Quality assessment in head and neck oncologic surgery in a Brazilian cancer center compared with MD Anderson Cancer Center benchmarks

Eugene Nicholas Myers' Lecture on Head and Neck Cancer, 2020: The Surgeon as a Prognostic Factor in Head and Neck Cancer Patients Undergoing Surgery

This paper is a transcript of the 29 th Eugene N. Myers, MD International Lecture on Head and Neck Cancer presented at the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in 2020. By the end of the 19 th century, the survival rate in treated patients was 10%. With the improvements in surgical techniques, currently, about two thirds of patients survive for > 5 years. Teamwork and progress in surgical reconstruction have led to advancements in ablative surgery; the associated adjuvant treatments have further improved the prognosis in the last 30 years. However, prospective trials are lacking; most of the accumulated knowledge is based on retrospective series and some real-world data analyses. Current knowledge on prognostic factors plays a central role in an efficient treatment decision-making process. Although the influence of most tumor- and patient-related prognostic factors in head and neck cancer cannot be changed by medical interventions, some environmental factors-including treatment, decision-making, and quality-can be modified. Ideally, treatment strategy decisions should be taken in dedicated multidisciplinary team meetings. However, evidence suggests that surgeons and hospital volume and specialization play major roles in patient survival after initial or salvage head and neck cancer treatment. The metrics of surgical quality assurance (surgical margins and nodal yield) in neck dissection have a significant impact on survival in head and neck cancer patients and can be influenced by the surgeon's expertise. Strategies proposed to improve surgical quality include continuous performance measurement, feedback, and dissemination of best practice measures.

Robotic neck dissection: state of affairs

PURPOSE OF REVIEW

The progressive growth of endoscopic and robotic-assisted procedures provided the tools for development of remote approaches to the neck, which could avoid a visible large neck scar usually necessary for neck dissections. This review explores the current experience with robotic neck dissection, looking for pros and cons in surgical, oncologic and aesthetic outcomes.

RECENT FINDINGS

Robotic neck dissection was shown to be feasible and well tolerated, with adequate oncological outcomes in different tumours. Although difficult to objectively analyse, cosmetic satisfaction seems to be significatively higher in patients submitted to this procedure when compared with those submitted to conventional neck dissection. The only consistently reported disadvantage was longer operative time. Other potential advantages beyond cosmesis such as improvements on oedema, fibrosis, neck movement, sensory loss and social interactions were not well explored so far.

SUMMARY

Surgical treatment of neck metastasis had several evolutions in the last decades. Robotic neck dissection emerged as an option to avoid extensive visible neck scars, improving cosmesis and probably other functional outcomes, although securing oncologic effectiveness. Technological innovation is increasingly dynamic, promising progressive evolution in robotic surgery. Together, the lack of objective data on functional outcomes warrants the need for further investigation on robotic neck dissection.

Reducing morbidity and complications after major head and neck cancer surgery: the (future) role of enhanced recovery after surgery protocols

PURPOSE OF REVIEW

To review the development and the benefits of enhanced recovery after surgery (ERAS) protocols in non-head and neck disciplines and to describe early implementation efforts in major head and neck surgeries.

RECENT FINDINGS

Several groups have adopted ERAS protocols for major head and neck surgery and demonstrated its feasibility and effectiveness.

SUMMARY

There is growing evidence that clinical and financial outcomes for patients undergoing major head and neck surgery rehabilitation can be significantly improved by standardizing preoperative, intraoperative, and postoperative treatment protocols. Current experience is limited to single centers. A future goal is to broaden the adoption of ERAS in head and neck surgical oncology to include national and international collaboration, data sharing, and learning.

Variations and results of retroauricular robotic thyroid surgery associated or not with neck dissection

Background

Technological advances in the last decades allowed significant evolution in head and neck surgery toward less invasive procedures, with better esthetic and functional outcomes, without compromising oncologic soundness. Although robotic thyroid surgery has been performed for some years now and several published series reported its safety and feasibility, it remains the center of significant controversy. This study shows the results of a case series of robotic thyroid surgery, combined or not with robotic neck dissection.

Methods

A retrospective cohort including 48 cases of robotic thyroid surgery with or without neck dissection, using retroauricular or combined approaches, performed in a tertiary cancer center, comprised the study.

Results

Between 2015 and 2017, we performed 2,769 thyroid surgical procedures, of which 48 (1.7%) were robot-assisted, in 46 patients [26 hemithyroidectomies, 7 total thyroidectomies, and 12 total thyroidectomies (or totalization) with selective neck dissection (SND) II-VI; and 3 neck dissections for thyroid carcinoma]. There were 43 (89.6%) women, and the median age was 35 years. The mean hospital stay was 1.9 days. In 3 (6.2%) cases, drains were not placed (hemithyroidectomies), whereas the other 45 (93.8%) cases had a mean drain stay of 4.4 days (range, 1-9 days). The console time (robotic thyroid resection and neck dissection) ranged from 11 to 200 min (mean 66.1 min; median 40 min), and the total operating room time ranged from 80 to 440 min (mean 227.9 min; median 170 min). Three (6.2%) patients had transient vocal cord paresis. Transient hypocalcemia was reported in three cases (6.2%). There were 30 carcinomas (62.5%), and the mean number of retrieved lymph nodes (LNs) (considering only cases that included robotic neck dissection) was 27.2 (range, 17-40). The mean follow-up time was 17.4 months (range, 1.4-31.9 months), and no recurrence was diagnosed.

Conclusions

The quality outcomes and complication rates are comparable to the conventional approaches. Therefore, robotic thyroidectomy can be an option for selected patients that are motivated to avoid a visible neck scar, treated in high-volume centers. For the patients who require lateral neck dissection, the retroauricular robotic approach could be even more attractive, especially for young patients.

Performance Improvement in Head and Neck Cancer

Performance improvement requires establishing a platform to set benchmarks and monitor the quality of care provided through quality indicators and metrics. This has long been recognized as critical to overall quality improvement and more recently, has become federally mandated. Here, we review recent studies evaluating performance in head and neck cancer care, from those spanning all phases of head and neck cancer care to others focused on head and neck surgical performance, including both national and departmental/institutional efforts.

Impact of Urgent Chemotherapy in Critically Ill Patients

OBJECTIVE

Compare the mortality between critically ill patients who received urgent chemotherapy for a cancer-related life-threatening complication with matched patients (controls) who did not received it.

DESIGN

Propensity score-matched retrospective study.

SETTING

Adult intensive care unit in an oncological hospital.

PARTICIPANTS

All adults with solid tumor or hematological malignancies who received at least 1 day of urgent intravenous chemotherapy for a cancer-related life-threatening complication. Using the propensity score method adjusted for 10 variables, patients who received urgent chemotherapy were matched to patients who did not.

INTERVENTIONS

None.

MAIN OUTCOMES MEASURES

Intensive care unit and hospital mortality.

RESULTS

Forty-seven patients (57% with solid tumors and 43% with hematological malignancies) who received urgent chemotherapy were matched to 94 controls. At intensive care unit admission, patients were similar except that those who received urgent chemotherapy were less likely to have received chemotherapy previously (36% vs 85%; P < .01). The intensive care unit (48.9% vs 23.4%; P < .01) and hospital (76.6% vs 46.8%; P < .01) mortality of the patients who received urgent chemotherapy was higher than the controls. The subgroup analysis showed that the higher mortality was limited to patients with solid tumor.

CONCLUSION

The use of urgent chemotherapy is associated with an increase in the intensive care unit and hospital mortality of unselected critically ill patients with solid tumors but not in patients with hematological malignancies.