Global Forum of Cancer Surgeons: Cancer Surgery During the COVID-19 Pandemic: Impact and Lessons Learned

Background

The purpose of this article is to summarize the opinions of the surgical oncology leaders from the Global Forum of Cancer Surgeons (GFCS) about the global impact of COVID-19 pandemic on cancer surgery.

Methods

A panel session (virtual) was held at the annual Society of Surgical Oncology 2021 International Conference on Surgical Cancer Care to address the impact of COVID-19 on cancer surgery globally. Following the virtual meeting, a questionnaire was sent to all the leaders to gather additional opinions. The input obtained from all the leaders was collated and analyzed to understand how cancer surgeons from across the world adapted in real-time to the impact of COVID-19 pandemic.

Results

The surgical oncology leaders noted that the COVID-19 pandemic led to severe disruptions in surgical cancer care across all domains of clinical care, education, and research. Several new changes/protocols associated with increased costs were implemented to deliver safe care. Leaders also noted that preexisting disparities in care were exacerbated, and the pandemic had a detrimental effect on well-being and financial status.

Conclusions

The COVID-19 pandemic has led to severe disruptions in surgical cancer care globally. Leaders of the GFCS opined that new strategies need to be implemented to prepare for any future catastrophic events based on the lessons learned from the current events. The GFCS will embark on developing such a roadmap to ensure that surgical cancer care is preserved in the future regardless of any catastrophic global events.

A comparison of the immune response of 2003 commercial turkeys and a 1966 randombred strain when fed representative 2003 and 1966 turkey diets

The immunological performance of modern turkeys (one-third each of the Nicholas Turkey, British United Turkeys of America, and Hybrid Turkey strains) hatched in 2003 (2003 strain) was compared with that of a randombred control turkey strain (RBC2) established in calendar year 1966, when fed representative 1966 and 2003 type diets. The 2003 strain had a higher BW and bursa of Fabricius weight relative to total BW compared with the RBC2 strain (P = 0.0001) when measured at 12 and 13 d of age, respectively. Total antibody response against SRBC did not differ between strains, nor were any differences observed in the IgM antibody levels either during a primary or secondary SRBC challenge. However, RBC2 poults had higher IgG levels (P = 0.02) than the 2003 strain at 7 d post secondary SRBC challenge. No significant differences were observed in the phytohemagglutinin phosphate-mediated toe-web lymphoblastic response. However, the 2003-strain turkeys seemed to have a better swelling response (P = 0.06) than the RBC2-strain turkeys when measured at 24 h post phytohemagglutinin phosphate injection. The modern turkeys also had higher mononuclear phagocytic system function, as measured by clearance of carbon particles from the bloodstream 5 min post intravenous injection of colloidal carbon (P = 0.02). These results indicate that selection over the years of turkeys for improved performance traits has had no adverse effects on most of the immune system indicators when examined prior to sexual maturity in the current study.

Role of iodine-131 MIBG scanning in the management of paediatric patients with neuroblastoma

OBJECTIVES

To evaluate the role of iodine-131 metoiodobenzylguanidine (iodine-131 MIBG) scanning in the management of paediatric patients with neuroblastoma.

SUBJECTS AND METHODS

Forty-three iodine-131 MIBG scans were performed on 26 children, 18 male and 8 female, ranging in age from 8 months to 11 years. Bone scan, computed tomography (CT) images and findings of bone marrow biopsy were compared with the iodine-131 MIBG scan findings.

RESULTS

Of the 26 patients, 18 (69%) showed abnormal iodine-131 MIBG avidity and were proven to have a neural crest tumour on histology. The remaining 8 (31%) patients had normal iodine-131 MIBG scans, and histology showed a malignancy other than a neural crest tumour. Iodine-131 MIBG scans showed the primary site in 16 of 17 patients while CT showed 14 primary sites. In follow-up studies, the results were as follows: iodine-131 MIBG showed no evidence of disease in 4 compared with 3 on CT, persistent disease in 2 on iodine-131 MIBG and 4 on CT; recurrence in 1 on iodine-131 MIBG and 0 on CT; MIBG scans detected double the number of bony lesions compared with bone scans. The findings on iodine-131 MIBG scans and bone marrow biopsy were in agreement in 16/18 cases. Patients in whom iodine-131 MIBG scans showed disease resolution had better clinical outcomes.

CONCLUSION

The findings indicate that iodine-131 MIBG scanning is useful for the diagnosis, staging, evaluation of response to therapy and detection of recurrences in patients with neuroblastoma. It exhibited a clear advantage over CT in detecting the primary site and soft issue metastases and was also superior to bone scanning in detecting skeletal metastases. It also reliably demonstrated bone marrow involvement.

A comparison of the immune response of a 2001 commercial broiler with a 1957 randombred broiler strain when fed representative 1957 and 2001 broiler diets

Immunocompetence of the 2001 Ross 308 broiler strain and the 1957 Athens Canadian Randombred Control (ACRBC) strain was compared when they were given diets representative of those that were being used in 1957 and 2001. Antibody response against SRBC, in vivo lymphoproliferation against Phytohemagglutinin-P (PHA-P), and inflammatory and phagocytic responses of the macrophages were measured. The Ross 308 strain on the 2001 diet had higher BW at 24 d of age (P = 0.0001), whereas the ACRBC had greater lymphoid organ weights (except thymus) relative to BW (P < or = 0.003). The ACRBC strain showed greater antibody responses against SRBC than the 2001 Ross 308 birds for much of the trial (P < or = 0.0362). However, the Ross 308 broilers had greater PHA-P-induced toe-web swelling response (P < or = 0.0129). Inflammatory exudate cell numbers were higher in the Ross 308 broilers than in the ACRBC birds (P = 0.0261). The percentage of macrophages that phagocytized SRBC was comparable between the two strains, but the number of SRBC phagocytized by individual macrophages was higher (P = 0.0122) in the Ross 308 broiler than in the ACRBC chickens. Nitrite production by macrophages following lipopolysacharide stimulation was comparable between the two strains. Interactions of diet, strain, and sex were inconsistent among all parameters tested. In conclusion, the current study suggested that genetic selection for improved broiler performance has resulted in a decrease in the adaptive arm of the immune response but an increase in the cell-mediated and inflammatory responses.

Interactions of poult enteritis and mortality syndrome-associated reovirus with various cell types in vitro

An avian reovirus, ARV-CU98, has recently been isolated from poults experiencing poult enteritis and mortality syndrome (PEMS). To further understand ARV-CU98 and its role in PEMS, the current study investigates interactions of ARV-CU98 with various cell types in vitro. When macrophages, B cells, T cells, and liver cells of chicken or turkey origin were co-incubated with ARV-CU98, only cells of liver origin demonstrated cytopathic effects, the presence of viral antigen, and reduced metabolic activity over time. Furthermore, distinctive pockets of viral particles were evident in electron microscopic examination of a chicken hepatocellular carcinoma (LMH) cell line, but not in a chicken macrophage cell line (MQ-NCSU) co-incubated with virus. Additional evidence of viral replication in LMH, cells but not MQ-NCSU cells was demonstrated by the presence of two viral bands (43 and 145 kD size) in cell lysates from LMH cells exposed to ARV-CU98. Although not capable of being infected by ARV-CU98, MQ-NCSU cells do appear to be activated by the virus since IL-1 mRNA expression is increased in MQ-NCSU cells 2 h after addition of the virus. LMH cells exposed to the virus demonstrate a decrease in IL-1 mRNA expression by 8 to 10 h after addition of the virus, perhaps corresponding to the initiation of infection by the virus. In conclusion, this study demonstrates that ARV-CU98 actively infects and replicates in LMH cells, but not in lymphocytes or macrophages, suggesting that the liver may be a target and site of replication of ARV-CU98 in poults experiencing PEMS.

Is surgical intervention in acute cholecystitis in pregnancy justified?

Over a three-year period 49 cases were admitted to our hospital with an acute abdomen in pregnancy due to cholecystitis. In this article we compare surgical treatment with medical treatment and consider the aetiology of the high prevalence. Out of the 49 cases admitted, 15 cases (31%) had emergency cholecystectomy within the first week and 34 cases (69%) were treated conservatively of whom 24 relapsed many times and had to be readmitted to the hospital (mean number of admissions was 4 +/- 1.4 and the mean hospital stay was 8 +/- 2.3 days) and of the remaining 10 on conservative management, three had emergency cholecystectomy and seven reached term safely. The maternal morbidity is significantly less in the surgically treated group (P < 0.0001) but the perinatal outcome failed to show any significant difference. The frequency of acute cholecystitis in pregnancy (0.33%) is high in comparison with other studies. Although tocolytics were used in 13 cases they did not improve the fetal outcome significantly and had maternal and fetal side effects. In conclusion early surgical intervention is recommended and the use of tocolytics did not improve the perinatal outcome.

Xanthogranulomatous pyelonephritis presenting as a pseudotumor in a 2-month-old boy

The authors report on a 2-month-old boy presenting with a right renal mass. Investigations including ultrasound scan and computed tomogram were suggestive of a renal tumor. A right nephrectomy was performed with great difficulty because of dense adhesions to the adjacent structures. Cut section of the specimen showed the entire kidney to be replaced by cheesy-yellow areas. Histological examination was suggestive of xanthogranulomatous pyelonephritis. Although rare at this age, xanthogranulomatous pyelonephritis should be considered in the differential diagnosis of a renal mass in children. The lesion is unique among the inflammatory conditions in closely mimicking renal tumours clinically. A thorough histological examination also is suggested because the features can get confused easily with those of renal tumors.

Rapid communication: Cervical Chlamydia trachomatis in women at low risk for infection

BACKGROUND

Evidence suggests that the bacterium Chlamydia trachomatis can cause asymptomatic genital infection in persons at risk for acquisition of the organism. We employed 2 independent molecular screening systems to assess such inapparent cervical chlamydial infections in low-risk female patients attending general (non-STD) clinics in 2 locations.

METHODS

Three hundred seventy-five cervical swab samples were obtained in duplicate from patients attending a general women's clinic (278 samples) and a colposcopy clinic (97 samples). One set of samples from the general clinic was screened by a highly-specific molecular hybridization system, using a probe targeting the chlamydial 16S ribosomal RNA; the other set was screened with the use of the Chlamydiazyme test. Samples from the colposcopy clinic were screened using a sensitive and specific polymerase chain reaction (PCR) assay system targeting chlamydia; the duplicates were assayed by direct fluorescent antibody assay (DFA).

RESULTS

Of the 278 patients screened by RNA-directed hybridization, 6.5% were positive for C. trachomatis, in contrast to screening of duplicate samples via Chlamydiazyme, which indicated that 3.6% were infected. PCR-based screening of the additional 97 patients gave a positivity rate of 17.5% for the organism, whereas DFA on duplicate samples from this group showed only 7.5% positive.

CONCLUSIONS

These observations suggest that the level of asymptomatic cervical C. trachomatis infection is significant even in women who are at low risk for such infections; the data also indicate that results from standard laboratory screening for chlamydia should be viewed with caution.

Primary midline cranial vault lymphoma simulating a parasagittal meningioma: the role of angiography in preoperative diagnosis

Primary non-Hodgkin's lymphoma (NHL) of the skull with extra- and intracranial extension without systemic or skeletal manifestation in a non-immunocompromised patient is extremely rare. Up to date, only nine such cases have been reported in the literature and in none was the lesion located in the midline. The authors report a unique case of a primary NHL involving the midline of the cranium. The lesion presented as a slowly growing scalp swelling mimicking a parasagittal meningioma. The angiographic findings of mild vascularity in the periphery of the tumor and downward displacement of a patent superior sagittal sinus indicated that the lesion was unlikely to be a meningioma. Neurosurgeons must maintain a broad differential diagnosis in any patient with a scalp mass eroding through the skull and associated neurological symptoms or signs. An intraoperative frozen section is recommended since the identification of a lymphoma is likely to influence the neurosurgeon's decision about the extent of the surgical excision.

Surgery for bleeding esophageal varices

A total of 72 patients were operated for bleeding esophageal varices over five years. Cause of portal hypertension was cirrhosis in 33, Schistosomal fibrosis in 23 and a combination of the two diseases in 3 cases. Biopsy was not available in 13 patients. Fifty-eight patients were child grade A and B, while 14 patients were grade C. Overall, there were 16 hospital deaths (22.2%) and 28 patients had complications (38.8%). Specifically, Hassab's operation was done in 40 patients with 12.5% mortality and 11.7% incidence of rebleeding. Hassab's operation plus esophageal transection in 13 patients was associated with 46.1% mortality and no incidence of rebleeding. Warren's splenorenal shunt, done in 11 patients, was accompanied by 1 (9%) death and no incidence of rebleeding. Mortality rate increased significantly when esophageal transection was added to Hassab's operation. It is concluded that for low risk patients being operated electively, Warren's shunt is an acceptable alternative to Hassab's operation which is better suited to emergency situations. Esophageal transection should not be added to Hassab's operation because this increases the mortality.

Pectoralis major myocutaneous flap for reconstruction of defects following resections in head and neck area

Pectoralis major myocutaneous flap (PMMF) has become the standard for reconstruction of major defects in head and neck area. Eleven cases, operated over a three year period, in which PMMF was used for reconstruction have been reviewed retrospectively. Nine patients had oral squamous cell carcinoma, one had a basal cell carcinoma of the external ear and one had lost skin and soft tissue of neck following synergistic gangrene. Ten of the eleven flaps survived (success rate 91%). One of the three rib grafts used to reconstruct mandible got infected and had to be removed. Three patients developed wound infections and one had a temporary orocutaneous fistula which closed spontaneously. This brief experience confirms the reliability and efficiency of PMMF for head and neck reconstruction.

Merits of posterior lumbotomy approach to the upper urinary tract

Posterior lumbotomy incision is anatomically the most straightforward approach to the kidney and the upper ureter. A brief description of the operative technique is followed by a report of the author's experience with this approach in 38 operations on the upper urinary tract. The access provided was judged to be adequate in 35 (92%) patients although twelve patients (31.5%) required upward extension of the incision for the access to become adequate. Thirty-three patients (87%) were mobile and did not require analgesia by third postoperative day. Average hospital stay was 6 days. Complications occurred in seven patients (21%). There was no hospital mortality. This incision is recommended for relatively simple operations of upper urinary tract like pyelolithotomy and ureterolithotomy.

Splenic abscess: Presentation, diagnosis and management

Splenic abscess is infrequently encountered. This paper reports on the diagnosis and management of six cases from Southern Saudi Arabia. Common presenting features were diffuse abdominal pain and fever. Signs localized to left upper quadrant of the abdomen were present in only two patients. The difficulty of diagnosis is signified by the fact that two cases were overlooked during initial surgery. The computed tomographic (CT) scan was quite accurate in three cases while ultrasound was reliable in five patients. Known causes of splenic abscess were present in four of the six patients. Two patients had gangrenous bowel and one each had bacterial and splenectomy. Review of the literature shows that splenectomy remains the treatment of choice while CT-guided aspiration is being increasingly employed especially for the poor-risk patients with unilocular abscesses.

Molecular evidence for the presence of chlamydia in the synovium of patients with Reiter's syndrome

OBJECTIVE

There is much evidence indicating that chlamydial antigens in the synovium may be critical in the pathogenesis of Reiter's syndrome (RS), but it is not known whether intact organisms are present in that tissue in any stage of the disease. The present study was undertaken to begin to address this question.

METHODS

We used a highly specific and sensitive molecular hybridization screening system which detects chlamydial RNA, to examine synovial biopsy samples from 22 patients with various arthropathies, including 9 with RS.

RESULTS

Seven of the 9 RS patients were positive for chlamydial RNA, while 3 of the 13 non-RS patients were also positive; positive results in the non-RS patients probably indicate the actual presence of the organism, since these patients had arthritis that was otherwise incompletely explained.

CONCLUSION

The detection of chlamydial RNA, in combination with previous findings of chlamydia-like particles and/or chlamydial antigens in the synovium of RS patients, suggests that whole bacterial cells are present in that tissue.

Reconstruction of thumb in traumatic or congenital loss

Reconstruction of thumb after traumatic or congenital loss in 17 cases is reported. Cases were divided into three groups according to the level of thumb loss. There were two cases in distal zone, seven in middle and eight in proximal zone. Thirteen cases were traumatic in origin and four had congenital loss. Different reconstruction procedures were used at each level. Osteoplastic reconstruction for the middle zone and index finger pollicization for proximal thumb loss are considered to be most useful methods of thumb reconstruction if microsurgical facilities are not available.

RNA-directed molecular hybridization screening: evidence for inapparent chlamydial infection

Both clinical and epidemiological data suggest that inapparent infection by Chlamydia trachomatis occurs in humans. To confirm and study such infections, we developed a hybridization screening system directed toward chlamydial ribosomal RNA (rRNA). Six restriction endonuclease fragments derived from the cloned rrnA operon of chlamydial serovar L2(434) were tested as hybridization screening probes, but only one fragment encoding the 5' portion of the 16s rRNA gene plus some upstream flanking sequence was both sensitive and highly specific in such experiments. In Northern slot blot assays, hybridization analyses with this fragment as probe routinely detected one picogram or less of chlamydial RNA when that RNA was bound to membranes alone or as part of a mixture with a vast excess of mammalian RNA. The probe did not hybridize to RNA from mammalian and relevant bacterial sources but did hybridize to rRNA from B (ocular) and E (genital) serovars of C. trachomatis. Experiments using RNA from conjunctival biopsies and standard conjunctival swab samples from cynomolgus monkeys showed that the probe reliably distinguishes between known chlamydia-infected and uninfected samples. This suggests that it may be useful for clinical screening. Characterization assays for the RNA-directed probe screening system in this monkey model of trachoma provide initial molecular evidence that ocular chlamydial infection may persist longer than previously thought, based solely on direct fluorescence antibody assay (DFA) and culture analyses.

Surgical audit: A prospective study of the morbidity and mortality of acute appendicitis

Between March and September 1989, acute apendicitis was clinically diagnosed in 317 patients who were studied as part of a prospective surgical audit. The study was designed to determine the accuracy of diagnosis, comparison of the macroscopic appearance of the appendix at operation, and subsequent histopathology and complications associated with the morbidity and mortality of emergency appendectomy. The clinical diagnosis was correct in 278 patients (88%). Thirty-nine (12%) of the patients had a negative laparotomy. There was no mortality, and wound infection was the source of increased morbidity in 37 (12%) patients. The highest incidence of wound infection was among those who had pus in the peritoneum (20%) or had a perforated or gangrenous appendix (25%). When the macroscopic appearance of the appendix was compared with the subsequent histopathological findings, a false positive error of 7% and a false negative error of 42% was found. During appendectomy the gross appearance of the appendix must be carefully noted so that a meticulous surgical technique can be complemented by appropriate antibiotic prophylaxis against wound infection, started at the time of surgery.

Transfer of latissimus dorsi muscle as myocutaneous flap

Latissimus dorsi muscle can be transferred as a muscle flap, myocutaneous flap or as a functioning muscle. It can also be used as free muscle or myocutaneous flap. Its long vascular pedicle makes it possible to rotate this muscle through a wide arc of rotation covering neck and upper extremity. It is a large muscle with extensive area and is ideally suited to cover large areas of skin defect. We are reporting eight cases of latissimus dorsi transfer as a myocutaneous flap to cover the skin defects in neck, axilla and upper extremity. Two cases were post-burn and five post-traumatic. One defect was secondary to excision of a large neurofibroma in the area of elbow. Most of the defects at donar sites could be closed primarily. There was only a partial marginal necrosis of transferred tissue in one case. Based upon the knowledge of its vascular anatomy, part of the muscle can be used for transfer which makes the flap less bulky and it can be tailored exactly to the primary defect.