Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study (2021)

Type of publication:
Journal article

Author(s):
COVIDSurg Collaborative (includes *Blair J, *Lakhiani A, *Parry-Smith W, *Sahu B)

Citation:
The Lancet Oncology; 5th October 2021 [epub ahead of print]

Abstract:
Background: Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction.
Methods; This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926.
Findings; Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays.
Interpretation: Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services.

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Primary acinic cell carcinoma in a young female patient: a case report (2021)

Type of publication:
Journal article

Author(s):
*Venkatasami, M ; *Harrison, K

Citation:
Oral Surgery, Oral Medicine, Oral Pathology & Oral Radiology; Jul 2021; vol. 132 (no. 1)

Abstract:
Background: Acinic cell carcinoma (ACC) is a rare, low-grade tumor, accounting for about 5% of all primary salivary gland malignancies. ACCs predominate in the parotid gland, are seen in the fifth and sixth decades of life, and have a female predilection. Well-differentiated and low-grade tumors are associated with a favorable prognosis.
Description: We report a case of a 16-year-old female patient presenting with a right parotid lump that had been slowly increasing over the past year. Clinical examination revealed a 1.5-cm right parotid nodule with no facial nerve involvement and presence of cervical lymphadenopathy. Her past medical history was unremarkable.
Findings: Radiological investigations revealed a well-circumscribed, lobulated lesion in the anterior right parotid gland with presence of reactive lymph nodes bilaterally. Fine-needle aspiration showed granular cells with a differential diagnosis of oncocytoma, Warthin’s tumor, or acinic cell carcinoma. Histologic examination showed a multinodular appearance with some marked granular cytoplasm with oncolytic and lymphoid infiltrate. The results of immunohistochemistry were negative for S100 and positive with DOG-1. There were widespread periodic acid-Schiff diastase-resistant granules throughout the tumor cells, with a Ki67 proliferation index of approximately 5%.
Outcome: The tumor was completely excised, and the patient made a full recovery and was considered to have a good long-term prognosis.
Conclusions: This is an unusual case of ACC seen in this age group and gender, where less than 4% of cases of ACC have been reported in patients younger than 20. It is important to consider differential diagnoses of salivary gland pathology, such as ACC, in the young female patient.

Craniofacial osteosarcoma: a case report (2021)

Type of publication:
Journal article

Author(s):
*Venkatasami, M ; *Harrison, K

Citation:
Oral Surgery, Oral Medicine, Oral Pathology & Oral Radiology; Jul 2021; vol. 132 (no. 1)

Abstract:
Background: Osteosarcoma is the most common primary bone tumor, with 10% of cases affecting the head and neck. Demographics of head and neck osteosarcoma are different from those elsewhere in the musculoskeletal system. Prognosis is strongly dependent on negative resection margins with the use of neoadjuvant chemoradiotherapy in select cases.
Description: We present a case of a 58-year-old male nonsmoker patient who presented with a lump in his left upper jaw. Clinical examination revealed an exophytic mass in the upper left tuberosity of the maxilla suspicious for squamous cell carcinoma with no associated lymphadenopathy.
Findings: Radiological investigations revealed a metabolically active left maxillary lesion with destruction of the maxillary sinus. Histologic examination of a superficial biopsy initially suggested a proliferative fibro-osseous lesion; however, a second deeper biopsy was diagnostic of osteosarcoma, and the patient was referred to a sarcoma center. Immunohistochemistry showed AE1/AE3 and CK(MNF.116) positivity in occasional cells with a Ki67 proliferation index of 60%. This was diagnostic of grade 2-3 osteosarcoma. Multidisciplinary management of the patient included neoadjuvant chemotherapy and total maxillectomy and dental prosthetic rehabilitation. The patient is still under follow-up.
Conclusions: This case of primary osteosarcoma of the maxilla is rare and scarcely reported in the literature. Clinical differential diagnoses include squamous cell carcinoma, and histologic differential diagnosis includes fibro-osseous proliferative lesions in undersampled cases. It is important to consider osteosarcoma in destructive lesions, as it requires prompt and early specialist intervention to maximize the chances of negative surgical margins, which is the mainstay of treatment for this disease for prognosis.

A rare case of isolated laryngeal metastasis 23 years after nephrectomy for clear cell renal carcinoma (2021)

Type of publication:
Journal article

Author(s):
*Eastwood, Michael J ; *Ahsan, Syed F; *Harris, Richard

Citation:
British Journal of Hospital Medicine; Aug 2021; vol. 82 (no. 8); p. 1-3

Abstract:
The article describes the case of isolated laryngeal metastasis 23 years after nephrectomy for clear cell renal
carcinoma in an 84-year-old man.

Results of DARS: a randomised phase III trial of dysphagia-optimised intensity modulated radiotherapy (DO-IMRT) versus standard IMRT (S-IMRT) in oropharyngeal (OPC) and hypopharyngeal (HPC) cancer (2021)

Type of publication:
Conference abstract

Author(s):
Nutting C.; Roe J.; Tyler J.; Bhide S.; Rooney K.; Foran B.; *Pettit L.; Beasley M.; Finneran L.; Sydenham M.; Emson M.; Hall E.; Petkar I.; Frogley R.

Citation:
Oral Oncology; Jul 2021; vol. 118 Supplement ; p. 10-11

Abstract:
Presented by: Chris Nutting (Chris.Nutting@rmh.nhs.uk) Introduction Most newly diagnosed OPC & HPC are treated with (chemo)RT with curative intent but at the consequence of adverse effects on quality of life. DARS (ISRCTN:25458988) tested if using DO-IMRT to reduce RT dose to the dysphagia/aspiration related structures (DARS) improved swallowing function compared to S-IMRT. Materials and Methods Patients with T1-4, N0-3, M0 OPC/HPC were randomised 1:1 to S-IMRT (65 Gray (Gy)/30 fractions (f) to primary & nodal tumour; 54 Gy/ 30f to remaining pharyngeal subsite & nodal areas at risk of microscopic disease) or DO-IMRT. The volume of the superior & middle pharyngeal constrictor muscle (PCM) (OPC) or inferior PCM (HPC) lying outside the high-dose target volume was set a mandatory mean dose constraint in DO-IMRT. Treatment allocation was by minimisation balanced by centre, use of induction/concomitant chemotherapy, tumour site & AJCC stage. Primary endpoint was mean MD Anderson Dysphagia Inventory (MDADI) composite score 12 months after RT with 102 patients needed to detect a 10 point improvement (assuming S-IMRT score of 72, standard deviation (SD) 13.8; 90% power, 2-sided 5% alpha). Patients were blind to treatment allocation. Secondary endpoints assessing swallowing function included University of Washington (UW)-Qol & Performance Status Scale Head & Neck (PSS-HN) scores. Results 112 patients (56 S-IMRT, 56 DO-IMRT) were randomised from 22 UK centres from 06/2016 to 04/2018. Mean age was 57 years; 80% were male; 97% had OPC; 90% had AJCC stage 3&4 disease; 86% had concomitant chemotherapy only, 4% induction & concomitant and 10% no chemotherapy. 111/112 had RT doses as prescribed (1 patient died before RT). Median of the mean inferior PCM dose was SIMRT 49.8 Gy (IQR 47.1-52.4) vs. DO-IMRT 28.4 Gy (21.3-37.4), p < 0.0001; superior & middle PCM dose was
S-IMRT 57.2 Gy (56.3-58.3) vs. DO-IMRT 49.7 Gy (49.4-49.9), p < 0.0001. At 12 months, DO-IMRT had significantly higher MDADI scores: S-IMRT mean: 70.5 (SD 17.3) vs. DO-IMRT 77.7 (16.1), p = 0.037. At 12 months the proportion of patients reporting UW-QoL as being able to swallow “as well as ever” was 40.4% for DO-IMRT & 15.2% for S-IMRT; scores of?>50 were reported for PSS-HN normalcy of diet by 70.6% DO-IMRT & 58.1% S-IMRT patients & for eating in public scores by 84.3% DO-IMRT & 74.4% S-IMRT. Conclusions DOIMRT reduced RT dose to the DARS and improved patient reported swallowing function compared with S-IMRT. This is the first randomised study to demonstrate functional benefit of swallow-sparing IMRT in OPC.

Effective implementation of an advanced clinical practitioner role in breast imaging (2021)

Type of publication:
Conference abstract

Author(s):
*Deane L.; *Williams S.; *Cielecki L.; *Burley S.

Citation:
Breast Cancer Research 2021, 23(Suppl 1):P57

Abstract:
Background: Due to the immense pressure to provide capacity for women with breast symptoms, to be seen  within two weeks, a new innovative role has been created to provide increased capacity. Introduction: The breast services see many women with conditions that are benign and easily identified upon ultrasound. The majority of these conditions occur in women under the age of 40years. The role of an advanced clinical practitioner was created to answer a service need. This role requires a highly specialised cohort of skills combining breast image interpretation, breast ultrasound and breast biopsying alongside a range of clinical competences enabling autonomous practice within clear governance.
Method(s): A new clinic was created for under 40 aged women only requiring only a breast clinical specialist and an advanced clinical practitioner, using ultrasound for assessment. Unexpected findings suspicious upon ultrasound-would be redirected to the next consultant led clinic for full imaging assessment and biopsy.
Result(s): Increased capacity was achieved, without increased costs. Anxiety levels were reduced due to these patients seen within these clinics and more specialist skills could be directed to more complex cases in the traditional cancer clinics.
Conclusion(s): The use of this specialist role has proven to be innovative and specialised in answering capacity issues within the workforce. The ACP role is utilised as a support to all clinics working alongside consultant radiographers as well as in an autonomous role, thereby freeing up the consultants for cases requiring specialist skills. The stability of the breast service has been ensured

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Male breast ultrasound: 2019 audit results (2021)

Type of publication:
Conference abstract

Author(s):
*Ozcan U.A.; *Williams S.; *Metelko M

Citation:
Breast Cancer Research 2021, 23(Suppl 1):O3.3

Abstract:
Background and Purpose: Male breast cancer is rare whereas gynaecomastia is very common. Only asymmetrical gynaecomastia require breast imaging and focal lumps are amenable to clinical core biopsy. So the use of ultrasound in the assessment of male breast should be limited. The aim of this study is to audit the referral indications and ultrasound outcomes in male breast US (MBUS) patients against local guidelines.
Method(s): In the last 5 years, 968 patients were referred for MBUS in our Trust. This audit includes the patients between 02/01/2019-04/12/2019. The duplicate patients and follow-ups were excluded from the study. In total, 197 patients were analysed (mean age: 58 (8-90) retrospectively. Referral diagnosis, age, US grading and clinical outcomes were noted.
Result(s): Of the 197 patients, 79% were gynecomastia (133), lipoma (21) or fat necrosis (2), and 15% (30) were normal. There was 1 chest wall lymphoma and 1 DCIS, and 9 (5%) patients had benign breast disease (fibroepithelial lesions, abscess, papilloma, sebaceous cysts, haematoma). In 122 patients (62%) clinical grade was not given, 66 had P2, 8 had P3, 1 had P5. 2 patients were scored as U4 and 4 patients as U3.
Conclusion(s): These results clearly show that 99% of the patients referred to MBUS were benign. And also 95% of the patients were clinically benign or not assessed. The excessive use of MBUS without a clinical indication leads to patient anxiety, increased waiting times and might delay the proper imaging to the patients who should have the priority in terms of clinical indication. Careful clinical assessment before ultrasound referral is mandatory for better care.

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Does arbitration work? (2021)

Type of publication:
Conference abstract

Author(s):
*Williams S.; *Deane L.; *Burley S.; *Cielecki L.; *Aksoy U.; *Metelko M.

Citation:
Breast Cancer Research 2021, 23(Suppl 1):P63

Abstract:
Introduction: To improve cancer detection rates, personal performance and as part of our routine service improvement programme, an audit was undertaken of discordant cases returned directly to routine recall between 1/4/15 and 31/3/17 inclusive. These were reviewed against the results of the subsequent screening round to determine if the correct judgement had been made at the previous screening round or if there were any opportunities to learn from misinterpretation.
Method(s): All cases arbitrated and directly returned to routine screening between 2015/16 and 2016/17 were identified and crossreferenced with the results for the subsequent screening episode. All screen detected cancers previously arbitrated on the same side were reviewed by the same routine method and criteria as all interval cancers within our unit and each was given an ‘interval’ category. All of the screen detected cancers previously arbitrated on the same side were included in the annual interval cancer review session to discuss learn opportunities and improved outcomes.
Result(s): There were 829 cases arbitrated and returned to routine screening at the original screening episode 2015/16 or 2016/17. 11 cases were diagnosed with a same side screen detected cancer at the subsequent screening round and 2 cases presented as a same side interval cancer. Neither interval cancers detected at the case review. 1 of the 11 same side screen detected cancers classified as minimal signs.
Conclusion(s): In our unit arbitration cases returned to routine recall is the correct decision in the vast majority.

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British Society for Echocardiography and British Cardio-Oncology Society guideline for transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or trastuzumab (2021)

Type of publication:
Journal article

Author(s):
Dobson R.; Ghosh A.K.; Stanway S.; Manisty C.; Ky B.; Marwick T.; Stout M.; Pearce K.; Harkness A.; Steeds R.; Robinson S.; Oxborough D.; Adlam D.; Rana B.; *Ingram T.; Ring L.; Rosen S.; Plummer C.; Harbinson M.; Sharma V.; Lyon A.R.; Augustine D.X.

Citation:
Echo Research and Practice; Mar 2021; vol. 8 (no. 1)

Abstract:
The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor (EGF) receptor (HER) 2-positive targeted treatment (e.g. trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented.

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Impact of COVID-19 pandemic on the 2WW breast referrals to a district general hospital (2021)

Type of publication:
Conference abstract

Author(s):
*Tokode O.; *Rastall S.; *Wilson M.

Citation:
European Journal of Surgical Oncology; May 2021; vol. 47 (no. 5)

Abstract:
Introduction: Recommendations were issued to the hospital Trusts to configure service delivery to balance cancer care with the safety of the patient and the hospital staff during the COVID-19 pandemic. The public felt the service restrictions might lead to delays in diagnosis and treatment of cancer patients. We compared the management of 2ww breast referrals in our centre between May to July 2019 and 2020. Method(s): We triaged all referrals to face-face consultation or initial telephone consultation during the pandemic. Patients with suspicious symptoms were offered face-face consultation after the telephone triage. Result(s): Overall, breast patients’ referrals fell by 28.3% during the pandemic. 10.2% reduction was noted in May (95% CI 6.73 – 13.59, p<0.001) but a non-significant increase was recorded in June and July. Waiting time reduced by 8.43 days (95% CI -8.88 to -7.98, p< 0.0001). Breast cancer suspicion increased across all age groups in 2020 (+10.4% to + 16.2%). Breast cancer diagnosis rose by 2.0% in 2020 (95% CI 0.19 – 3.92, p=0.030). No cancer was diagnosed among under 29 years. 29.1% of the 522 patients triaged to telephone consultation were discharged, and 70.9% needed face-to-face follow-up. One patient discharged after telephone consultation was later diagnosed with breast cancer. Conclusion(s): COVID-19 pandemic did not lead to a prolonged waiting time or reduced breast cancer diagnosis, but there was an overall reduction in referrals to our breast service.

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