Does the extent of neck surgery based on preoperative calcitonin level influence survival in medullary thyroid carcinoma: a retrospective tertiary centre experience

INTRODUCTION

Medullary thyroid carcinoma (MTC) is a rare thyroid cancer arising from the calcitonin-secreting parafollicular cells. Previous studies suggested a preoperative calcitonin level >200ng/l is an indication for prophylactic lateral neck dissection (LND) to remove micrometastases and improve survival outcomes.

METHODS

This retrospective single-centre study assessed the efficacy of preoperative calcitonin levels as a marker for determining need for prophylactic LND in MTC. Data were obtained on demographics, preoperative calcitonin levels, size and laterality of index tumour, type of neck dissection (central neck dissection (CND), LND), nodes removed, levels with involved nodes, number of nodes histologically involved, mortality, adjuvant therapy and locoregional recurrence.

RESULTS

A total of 33 patients were identified from St George's University Hospitals NHS Foundation Trust between 1 January 2001 and 19 August 2021; 8 were excluded for data quality issues. Of the 18 classified with a high preoperative calcitonin level (>200ng/l), 10 (56%) had a LND and 8 (44%) had a CND. In the low-calcitonin group, three (43%) patients had a CND only and four (57%) had a LND. There was no difference in absolute or disease-free survival between the low and high groups (p=0.960, p=0.817), or between those who had a CND and LND in the high-calcitonin group (p=0.607, hazard ratio (HR) 0.55; p=0.129, HR 8.78).

CONCLUSION

There was no statistically significant difference in outcomes between high and low calcitonin groups. A selective approach to performing LND in MTC patients based on clinical and imaging findings suggesting disease presence in the lateral neck should be explored further.

New robotic platform for transoral robotic surgery: an IDEAL stage 0 study

Objectives

This study aims to assess the feasibility to perform transoral robotic surgery (TORS) with a new robotic platform, the Versius Surgical System (CMR Surgical, UK) in a preclinical cadaveric setting in accordance to stage 0 of the IDEAL-D framework.

Design

IDEAL stage 0 preclinical assessment of the Versius Robotic System in TORS in human cadavers.

Setting

All procedures were performed in a simulated operating theatre environment at a UK surgical training centre.

Participants

11 consultant head and neck surgeons from the UK, mainland Europe and the USA took part in TORS procedures on six human cadavers.

Interventions

3 key index procedures were assessed that represent the core surgical workload of TORS: lateral oropharyngectomy, tongue base resection and partial supraglottic laryngectomy.

Main outcome measures

The primary outcome was the successful completion of each surgical procedure. Secondary outcomes included the optimisation of system setup, instrumentation and surgeon-reported outcomes for feasibility of each component procedural step.

Results

33 cadaveric procedures were performed and 32 were successfully completed. One supraglottic laryngectomy was not fully completed due to issues dividing the epiglottic cartilage with available instrumentation. Surgeon-reported outcomes met the minimal level of feasibility in all procedures and a consensus that it is feasible to perform TORS with Versius was reached. Available instrumentation was not representative of other robotic platforms used in TORS and further instrument optimisation is recommended before wider dissemination.

Conclusions

It is feasible to perform TORS with the Versius Surgical System (CMR Surgical) within a pre-clinical cadaveric setting. Clinical evaluation is needed and appropriate with the system. Further instrument development and optimisation is desirable.

A high-definition, low cost endoscope to video record head and neck surgery- our experience

Head and neck surgery is a challenging speciality to video-record due to its open, small and sometimes deep operative field. Consequently current commercial technologies yield a high financial cost. This study explores how a low-cost, commercially available endoscope, called a borescope, may be used to overcome these challenges. It was hypothesised that due to its size, versatility and low-cost, it may be an accessible tool to circumnavigate the pitfalls of previously trialled recording devices. We report two cases in which a borescope was used intra-operatively. We found that the borescope can capture images suitable for teaching and training purposes but not when mounted as a headcam. As such the borescope is unable to provide a surgeons point of view.

36 A Randomised Trial to Compare How Undergraduates Diagnose Common Ear Pathology Using A Smartphone Otoscope and Standard Otoscope in A Simulated Setting

Introduction

Competent otoscopy is a key otolaryngology skill for a broad range of medical careers, yet undergraduate’s confidence to perform otoscopy is reported as low. This study aimed to evaluate whether a smartphone-otoscope could enhance medical undergraduates recognition of common ear pathology.

Method

52 medical students were randomised into a standard group (traditional otoscope) and an intervention group (smartphone-otoscope). Following a short didactic presentation, participants were asked to diagnose four simulated pathologies. Force response items and 5-point Likert scales loaded on an electronic platform recorded their diagnosis and their perceptions towards the otoscope.

Results

The smartphone-group (n = 20) had higher overall rates of correct diagnosis compared to control (n = 22) (84% vs 39%, p = <0.001). Only the grommet station did not show a significant improvement between the two groups (100% vs 91%, p = 0.49). 90% (n = 20) of participants felt the smartphone-otoscope was preferential for their learning. The same number expressed they want to use it in future learning. The remainder were indifferent.

Conclusions

The smart-phone otoscope enabled learners to better observe and recognise middle ear pathology. This popular learning tool has the potential to accelerate the learning curve of otoscopy and therefore improve the proficiency of future doctors at recognising middle ear diseases.

The single-use rhinolaryngoscope: an evaluation and cost comparison

BACKGROUND

This study investigated whether the single-use rhinolaryngoscope is clinically and economically comparable to the conventional reusable rhinolaryngoscope within a tertiary otolaryngology centre in the UK.

METHODS

A non-blinded, prospective and single-arm evaluation was carried out over a 5-day period, in which micro-costing was used to compare single-use rhinolaryngoscopes with reusable rhinolaryngoscopes.

RESULTS

Overall, 68 per cent of the investigators perceived the single-use rhinolaryngoscope to be 'good' or 'very good', while 85 per cent believed the single-use rhinolaryngoscope could replace the reusable rhinolaryngoscope (n = 59). The incremental costs of reusable rhinolaryngoscope eyepieces and videoscopes in the out-patient clinic, when compared to single-use rhinolaryngoscopes, were £30 and £11, respectively. The incremental costs of reusable rhinolaryngoscope eyepieces and videoscopes in the acute surgical assessment unit, when compared to single-use rhinolaryngoscopes, were -£4 and -£73, respectively.

CONCLUSION

The single-use rhinolaryngoscope provides a clinically comparable, and potentially cost-minimising, alternative to the reusable rhinolaryngoscope for use in the acute surgical assessment unit of our hospital.

Outcomes of elective head and neck confirmed or suspected cancer surgery during the COVID-19 pandemic

PURPOSE

To analyse the complication outcomes of COVID-19 negative patients undergoing elective head and neck surgery during the COVID-19 pandemic.

METHODS

This was a retrospective case review of all patients undergoing elective head and neck surgery for confirmed or suspected head and neck cancer.

RESULTS

There were no mortalities recorded in the cohort of patients analysed. At 30 days, pulmonary complications had occurred in 4 patients (9%). None of these were related to COVID infection.

CONCLUSION

With careful pre-operative screening of patients for COVID-19 and post-operative care in a COVID-19 clean ward, head and neck surgery can proceed safely during the epidemic. This data could help to minimise delay in treatment by allowing a greater number of elective head and neck cancer operations to proceed.

Transoral robotic surgery for the benefit of patients with head and neck cancer of unknown primary: our experience at St George's University Hospital, London

INTRODUCTION

Head and neck carcinoma of unknown primary represents 1-5% of all head and neck cancers and presents a diagnostic and therapeutic dilemma. In approximately 40% of cases, a primary tumour location remains unknown despite investigation. With advancements in our understanding of the role of high-risk human papilloma virus in head and neck cancer, transoral robotic surgery presents an option for diagnosis and therapy.

MATERIALS AND METHODS

This is a retrospective case series from a single centre. Case notes were reviewed for 28 patients who had transoral robotic surgery for head and neck carcinoma of unknown primary between May 2015 and July 2019.

RESULTS

Transoral robotic surgery identified an oropharyngeal primary tumour in 19 of 28 (67.8%) patients. All oropharyngeal primaries were p16 positive. The base of tongue identification rate was 63.2%. Median length of inpatient stay postoperatively was 1.0 day. Normal oral intake resumed within 48 hours in 96% (27/28) of patients. Three patients (10.3%) suffered minor postoperative bleeds that were all managed conservatively.

DISCUSSION

The base of tongue primary identification rate (63.2%) in this series is consistent with that previously reported (43-63%; 95% confidence interval). Primary tumour identification rate if a patient is p16 positive is 86.3% (19/22), with 100% of these being oropharyngeal. We suggest future investigation into p16 status as a means of stratifying patients with head and neck carcinoma of unknown primary for transoral robotic surgery.

CONCLUSION

Transoral robotic base of tongue mucosectomy (or lingual tonsillectomy) is a promising technique that offers a high yield of positive identification for the primary tumour. It is well tolerated with minimal associated morbidity. Our findings are comparable with those in the current literature.

Tracheostomy care and decannulation during the COVID-19 pandemic. A multidisciplinary clinical practice guideline

Purpose

Traditional critical care dogma regarding the benefits of early tracheostomy during invasive ventilation has had to be revisited due to the risk of COVID-19 to patients and healthcare staff. Standard practises that have evolved to minimise the risks associated with tracheostomy must be comprehensively reviewed in light of the numerous potential episodes for aerosol generating procedures. We meet the urgent need for safe practise standards by presenting the experience of two major London teaching hospitals, and synthesise our findings into an evidence-based guideline for multidisciplinary care of the tracheostomy patient.

Methods

This is a narrative review presenting the extensive experience of over 120 patients with tracheostomy, with a pragmatic analysis of currently available evidence for safe tracheostomy care in COVID-19 patients.

Results

Tracheostomy care involves many potentially aerosol generating procedures which may pose a risk of viral transmission to staff and patients. We make a series of recommendations to ameliorate this risk through infection control strategies, equipment modification, and individualised decannulation protocols. In addition, we discuss the multidisciplinary collaboration that is absolutely fundamental to safe and effective practise.

Conclusion

COVID-19 requires a radical rethink of many tenets of tracheostomy care, and controversy continues to exist regarding the optimal techniques to minimise risk to patients and healthcare workers. Safe practise requires a coordinated multidisciplinary team approach to infection control, weaning and decannulation, with integrated processes for continuous prospective data collection and audit.

Trans-oral robotic assisted tongue base mucosectomy for investigation of cancer of unknown primary in the head and neck region. The UK experience

OBJECTIVES

The diagnosis of cancer of unknown primary (CUP) in head and neck occurs when the treating clinicians have utilised all available diagnostic tests and failed to identify the origin of the disease. There is no agreed consensus on which diagnostic investigations to use, or the order in which to use them in, although broad recommendations exist. Small tumours arising in the tongue base can be below the limits of resolution of conventional diagnostic techniques. Given the difficulty in targeting the tongue base, current practice involves blind random biopsies, which leads to a variable detection rate. Robotically assisted surgical removal of the tongue base, tongue base mucosectomy (TBM) has been shown to improve diagnostic yield. This study reports the diagnostic hit rate for tongue base primaries using this technique.

DESIGN

Retrospective case review.

SETTING

UK Head and Neck Centres.

PARTICIPANTS

Patients presenting as an unknown primary, investigated with clinical examination, PET-CT and palatine tonsillectomy.

MAIN OUTCOME MEASURES

The detection of a primary site of head and neck cancer in the otherwise unknown primary tumour.

RESULTS

The primary tumour site was identified in the tongue base in 53% (n=17) of patients. In 15 patients the tumour was in the ipsliateral tongue base (88%) while in two cases (12%) the tumour was located in contra lateral tongue base.

CONCLUSIONS

Trans-oral robotic assisted TBM raises the possibility of identifying over 50% of tumours that would otherwise be classified as CUP. Identifying these in the contralateral tongue base has implications for treatment planning and outcome.

Mucoepidermoid carcinoma in a thyroglossal duct remnant

•

Thyroglossal duct remnants should be surgically excised, if possible due to the risk of malignant transformation.

•

Mucoepidermoid carcinomas can present in diverse locations outside of salivary glands.

•

A high index of suspicion for malignancy is required with neck masses in adults, especially following a period of rapid growth.

•

If aggressively treated, patients with mucoepidermoid carcinoma outside of salivary glands may still have a favourable prognosis.

Introduction

Thyroglossal duct cysts (TDC) are common midline neck swellings resulting from embryological remnants of the thyroglossal duct. They often contain ectopic thyroid tissue and malignant transformation has been reported, most commonly to papillary thyroid carcinoma. Mucoepidermoid carcinoma (MEC) usually occurs in the salivary glands and only rarely in the thyroid. This is the first case of a MEC occurring within a thyroglossal duct remnant.

Presentation of a case

A 73 year old lady presented with a thyroglossal duct cyst. She declined surgical excision, as she was adamant she wanted to avoid surgery. The neck mass rapidly enlarged at two years following initial diagnosis. Fine needle aspiration cytology was suspicious for carcinoma. She underwent total thyroidectomy and selective central compartment neck dissection with adjuvant radiotherapy. She remains alive and well two years post treatment.

Discussion

Mucoepidermoid carcinoma is the most common malignant neoplasm of salivary glands, although it has rarely been reported in diverse locations including the thyroid, lung and pancreas. To the best of our knowledge, this is the first reported case of mucoepidermoid carcinoma arising from a thyroglossal duct remnant.

Conclusion

This case adds weight to the literature favouring surgical excision of thyroglossal duct remnants due to the risk of malignant transformation.

Abstract P2-10-29: Time dependent breast cancer metastasis prediction using novel biological imaging, clinico-pathological and genomic data combined with Bayesian modeling to reduce over-fitting and improve on inter-cohort reproducibility

Background: Breast cancer heterogeneity demands that prognostic models must be biologically driven and recent clinical evidence indicates that future prognostic signatures need evaluation in the context of early versus late metastatic risk prediction. The aim of our work was to identify biologically validated quantitative imaging parameters with improved correlation to clinical outcome, and to address some of the remaining obstacles for a truly robust prognostic model in clinical use.

Method: We identified 4 seed proteins (ezrin/radixin/moesin-cofilin), along with several kinases as biologically relevant subnetwork of proteins that control tumor cell motility and metastasis. Patient-derived breast cancer tumour samples were used to perform a combination of imaging methods such as Fluoresecence lifetime imaging microscopy, automated segmentation and co-localisation intensity analysis. A complexity optimized Bayesian proportional hazard regression model was performed on a total of 419 breast cancer patients to validate time dependent predictions using traditional clinicopathological, genomic and our novel optical imaging-derived parameters. An independent dataset of 300 patient samples from the Leeds Institute of Molecular Medicine is currently being evaluated, representing a large cross centre validation of our integrated model.

Results: We demonstrate that the traditional gold standard clinico-pathological variables are poor predictors for patients that survive long periods, and that their predictive significance (in terms of hazard ratios) varies significantly between two temporal cohorts where the adjuvant treatments are vastly different. Moreover, we investigate the predictive accuracy of a combined imaging/clinicopathological model compared with genomic/clinicopathological models. We demonstrate how to reduce over-fitting to help improve the performance of prognostic models. Results of an integrated model combining genomic and imaging parameters are still awaited.

Discussion: We have produced the first optical imaging-derived multivariate tumour metastatic signature, which measures underlying key biological variables involved in regulating cancer cell motility. Using Bayesian proportional hazards regression in a time-dependent manner, we highlight the inadequacies of existing prediction tools and present a model combining the clinicopathological parameters with our imaging-based metastatic signature, as an integrative reproducible prognostic tool across different temporal cohorts.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-10-29.

The challenges of integrating molecular imaging into the optimization of cancer therapy

We review novel, in vivo and tissue-based imaging technologies that monitor and optimize cancer therapeutics. Recent advances in cancer treatment centre around the development of targeted therapies and personalisation of treatment regimes to individual tumour characteristics. However, clinical outcomes have not improved as expected. Further development of the use of molecular imaging to predict or assess treatment response must address spatial heterogeneity of cancer within the body. A combination of different imaging modalities should be used to relate the effect of the drug to dosing regimen or effective drug concentration at the local site of action. Molecular imaging provides a functional and dynamic read-out of cancer therapeutics, from nanometre to whole body scale. At the whole body scale, an increase in the sensitivity and specificity of the imaging probe is required to localise (micro)metastatic foci and/or residual disease that are currently below the limit of detection. The use of image-guided endoscopic biopsy can produce tumour cells or tissues for nanoscopic analysis in a relatively patient-compliant manner, thereby linking clinical imaging to a more precise assessment of molecular mechanisms. This multimodality imaging approach (in combination with genetics/genomic information) could be used to bridge the gap between our knowledge of mechanisms underlying the processes of metastasis, tumour dormancy and routine clinical practice. Treatment regimes could therefore be individually tailored both at diagnosis and throughout treatment, through monitoring of drug pharmacodynamics providing an early read-out of response or resistance.

Time-lapse FRET microscopy using fluorescence anisotropy

We present recent data on dynamic imaging of Rac1 activity in live T-cells. Förster resonance energy transfer between enhanced green and monomeric red fluorescent protein pairs which form part of a biosensor molecule provides a metric of this activity. Microscopy is performed using a multi-functional high-content screening instrument using fluorescence anisotropy to provide a means of monitoring protein-protein activity with high temporal resolution. Specifically, the response of T-cells upon interaction of a cell surface receptor with an antibody coated multi-well chamber was measured. We observed dynamic changes in the activity of the biosensor molecules with a time resolution that is difficult to achieve with traditional methodologies for observing Förster resonance energy transfer (fluorescence lifetime imaging using single photon counting or frequency domain techniques) and without spectral corrections that are normally required for intensity based methodologies.

Use of novel optical proteomics to profile breast cancer patients leading to individualised prognosis and tailored treatment

e22090

Background: Optical proteomics quantifies interactions between proteins and post-translational modifications by measuring Förster resonance energy transfer (FRET) quantified by fluorescence lifetime imaging microscopy (FLIM). This project aims to derive multiple high throughput optical proteomic markers, to predict metastatic risk at first diagnosis, and to perturb ‘high risk' protein-protein interactions using targeted therapeutics. This initial step develops robust FRET/FLIM assays, suitable for use in formalin fixed paraffin embedded (FFPE) tissue to be correlated with patient outcome. Methods: Fluorophore-conjugated antibodies to proteins involved in cell migration and survival, were applied to tissue microarrays (TMA), created from archived FFPE invasive ductal breast carcinoma samples. Where fluorophores are located within nanometer proximity, FRET occurs, thus allowing quantification of protein-protein interaction. Ezrin and PKCα phosphorylation, distribution, and interaction were imaged on four TMAs (patients diagnosed with early breast cancer 1984 -1987: 20 years follow-up data). Results: 71 patient samples were optically imaged. Patients were clustered based on the pairwise distances between 18 optical variables ‘input data'. Data are represented on self organising maps and dendrograms and correlated with clinical outcome ‘output data', displaying a heatmap distribution. Conclusions: Ezrin and PKCα phosphorylation, distribution, and interaction imaged optically within FFPE contain prognostic information regarding metastatic outcome in breast cancer, thus stepping ever closer to individualising prognosis. These advanced optics-based parameters informing on metastatic potential will be validated in prospective studies in conjunction with FRET/FLIM assays measuring HER2/HER3 dimerisation, and EGFR and HER2 ubiquitination in order to improve patient selection for targeted therapy.

No significant financial relationships to disclose.

Spontaneous retropharyngeal haematoma: a case report

Introduction

Spontaneous retropharyngeal haematoma is an unusual condition. It has multiple aetiological factors and can present to a number of specialists including the otolaryngologist.

Case presentation

We describe a case of spontaneous retropharyngeal haematoma which demonstrates the dramatic presentation and emphasises the need for a conservative approach.

Conclusion

It is important to be aware of this unusual condition with its distinct presentation. Surgical intervention should be resisted unless a treatable aetiological factor is found or airway compromise occurs. Most cases will resolve with conservative management.

Steroids in rhinoplasty: a survey of current UK otolaryngologists' practice

The use of steroids during rhinoplasty to reduce post-operative periorbital oedema and ecchymosis has been advocated. A number of randomized controlled trials have demonstrated the benefit of steroids in rhinoplasty. The aim of this study was to determine current UK practice in the use of steroids during rhinoplasty performed by otolaryngologists.

A postal survey of consultant otolaryngologists in the UK was conducted. We received 203 responses, with 115 consultants performing 12 or more rhinoplasties per year. Only 28 consultants (24 per cent) used steroids routinely in patients undergoing rhinoplasty and of these 11 used a protocol, although this was unpublished. Dexamethasone was the most common steroid used (82 per cent), being administered as a single intravenous dose of 8 mg in the majority of cases (54 per cent). There was no correlation between the use of steroids and the number of rhinoplasties performed by individual consultants.

Despite the evidence supporting the use of steroids to reduce post-operative sequelae following rhinoplasty, only a minority of consultants in the UK appear to use them as part of their practice.