Management considerations for the surgical treatment of Colorectal Cancer during the Global COVID-19 pandemic

The COVID-19 pandemic requires to conscientiously weigh ''timely surgical intervention'' for colorectal cancer against efforts to conserve hospital resources and protect patients and health care providers. Professional societies provided ad-hoc guidance at the outset of the COVID-19 pandemic on deferral of surgical and perioperative interventions, but these lack specific parameters to determine the optimal timing of surgery. Using the GRADE system, published evidence was analyzed to generate weighted statements for stage, site, acuity of presentation, and hospital setting to specify when surgery should be pursued, the time and duration of oncologically acceptable delays, and when to utilize nonsurgical modalities to bridge the waiting period. Colorectal cancer surgeries­prioritized as emergency, urgent with imminent emergency or oncologically urgent, or elective­were matched against the phases of the pandemic. Surgery in COVID-19-positive patients must be avoided. Emergent and imminent emergent cases should mostly proceed unless resources are exhausted. Standard practices allow for postponement of elective cases and deferral to nonsurgical modalities of stage II/ III rectal and metastatic colorectal cancer. Oncologically urgent cases may be delayed for 6(­12) weeks without jeopardizing oncological outcomes. Outside established principles, administration of nonsurgical modalities is not justified and increases the vulnerability of patients. The COVID-19 pandemic has stressed already limited health care resources and forced rationing, triage, and prioritization of care in general, specifically of surgical interventions. Established guidelines allow for modifications of optimal timing and type of surgery for colorectal cancer during an unrelated pandemic.

Management Considerations for the Surgical Treatment of Colorectal Cancer During the Global Covid-19 Pandemic.

OBJECTIVE: The COVID-19 pandemic requires to conscientiously weigh "timely surgical intervention" for colorectal cancer against efforts to conserve hospital resources and protect patients and health care providers. SUMMARY BACKGROUND DATA: Professional societies provided ad-hoc guidance at the outset of the COVID-19 pandemic on deferral of surgical and perioperative interventions, but these lack specific parameters to determine the optimal timing of surgery. METHODS: Using the GRADE system, published evidence was analyzed to generate weighted statements for stage, site, acuity of presentation, and hospital setting to specify when surgery should be pursued, the time and duration of oncologically acceptable delays, and when to utilize nonsurgical modalities to bridge the waiting period. RESULTS: Colorectal cancer surgeries-prioritized as emergency, urgent with imminent emergency or oncologically urgent, or elective-were matched against the phases of the pandemic. Surgery in COVID-19-positive patients must be avoided. Emergent and imminent emergent cases should mostly proceed unless resources are exhausted. Standard practices allow for postponement of elective cases and deferral to nonsurgical modalities of stage II/III rectal and metastatic colorectal cancer. Oncologically urgent cases may be delayed for 6(-12) weeks without jeopardizing oncological outcomes. Outside established principles, administration of nonsurgical modalities is not justified and increases the vulnerability of patients. CONCLUSIONS: The COVID-19 pandemic has stressed already limited health care resources and forced rationing, triage, and prioritization of care in general, specifically of surgical interventions. Established guidelines allow for modifications of optimal timing and type of surgery for colorectal cancer during an unrelated pandemic.

Fine-needle aspiration biopsy of thyroid nodules: Is routine ultrasound-guidance necessary?

BACKGROUND: Current guidelines recommend either ultrasound-guided or palpation-guided fine-needle aspiration biopsy for evaluation of a thyroid nodule. However, it has been suggested that ultrasound-guided fine-needle aspiration biopsy should be used routinely in all patients to reduce the rate of nondiagnostic and false negative results. The purpose of this study was to determine whether any difference exists in nondiagnostic and false negative rates between the two methods of fine-needle aspiration biopsy at our institution. METHODS: A retrospective review of a prospectively maintained thyroid database was completed to determine the rates of nondiagnostic and false negative fine-needle aspiration biopsy in patients with nodular thyroid disease evaluated during the period 1990-2017. RESULTS: From 1990 to 2017, a total of 2,322 patients underwent fine-needle aspiration biopsy for evaluation of nodular thyroid disease, 1,123 (48%) underwent ultrasound-guided fine-needle aspiration biopsy and 1,199 (52%) underwent palpation-guided fine-needle aspiration biopsy. Ultrasound-guided fine-needle aspiration biopsy was nondiagnostic in 4.5% and had a 5.2% false negative rate, compared with palpation-guided fine-needle aspiration biopsy, which was nondiagnostic in 5.0% and had a 2.6% false negative rate (P = .53 and .14, respectively). CONCLUSION: The rate of nondiagnostic and false negative fine-needle aspiration biopsy results is similar whether US guidance is used or not. To minimize resource utilization, ultrasound-guided fine-needle aspiration biopsy can be used selectively for nonpalpable, predominantly cystic, or previously nondiagnostic nodules.

Thyroid cancer in patients with toxic nodular goiter--is the incidence increasing?

BACKGROUND: There has been a dramatic increase in the incidence of thyroid cancer, but it is unclear if this has occurred in patients with toxic nodular goiter (TNG). METHODS: TNG was defined as one or more thyroid nodules in combination with a low serum TSH level. Patients who underwent thyroidectomy for TNG were identified from a prospectively maintained database. The rates of incidental thyroid cancer were compared over the intervals 1990 to 1999, 2000 to 2009, and 2010 to 2014. RESULTS: There was no significant difference in cancer rate between the 3 time periods. Overall, 7 (4.7%) of the 148 patients had thyroid cancer; similarly, 1 (3.2%) of the 31 patients from 1990 to 1999, 3 (4.2%) of 72 patients from 2000 to 2009, and 3 (6.7%) of the 45 patients from 2010 to 2014 (P > .05) had thyroid cancer. CONCLUSIONS: No significant increase in the rate of carcinoma was observed in patients with TNG. As a result, the risk benefit analysis should not change when considering therapeutic options for TNG.

ortho-Quinone methides from para-quinones: total synthesis of rubioncolin B.

A concise synthesis of rubioncolin B is described, which features an unprecedented intramolecular Diels-Alder reaction involving an ortho-quinone methide and a naphthofuran moiety. The ortho-quinone methide is generated through a surprisingly facile tautomerization of a para-quinone.