The timing of drain removal in parotidectomies: outcomes of removal at 4 h post-operatively and a Canadian survey of practice patterns

BACKGROUND

The post-operative management of parotidectomies is highly provider dependent. No guidelines are currently available for timing of parotid drain removal. This study aimed to assess: (1) outcomes and complications after early drain removal (< 4 h, post-operative day [POD] 0) versus late drain removal (POD ≥ 1); (2) current Canadian provider practices.

METHODS

A single surgeons ten-year parotidectomy practice was reviewed, spanning his practice change from routine POD ≥ 1 drain removal to POD 0 removal, with extraction of patient demographic, disease, and complication variables. An anonymous, cross-sectional survey on parotid drain practices was distributed to Canadian Society of Otolaryngology-Head and Neck Surgery members. Descriptive statistics, Wilcoxon Rank Sum, and unpaired student's t-tests were calculated.

RESULTS

In total, 526 patients were included and 44.7% (235/526) had drains removed POD 0. There was no significant difference in hematoma or seroma rates between the POD 0 and POD ≥ 1 drain removal cohorts. The national survey on parotid drain management had 176 responses. The majority (67.9%) reported routinely using drains after parotidectomy and 62.8% reported using a drain output based criteria for removal. The most common cut-off output was 30 ml in 24 h (range 5-70 ml).

CONCLUSION

There was no difference in hematoma or seroma rates for patients with parotid drains removed on POD 0 versus POD ≥ 1. Our national survey found significant variation in Canadian parotidectomy drain removal practices, which may be an area that can be further assessed to minimize hospital resources and improve patient care.

Treatment of Laryngeal Verrucous Carcinoma: 28-Year Retrospective Cohort Study and Literature Review

Objective

Laryngeal verrucous carcinoma (LVC) comprises 1% to 4% of all laryngeal tumors. Although controversial, surgery has been the mainstay of treatment, due to concern about anaplastic transformation with radiotherapy. We aimed to study LVC patients to identify treatment patterns for primary and recurrent diseases.

Study Design

Retrospective cohort study.

Setting

Tertiary referral center.

Methods

Patients with a pathological diagnosis of LVC treated over a 28-year period were included. Baseline demographics, and treatment outcome measures including 5-year laryngeal preservation rates (LPR), overall survival (OS), and recurrence-free survival (RFS) were included. A literature review of published studies within the same study period was also completed.

Results

Thirty-two patients were included in the analysis (median age 61.5 years, 93.8% [30/32] male). Twenty-three patients had T1 disease, and 9 had T2 disease with no evidence of regional or metastatic disease. The most common presenting symptom was hoarseness (93.8%) and the majority within the glottis 81.3% (26/32). Twenty-nine patients underwent primary surgery only (28 local excisions, 1 vertical partial laryngectomy) meanwhile 3 underwent local excision with postoperative radiotherapy. LPR, OS, and RFS at 5 years were 95.8%, 90.1%, and 80.6%, respectively. Our literature review identified 23 previous studies, mostly single-institution retrospective case series. Our study was the largest Canadian study in the literature to date.

Conclusion

All LVC patients were treated with primary surgery, consistent with the current literature with excellent 5-year OS and LPR. There was no consensus on the treatment of recurrent disease. Future prospective multicenter studies are warranted to further study this rare disease population.

Synchrony in head and neck surgery: Feasibility and outcomes of simultaneous scapular free flap reconstruction

BACKGROUND

The scapula free flap is a versatile option in head and neck reconstruction but is less amenable to simultaneous harvest and ablation.

METHODS

Retrospective series (2015-2021) of consecutive scapula flaps. Cases categorized as simultaneous versus sequential, compared for operative time, oncological and patient-reported outcomes.

RESULTS

Seventy consecutive scapula free flaps were performed (n = 21 simultaneous, n = 49 sequential). Mandible reconstruction was performed in 51.0% and 61.9% of sequential and simultaneous cases, respectively; 49.0% and 38.1% addressed bony maxillary defects. Simultaneous surgery reduced operative time by 37.9% (151 min, p < 0.00001) and there were fewer tracheostomies performed (p < 0.005). Rates of positive margins and free flap compromise were equivalent (n = 1, 4.8% vs. n = 2, 4.1%). There was no difference in patient-reported outcomes.

CONCLUSIONS

This series demonstrates feasibility, efficacy, and outcomes of bony scapula reconstruction of maxillofacial defects comparing simultaneous and sequential approaches. Benefits of the two-team approach are highlighted including decreased operative time.

Intraoral Hirudotherapy for Venous Congestion following Free Flap Head and Neck Reconstruction: Novel Intraoral Technique

Intraoral hirudotherapy is traditionally used for venous congestion following head and neck free flap reconstruction. Many institutions and healthcare teams have been reluctant to use intraoral leech therapy due to risks such as migration into the airway, increased infection from intraoral manipulation, and patient discomfort. Several protocols recommend blocking the path to the oropharynx via gauze or leaving a tracheotomy in place to protect the airway. This report pre-sents a novel technique for intraoral hirudotherapy that is safe and simple for treatment of free flap venous congestion. The base of a clear cup or a plastic lid is utilized, and the leech is attached onto the inside of the lid with 2 sutures near each end. Several cups with leeches attached are made at a time to reduce delay and difficulty of application by less experienced clinical staff. The leech is then applied onto the compromised flap and then simply removed once it has unlatched from the flap. This method allows the leech to be applied with ease by multiple members of the healthcare team, decreases the need for intraoral manipulation, and reduces the risk of migration into the aerodigestive tract. Future prospective studies are warranted to assess the efficacy of this technique.

Proceedings of the Canadian Thyroid Cancer Active Surveillance Study Group 2019 national investigator meeting

Abstract

Active surveillance (AS) in the management of small, low risk papillary thyroid cancer (PTC) as an alternative option to thyroidectomy, is an area of active research. A national Canadian study is proposed to evaluate the long-term outcomes of patients with small, low risk PTC who choose AS or surgery. This letter describes the proceedings of a national investigator meeting to plan the study.

Graphical abstract

Prospective cohort study of voice outcomes following secondary tracheoesophageal puncture in gastric pull-up reconstruction after total laryngopharyngoesophagectomy

Background

Gastric pull-up is a reconstructive option for circumferential defects after resection of advanced laryngopharyngeal malignancy. Voice loss is expected and vocal rehabilitation remains a challenge. Our study objectives were to investigate the feasibility of secondary tracheoesophageal puncture following gastric pull-up and to analyze voice outcomes.

Methods

This was a prospective cohort study of patients with advanced laryngopharyngeal malignancies who underwent gastric pull-up and secondary tracheoesophageal puncture between 1988 and 2017 at a tertiary-care academic institution. Objective acoustic measures included fundamental frequency and vocal intensity. Perceptual analysis was performed using voice recordings (“Rainbow Passage”) randomly presented in a blinded fashion to four clinicians using the validated GRBAS scale. Speech intelligibility was assessed in a blinded fashion using a validated 7-point scale. Additionally, the Voice Handicap Index-10 was administered as a validated patient self-reporting tool.

Results

Ten patients (7 male, 3 female) were included, all of whom preferentially used tracheoesophageal puncture for communication. These patients had abnormal median fundamental frequency of 250 (interquartile range (IQR) 214–265) Hz and a limited median vocal intensity of 65.8 (IQR 64.1–68.3) dB. Perceptual analysis (GRBAS) revealed a median ‘moderate’ degree of impairment [grade 2 (IQR 2–3), roughness 2 (IQR 2–3), breathiness 3 (IQR 2–3), asthenia 2 (IQR 1–2), strain 2 (IQR 1–2)] as did median intelligibility scores [median 5 (IQR 4–7)]. Most patients self-reported an abnormal voice handicap-10 [median 26.5 (IQR 22.8–35.0)].

Conclusion

Secondary tracheoesophageal puncture is a safe and feasible option for voice rehabilitation after gastric pull-up. Although analyses demonstrated moderate subjective and objective impairment, tracheoesophageal puncture provided patients with a self-reported means of functional verbal communication and was their preferred method of communication.

Graphical abstract

Effect of Fluorescence Visualization-Guided Surgery on Local Recurrence of Oral Squamous Cell Carcinoma: A Randomized Clinical Trial

Importance

High local recurrence rates with aggressive disease remain the main concern in oral cancer survival. Use of a translational device using fluorescence visualization (FV) approved by the US Food and Drug Administration and Health Canada, has shown a marked reduction in the 3-year local recurrence rate of high-grade oral lesions in a single-center observational study.

Objective

To determine whether FV- guided surgery can improve local control rates in the treatment of in situ or T1 to T2 category oral squamous cell carcinoma (OSCC).

Design, Setting, and Participants

A multicenter randomized clinical trial was conducted in a surgical setting. A total of 457 patients were enrolled between January 18, 2010, and April 30, 2015. Data analysis of the intention-to-treat population was performed from April 3, 2019, to March 20, 2020. Patients with histologically confirmed high-grade dysplasia/carcinoma in situ or T1 to T2 category OSCC were randomized to receive traditional peroral surgery or FV-guided surgery.

Intervention

Fluorescence visualization during surgery.

Main Outcomes and Measures

The primary outcome was local recurrence of OSCC. Secondary outcomes were failure of the first-pass margin, defined as a histologically confirmed positive margin for severe dysplasia or greater histologic change of the main specimen (ie, not the margins taken from the resection bed), regional or distant metastasis, and death due to disease.

Results

Of the 457 patients enrolled in the study, 443 patients (264 [59.6%] men; mean [SD] age, 61.5 [13.3] years) completed the randomized treatment: 227 FV-guided and 216 non-FV guided surgery. The median follow-up was 52 (range, 0.29-90.8) months. In total, 45 patients (10.2%) experienced local recurrence. The 3-year local recurrence rate was 9.4% in the FV-guided group and 7.2% in the non-FV group (difference, 2.2%; 95% CI, -3.2% to 7.4%). Other similarities between the FV vs non-FV groups included failure of first-pass margin (68/227 [30.0%]) vs 65/216 [30.1%]), regional failure (39/227 [17.2%] vs 37/216 [17.1%]), disease-specific survival (23/227 [10.1%] vs 19/26 [8.8%]), and overall survival (41/227 [18.1%] vs 38/216 [17.6%]) were also similar between groups. No adverse events were judged to be related to the intervention.

Conclusions and Relevance

In this randomized clinical trial, FV-guided surgery did not improve local control rates in the treatment of patients with in situ or T1 to T2 category oral cancer. Under a controlled environment, FV-guided surgery did not have an evident effect in reduction of local recurrence for localized OSCC. This result suggests that attention be directed to strategies other than improving definitions of nonapparent disease at clinical margins to identify the sources of local recurrence.

Trial Registration

ClinicalTrial.gov Identifier: NCT01039298.

The association between the Nutrition-Related index and morbidity following head and neck microsurgery

OBJECTIVES/HYPOTHESIS

Despite consensus that preoperative nutritional assessment is of importance in the head and neck surgical oncology population, it remains unclear how exactly malnutrition is associated with perioperative morbidity especially among those undergoing microvascular surgery. We aimed to study this association to help inform preoperative risk stratification, guide the use of nutritional interventions, and ultimately help prevent malnutrition related morbidity.

STUDY DESIGN

Database analysis.

METHODS

Retrospective, linked analysis of the 2011 to 2016 National Surgical Quality Improvement Program. After identifying eligible patients and stratifying according to the Nutrition-Related Index, a univariate screen of preoperative demographic and clinical covariates was performed. Subsequently, propensity score matching was utilized to control for differences in baseline covariates. Perioperative complications and mortality were then analyzed using the propensity score-matched cohorts.

RESULTS

Among 977 identified patients, 276 (28.2%) were malnourished. Malnourished patients had higher rates of comorbidity, were more likely to actively smoke, and were more likely to have primaries in the oropharynx or hypopharynx/larynx. After propensity score matching to control for confounders, malnourished patients had higher rates of pulmonary complications (21.5% vs. 11.6%, P < .01), higher rates of bleeding or need for transfusion (56.6% vs. 43.0%, P < .01), higher rates of venous thromboembolism (3.7% vs. 0.8%, P = .03), and a higher 30-day mortality rates (3.7% vs. 0.0%, P < .01).

CONCLUSIONS

This nationwide analysis finds that 28.2% of patients undergoing surgery for head and neck cancers with free flap reconstruction are malnourished. Malnourishment was found to be independently associated with postoperative pulmonary complications, bleeding or need for transfusion, and 30-day mortality.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:375-380, 2020.

A systematic approach to the recurrent laryngeal nerve dissection at the cricothyroid junction

Background

To describe and evaluate a four step systematic approach to dissecting the recurrent laryngeal nerve (RLN) starting at the cricothyroid junction during thyroid surgery (subsequently referred to as the retrograde medial approach).

Methods

All thyroidectomies completed by the senior author between August 2014 and January 2016 were retrospectively reviewed. Patients were excluded if concurrent lateral or central neck dissection was performed. A follow up period of 1 year was included.

Results

Surgical photographs and illustrations demonstrate the four steps in the retrograde medial approach to dissection of the RLN in thyroid surgery.

Three hundred forty-two consecutive thyroid surgeries were performed in 17 months, including 213 hemithyroidectomies, 91 total thyroidectomies, and 38 completion thyroidectomies. The rate of temporary and permanent hypocalcemia was 13% (95% confidence interval [CI]: 8–20%) and 3% (95% CI: 1–8%) respectively. The rate of temporary and permanent vocal cord palsy was 9% (95% CI: 6–12%) and 0.3% (95%CI: 0.01–2%) respectively. The median surgical times for hemithyroidectomy, total thyroidectomy, and completion thyroidectomy were 39 min (Interquartile range [IQR]: 33–47 min), 48 min (IQR: 40–60 min), and 40 min (IQR: 35–51 min) respectively. 1% of cases required conversion to an alternative surgical approach.

Conclusion

In a tertiary endocrine head and neck practice, the routine use of the retrograde medial approach to RLN dissection is safe and results in a short operative time, and a low conversion rate to other RLN dissection approaches.

Analysis of readmissions after transoral robotic surgery for oropharyngeal squamous cell carcinoma

BACKGROUND

As transoral robotic surgery (TORS) is being increasingly used to treat patients with oropharyngeal squamous cell carcinoma (OPSCC), there is an interest in determining contributors to readmission.

METHODS

We conducted this retrospective multivariate analysis modeling 30-day readmission using the Nationwide Readmissions Database (2012-2014).

RESULTS

Of 950 patients, 117 (12.3%) were readmitted. Hemorrhage and diet/aspiration accounted for 32.5% and 19.7% of readmissions, respectively. Of those readmitted, 23.1% required operative bleeding control, 11.1% required transfusion, 1.7% required tracheostomy, and 18.8% required gastrostomies. Those readmitted were older (mean 63.2 years, SD 9.5 vs 60.9 mean years, SD 10.3) and had longer hospitalizations (mean 5.7 days, SD 6.8 vs mean 4.3 days, SD 4.1) and higher rates of aspiration/pneumonia (9.4% vs 2.4%, P < .01) on index admission. Multivariate analysis demonstrated that aspiration/pneumonia on index admission was independently associated with readmission (OR 3.128, 95% CI 1.178-8.302).

CONCLUSIONS

Of the patients 12.3% were readmitted within 30 days with hemorrhage and diet complications as significant contributors.

Effects of developmental lead exposure on the hippocampal methylome: Influences of sex and timing and level of exposure

Developmental lead (Pb) exposure results in persistent cognitive/behavioral impairments as well as an elevated risk for developing a variety of diseases in later life. Environmental exposures during development can result in a variety of epigenetic changes, including alterations in DNA methylation, that can influence gene expression patterns and affect the function and development of the nervous system. The present promoter-based methylation microarray profiling study explored the extent to which developmental Pb exposure may modify the methylome of a brain region, hippocampus, known to be sensitive to the effects of Pb exposure. Male and female Long Evans rats were exposed to 0 ppm, 150 ppm, 375 ppm, or 750 ppm Pb through perinatal exposures (gestation through lactation), early postnatal exposures (birth through weaning), or long-term postnatal exposures (birth through postnatal day 55). Results showed a significant contribution of sex to the hippocampal methylome and effects of Pb exposure level, with non-linear dose response effects on methylation. Surprisingly, the developmental period of exposure contributed only a small amount of variance to the overall data and gene ontology (GO) analysis revealed the largest number of overrepresented GO terms in the groups with the lowest level of exposure. The highest number of significant differentially methylated regions was found in females exposed to Pb at the lowest exposure level. Our data reinforce the significant effect that low level Pb exposure may have on gene-specific DNA methylation patterns in brain and that this occurs in a sex-dependent manner.

Revisiting the gastric pull-up for pharyngoesophageal reconstruction: A systematic review and meta-analysis of mortality and morbidity

Gastric pull-up (GPU) is among the oldest techniques for reconstructing the pharyngoesophageal junction following cancer resection. This review examines morbidity and mortality rates following GPU pharyngoesophageal junction reconstruction from 1959 until present: 77 studies, 2,705 patients. The odds of mortality, anastomotic complications, and other complications decreased by 37.2% (95%CI = 28.0-45.3%; P < 0.0001), 8.0% (95%CI = -2.1 to 17.1%; P = 0.12), 21.0% (95%CI 3.5-35.2%; P = 0.021) per decade respectively. J. Surg. Oncol. 2016;114:907-914. © 2016 Wiley Periodicals, Inc.

Ectopic parathyroid adenoma in the soft palate: a case report

Background

Ectopic parathyroid adenomas can occur in numerous anatomic locations. While ectopic parathyroid adenomas can rarely occur in the pharyngeal region, this has not previously been described in the soft palate.

Case presentation

We report the first case of ectopic parathyroid adenoma within the soft palate. A 59 year old woman presented with hyperparathyroidism. She remained persistently hyperparathyroid after initial parathyroidectomy. Repeat exploration for a lesion suspicious on PET-CT for an ectopic parathyroid adenoma in the parapharyngeal region was unsuccessful in treating the hyperparathyroidism. An ectopic adenoma in the soft palate was eventually discovered. Removal through a transoral approach was successful in treating the hyperparathyroidism.

Conclusions

Ectopic parathyroid adenomas can occur in various anatomical locations that may be missed even with the use of the various imaging modalities. The soft palate should be added to the list of possible ectopic locations high in the neck.

Management algorithm for failed gastric pull up reconstruction of laryngopharyngectomy defects: case report and review of the literature

BACKGROUND

Gastric pull up remains a popular reconstructive option for pharyngoesophagectomy defects extending to thoracic inlet. Gastric necrosis is a dreaded complication of gastric pull up reconstruction and few studies report on management of this complication. MEDLINE, EMBASE, and Web of Science™ databases were searched for publications in the last 25 years on gastric pull up reconstruction following pharyngoesophagectomy. The rates of complications related to gastropharyngeal anastomosis were extracted, and methods of managing gastric necrosis were noted. Forty seven case series were identified reporting on the use of gastric pull up for reconstruction of pharyngoesophageal defects. Mortality rate varied from 0 to 33 % with a weighted average of 8.6 %. In 39 % of patients, mortality was either caused or directly related to failure of the gastropharyngeal anastomosis. The reported rate of gastric necrosis ranged from 0 to 24 % resulting in a 28 % mortality. Options for managing gastric necrosis included: temporary cervical diversion, free jejunum flap, colonic interposition, tubed radial forearm flap, deltopectoralis and pectoralis myocutaneous flaps.

CASE PRESENTATION

We present the first case of an anterolateral thigh flap rescue of gastric necrosis after gastric pull up reconstruction. The case report is followed by a review of literature on management of gastric pull up failures.

CONCLUSION

Based on the extracted information, we propose an algorithm for managing gastric pull up failure following pharyngoesophageal reconstruction.

Upper airway obstruction due to a change in altitude: first report in fifty years

BACKGROUND

Air travel mostly causes minor ear, nose and throat complaints. We describe a second report in literature of airway obstruction caused by a drop in atmospheric pressure during a routine commercial flight.

CASE PRESENTATION

A 54-year-old male was referred to a head and neck surgeon with a 2 cm left submandibular mass that would enlarge during commercial flights. As the plane gained elevation, the mass would grow and cause him to become stridorous and short of breath. The shortness of breath and stridor would only resolve upon landing of the plane. A CT scan showed a large air sac extending from the larynx at the level of the true vocal cords up to the angle of the mandible. Based on the history and the CT findings a diagnosis of a laryngocele was made. The laryngocele was excised using an external approach, resolving the patient's difficulty with flying.

CONCLUSION

This article reports a rare case of upper airway obstruction caused by atmospheric pressure changes during air travel. The reported case is of significance as only a few uncomplicated laryngoceles have been reported to cause airway distress in the literature. This report highlights the epidemiology, presentation, complication and management of laryngoceles.

Effects of low level lead exposure on associative learning and memory in the rat: Influences of sex and developmental timing of exposure

Lead (Pb) exposure during development impairs a variety of cognitive, behavioral and neurochemical processes resulting in deficits in learning, memory, attention, impulsivity and executive function. Numerous studies have attempted to model this effect of Pb in rodents, with the majority of studies focusing on hippocampus-associated spatial learning and memory processes. Using a different paradigm, trace fear conditioning, a process requiring coordinated integration of both the medial prefrontal cortex and the hippocampus, we have assessed the effects of Pb exposure on associative learning and memory. The present study examined both female and male long evans rats exposed to three environmentally relevant levels of Pb (150 ppm, 375 ppm and 750 ppm) during different developmental periods: perinatal (PERI; gestation-postnatal day 21), early postnatal (EPN; postnatal days 1-21) and late postnatal (LPN; postnatal days 1-55). Testing began at postnatal day 55 and consisted of a single day of acquisition training, and three post training time points (1, 2 and 10 days) to assess memory consolidation and recall. All animals, regardless of sex, developmental window or level of Pb-exposure, successfully acquired conditioned-unconditioned stimulus association during training. However, there were significant effects of Pb-exposure on consolidation and memory recall at days 1-10 post training. In females, EPN and LPN exposure to 150 ppm Pb (but not PERI exposure) significantly impaired recall. In contrast, only PERI 150 ppm and 750 ppm-exposed males had significant recall deficits. These data suggest a complex interaction between sex, developmental window of exposure and Pb-exposure level on consolidation and recall of associative memories.

Tumor Grade and Immunohistochemical Expression for Predicting Nodal Disease in Early-Staged Oral Squamous Cell Carcinomas

Objectives:

1) Categorize oral squamous cell carcinoma (OSCC) patients according to nodal status at and after surgery. 2) Determine demographics, clinicopathological and histological factors contributing to nodal disease. 3) Investigate biomarkers to predict nodal status.

Methods:

Using the BC Cancer Registry Database, 303 primary OSCC patients who received primary curative surgical treatment from 2003 to 2007 with at least 5 years of follow-up were identified. Patients were categorized based on nodal status at and after surgery. Demographics, clinico-pathological details, treatment modalities and time to outcomes were collected and compared among groups. Immunohistochemistry (IHC) was performed on a pilot tissue microarray (n = 21) for p16, cyclin D1 (CD-1), Ki-67, p53, and pRB.

Results:

Patients with nodal diseases (n = 303) at the time of surgery or during the FU has a pivotal impact on the 5-year survival rates (P < 0.0001). Cox proportional hazard models identified usage of adjuvant radiotherapy and presence of nodal disease as significant predictors for poor survival (hazard ratio [HR]: 6.53, 95% confidence interval [CI], 2.86-14.91, P < 0.0001; 2.43, 95%CI, 1.18-5.02, P = 0.02, respectively). Among the 205 N0-at-surgery, one in four of them developed nodal disease and with 76% at the first 18 months post-surgery. Among those markers examined, nuclear CD-1 expression is a negative predictor for nodal disease (100% vs. 58%, P < 0.05).

Conclusions:

The data strongly support aggressiveness of neck metastasis either at-time-of surgery or during follow-up. Effective pathological or IHC markers to predict nodal disease pre-surgery can benefit high-risk patients receiving early intervention and avoid unnecessary ND for the low-risk patients.

Cyclin D1 overexpression is associated with poor prognosis in oropharyngeal cancer

OBJECTIVES

To determine the biological characteristics of oropharyngeal squamous cell carcinoma (OpSCC) and related outcome.

DESIGN

Retrospective study.

METHODS

Patients (N=60) with primary OpSCC from 2000 to 2005 were retrospectively identified from Pathology database and the outcome was confirmed through chart review. Among these, 41 biopsy samples with enough tissues were retrieved to construct a tissue microarray for detection of the presence of high-risk human papillomavirus (HPV) using Chromogenic in situ hybridization (CISH) as well as the expression of p16 and cyclin D1 using immunohistochemistry.

MAIN OUTCOME MEASURES

Disease-free survival.

RESULTS

Among 60 patients, 39 (65%) patients had no recurrence or died without disease at the last follow-up (disease-free survival or Group 1), and 21 (35%) patients had persistent disease or died of disease (progression-free survival or Group 2). Although follow-up time was twice as long in group 1 (4.7 ± 2.2 vs. 2.0 ± 1.6 years; P < 0.0001), there was no difference between the 2 groups in age, gender, smoking/alcohol habits, TNM staging and treatment modalities. Among those 41 cases with available tumour tissues, there was no difference in HPV status and p16 expression between the 2 groups but a significant difference in cyclin D1 expression (P = 0.05). Using Kaplan-Meir survival analysis and log-rank test, cyclin D1 overexpression was highly associated with a poor prognosis when comparing time to outcome (P < 0.0001).

CONCLUSION

Cyclin D1 overexpression is a potential prognostic marker of OpSCC.

Rearing environment, sex and developmental lead exposure modify gene expression in the hippocampus of behaviorally naïve animals

Developmental lead (Pb) exposure impairs various cognitive processes and behaviors in both humans and animals. In particular, specific deficits in spatial learning and memory have been described in Pb-exposed rats. It is also known that rearing environment (i.e., non-enriched vs. enriched) can have significant influences on cognitive performance and that rearing environment and sex may modify the influence of Pb exposure on learning and memory processes. It is also known that behavioral testing can alter hippocampal gene expression and interactive effects of environment. Little is known however about the molecular correlates of developmental Pb-exposure on expression of key sets of cognition-relevant genes in the hippocampus and how sex and environmental rearing condition may modify these effects. The present study examined expression profiles of neurobiologically-relevant genes (i.e., neurotrophic factors, NMDA receptors, metabotropic glutamate receptors, synaptic function/plasticity, and transcription/gene regulation) in behaviorally naïve rats with perinatal exposure (i.e., gestation through weaning) to different levels of Pb (250, 750 and 1,500 ppm Pb acetate) in males and females raised in a non-enriched environment (standard housing without toys) or an enriched environment (large cage containing toys changed twice weekly). Unlike previous studies identifying gene changes following behavioral testing, which alters expression analysis, we identified both sex and environmental related changes in hippocampal genes following Pb exposure alone. The gene expression changes described may be associated with learning and memory and may pre-determine how cognitive profiles develop following Pb exposure.

Are Prophylactic Antibiotics Required in Thyroidectomies?

Objective: In clean surgical wounds, the rate of infection ranges between 0.3% and 5%. Although postoperative prophylactic antibiotics use is not recommended, practice depends on surgeon preference. We wish to report our rate of postsurgical wound infection requiring antibiotic use following thyroidectomies and parathyroidectomies, where no preoperative or postoperative antibiotic prophylaxis was used.

Method: A retrospective chart review of thyroidectomies and parathyroidectomies without additional procedures from January 2005 to June 2011 was undertaken. The incidence of mild and significant postsurgical wound infections, use of antibiotics, need for readmission, surgical drainage, length of hospitalization, and potential risk factors for postsurgical wound infections were assessed.

Results: Of 767 charts reviewed, 697 met the inclusion criteria. Six hundred eighteen thyroidectomies and 95 parathyroidectomies were undertaken, 21 requiring postoperative drains. Nine (1.29%) were on antibiotics preoperatively, and 3 (0.43%) were on postoperative prophylactic antibiotics. Nine (1.31% of patients not on antibiotics) were given oral antibiotics for symptoms of mild infection. Two (0.29%) more significant infections required intravenous antibiotic therapy 16 and 20 days postoperatively, 1 necessitating readmission for 4 days and seroma drainage, although a wound drain was placed intraoperatively. Surgical drains (1/11 infections; P = .29) and obesity (4/11 infections, P = .28), among others, were not statistically significant risk factors for postsurgical wound infections.

Conclusion: Although prophylactic antibiotics were not used for our thyroidectomies and parathyroidectomies, our rate of postsurgical wound infections (1.6%) was comparative to current literature values (0.3%-5%). Our results suggest that it might not be beneficial or cost-effective to use prophylactic antibiotics in such clean procedures; a randomized control trial is planned.

FV-Guided Surgery Improves Outcome in HGD and Early Oral Cancer

Objective: 1) Become aware of the role of intraoperative fluorescence visualization in assessing subclinical changes at surgical margins in patients presenting with severe dysplasia and carcinoma in situ (HGD) or squamous cell carcinoma (SCC). 2) Understand the effectiveness of FV-guided surgery in reducing locoregional recurrence and improving overall survival.

Method: A retrospective review was conducted from September 1, 2004, to August 31, 2009, identifying 246 patients (SCC 132; HGD 114) presenting to the BCCA. Surgery was done under FV guidance in 149 patients while 97 were treated conventionally. Outcome measures included pathology-proven local recurrence, regional failure, and death.

Results: There was no significant difference between FV and control groups in age, smoking habit, lesion anatomic site, diagnosis, tumor size, and previous cancer history. There were more females in the FV group (51% vs 33%, P = .006). Time to outcome curve was estimated by the Kaplan-Meier method. With an average of 40 months follow-up, the FV group shows significantly lower local recurrence (7% vs 38%), regional failure (6% vs 23%), and death (5% vs 20%), and significant longer time to recurrence ( P < .0001), regional failure ( P = .0007), and death of disease ( P = .004).

Conclusion: The data strongly suggest that use of FV for surgical margin guidance can significantly improve outcomes in early stage oral cancer and HGD. An ongoing 5-year multicenter phase III randomized surgical trial (COOLS), funded by Terry FoResearch Institute, has been established to validate the results of this study.

Abstract 4603: Optically-guided surgical approach using fluorescence visualization can significantly improve locoregional recurrence and overall survival for early stage oral cancer

Recurrence following excision of high-grade dysplasia (HGD, severe dysplasia and carcinoma in situ) or squamous cell carcinoma (SCC) implies that the presence of subclinical changes at the margins is not apparent at surgery, resulting in incomplete excision. Fluorescence visualization (FV) has shown its value in identifying clinically not apparent high-risk oral lesions. The objective of this study is to assess the effectiveness of FV-guided surgery in reducing the loco-regional recurrence and improving overall survival. Method: From September 1st 2004 to August 31, 2009, 264 consecutive patients diagnosed with T1/T2 SCC or HGD were registered at the BC Cancer Agency and treated with surgical excision with intent to cure. Among these, 246 patients (93%; SCC, 132; HGD, 114) had a follow-up period of at least 6 months. Among these patients, 149 had the surgery done under FV guidance (FV group) while the other 97 were treated with conventional surgery procedure (control group). The outcome measurements include pathology-proven local recurrence to severe dysplasia or higher requiring another surgical procedure, regional failure, and death at follow-up. Time to outcome curve was estimated by the Kaplan-Meier method. Results: There is no significant difference between FV and control groups in age, smoking habit, lesion anatomical site, diagnosis, tumor size, and previous cancer history. There were more females in the FV group (51% vs. 33%, P = 0.006). With an average of 40 months follow-up, the FV group shows significantly lower local recurrence (7% vs. 38%), regional failure (6% vs. 23%), and death (5% vs. 20%), and significant longer time to recurrence (P &lt; 0.0001), regional failure (P = 0.0007), and death of disease (P = 0.004). Conclusion: Although they are retrospectively collected from a single centre, the data have strongly demonstrated that the use of FV for surgical margin decision can significantly improve outcomes of the early stage oral cancer. An on-going 5-year multi-centre phase III randomized surgical trial (the COOLS trial), funded by Terry Fox Research Institute, has started to recruit patients and the data will be used to validate the results of this study. (Supported by R01 DE17013 from the National Institute of Dental and Craniofacial Research, CCSRI-20336 from Canadian Cancer Society Research Institute, and TFRI-2009-24 from Terry Fox Research Institute. CFP is currently supported by a Scholar Award from the Michael Smith Foundation for Health Research).

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4603. doi:1538-7445.AM2012-4603

Differential effect of postnatal lead exposure on gene expression in the hippocampus and frontal cortex

Although developmental lead exposure is known to have detrimental effects on a variety of cognitive functions that depend on the integrity of the hippocampus and frontal cortex, little is known about how low levels of lead exposure affect expression of key families of genes in these structures. The present study examined the effects of exposure to environmentally relevant levels of lead during the sensitive early post-weaning period in the rat on the expression profiles of a select number of neurobiologically relevant genes (i.e., genes for neurotrophic factors, NMDA receptors, metabotropic glutamate receptors, synaptic function/plasticity, cell signaling, and transcription/regulation) in the rat hippocampus and frontal cortex. Exposure to lead (180 and 375-ppm lead acetate in food for 30 days) significantly increased blood lead levels (5.8 to 10.3 μg/dl) and significantly affected expression of many of the genes examined. In many instances, lead exposure had different effects on the same gene depending on the brain region in which the expression of that gene was examined. Gene expression in the frontal cortex was often more sensitive to modification than gene expression in the hippocampus. These results suggest that even past infancy, exposures to low levels of lead can have significant effects on gene expression in the frontal cortex and the hippocampus with the potential to exert long-term effects on behavior and cognition.

Canadian Optically-guided approach for Oral Lesions Surgical (COOLS) trial: study protocol for a randomized controlled trial

Background

Oral cancer is a major health problem worldwide. The 5-year survival rate ranges from 30-60%, and has remained unchanged in the past few decades. This is mainly due to late diagnosis and high recurrence of the disease. Of the patients who receive treatment, up to one third suffer from a recurrence or a second primary tumor. It is apparent that one major cause of disease recurrence is clinically unrecognized field changes which extend beyond the visible tumor boundary. We have previously developed an approach using fluorescence visualization (FV) technology to improve the recognition of the field at risk surrounding a visible oral cancer that needs to be removed and preliminary results have shown a significant reduction in recurrence rates.

Method/Design

This paper describes the study design of a randomized, multi-centre, double blind, controlled surgical trial, the COOLS trial. Nine institutions across Canada will recruit a total of 400 patients with oral severe dysplasia or carcinoma in situ (N = 160) and invasive squamous cell carcinoma (N = 240). Patients will be stratified by participating institution and histology grade and randomized equally into FV-guided surgery (experimental arm) or white light-guided surgery (control arm). The primary endpoint is a composite of recurrence at or 1 cm within the previous surgery site with 1) the same or higher grade histology compared to the initial diagnosis (i.e., the diagnosis used for randomization); or 2) further treatment due to the presence of severe dysplasia or higher degree of change at follow-up. This is the first randomized, multi-centre trial to validate the effectiveness of the FV-guided surgery.

Discussion

In this paper we described the strategies, novelty, and challenges of this unique trial involving a surgical approach guided by the FV technology. The success of the trial requires training, coordination, and quality assurance across multiple sites within Canada. The COOLS trial, an example of translational research, may result in reduced recurrence rates following surgical treatment of early-stage oral cancer with significant impacts on survival, morbidity, patients' quality of life and the cost to the health care system.

Trial Registration

Clinicaltrials.gov NCT01039298

Sex-based differences in gene expression in hippocampus following postnatal lead exposure

The influence of sex as an effect modifier of childhood lead poisoning has received little systematic attention. Considering the paucity of information available concerning the interactive effects of lead and sex on the brain, the current study examined the interactive effects of lead and sex on gene expression patterns in the hippocampus, a structure involved in learning and memory. Male or female rats were fed either 1500 ppm lead-containing chow or control chow for 30 days beginning at weaning.Blood lead levels were 26.7±2.1 μg/dl and 27.1±1.7 μg/dl for females and males, respectively. The expression of 175 unique genes was differentially regulated between control male and female rats. A total of 167 unique genes were differentially expressed in response to lead in either males or females. Lead exposure had a significant effect without a significant difference between male and female responses in 77 of these genes. In another set of 71 genes, there were significant differences in male vs. female response. A third set of 30 genes was differentially expressed in opposite directions in males vs. females, with the majority of genes expressed at a lower level in females than in males. Highly differentially expressed genes in males and females following lead exposure were associated with diverse biological pathways and functions. These results show that a brief exposure to lead produced significant changes in expression of a variety of genes in the hippocampus and that the response of the brain to a given lead exposure may vary depending on sex.

Broad neuroprotective profile of nicotinamide in different mouse models of MPTP-induced parkinsonism

The factors contributing to substantia nigra pars compacta (SNc) dopamine (DA) neuron death and striatal DA depletion in Parkinson's disease (PD) are still poorly understood. However, mitochondrial dysfunction, cellular energy depletion and oxidative stress appear to play important roles in the pathogenesis of PD. In view of this, the current study examined the potential of nicotinamide, a form of the B-complex vitamin niacin, to protect against 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced SNc cell loss and striatal DA depletion in two mouse MPTP models that respond differently to putative neuroprotective agents. Adult male C57Bl/6 mice received nicotinamide (125, 250 or 500 mg/kg i.p.) prior to either acute (four injections in 1 day at 2-h intervals) or sub-acute (two injections per day at 4-h intervals for 5 days) MPTP administration. Striatal DA levels, changes in numbers of tyrosine hydroxylase (TH)- and cresyl violet-stained cells in the SNc at 2 and 6 weeks following the last MPTP exposure were analyzed. Nicotinamide administration resulted in a dose-dependent sparing of striatal DA levels and SNc neurons in acute MPTP-treated animals. Only the highest dose of nicotinamide had similar effects in sub-acute MPTP-treated animals. At 6 weeks after MPTP exposure, there was some spontaneous recovery of striatal DA levels in both models: neuroprotective effects were still apparent in acute but not sub-acute MPTP-treated animals. These results show neuroprotective effects of nicotinamide in different mouse Parkinson models associated with different forms of cell death and suggest that nicotinamide may have broad neuroprotective potential in PD.

Mobile colonoscopic surveillance provides quality care for hereditary nonpolyposis colorectal carcinoma families in South Africa

BACKGROUND

It is difficult to provide a colonoscopic surveillance service for at-risk family members with hereditary nonpolyposis colorectal carcinoma when many of those family members live in a remote area of South African far from endoscopic services. A mobile surveillance programme was established to service these individuals.

OBJECTIVE

The aim of this study was to compare the quality of the mobile service to that provided in established endoscopy units.

METHOD

Ninety-one asymptomatic subjects with known disease-causing mutations underwent 259 colonoscopies. Of these, 171 colonoscopies were performed by a mobile colonoscopy service in small rural hospitals and 88 in established endoscopy units. The quality of the colonoscopic services was measured by completion rate, the rate of detection of colonoscopic abnormalities, histopathological analyses of biopsies, surgical intervention and colorectal cancer deaths.

RESULTS

The caecum was reached in 96% of all colonoscopies. A significant lesion was detected in 8.8% of colonoscopies. There was no difference in the rate of complete colonoscopy and detection rate of lesions in the established units and the mobile service (both P = 0.6). The rate of detection of early adenocarcinomas was similar (P = 0.17). The colonoscopic screening/surveillance programme meets international standards with a high accuracy (95.75%) and negative predictive value (100%).

CONCLUSION

The mobile service provides access to colonoscopy in remote areas without compromising the quality of service.

The self-pith

We describe a middle-aged woman who inserted a sewing needle into her spinal cord in an attempt at performing her own acupuncture. Reports of neurologic injury are rare in the literature, despite the widespread use of acupuncture. This is the first case we have identified involving spinal cord injury from self-performed acupuncture.

Introduction of grids to mobile ICU radiography in a teaching hospital

The purpose of this study was to review the change in image quality before and after introducing grid use routinely to our mobile X-ray service. This was studied in the intensive care unit (ICU) setting, comparing images obtained over a 2 week period prior to and after the introduction of the change in technique. We introduced a 6:1 grid with appropriate changes in exposure factors. No other alterations were made. There were 133 patients in the preliminary group and 196 patients in the post-grid group. We found a reduction in the proportion of images that were of non-diagnostic or barely diagnostic quality. Non-diagnostic examinations were reduced from 18% to 1%. Introducing grids to our mobile service resulted in improvement in image diagnostic quality, largely by reducing the proportion of poor and unacceptable quality images. This effect does not appear to have been documented in the literature.

The synthetic ceramide analog L-PDMP partially protects striatal dopamine levels but does not promote dopamine neuron survival in murine models of parkinsonism

A number of previous studies have demonstrated a positive effect of exogenously administered monosialoganglioside GM1 on striatal dopamine (DA) levels and DA neuron survival in animal models of parkinsonism. However, due to low bioavailability of peripherally administered GM1, the present study investigated the neuroprotective/neurorestorative potential of enhancing endogenous GM1 biosynthesis by administration of the synthetic ceramide analog L-threo-1-phenyl-2-decanoylamino-3-morpholino-1-propanol (L-PDMP) in two mouse models of Parkinsonism produced by acute or subacute 1-methy-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) administration. L-PDMP treatment caused an increase in brain GM1 levels in both Parkinson models and resulted in a partial sparing of striatal DA levels in the subacute MPTP model but not in the acute MPTP model. L-PDMP treatment had no effect on DA neuron survival in either model. These data suggest that the administration of L-PDMP as a means to enhance endogenous brain GM1 levels may hold limited promise as a potential neuroprotective or neurorestorative therapeutic strategy for Parkinson's disease.

Hemithyroidectomy: the preferred initial surgical approach for management of Hurthle cell neoplasm

BACKGROUND

The objective of this study was to evaluate the cancer risk of patient clinicopathologic characteristics to determine the optimal approach for the surgical management of individuals with Hurthle cell neoplasm (HN) diagnosed by cytology.

METHODS

Patient clinicopathologic characteristics evaluated included age, sex, tumor size, and ipsilateral thyroid lobe nodularity. The association of these characteristics with a pathologic cancer diagnosis was evaluated using Fisher's exact test and Student t test.

RESULTS

Of the 422 patients undergoing thyroidectomy, 27 presented with a fine-needle aspiration biopsy diagnosis of HN, and by pathologic assessment 7 HN patients (25.9%) had a cancer diagnosis. Although none of the clinicopathologic characteristics evaluated were able to reliably differentiate benign from malignant tumors, large tumor size and male sex were significantly associated with a pathologic diagnosis of Hurthle cell carcinoma (P < .05).

CONCLUSIONS

Hemithyroidectomy represents the preferred initial surgical approach for the management of individuals presenting with nodular thyroid disease and a cytologic diagnosis of HN.

Raman spectroscopy for optical diagnosis in the larynx: preliminary findings

BACKGROUND AND OBJECTIVES

Raman spectroscopy (RS) provides information about molecular structure and is a potential tool for non-invasive tissue diagnosis. To determine if Raman spectra could be obtained rapidly from laryngeal tissue in vitro, and compare Raman spectra from normal, benign, and cancerous laryngeal tissue.

STUDY DESIGN/MATERIALS AND METHODS

Forty-seven laryngeal specimens were studied using RS with signal acquisition times (SAT) between 1 and 30 second(s). Multivariate analysis was used to determine the diagnostic ability of RS compared to standard histology (n = 18, 13, and 16 respectively for normal tissue, carcinoma, and squamous papilloma).

RESULTS

Good quality spectra were obtained with 5-second SAT. Spectral peak analysis showed prediction sensitivities of 89%, 69%, and 88%, and specificities of 86%, 94%, and 94% for normal tissue, carcinoma, and papilloma.

CONCLUSIONS

In the larynx, spectral differences appear to exist between normal tissue, carcinoma, and papilloma. The ability to obtain spectra rapidly supports potential for future in vivo studies.

Selective unilateral parathyroid exploration: an effective treatment for primary hyperparathyroidism

BACKGROUND

Unilateral neck exploration (UNE) is a well-recognized approach in the treatment of primary hyperparathyroidism (PHP). The objective of this study was to review the success of an approach involving UNE guided by preoperative sestamibi (SM) scanning.

METHODS

All data were gathered by retrospective chart review. All patients undergoing surgery for the treatment of primary hyperparathyroidism at a tertiary referral center over a 3-year period were included in the study cohort.

RESULTS

Fifty-two of 80 patients (65%) had an SM scan consistent with a solitary adenoma and were eligible for a UNE, with 57.5% (46/80) undergoing a UNE. Seventy-seven of 80 (96.3%) patients were normocalcemic after initial neck exploration. UNE was curative in 50 of 52 (96.2%) UNE eligible patients and required less operative time than bilateral neck exploration (mean, 60 versus 87 minutes).

CONCLUSION

Selective unilateral neck exploration, guided by preoperative SM scanning, is an effective surgical approach for the management of primary hyperparathyroidism.

Bilateral absence of the internal carotid artery: MR angiography and ultrasound findings

Presented is a case of congenital absence of the internal carotid arteries (ICAs) in a 13-year-old boy. This condition has been rarely reported in the literature and presented are our imaging findings, including descriptions of findings with MRI, MR angiography and ultrasound.

Inhibition of progenitor cell proliferation in the dentate gyrus of rats following post-weaning lead exposure

Although lead is a potent developmental neurotoxin, the effects of postnatal lead exposure on progenitor cell proliferation in the hippocampus has not been examined. Postnatal day 25 rats were fed a lead containing diet (1500 ppm lead acetate) for 30-35 days and administered bromodeoxyuridine (BrdU, 50 mg/kg, i.p.) during the last 5 days of lead exposure. Animals were killed 24 h after the last BrdU injection. Proliferation of new cells in the subgranular zone and dentate gyrus was significantly decreased in lead-exposed rats compared to control animals that ate a similar diet devoid of lead. These results suggest that postnatal lead exposure can have significant deleterious effects on progenitor cell proliferation and thus the structure and function of the hippocampus.

Effects of SP500263, a novel selective estrogen receptor modulator, on bone, uterus, and serum cholesterol in the ovariectomized rat

We describe here the activity of a novel selective estrogen receptor modulator, SP500263. When given to adult ovariectomized (OVX) rats for 28 days at doses of 0.3, 1, or 3 mg/kg/day, we found that SP500263 partially protected against OVX-induced loss of bone mineral content in the distal ends of femurs and in the whole bone. SP500263 also antagonized the OVX-induced increase in body weight. However, unlike 17beta-estradiol, SP500263 at efficacious doses did not prevent the OVX-induced loss in uterine wet weight. A small but significant effect on uterine wet weight was noted with raloxifene dosed at 1 mg/kg. As expected, SP500263 but not raloxifene acted as an estrogen antagonist on the uterus in adult rats when administered for 7 days at 30 mg/kg/day. Finally, SP500263 had no statistically significant effects on total serum cholesterol and serum triglycerides in OVX rats treated for 28 days. Raloxifene had no significant effects on body weight, bone mineral content, and serum cholesterol or triglycerides in the OVX-rat model. In summary, SP500263 is a new orally active SERM that acts in rats as an estrogen agonist on bone without causing uterine stimulatory effects.

Deriving service costs for a clubhouse psychosocial rehabilitation program

This article (a) discusses "function cost," a concept to estimate costs where consumers are involved both in delivery and receipt of services; (b) develops a methodology for costing service units for psychosocial rehabilitation clubhouses; and (c) presents a case study of a clubhouse program. Using function cost to estimate the value of member time leads to costs being on average about 10% higher than when using opportunity cost. Because the case-study clubhouse is typical in key dimensions, the methods used here appear generalizable to other programs and should have utility for other rehabilitation-based services for individuals with mental illness.