Postablation Stimulated Thyroglobulin Level is an Important Predictor of Biochemical Complete Remission after Reoperative Cervical Neck Dissection in Persistent/Recurrent Papillary Thyroid Carcinoma

Background

The efficacy of reoperative cervical neck dissection (RND) in achieving biochemical complete remission (BCR) (or postreoperation stimulated thyroglobulin [sTg] of <0.5 ng/mL) remains unclear in persistent/recurrent papillary thyroid carcinoma (PTC). We hypothesized that lower postablation sTg levels would indicate a higher rate of BCR after RND. Our study examined the association between postablation sTg and BCR after one or more RNDs.

Methods

Of 199 patients who underwent RND, 81 patients were eligible. The postablation sTg levels (≤2 and >2 ng/mL) were correlated with the postreoperation sTg levels after RNDs. Patients’ clinicopathological characteristics, operative findings, and subsequent RNDs were compared between those with BCR after RNDs and those without.

Results

Those with postablation sTg levels of ≤2 ng/mL had significantly higher BCR rate after the first RND (77.8 vs. 5.6 %, p < 0.001), overall BCR after one or more RNDs (77.8 vs. 9.3 %, p < 0.001), and better 5-year recurrence-free survival after the first RND (80.0 vs. 60.1 %, p = 0.049) than those with postablation sTg levels of >2 ng/mL. Overall BCR gradually decreased after each subsequent RND. Postablation sTg significantly correlated with postreoperation sTg (ρ = 0.509, p < 0.001). After adjusting for the number of metastatic lymph nodes excised at first RND and presence of extranodal extension, postablation sTg of ≤ 0.2 ng/mL was the only independent factor for BCR after one or more RNDs (odds ratio 37.0, 95 % confidence interval 5.68–250.0, p = 0.001).

Conclusions

Only a third of patients who underwent one or more RNDs for persistent/recurrent PTC had BCR afterward. Postablation sTg level was an independent factor for BCR. Completeness of the initial operation is important for the subsequent success of RND.     

Facilitators and Barriers to Teamworking and Patient Centeredness in Multidisciplinary Cancer Teams: Findings of a National Study

Background

Multidisciplinary teams (MDTs) are the standard means of making clinical decisions in surgical oncology. The aim of this study was to explore the views of MDT members regarding contribution to the MDT, representation of patients’ views, and dealing with disagreements in MDT meetings—issues that affect clinical decision making, but have not previously been addressed.

Methods

Responses to open questions from a 2009 national survey of MDT members about effective MDT working in the United Kingdom were analyzed for content. Emergent themes were identified and tabulated, and verbatim quotes were extracted to validate and illustrate themes.

Results

Free-text responses from 1,636 MDT members were analyzed. Key themes were: (1) the importance of nontechnical skills, organizational support, and good relationships between team members for effective teamworking; (2) recording of disagreements (potentially sharing them with patients) and the importance of patient-centered information in relation to team decision making; (3) the central role of clinical nurse specialists as the patient’s advocates, complementing the role of physicians in relation to patient centeredness.

Conclusions

Developing team members’ nontechnical skills and providing organizational support are necessary to help ensure that MDTs are delivering high-quality, patient-centered care. Recording dissent in decision making within the MDT is an important element, which should be defined further. The question of how best to represent the patient in MDT meetings also requires further exploration.     

Single‐stage application of a novel decellularized dermis for treatment‐resistant lower limb ulcers: Positive outcomes assessed by SIAscopy,laser perfusion,and 3D imaging,with sequential timed histological analysis

We present results of an original clinical study investigating efficacy of a decellularized dermal skin substitute (DCD) as part of a one‐stage therapeutic strategy for recalcitrant leg ulcers. Twenty patients with treatment‐resistant ulcers underwent hydrosurgical debridement, after which DCD was applied and covered with negative pressure dressings for 1 week. Participants were reviewed on seven occasions over 6 months. 3D photography, full‐field laser perfusion imaging, spectrophotometric intracutaneous analysis, and sequential biopsies were used to monitor healing. Mean ulcer duration and surface area prior to DCD placement were 4.76 years (range 0.25–40 years) and 13.11 cm² (range 1.06–40.75 cm²), respectively. Seventy percent of ulcers were venous. Surface area decreased in all patients after treatment (range 23–100%). Mean reduction was 87% after 6 months, and 60% of patients healed completely. Wound bed hemoglobin flux increased significantly 6 weeks after treatment (p = 0.005). Histological and immunohistochemical analysis confirmed progressive DCD integration with colonization by host fibroblasts, lymphocytes, and neutrophils, resulting in fibroplasia, reepithelialisation, and angiogenesis, with correlating raised CD31, collagen I, and collagen III levels. Subgroup analysis showed differing cellular behavior depending on wound duration, with delayed angiogenesis, reduced collagen deposition, and smaller reductions in surface area in ulcers present for over 1 year. The stain intensities of immunohistochemical markers including fibronectin, collagen, and CD31 differed depending on depth from the wound surface and presence of intact epithelium. DCD safely produced significant improvement in treatment‐resistant leg ulcers. With no requirement for hospital admission, anesthetic, or autogenic skin grafting, this treatment could be administered in hospital and community settings.     

Muscle‐specific kinase antibodies: A novel cause of peripheral nerve hyperexcitability?

Introduction: Antibodies that target the postsynaptic neuromuscular junction (NMJ) protein, muscle‐specific kinase (MuSK), have been associated with myasthenia gravis (MG), often with cramps and fasciculations, after administration of acetylcholinesterase inhibitors (AChE‐I). Methods: In this report, 2 patients are described with elevated MuSK antibodies and evidence of peripheral nerve hyperexcitability (PNH) unrelated to AChE‐I medication. Results: Patient 1 presented with facial neuromyotonia and fasciculations, without overt weakness. EMG studies demonstrated myokymic discharges in facial muscles, with bursts of discharges after voluntary activation, and widespread fasciculation potentials in limb muscles. Patient 2 presented with bulbar weakness and fasciculations in the tongue and limbs, initially diagnosed as bulbar‐onset amyotrophic lateral sclerosis. Subsequent investigation identified the presence of MuSK antibodies. Conclusions: We hypothesize that MuSK antibodies may induce these phenotypes through disruptive actions at the NMJ, in particular the binding of acetylcholinesterase (AChE) to MuSK via its collagen Q (ColQ) tail, producing a reduction in synaptic AChE activity. Muscle Nerve 48:819–823, 2013