A Novel Standard for Systematic Reporting of Neuroblastoma Surgery: The International Neuroblastoma Surgical Report Form (INSRF): A Joint Initiative by the Pediatric Oncological Cooperative Groups SIOPEN∗, COG∗∗, and GPOH∗∗∗

OBJECTIVE

To create the first structured surgical report form for NBL with international consensus, to permit standardized documentation of all NBL-related surgical procedures and their outcomes.

SUMMARY OF BACKGROUND DATA

NBL, the most common extracranial solid malignant tumor in children, covers a wide spectrum of tumors with significant differences in anatomical localization, organ or vessel involvement, and tumor biology. Complete surgical resection of the primary tumor is an important part of NBL treatment, but maybe hazardous, prone to complications and its role in high-risk disease remains debated. Various surgical guidelines exist within the protocols of the different cooperative groups, although there is no standardized operative report form to document the surgical treatment of NBL.

METHODS

After analyzing the treatment protocols of the SIOP Europe International Neuroblastoma Study Group, Children's Oncology Group, and Gesellschaft fuer Paediatrische Onkologie und Haematologie - German Association of Pediatric Oncology and Haematology pediatric cooperative groups, important variables were defined to completely describe surgical biopsy and resection of NBL and their outcomes. All variables were discussed within the Surgical Committees of SIOP Europe International Neuroblastoma Study Group, Children's Oncology Group, and Gesellschaft fuer Paediatrische Onkologie und Haematologie - German Association of Pediatric Oncology and Haematology. Thereafter, joint meetings were organized to obtain intercontinental consensus.

RESULTS

The "International Neuroblastoma Surgical Report Form" provides a structured reporting tool for all NBL surgery, in every anatomical region, documenting all Image Defined Risk Factors and structures involved, with obligatory reporting of intraoperative and 30 day-postoperative complications.

CONCLUSION

The International Neuroblastoma Surgical Report Form is the first universal form for the structured and uniform reporting of NBL-related surgical procedures and their outcomes, aiming to facilitate the postoperative communication, treatment planning and analysis of surgical treatment of NBL.

High-Intensity vs Low-Intensity Knowledge Translation Interventions for Surgeons and Their Association With Process and Outcome Measures Among Patients Undergoing Rectal Cancer Surgery

IMPORTANCE

Surgeon-directed knowledge translation (KT) interventions for rectal cancer surgery are designed to improve patient measures, such as rates of permanent colostomy and in-hospital mortality, and to improve survival.

OBJECTIVE

To evaluate the association of sustained, iterative, integrated KT rectal cancer surgery interventions directed at all surgeons with process and outcome measures among patients undergoing rectal cancer surgery in a geographic region.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used administrative data from patients who underwent rectal cancer surgery from April 1, 2004, to March 31, 2015, in 14 health regions in Ontario, Canada. Follow-up was completed on March 31, 2020.

EXPOSURES

Surgeons in 2 regions were offered intensive KT interventions, including annual workshops, audit and feedback sessions, and, in 1 of the 2 regions, operative demonstrations, from 2006 to 2012 (high-intensity KT group). Surgeons in the remaining 12 regions did not receive these interventions (low-intensity KT group).

MAIN OUTCOMES AND MEASURES

Among patients undergoing rectal cancer surgery, proportions of preoperative pelvic magnetic resonance imaging (MRI), preoperative radiotherapy, and type of surgery were evaluated, as were in-hospital mortality and overall survival. Logistic regression models with an interaction term between group and year were used to assess whether process measures and in-hospital mortality differed between groups over time.

RESULTS

A total of 15 683 patients were included in the analysis (10 052 [64.1%] male; mean [SD] age, 65.9 [12.1] years), of whom 3762 (24.0%) were in the high-intensity group (2459 [65.4%] male; mean [SD] age, 66.4 [12.0] years) and 11 921 (76.0%) were in the low-intensity KT group (7593 [63.7%] male; mean [SD] age, 65.7 [12.1] years). A total of 1624 patients (43.2%) in the high-intensity group and 4774 (40.0%) in the low-intensity KT group underwent preoperative MRI (P < .001); 1321 (35.1%) and 4424 (37.1%), respectively, received preoperative radiotherapy (P = .03); and 967 (25.7%) and 2365 (19.8%), respectively, received permanent stoma (P < .001). In-hospital mortality was 1.6% (59 deaths) in the high-intensity KT group and 2.2% (258 deaths) in the low-intensity KT group (P = .02). Differences remained significant in multivariable models only for permanent stoma (odds ratio [OR], 1.67; 95% CI, 1.24-2.24; P < .001) and in-hospital mortality (OR, 0.67; 95% CI, 0.51-0.87; P = .003). In both groups over time, significant increases in the proportion of patients undergoing preoperative MRI (from 6.3% to 67.1%) and preoperative radiotherapy (from 16.5% to 44.7%) occurred, but there were no significant changes for permanent stoma (25.4% to 25.3% in the high-intensity group and 20.0% to 18.3% in the low-intensity group) and in-hospital mortality (0.8% to 0.8% in the high-intensity group and 2.2% to 1.8% in the low-intensity group). Time trends were similar between groups for measures that did or did not change over time. Patient overall survival was similar between groups (hazard ratio, 1.00; 95% CI, 0.90-1.11; P = .99).

CONCLUSIONS AND RELEVANCE

In this quality improvement study, between-group differences were found in only 2 measures (permanent stoma and in-hospital mortality), but these differences were stable over time. High-intensity KT group interventions were not associated with improved patient measures and outcomes. Proper evaluation of KT or quality improvement interventions may help avoid opportunity costs associated with ineffective strategies.

Breast reconstruction and radiation therapy: An Italian expert Delphi consensus statements and critical review

Breast conserving surgery (BCS) plus radiation therapy (RT) or mastectomy have shown comparable oncological outcomes in early-stage breast cancer and are considered standard of care treatments. Postmastectomy radiation therapy (PMRT) targeted to both the chest wall and regional lymph nodes is recommended in high-risk patients. Oncoplastic breast conserving surgery (OBCS) represents a significant recent improvement in breast surgery. Nevertheless, it represents a challenge for radiation oncologists as it triggers different decision-making strategies related to treatment volume definition and target delineation. Hence, the choice of the best combination and timing when offering RT to breast cancer patients who underwent or are planned to undergo reconstruction procedures should be carefully evaluated and based on individual considerations. We present an Italian expert Delphi Consensus statements and critical review, led by a core group of all the professional profiles involved in the management of breast cancer patients undergoing reconstructive procedures and RT. The report was structured as to consider the main recommendations on breast reconstruction and RT and analyse the current open issues deserving investigation and consensus. We used a three key-phases and a Delphi process. The final expert panel of 40 colleagues selected key topics as identified by the core group of the project. A final consensus on 26 key statements on RT and breast reconstruction after three rounds of the Delphi voting process and harmonisation was reached. An accompanying critical review of available literature was summarized. A clear communication and cooperation between surgeon and radiation oncologist is of paramount relevance both in the setting of breast reconstruction following mastectomy when PMRT is planned and when extensive glandular rearrangements as OBCS is performed. A shared-decision making, relying on outcome-based and patient-centred considerations, is essential, while waiting for higher level-of-evidence data.

Opioid prescribing exceeds consumption following common surgical oncology procedures

BACKGROUND AND OBJECTIVES

Surgical oncology patients are vulnerable to persistent opioid use. As such, we aim to compare opioid prescribing to opioid consumption for common surgical oncology procedures.

METHODS

We prospectively identified patients undergoing common surgical oncology procedures at a single academic institution (August 2017-March 2018). Patients were contacted by telephone within 6 months of surgery and asked to report their opioid consumption and describe their discharge instructions and opioid handling practices.

RESULTS

Of the 439 patients who were approached via telephone, 270 completed at least one survey portion. The median quantity of opioid prescribed was significantly larger than consumed following breast biopsy (5 vs. 2 tablets of 5 mg oxycodone, p < .001), lumpectomy (10 vs. 2 tablets of 5 mg oxycodone, p < .001), and mastectomy or wide local excision (20 tablets vs. 2 tablets of 5 mg oxycodone, p < .001). The majority of patients reported receiving education on taking opioids, but only 27% received instructions on proper disposal; 82% of prescriptions filled resulted in unused opioids, and only 11% of these patients safely disposed of them.

CONCLUSIONS

This study demonstrates that opioid prescribing exceeds consumption following common surgical oncology procedures, indicating the potential for reductions in prescribing.

Recommendations for head and neck surgical oncology practice in a setting of acute severe resource constraint during the COVID-19 pandemic: an international consensus

The speed and scale of the global COVID-19 pandemic has resulted in unprecedented pressures on health services worldwide, requiring new methods of service delivery during the health crisis. In the setting of severe resource constraint and high risk of infection to patients and clinicians, there is an urgent need to identify consensus statements on head and neck surgical oncology practice. We completed a modified Delphi consensus process of three rounds with 40 international experts in head and neck cancer surgical, radiation, and medical oncology, representing 35 international professional societies and national clinical trial groups. Endorsed by 39 societies and professional bodies, these consensus practice recommendations aim to decrease inconsistency of practice, reduce uncertainty in care, and provide reassurance for clinicians worldwide for head and neck surgical oncology in the context of the COVID-19 pandemic and in the setting of acute severe resource constraint and high risk of infection to patients and staff.

Considerations for head and neck oncology practices during the coronavirus disease 2019 (COVID-19) pandemic: Wuhan and Toronto experience

The practices of head and neck surgical oncologists must evolve to meet the unprecedented needs placed on our health care system by the Coronavirus disease 2019 (COVID-19) pandemic. Guidelines are emerging to help guide the provision of head and neck cancer care, though in practice, it can be challenging to operationalize such recommendations. Head and neck surgeons at Wuhan University faced significant challenges in providing care for their patients. Similar challenges were faced by the University of Toronto during the severe acute respiratory syndrome (SARS) pandemic in 2003. Herein, we outline our combined experience and key practical considerations for maintaining an oncology service in the midst of a pandemic.

Head and neck surgical oncology in the time of a pandemic: Subsite-specific triage guidelines during the COVID-19 pandemic

BACKGROUND

COVID-19 pandemic has strained human and material resources around the world. Practices in surgical oncology had to change in response to these resource limitations, triaging based on acuity, expected oncologic outcomes, availability of supportive resources, and safety of health care personnel.

METHODS

The MD Anderson Head and Neck Surgery Treatment Guidelines Consortium devised the following to provide guidance on triaging head and neck cancer (HNC) surgeries based on multidisciplinary consensus. HNC subsites considered included aerodigestive tract mucosa, sinonasal, salivary, endocrine, cutaneous, and ocular.

RECOMMENDATIONS

Each subsite is presented separately with disease-specific recommendations. Options for alternative treatment modalities are provided if surgical treatment needs to be deferred.

CONCLUSION

These guidelines are intended to help clinicians caring for patients with HNC appropriately allocate resources during a health care crisis, such as the COVID-19 pandemic. We continue to advocate for individual consideration of cases in a multidisciplinary fashion based on individual patient circumstances and resource availability.

Head and neck cancer surgery in COVID-19 pandemic in Northern Italy

•

COVID-2019 pandemic represents a great challenge both in itself and for time-sensitive diseases.

•

Head and neck cancer surgery is a high risk procedure for COVID-19.

•

Possibility of SARS-CoV-2 false negative at pre-operative evaluation in asymptomatic subjects should not let guard down in the post-operative time.

French consensus on management of head and neck cancer surgery during COVID-19 pandemic

In the context of the current pandemic, there is a need for specific advice concerning treatment of patients with Head and Neck cancers. The rule is to limit as much as possible the number of patients in order to reduce the risks of contamination by the SARS-Cov-2 virus for both patients and the caregivers, who are particularly exposed in ENT. The aim is to minimize the risk of loss of opportunity for patients and to anticipate the increased number of cancer patients to be treated at the end of the pandemic, taking into account the degree of urgency, the difficulty of the surgery, the risk of contaminating the caregivers (tracheotomy) and the local situation (whether or not the hospital and intensive care departments are overstretched).

European Society of Gynaecological Oncology quality indicators for surgical treatment of cervical cancer

BACKGROUND

Optimizing and ensuring the quality of surgical care is essential to improve the management and outcome of patients with cervical cancer.To develop a list of quality indicators for surgical treatment of cervical cancer that can be used to audit and improve clinical practice.

METHODS

Quality indicators were developed using a four-step evaluation process that included a systematic literature search to identify potential quality indicators, in-person meetings of an ad hoc group of international experts, an internal validation process, and external review by a large panel of European clinicians and patient representatives.

RESULTS

Fifteen structural, process, and outcome indicators were selected. Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are also detailed to define how the indicator will be measured in practice. Each indicator has a target which gives practitioners and health administrators a quantitative basis for improving care and organizational processes.

DISCUSSION

Implementation of institutional quality assurance programs can improve quality of care, even in high-volume centers. This set of quality indicators from the European Society of Gynaecological Cancer may be a major instrument to improve the quality of surgical treatment of cervical cancer.

Clinical trial registry use in minimally invasive surgical oncology systematic reviews and meta-analyses

Publication bias can arise in systematic reviews when unpublished data are omitted and lead to inaccurate clinical decision making and adverse clinical outcomes. By conducting searches of clinical trial registries (CTRs), researchers can create more accurate systematic reviews and mitigate the risk of publication bias. The aims of this study are: to evaluate CTR use in systematic reviews and meta-analyses within the minimally invasive surgical oncology (MISO) literature; to conduct a search of ClinicalTrials.gov for a subset of reviews to determine if eligible trials exist that could have been used. This is a cross-sectional study of 197 systematic reviews and meta-analyses retrieved from PubMed. Of 137 included studies, 18 (13.1%) reported searching a CTR. Our ClinicalTrials.gov search revealed that of the 25 randomly selected systematic reviews that failed to conduct a trial registry search, 16 (64.0%) would have identified additional data sources. MISO systematic reviews and meta-analyses do not regularly use CTRs in their data collection, despite eligible trials being freely available.

Blood parameters score predicts long-term outcomes in stage II-III gastric cancer patients

BACKGROUND

Increasing numbers of laboratory blood parameters (BPM) have been reported to greatly affect the long-term outcomes of gastric cancer (GC) patients. However, the existing prognostic models do not comprehensively analyze these predictors.

AIM

To construct a new prognostic tool, based on all the prognostic BPM, to achieve more accurate prognosis prediction for GC.

METHODS

We retrospectively assessed 850 consecutive patients who underwent curative resection for stage II-III GC from January 2010 to April 2013. The patients were classified into developing (n = 567) and validation (n = 283) cohorts using computer-generated random numbers. A scoring system, namely BPM score, was then constructed using least absolute shrinkage and selection operator (LASSO) Cox regression model in the developing cohort, and validated in the validation cohort. A nomogram consisting of BPM score and tumor-lymph node-metastasis (TNM) stage was further created. The discrimination and calibration of the nomogram were evaluated via Harrell’s C-statistic and the Hosmer-Lemeshow test.

RESULTS

Using the LASSO model, we established the BPM score based on five BPM: Albumin, lymphocyte-to-monocyte ratio, neutrophil-to-lymphocyte ratio, carcinoembryonic antigen, and carbohydrate antigen 19-9. The BPM scores were divided into high- and low-BPM groups based on a cut-off value of -0.93. High-BPM patients were significantly older and had more advanced, larger tumors. In the developing cohort, significant differences were found in 5-year overall survival (OS) and 5-year disease-specific survival between the high-BPM and low-BPM patients. Similar results were found in the validation group. Multivariable analysis showed that the BPM score was an independent predictor of OS. High-BPM patients had a poorer 5-year OS for each subgroup. Furthermore, a nomogram that combined the BPM score and TNM stage had significantly better prognostic value compared with TNM stage alone.

CONCLUSION

The BPM score provides more accurate prognosis prediction in stage II-III GC patients and is an effective complement to the TNM staging system.

Ongoing formative assessment in the training of post graduate students

INTRODUCTION

There is growing evidence that formative assessment is valuable tool in enhancing learning. Integrating formative assessment into post graduate students can be challenging.

AIM

Authors aimed in this study to describe an ongoing formative assessment activity in post graduates. We reported resident's performance and satisfaction.

METHODS

Authors performed an exploratory study over a 3-year period. Twenty five oncology residents participated. The first phase was test preparation by senior oncologists, according to residency curricula then taking the test by a small group of residents with an immediate feedback. The third phase was distribution of a survey each 6 months evaluating resident's perception of the testing.

RESULTS

Twenty two tests were taken by 17 medical oncology, 2 surgical oncology and 4 radiation therapy residents.  At the first test, median scores was 51/100 [30%-72%] with a mean of 53/100. Individual scores of each resident improved with time, becoming 68/100 (t(16)=3.172, p<0.02) with a mean of 64/100 and decrease between student's scores. All the students rated the correction session with a 5. The majority reported that the test reached their expectations (73% rated4-5), and considered it, as having an impact on their daily practice (77% rated4-5). Residents also considered the test as highly difficult (80% rated4-5).

CONCLUSION

Ongoing formative assessment showed improvement in overall knowledge of residents with high level of satisfaction.

Evaluating the Effect of Margin Consensus Guideline Publication on Operative Patterns and Financial Impact of Breast Cancer Operation

BACKGROUND

This study sought to evaluate re-excision rates, patient satisfaction with their breasts, and healthcare costs before and after publication of 2014 Society of Surgical Oncology/American Society of Radiation Oncology consensus guideline on margins for breast conserving operation with whole-breast irradiation for stage I and II breast cancer at an academic institution.

STUDY DESIGN

Patients with stage I and II invasive carcinomas who underwent partial mastectomy were divided into 2 groups based on whether they were treated before (PRE) or after (POST) guideline publication in March 2014. Groups were compared with respect to re-excision rates, conversion to mastectomy, specimen volumes, mean cost per patient of surgical care, and prospectively collected patient post-procedure quality of life.

RESULTS

A total of 237 patients who underwent partial mastectomy were examined (n = 126 in the PRE group and n = 111 in the POST group). Patients in the POST group were less likely to require re-excision (9% POST vs 37% PRE; p < 0.001) and were less likely to undergo conversion to mastectomy (5% POST vs 14% PRE; p = 0.02). After consensus guideline publication, mean operative cost per patient decreased ($4,874 POST vs $5,772 PRE; p < 0.001), and patients had improved breast quality of life scores (77 out of 100 POST vs 61 out of 100 PRE; p = 0.03). On multivariable analysis, publication of the consensus statement was an independent predictor of decreased re-excision rates (odds ratio 0.17; 95% CI 0.08 to 0.38; p < 0.001) and operative cost per patient (odds ratio 0.14; 95% CI 0.78 to 0.30; p < 0.001).

CONCLUSIONS

Widespread implementation of the consensus guideline on margins for breast conserving operation will likely lead to the intended improvements in operative and financial outcomes, as well as patient satisfaction with breast conserving operation.

Recommendations for Randomised Trials in Surgical Oncology

Trials of surgical procedures in the treatment of malignant disease face a unique set of challenges. This review aimed to describe recommendations for the design, delivery and reporting of randomised trials in surgical oncology. A literature search was carried out without date limits to identify articles related to trial methodology research in surgery and surgical oncology. A narrative review was framed around two open National Institute of Health Research portfolio trials in colon and rectal cancer: the STAR-TREC trial (ISRCTN14240288) and the ROCCS trial (ISRCTN46330337). Twelve specific challenges were highlighted: standardisation of technique; pilot and feasibility studies; balancing treatments; the recruitment pathway; outcome measures; patient and public representation; trainee-led networks; randomisation; novel techniques and training; learning curves; blinding; follow-up. Evidence-based recommendations were made for the future design and conduct of surgical oncology trials. Better understanding of the challenges facing trials in the surgical treatment of cancer will accelerate high-quality evaluation and rapid adoption of innovation for the benefit of patient care.

The need for multidisciplinarity in specialist training to optimize future patient care

Harmonious interactions between radiation, medical, interventional and surgical oncologists, as well as other members of multidisciplinary teams, are essential for the optimization of patient care in oncology. This multidisciplinary approach is particularly important in the current landscape, in which standard-of-care approaches to cancer treatment are evolving towards highly targeted treatments, precise image guidance and personalized cancer therapy. Herein, we highlight the importance of multidisciplinarity and interdisciplinarity at all levels of clinical oncology training. Potential deficits in the current career development pathways and suggested strategies to broaden clinical training and research are presented, with specific emphasis on the merits of trainee involvement in functional multidisciplinary teams. Finally, the importance of training in multidisciplinary research is discussed, with the expectation that this awareness will yield the most fertile ground for future discoveries. Our key message is for cancer professionals to fulfil their duty in ensuring that trainees appreciate the importance of multidisciplinary research and practice.

Bethesda System in the evaluation of thyroid nodules: Review

Fine needle aspiration (FNA) biopsy is an important and widely accepted method used in the diagnosis of patients with thyroid nodules.The lack of consistency in reporting FNA taken from the thyroid gland has led to divergences in the calculation of the sensitivity and specificity of the method. Discrepancies depend on what was considered to be true or false negative/positive. This resulted in confusion among doctors, who had to decide how to manage the patient with constantly changing positive or negative results of the FNA. The problem was solved in 2007, when "The Bethesda System for Reporting Thyroid Cytopathology" (TBSRTC) was introduced. Generally, TBSRTC, compared to previous systems, results in reducing the number of non-diagnostic/indeterminate cases and enables a better clinical usefulness of the results of the FNA of the thyroid gland. This is probably due to the introduction of more standard criteria for interpreting and reporting. TBSRTC improves communication between cytopathologists, reduces the number of unnecessary operations on benign lesions, and makes it possible to perform the operation on time in patients with malignant lesions and predict the risk of thyroid cancer. It provides a simple and reliable exchange of data not only between various laboratories but also between institutions throughout the world. Research shows that all indicators of malignancy calculated for all categories have similar value to the recommended rate of malignancy.

ACR Appropriateness Criteria® Adjuvant Management of Early-Stage Endometrial Cancer

These consensus guidelines on adjuvant radiotherapy for early-stage endometrial cancer were developed from an expert panel convened by the American College of Radiology. The American College of Radiology Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method; and Grading of Recommendations Assessment, Development, and Evaluation, or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. After a review of the published literature, the panel voted on three variants to establish best practices for the utilization of imaging, radiotherapy, and chemotherapy after primary surgery for early-stage endometrial cancer.

Anaesthesia for head and neck surgery: United Kingdom National Multidisciplinary Guidelines

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. The anaesthetic considerations for head and neck cancer surgery are especially challenging given the high burden of concurrent comorbidity in this patient group and the need to share the airway with the surgical team. This paper provides recommendations on the anaesthetic considerations during surgery for head and neck cancer. Recommendations • All theatre staff should participate in the World Health Organization checklist process. (R) • Post-operative airway management should be guided by local protocols. (R) • Patients admitted to post-operative care units with tracheal tubes in place should be monitored with continuous capnography. Removal for tracheal tubes is the responsibility of the anaesthetist. (R) • Anaesthetists should formally hand over care to an appropriately trained practitioner in the post-operative or intensive care unit. (G) • Intensive care unit staff looking after post-operative tracheostomies must be clear about which patients are not suitable for bag-mask ventilation and/or oral intubation in the event of emergencies. (R).

Future perspectives: United Kingdom National Multidisciplinary Guidelines

The multidisciplinary management of head and cancer has changed radically in the last decade. This paper provides a glimpse of the emerging surgical and oncological interventions that may play major roles in the treatment paradigms of tomorrow.