancer is dependent on awareness that persistent hoarseness needs to be investigated as well as access to an otolaryngologist. This study aimed to better classify and understand 3 factors that may lead to variability in stage at presentation of laryngeal cancer: (1) socioeconomic status (SES), (2) differences in access to health care by location of residence (rural vs urban or by province), and (3) access to an otolaryngologist (by otolaryngologists per capita). STUDY DESIGN: Registry-based multicenter cohort analysis. SETTING: This was a national study across Canada, a country with a single-payer, universal health care system. SUBJECTS: All persons 18 years or older who were diagnosed with laryngeal cancer from 2005 to 2013 inclusive were extracted from the Canadian Cancer Registry (CCR). METHODS: Ordered logistic regression was used to determine the effect of income, age, sex, province of residence, and rural vs urban residence on stage at presentation. RESULTS: A total of 1550 cases were included (1280 males and 265 females). The stage at presentation was earlier in the highest income quintile (quintile 5) compared to the lower income quintiles (quintiles 1-4) (odds ratio [OR], 0.68; P < .05). There was a statistically significant difference in stage at presentation based on rural or urban residence within the highest income quintile (OR, 1.73; P < .005). CONCLUSION: There is a relationship between SES and stage at presentation for laryngeal cancer even in the Canadian universal health care system.

Peri-operative factors predisposing to pharyngocutaneous fistula after total laryngectomy: analysis of a large multi-institutional patient cohort.

BACKGROUND: Pharyngocutaneous fistula (PCF) is a problematic complication following total laryngectomy. Disagreement remains regarding predisposing factors. This study examines perioperative factors predicting PCF following total laryngectomy using a large multicenter data registry. METHODS: Retrospective cohort analysis was performed using patients undergoing total laryngectomy in the ACS-NSQIP database for 2006-2014. Sub-analysis was performed based on reconstruction type. Outcome of interest was PCF development within 30 days. RESULTS: Multivariate analysis of 971 patients was performed. Three variables showed statistical significance in predicting PCF: wound classification of 3 and 4 vs. 1-2 (OR 6.42 P < 0.0004 and OR 8.87, P < 0.0042), pre-operative transfusion of > 4 units of packed red blood cells (OR 6.28, P = 0.043), and free flap versus no flap reconstruction (OR 2.81, P = 0.008). CONCLUSIONS: This study identifies important risk factors for development of PCF following total laryngectomy in a large, multi-institutional cohort of patients, thereby identifying a subset of patients at increased risk.

Incidence of cutaneous malignant melanoma by socioeconomic status in Canada: 1992-2006.

BACKGROUND: There are no nationwide studies documenting changes in cutaneous malignant melanoma incidence or association of incidence with socioeconomic status (SES) in Canada. We sought to determine whether melanoma incidence increased from 1992 to 2006 and if there was an association between SES and melanoma incidence. Additionally, we studied whether there was a correlation between province of residence and melanoma incidence. METHODS: Cases from the Canadian Cancer Registry were reviewed. Demographic and socioeconomic information were extracted from the Canadian Census of Population data. Cases were linked to income quintiles by postal code. A negative binomial regression was performed to identify relationships among these variables. RESULTS: Overall incidence of melanoma in Canada increased by 67 % from 1992 to 2006 (p < 0.0001). The increase in incidence was greater for melanoma in situ compared with invasive melanoma (136 % versus 52 % [p < 0.0001]). Incidence was positively correlated with higher income quintiles; the incidence rates among patients in the lowest income quintiles were 67 % of that for the highest income quintiles (p < 0.0001). DISCUSSION: A wide variety of explanations have been postulated for an increased incidence in melanoma among persons of higher SES, including access to and awareness of screening, more access to vacations in sunny climates, and increased leisure time. Variations in incidence of melanoma by urban vs. rural location and province may indicate differences in access to dermatologists across Canada. CONCLUSIONS: Melanoma incidence is increasing in Canada and is higher among people in high SES groups. This rise is likely due to a combination of factors including a true rise in incidence due to increases in sun exposure, and also an increased detection rate, particularly in those who are more aware of the disease and have access to resources for detection.

Incidence of differentiated thyroid cancer in Canada by City of residence.

BACKGROUND: Thyroid cancer incidence in Canada is increased in high socioeconomic groups, and in urban compared with rural areas. The objective of this study was to analyze patterns in thyroid cancer incidence across Canada, particularly with respect to the major urban areas across the country, to identify whether there are any discrepancies in thyroid cancer incidence between Canadian cities. METHODS: Cases were drawn from the Canadian Cancer Registry. Demographic and socioeconomic information were extracted from the Canadian Census of Population data. We linked cases to income quintiles (InQs) by patients' postal codes, and categorized residence by census metropolitan area ((CMA), population >100,000). Within the Toronto CMA we further classified by census subdivision (CSD). RESULTS: There were a total of 33 CMAs across the country. After controlling for demographic and socio-economic factors, we found that the Toronto CMA had an IRR of thyroid cancer that was significantly higher than all other CMAs across the country. For 70% of CMAs and CAs across Canada, the IRR for thyroid cancer was less than half of the IRR for thyroid cancer in the Toronto CMA. As Toronto is one of the largest CMAs, we then subdivided the Toronto area into CSDs to examine how incidence of thyroid cancer varies within this large area. The Toronto City core was used as the reference category and all other areas were compared directly to it. In doing so, we found that a contiguous area of three CSDs North of Toronto had higher IRRs compared with the Toronto city core: Markham, Vaughan and Richmond Hill. CONCLUSIONS: After controlling for demographic and socioeconomic factors, we found that the Toronto CMA has the highest incidence of thyroid cancer nationwide. Several explanations could account for this discrepancy including increased detection due to increased access to imaging, differences in ethnicity or environmental exposures.

Diagnostic imaging dilemma of a clival lesion and its clinical management implications.

Background A retroclival lesion can represent a notochordal remnant-derived mass. The differential diagnoses includes benign lesions such as ecchordosis physaliphora (EP) and neuroenteric cyst or malignant ones such as chordomas. In the case of EP and chordoma, although both types arise from remnants of fetal notochord tissues, they represent two separate entities with different radiographic and biologic behaviors. Case Description We present a case of an incidental finding of a retroclival lesion. The magnetic resonance imaging (MRI) characteristics of the lesion match the neuroimaging profile of a benign lesion and are suggestive of an EP. There was no enhancement noted with the addition of gadolinium. Nonetheless, pathology determined the lesion to be a malignant chordoma. Conclusion The differential diagnosis of a retroclival lesion includes benign and malignant notochordal lesions. Here we present a case of a patient with an incidental finding of a retroclival lesion. Radiographic findings were suggestive of a benign lesion, possibly EP, yet the pathology revealed a chordoma. This report suggests that despite benign imaging, chordoma cannot be excluded and the implications for treatment can be significant. It is important to achieve the correct diagnosis because the prognostic and therapeutic implications are different.

Management of the radial forearm free flap donor site using a topically applied tissue expansion device.

BACKGROUND: The purpose of this study was to prospectively assess clinical outcomes in patients undergoing a new method of donor site management for radial forearm free flaps. METHODS: 177 patients underwent reconstruction of ablative defects of the head and neck using a radial forearm free-flap. All patients had topical tissue expansion tapes applied to their forearms preoperatively. Closure rates, healing time and complications associated with the technique were assessed. RESULTS: Ninety-five percent of patients had their donor sites closed primarily with a locally harvested full thickness skin graft. Complications related to the tissue expansion device included a loss of device adhesion (19.3%) requiring reapplication and minor pruritic reactions (4.1%). CONCLUSIONS: This system of donor site management has resulted in a significant reduction in the requirement of a split thickness skin graft for coverage of the donor site in a radial forearm free flap without any significant economic cost or patient morbidity.

Healing time of radial forearm free flap donor sites after preoperative tissue expansion: randomized controlled trial.

OBJECTIVE: The objective of this study is to test the hypothesis that using a simple and inexpensive preoperative tissue expansion device for radial forearm free flap donor sites will result in a significant reduction in healing time and reduced postoperative pain compared to unexpanded radial forearm free flap donor site skin. METHODS: Twenty-nine patients were enrolled and randomized to either the treatment (tissue pre-expansion) or the control group. An intention-to-treat analysis was used. Healing time was recorded for all patients. The Short Form McGill Pain Questionnaire was used to record arm pain and overall surgical pain 1 week postsurgery. RESULTS: The mean (95% CI) healing time was 5.7 (3.9-7.6) days for the treatment group and 32.5 (12.2-53.0) days for the control group (p < .001). Overall surgical pain (p < .001) was significantly lower in the treatment group. There was no significant difference in donor site arm pain (p < .2). CONCLUSION: Using a simple, noninvasive method of preoperative tissue expansion results in both clinically and statistically significant reductions in healing time and postoperative pain.

Cosmetic and functional outcomes after preoperative tissue expansion of radial forearm free flap donor sites: a cohort study.

INTRODUCTION: The use of the DynaClose topical tissue expansion device for closure of radial forearm free flap (RFFF) donor sites has been demonstrated to significantly reduce healing time and postoperative pain compared to the traditional use of a split-thickness skin graft. However, long-term cosmetic and functional outcomes are not known. OBJECTIVE: The objective of this study was to test the hypothesis that using a new method of donor site management will result in improved cosmesis of RFFF donor sites as assessed by both patients and expert observers without resulting in a reduction in the function of the patients' forearm. METHODS: A cohort of 25 patients previously randomized to either the treatment (tissue expansion) or the control group were assessed at 10 months. The Patient and Observer Scar Assessment Scale (PAOSAS) was used to assess forearm scars, whereas the Michigan Hand Outcomes Questionnaire assessed hand function. RESULTS: Expert observers noted improved scar cosmesis in the treatment group (p  =  .013), with primary closure having the best cosmetic outcome, followed by local full-thickness skin graft closure (p < .001). There was no statistically significant improvement in cosmesis as assessed by patients (p  =  .03) or differences in Michigan Hand Outcomes Questionnaire scores between treatment groups (p  =  .57). CONCLUSION: Using an inexpensive, noninvasive preoperative tissue expansion device safely results in improved cosmetic outcomes as assessed by expert observers, without any significant functional forearm and hand deficits.

Number needed to treat analysis for planned neck dissection after chemoradiotherapy for advanced neck disease.

OBJECTIVE: to analyze how many planned neck dissections (PNDs) must be performed to prevent one fatal neck recurrence after chemoradiotherapy for head and neck cancer with regional metastasis. METHODS: a systematic literature review of studies using chemoradiotherapy as primary treatment for head and neck cancer was performed. Data were extracted where possible to determine estimates for the following variables: (1) percentage of N2-3 necks still harbouring cancer after chemoradiotherapy as proven by pathology from neck dissection (C); (2) percentage of regional recurrence after PND (P); (3) percentage of regional recurrence after salvage neck dissection for patients without initial PND in whom neck disease recurred after chemoradiotherapy (S); and (4) mortality rate of PND (M). The number needed to treat was calculated using the following equation: NNT = 1/[C*(S+M) - (P+M)]. RESULTS: the number needed to treat is 7.5. CONCLUSION: to prevent one fatal neck recurrence after chemoradiotherapy for head and neck cancer with N2-3 disease, one would need to perform 7.5 PNDs. The results of this study will aid surgeons and patients in making more informed decisions regarding neck dissections.

Cancer prevalence and education by cancer site: logistic regression analysis.

BACKGROUND: Previously, using the American National Health Interview Survey (NHIS) and a logistic regression analysis, we found that upper aerodigestive tract (UADT) cancer is correlated with low socioeconomic status (SES). The objective of this study was to determine if this correlation between low SES and cancer prevalence exists for other cancers. METHODS: We again used the NHIS and employed education level as our main measure of SES. We controlled for potentially confounding factors, including smoking status and alcohol consumption. RESULTS: We found that only two cancer subsites shared the pattern of increased prevalence with low education level and decreased prevalence with high education level: UADT cancer and cervical cancer. CONCLUSIONS: UADT cancer and cervical cancer were the only two cancers identified that had a link between prevalence and lower education level. This raises the possibility that an associated risk factor for the two cancers is causing the relationship between lower education level and prevalence.

Does Size Matter? Evaluation of malignancy rate differences between small and large thyroid follicular neoplasms.

OBJECTIVE: To determine if there is a significant difference in the malignancy rates of thyroid follicular neoplasms, based on lesion size. DESIGN: Retrospective study. SETTING: Tertiary care institution. MATERIALS AND METHODS: We retrospectively reviewed charts from patients with a thyroid fine-needle biopsy diagnosis of "follicular neoplasm," who subsequently had thyroidectomy, from 2000 to 2005 at our institution. The size of the lesion was determined from pathology reports or preoperative sonograms. We divided the patients into "large nodule" and "small nodule" groups, based on the median size. MAIN OUTCOME MEASURE: Malignancy rate difference between thyroid follicular neoplasms in large nodule and small nodule size groups. RESULTS: One hundred seventeen patients were included. The median size was 2.2 cm; thus, our small nodule group included lesions < or = 2.2 cm with a malignancy rate of 16.7%. The large nodule group included lesions > 2.2 cm with a malignancy rate of 26.3%. Chi-square analysis showed no statistically significant difference between the groups (p = .20). A receiver operating characteristic (ROC) curve was generated, and all cutoff values of tumour size did not lie far from the line of no discrimination. The area under the ROC curve was 0.52 (95% confidence interval = 0.38-0.66), indicating that the use of increasing tumour size as a diagnostic tool may be worse than chance. CONCLUSION: There was no statistical difference in the malignancy rates of follicular neoplasms observed in the small nodule and large nodule groups. Our ROC curve also indicated that tumour size cannot be used to predict malignancy.

Facial transplantation in a new era: what are the ethical implications?

PURPOSE OF REVIEW: Facial transplantation has become a clinical reality, with the successful completion of five procedures to date in France, China, and most recently the United States. The technical and immunological obstacles associated with this procedure have largely been overcome. There is ongoing debate, however, regarding the ethical implications of the procedure. RECENT FINDINGS: The early literature in facial transplantation stressed the ethical concerns regarding the procedure and recommended that the procedure not be attempted. Recently, however, ethicists and surgeons have created strict ethical guidelines regarding patient selection, informed consent, and accurate evaluation of the risks of the procedure - both medical and psychological. Research has demonstrated that individuals would be willing to accept significant risk to undergo facial transplantation, given the devastating nature of facial disfigurement. In addition, no insurmountable technical or immunological obstacles have been identified to prevent the further success of facial transplantation. SUMMARY: The ethical issues associated with facial transplantation will be further refined as more experience is gained with the procedure. With these strict ethical guidelines and with significant efforts in patient selection and preoperative counseling, facial transplantation will likely continue to remain a viable option for patients with significant facial disfigurement.

Socioeconomic factors in head and neck cancer.

OBJECTIVE: To evaluate the impact of socioeconomic status on the incidence of head and neck cancer using a population-based survey. METHODS: We employed pooled individual-level data from the US National Institutes of Health Survey for the years 1997 to 2006 inclusive. We performed a logistic regression analysis for four variables of socioeconomic status (marital status, family income, highest level of education achieved, immigration status) and four potential confounding variables (age, race, smoking status, alcohol consumption). The effects of these socioeconomic variables on head and neck cancer were compared with their effects on cancers overall. RESULTS: There was a statistically significant increase in head and neck cancer incidence for adult men with the following characteristics: status as single, never married and education less than high school completion. There was a trend toward higher rates of head and neck cancer with annual family income < $20,000 US. No such associations were seen for cancer in general. CONCLUSIONS: There is evidence to support the contention that individuals with more disadvantaged socioeconomic status have higher rates of developing head and neck cancer, even after controlling for associated health behaviours such as smoking and alcohol consumption. This work suggests that further study into the effects of socioeconomic deprivation and head and neck cancer is warranted.

Practical management of recurrent acute otitis media.

Recurrent acute otitis media (RAOM) represents a frequent challenge for the primary care physician and a major source of consultation to otolaryngologists. We recommend insertion of ventilation tubes when school performance or speech acquisition is compromised. Chemoprophylaxis with trimethoprim---sulfamethoxazole (TMP/SMX) is still a viable option in other cases, despite the potential development of drug resistance. Other medical treatments are available, including vaccination and steroids. Finally, we have used limited mastoidectomy in carefully selected cases where retention of infected secretions and lack of aeration are implicated.