Introducing minimally invasive inguinal lymph node dissection in a UK tertiary skin cancer service: Initial experience & outcomes.

AIMS: We report the first UK case series of minimally invasive inguinal lymphadenectomy (MILND) for patients with metastatic cutaneous pathology. METHODS: This was a retrospective, single-centre, single-surgeon cohort study. Twenty-one patients who underwent MILND from May 2015 to February 2019 were included. Demographic data, disease burden, and surgical quality assurance parameters were analysed. RESULTS: Median age was 69 (IQR: 58-76) with 14 women (66%) and 7 men (33%). Eighteen (85%) patients had melanoma with the rest having other skin malignancies. The median number of nodes resected was eight (IQR:6-11) and the median N-ratio was 0.18 [0.05-1.00]. The median surgical time for the procedure was 180 minutes (IQR: 147-225) Seven (33%) patients had complications--three trivial and four (19%) grade IIIB. Only one case (the first) was converted to an open procedure. CONCLUSIONS: We report the first UK series of MILND in a cutaneous oncology service. Our results show that MILND is a safe technique that can be introduced into a busy NHS practice with a structured training program, with surgical quality assurance outcomes identical to open inguinal lymphadenectomy. Our learning curve was similar to previously published data.

Successful Salvage of Late Anastomotic Thrombosis after Free Tissue Transfer.

Background Anastomotic thrombosis following free tissue transfer (FTT) on or after day 5 ("late thrombosis") is reported to have extremely low rates of salvage. Analysis of our institution's experience with FTT was performed to make recommendations about the optimal management of late thrombosis, and to identify any variables that are correlated with increased salvage rates. Methods The study included patients who underwent FTT between 1986 and 2014, then suffered anastomotic thrombosis on or after postoperative day 5. Twenty-six variables involving demographic information, flap characteristics, circumstances of the thrombotic event, and details of any salvage attempt were analyzed. Patients whose FTT were successfully salvaged and those whose were not were statistically compared. Results Of the 3,212 patients who underwent FTT, 23 suffered late thrombosis (0.7%), and the salvage rate was 60.8% (14 of 23). The salvage rate for reconstruction of the head and neck was 53.3%, breast was 66.7%, and extremity was 100%. There was a statistically significantly greater salvage rate in flaps performed after 1998 than in those performed before 1998 (p = 0.023). There was a nonstatistically significant trend toward increased salvage rates in patients who had no anastomotic thrombotic risk factors, reconstruction using fasciocutaneous flaps, and anastomotic revision using new recipient vessels. Conclusion Our data demonstrate that flap survival after episodes of late thrombosis can be higher than what the literature has previously reported. This underscores the importance of rigorous postoperative monitoring, as well as the importance of exploration at the earliest instance of concern for threatened flap viability.

Quality of patient-reported outcome reporting across cancer randomized controlled trials according to the CONSORT patient-reported outcome extension: A pooled analysis of 557 trials.

BACKGROUND: The main objectives of this study were to identify the number of randomized controlled trials (RCTs) including a patient-reported outcome (PRO) endpoint across a wide range of cancer specialties and to evaluate the completeness of PRO reporting according to the Consolidated Standards of Reporting Trials (CONSORT) PRO extension. METHODS: RCTs with a PRO endpoint that had been performed across several cancer specialties and published between 2004 and 2013 were considered. Studies were evaluated on the basis of previously defined criteria, including the CONSORT PRO extension and the Cochrane Collaboration's tool for assessing the risk of bias of RCTs. Analyses were also conducted by the type of PRO endpoint (primary vs secondary) and by the cancer disease site. RESULTS: A total of 56,696 potentially eligible records were scrutinized, and 557 RCTs with a PRO evaluation, enrolling 254,677 patients overall, were identified. PROs were most frequently used in RCTs of breast (n = 123), lung (n = 85), and colorectal cancer (n = 66). Overall, PROs were secondary endpoints in 421 RCTs (76%). Four of 6 evaluated CONSORT PRO items were documented in less than 50% of the RCTs. The level of reporting was higher in RCTs with a PRO as a primary endpoint. The presence of a supplementary report was the only statistically significant factor associated with greater completeness of reporting for both RCTs with PROs as primary endpoints (ß = .19, P = .001) and RCTs with PROs as secondary endpoints (ß = .30, P < .001). CONCLUSIONS: Implementation of the CONSORT PRO extension is equally important across all cancer specialties. Its use can also contribute to revealing the robust PRO design of some studies, which might be obscured by poor outcome reporting.

Acute facial oedema post live-donor renal transplantation.

Facial oedema leading to airway compromise immediately after surgery is a rare event. We report a case of acute facial swelling sufficient to cause a significant obstruction of the patient's airway in recovery. We believe it was caused by partial obstruction of the venous drainage from the head associated with a sudden and large fluid load. A 35-year-old man underwent a live ABO-incompatible renal transplantation during which a central line was inserted into the right subclavian vein and a large volume of fluid was given intraoperatively. He also had a longstanding permacatheter on the left side used for haemodialysis. In the recovery room he developed acute facial swelling which did not resolve with steroids or antihistamines. He was managed by intubation of his airway and ventilation in the intensive care unit overnight before he made a complete recovery with no further intervention. We hypothesise that this event was related to an impaired venous return from his head secondary to the central venous line and the permacatheter partially obstructing the venous drainage from his head and neck combined with an acute large venous fluid load.

A paradigm shift in U.S. breast reconstruction: Part 2. The influence of changing mastectomy patterns on reconstructive rate and method.

BACKGROUND: The aims of the current study were to (1) measure trends in the type of mastectomy performed, (2) evaluate sociodemographic/hospital characteristics of patients undergoing contralateral prophylactic mastectomy versus unilateral mastectomies, and (3) analyze reconstruction rates and method used following different mastectomy types. METHODS: Mastectomies from 1998 to 2008 were analyzed using the Nationwide Inpatient Sample database. Mastectomies (n = 178,603) were classified as either unilateral, contralateral prophylactic, or bilateral prophylactic. Reconstructive procedures were categorized into either implant or autologous. Longitudinal trends were analyzed with Poisson regression and sociodemographic/hospital variables were analyzed with logistic regression. RESULTS: Unilateral mastectomies decreased 2 percent per year, whereas contralateral and bilateral prophylactic mastectomies increased significantly by 15 and 12 percent per year, respectively (p < 0.01). Independent predictors for contralateral prophylactic mastectomy (compared with unilateral mastectomy) were patients younger than 39 years, Caucasian and Hispanic race, private insurance carriers, treated in teaching hospitals, and from South and Midwest regions. Contralateral prophylactic mastectomy is the only group with increased reconstruction rates throughout the study period (p < 0.01). Although implant use increased for all mastectomy types, it remains greater in bilateral and contralateral prophylactic mastectomy. CONCLUSIONS: There is increasing use of bilateral mastectomies in the United States, particularly in patients with unilateral cancer. Although implant use has increased for all mastectomy types, they are used most commonly following bilateral and contralateral prophylactic mastectomies. Changing mastectomy patterns are one factor underlying the paradigm shift away from autologous tissue to implant-based reconstruction.

Systematic review of quality of life and patient reported outcomes in patients with oncologic related lower extremity lymphedema.

BACKGROUND: Lower limb lymphedema (LLL) is a common complication of cancer treatment. The disease is chronic and progressive with no cure. Although a common and significant source of morbidity, the impact of this condition on health-related quality of life (HRQOL) has only recently been addressed. In effort to identify valid treatment strategies for LLL, we performed a systematic review, identifying studies describing HRQOL outcomes in patients with LLL secondary to cancer. METHODS AND RESULTS: Seven medical databases were searched to identify reports using validated Patient Reported Outcome (PRO) instruments on patients with cancer-related LLL. Studies were classified by levels of evidence set by the Agency for Healthcare Research and Quality (AHRQ) and evaluated using the Efficace criteria. 25 studies were identified, 6 met inclusion criteria. Levels of evidence included: no level I studies, level II (n=3), level III (n=1), and level 4 (n=2). 50% of studies were compliant with the Efficace criteria. 5 PRO HRQOL instruments were used, but only 1 was specific to cancer-related lymphedema. Treatment strategies assessed included complete decongestive physiotherapy (CDP), exercise, and compression bandaging. CDP yielded significant enhancements in HRQOL. CONCLUSIONS: There is a deficit in high quality studies for HRQOL in patients with LLL secondary to cancer. Furthermore, of the studies present, most did not conform to guidelines set for assessment of HRQOL, nor did they use lymphedema condition specific PRO instruments. New measures specific to assessing LLL are necessary to gain more accurate evaluation of how this debilitating disorder affects HRQOL.

Unilateral preoperative chest wall irradiation in bilateral tissue expander breast reconstruction with acellular dermal matrix: a prospective outcomes analysis.

BACKGROUND: Prior breast irradiation increases the rate of postoperative complications, including capsular contracture, in tissue expander/implant reconstruction. Acellular dermal matrix is heralded to decrease capsular contracture, but recent evidence suggests a possible increase in postoperative complications. The authors evaluated outcomes in patients undergoing bilateral tissue expander/implant reconstruction with acellular dermal matrix in the setting of prior unilateral irradiation. METHODS: A case-control study was conducted on all patients undergoing bilateral, acellular dermal matrix-assisted, tissue expander/implant reconstruction with a history of previous unilateral irradiation at Memorial Sloan-Kettering Cancer Center. Complication rates were compared. RESULTS: Twenty-three patients met inclusion criteria and had an average follow-up of 19 months (range, 4 to 60 months). The perioperative infection rate was 21.7 percent (n = 5) in irradiated breasts and 4.3 percent (n = 1) in control breasts (p = 0.079). Mastectomy skin flap necrosis, explantation, hematoma, and seroma rates were not significantly different between the groups. Sixty percent of patients had irradiated breast contracture that was one Baker grade greater than that in the nonirradiated breast. Body mass index greater than 25 and smoking history were significant independent risk factors for early postoperative complications in univariate analysis (p = 0.01). CONCLUSIONS: Previous irradiation does not appear to increase the risk of early postoperative complications associated with acellular dermal matrix use in tissue expander/implant breast reconstruction. However, body mass index greater than 25 and smoking history are cause for caution. In addition, acellular dermal matrix does not appear to affect the degree of capsular contracture formation in the setting of prior irradiation. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, III.

Quality of life among breast cancer patients with lymphedema: a systematic review of patient-reported outcome instruments and outcomes.

PURPOSE: Lymphedema following breast cancer surgery remains a common and feared treatment complication. Accurate information on health-related quality of life (HRQOL) outcomes among patients with lymphedema is critically needed to inform shared medical decision making and evidence-based practice in oncologic breast surgery. Our systematic review aimed to (1) identify studies describing HRQOL outcomes in breast cancer-related lymphedema (BCRL) patients, (2) assess the quality of these studies, and (3) assess the quality and appropriateness of the patient-reported outcome (PRO) instruments used. METHODS: Using the PRISMA statement, we performed a systematic review including studies describing HRQOL outcomes among BCRL patients. Studies were classified by levels of evidence and fulfillment of the Efficace criteria. PRO instruments were assessed using the COSMIN criteria. RESULTS: Thirty-nine studies met inclusion criteria, including 8 level I and 14 level II studies. Sixteen of 39 studies were compliant with the Efficace criteria. Seventeen HRQOL instruments were used, two specific to lymphedema patients. Exercise and complex decongestive therapy treatment interventions were associated with improved HRQOL. CONCLUSIONS: High-quality data on HRQOL outcomes is required to inform surgical decisions for breast cancer management and survivors. Of the lymphedema-specific PRO instruments, the Upper Limb Lymphedema 27 (ULL-27) was found to have strong psychometric properties. Future studies should strive to use high-quality condition- specific PRO instruments, follow existing guidelines for HRQOL measurement and to consider economic burdens of BCRL. IMPLICATIONS FOR CANCER SURVIVORS: As lymphedema may develop many years after breast cancer surgery, the ULL-27 may offer greater content validity for use in survivorship research.

Measuring and managing patient expectations for breast reconstruction: impact on quality of life and patient satisfaction.

The goal of postmastectomy breast reconstruction is to restore a woman's body image and to satisfy her personal expectations regarding the results of surgery. Studies in other surgical areas have shown that unrecognized or unfulfilled expectations may predict dissatisfaction more strongly than even the technical success of the surgery. Patient expectations play an especially critical role in elective procedures, such as cancer reconstruction, where the patient's primary motivation is improved health-related quality of life. In breast reconstruction, assessment of patient expectations is therefore vital to optimal patient care. This report summarizes the existing literature on patient expectations regarding breast reconstruction, and provides a viewpoint on how this field can evolve. Specifically, we consider how systematic measurement and management of patient expectations may improve patient education, shared medical decision-making and patient perception of outcomes.

Pathways of care for patients with suspected cancer of the pancreas: a tiered questionnaire-based survey of medical personnel across a single United kingdom Calman-Hine cancer network.

OBJECTIVE: This study examines clinical management pathways for patients with suspected pancreatic cancer within a single United Kingdom Calman-Hine NHS cancer network with particular focus on referral patterns and the primary care-hospital specialist interface. METHODS: A questionnaire-based study appraising responses from three key groups (general practitioners, gastrointestinal physicians and gastrointestinal surgeons) practising within a cancer network. The questionnaire addressed caseload, referral pathways, multidisciplinary care teams and involvement of specialists. PARTICIPANTS: The study population comprised 448 general practitioners, 14 gastroenterologists and 23 gastrointestinal surgeons. RESULTS: The mean number of new patients with suspected pancreatic cancer seen per general practitioner per annum was 0.4 (range: 0-1). Fifty-three percent of general practitioners refer to gastrointestinal physicians and 47% to gastrointestinal surgeons. In hospital, a relatively large number of physicians and surgeons see a small number of new patients each per annum. The involvement of multidisciplinary teams and referral of patients with non-resectable disease for chemotherapy is limited. Fourteen (60.9% out of 23 general surgeons) refer all patients to pancreatic specialists, 4 (17.4%) selectively refer and 5 (21.7%) never refer. CONCLUSION: The findings suggest divergence in standards of care from those advocated in governmental cancer strategic plans. In particular, not all patients with suspected pancreatic cancer see specialists, many hospital specialists see small numbers of cases and multidisciplinary care is limited.

Combined treatment, TACE and RF ablation, in HCC: preliminary results.

PURPOSE: The aim of this study was to assess the effectiveness of a combination of percutaneous radiofrequency thermal ablation (RF), stop-flow and transcatheter arterial chemo-embolisation (TACE) in the treatment of hepatic neoplasms. MATERIALS AND METHODS: From December 1997 to September 2000, 34 patients with hepatocellular carcinoma (HCC) underwent radiofrequency thermoablation treatment. The choice of method was based on the type of lesion (HCC vs metastasis) and the following dimensional criteria: 1. RF without stop-flow associated with the injection of diagnostic Lipiodol in the case of a single nodule with a maximum diameter smaller than 3 cm; 2. RF with stop-flow of the hepatic artery associated with TACE in the case of a single nodule with a diameter greater than 3 cm; 3. RF with stop-flow of the hepatic artery associated with TACE in the case of 2-3 nodules, a subdivision was made into 2 groups according to the volume: smaller or greater than 80 ml. RESULTS: 10 out of 34 patients affected by HCC with a diameter smaller than 3cm, treated only with RF, demonstrated 100% necrosis in the follow-up period, which varied between 6 and 24 months (average 10 months). The remaining 24 patients affected by HCC and treated with RF associated with stop-flow and TACE showed responses related to the volume of the tumour: 1. patients with a single nodule with a diameter of 3-5 cm showed 100% necrosis; 2. patients affected by multifocal HCC with a maximum of 3 nodules and/or total tumour mass smaller than 80 ml, for a total of 9 lesions, showed 95% necrosis; 3. patients affected by multifocal HCC with more than 3 nodules (total mass less than 40% of liver volume) or tumour mass greater than 80ml, for a total of 13 lesions, showed 90% necrosis. In the group of patients affected by multiple nodules with volumes smaller than 80ml, the technique did not show complete effectiveness, thus these patients cannot be considered cured. Such aspects are even clearer in the more advanced stages. CONCLUSIONS: In our case study, radiofrequency proved effective with lesions up to 3cm in diameter. By reducing thermal dispersion, the association of the stop-flow technique with radiofrequency ablation, determines a greater volume of necrosis, which allows effective treatment of single nodules with a diameter of up to 5cm and/or multiple nodules. The association with TACE: 1. provided a way to highlight and treat lesions not recognizable through other imaging techniques; 2. increased the accumulation of lipid contrast in the tissue surrounding the lesion and in the vessels not occluded by thermal ablation in the lesions with diameters greater than 3 cm; 3. enabled further treatment of tumour residue possibly left untouched by thermal ablation in large tumours; 4. increased the amount of Lipiodol accumulated in normal tissue surrounding the lesion, made evident through the comparison of the dimensions of the nodule's blush between angiography and Lipiodol CT.