General Surgical Oncology Research Articles

An analysis of the demography and histology of patients presenting with oral cavity malignancy

In the modern world one of the most dreaded disease is cancer. Among all the cancers that occur, cancer within the oral cavity ranks as the eleventh most common cancer globally In view of the changing trends in oral cancer we did a study to evaluate the practices followed for oral cancer in our study.The present study was a non-randomized prospective observational study that was done on patients who visited hospital and were diagnosed by histopathology as having oral cancer. The study was done at the department of general surgery and surgical oncology at the Father Muller Medical College. Kankanady in the state of Karnataka South India. The study was done. During the study period that extended from March 2014 to February 2020 the following observations were done on a total of 202 cases.Those who met a predefined criteria and gave a written informed consent were enrolled in the study. They were explained regarding their disease, the treatment options that are available and the alternative treatments if any. Once the patients was optimized, based on the decision of the tumour board appropriate therapy was given and the complications of each was noted down. During the study period that extended from March 2014 to February 2020 the following observations were done on a total of 202 cases .In the present study between the age of 20 and 60 years we had 148 cases (73.26%), the most common decade involved was 41-50 years with 68 cases (33.66%). In the productive age group between the age of 21 years and 50 years we had 146 cases. The predominant population affected by oral cancer was male’s 164 cases (81.19%)On evaluation of the clinical presentation distribution in the study subjects all cases presented with ulcer .Lesions of the tongue were seen in 99.01% cases. In most cases wide excision and reconstruction was possible (54 cases) near glossectomy with MRND was done in 1patient hemi glossectomy with MRND was done in 16 patient partial glossectomy with MRND was done in 17 patient. All case were proved as Squamous cell carcinoma. The minimum follow up was for 13 months and at the last follow-up all cases were found to be tumour free . The mainstay of current. Exciting challenges include improving success rates of current therapy, reducing the morbidity of treatment, and to select the most appropriate treatment.

A How-To Guide: Virtual Interviews in the Era of Social Distancing

The coronavirus crisis hit at the beginning of the Complex General Surgical Oncology Fellowship (CGSO) and Breast Oncology Fellowship interview cycles. Within 2 weeks, nearly all programs, including ours, switched to a virtual platform for the remainder of the season. Given that social distancing will remain in place for the foreseeable future, it is possible that all residency and fellowship interviews will need to be conducted virtually. Our methods and shared experience can assist other programs faced with this task for their upcoming interview cycle. We recommend using a virtual meeting platform in which staff have the most comfort; we chose Zoom as our platform. Information on the program traditionally included in the welcome packet, research opportunities, details on the institution, hospital and staff, and detailed interview instructions were distributed prior to the interview day. A virtual “happy hour” was conducted to provide an opportunity for candidates and current trainees to interact. Our virtual interview day schedule mimicked our traditional in person interview day, and we always had a back-up plan for completing the interview if the virtual platform became unstable. While many programs would not choose to perform virtual interviews, we felt that by conducting them in the methods we describe, we were able to closely replicate our traditional interview day and appreciate the candidacy of the applicants.

Letters of recommendation for surgical fellowships – Does gender make a difference?

BackgroundFemales comprise 1/3 of general surgery residents, 1/4 of surgical faculty and 10% of full professors. Inadequate sponsorship is one proposed mechanism for this decline. This study evaluated letters of recommendation (LOR) among applicants applying to a complex general surgical oncology (CGSO) fellowship. MethodsLinguistic analysis of LOR for CGSO applicants was conducted. Demographics of authors and features of the LOR were extracted. Differences by gender of the applicant were analyzed. ResultsAmong 340 letters, 67% were written for male and 33% written for female applicants. Males authored 84% of letters reviewed. Female authors used more grindstone adjectives than males (3.61 v 2.90). However, this difference was seen only among letters written for male applicants (3.82 v. 2.73). All other linguistic features were similar, aside from mention of physical appearance which was significantly more common in letters written about female applicants (4% v. 1%). ConclusionsFemale authors write substantively different letters than males. Physical appearance is a small but important difference in letters for female applicants.

Preparation for the complex general surgical oncology boards—Level I evidence and best sources of acquiring knowledge

Preparation for the complex general surgical oncology boards—Level I evidence and best sources of acquiring knowledge

Plant-based diet trends in oncology patients.

e19224 Background: Plant-based diets are beneficial in several cancers such as colorectal and prostate. However, their adoption among oncology patients is not well studied. We report trends in plant-based diet selection among medical and surgical oncology patients at a comprehensive cancer center. Methods: An IRB-approved retrospective review of all patients admitted to the University of New Mexico Hospitals between October 2009 and October 2017 was conducted. Inclusion criteria included: 1) vegetarian Ovo-Lacto (dairy and eggs ok) or vegan (no animal-derived foods) inpatient diet request and 2) age >= 18 years. For each individual, the dietary orders and discharge summaries were reviewed. Patients with cancer diagnosis principally related to admission and/or admission to an oncology inpatient service were defined as oncology patients. Surgical oncology services included 8 different surgical branches. Results: A total of 181 oncology patients ordered plant-based diets. Median age was 62 years (range 18 to 90) and 69% were female. Vegetarian Ovo-Lacto (66%) was requested more than vegan diet (34%). The services on which the greatest number of these patients were treated were Medical Oncology (31%), General Surgical Oncology (23%), and Gynecology-Oncology (20%). Comparing medical and surgical oncology patients, there was no difference in terms of median age (63 vs. 62 years, p=0.62), nor in the % requesting vegan diet (30 vs. 35%, p=0.50), respectively. However, females comprised 95 of 124 (77%) surgical patients, but only 29 of 57 (51%) medical patients (p<0.001). The number of patients requesting a plant-based diet grew from 81 in the first half of the study period to 100 in the second half (a 23% increase). During this time period, vegetarian diet became more popular than vegan with an increase from 48 patients (59%) in the first half to 72 (72%) in the second half (p=0.05). Conclusions: Oncology patients are increasingly requesting plant-based diets. Most are female and prefer vegetarian over vegan meals. These findings can help cancer centers improve quality of care by tailoring nutritional offerings.

Development of a surgical oncology training curriculum for accreditation.

In 2011, the American Board of Surgery announced a new specialty board certification for Complex General Surgical Oncology. The development of a 2-year fellowship training curriculum was based on the core values of multidisciplinary care, surgical management of oncologic disease, education in basic research and clinical trial design, community outreach, patient counseling, and leadership in oncology. This article highlights the elements necessary for developing a fellowship training program in the context of these core values.

Vascular surgery's identity

Vascular surgery's identity

Adherence to the National Comprehensive Cancer Network Criteria of Complete Circumferential Peripheral and Deep Margin Assessment in Treatment of High-Risk Basal and Squamous Cell Carcinoma.

The National Comprehensive Cancer Network (NCCN) has established guidelines for the treatment of keratinocyte carcinomas (KCs). Complete circumferential peripheral and deep margin assessment (CCPDMA) is recommended for "high-risk" tumors that cannot be closed primarily. If flap or grafts are needed and CCPDMA was not used, it is recommended that reconstruction be delayed until achieving clear margins. To measure provider utilization rates of the NCCN guidelines for high-risk KCs and assess barriers that are limiting adherence. A ten-item questionnaire was distributed to NCCN nonmelanoma skin cancer panel members and physicians participating in KC treatment at academic institutions. Response rate was 49% (57/116). Responses were categorized by practice area: Mohs surgery, pathology, and other specialties: General Dermatology, Otolaryngology, Plastic Surgery, Surgical Oncology, Radiation Oncology, and Oral and Maxillofacial Surgery. Mohs surgeons were most likely to use CCPDMA for tumors meeting NCCN criteria with 14/15 using this technique in a majority of their cases, versus 2/6 pathologists and 10/16 specialists from other fields. Reasons cited for not using CCPDMA included deference to pathologists to determine the appropriate method for margin assessment and logistical difficulty. Further efforts are needed to increase adherence to NCCN's guidelines regarding CCPDMA in KCs.

Senior resident versus fellow participation during complex cancer operations.

330 Background: Teaching hospitals that train both general surgery residents and fellows in complex general surgical oncology have become more common. Despite ACGME dictums, attending surgeons may favor either residents or fellows assisting on operations of greater complexity, depending upon a variety of factors, including local surgical culture. This study investigates whether participation of a senior resident versus a fellow impacts outcomes of complex cancer surgery. Methods: Patients who underwent esophagectomy, or gastrectomy with assistance from either a senior resident (PGY-4 or 5) or a fellow (PGY-6 to 8) were identified from the American College of Surgeon’s National Surgical Quality Improvement Program (2007-2012). Analyses were performed separately for each operation. Propensity-scores were created for the odds of undergoing the operation assisted by a fellow. Patients were matched based on propensity score, and outcomes were compared after matching. Results: In total, 1,160 esophagectomies and 2,432 gastrectomies were identified. Senior resident participation was reported in 60.2% and 86.6%, respectively. Resident involvement was associated with non-white race (17.0% vs. 13.8%; p < 0.001), and lower rates of neoadjuvant chemotherapy (6.4% vs. 11.7%; p < 0.001). After matching, rates major complication rates were slightly higher for patients who underwent esophagectomies involving a resident compared to fellow (38.1% vs. 31.8%; p = 0.0447). However, major complications rates were similar for gastrectomy (21.2% vs. 22.1%; p = 0.775). In addition, operative time was shorter for gastrectomy (212 vs. 232 min; p = 0.009) involving a resident compared to a fellow, but comparable for patients who underwent esophagectomy (327 vs. 337 min; p = 0.310). Conclusions: The results of this study suggest that senior resident participation in complex cancer operations does not negatively impact operative time or outcomes, compared to involvement of a surgical oncology fellow. Although confounding by operative autonomy may exist, these findings indicate that senior residents should be given the same opportunities as fellows to participate in these potentially more challenging operations.

The Value of C Reactive Protein and the Leukocytes in the Peritoneal Fluid in the Predicting Postoperative Digestive Fistulas

Anastomotic fistulas in digestive surgery are a severe complication of the patient. The identification of paraclinical laboratory investigations which would allow an early diagnosis of fistulas would lead to the optimization of patient's management. We have performed a retrospective study on 100 cancer patients, with digestive tract surgeries, between May 2016 and December 2017, in the First Clinic of General surgery and Surgical Oncology from the Bucharest Oncology Institute. The postoperative follow-up included: the testing of the C reactive protein (CRP ), and also the monitoring of the number of leukocytes (Ld) from the abdominal cavity, with probes taken from the drainage tube, all in association with the number of leukocytes in the blood (Ls) in all patients (with or without digestive fistula). By calculating the values of these tests and comparing them always with the clinical evolution of the patients, and sometimes with other tests as well, one would confirm an early diagnosis of fistula. The data obtained have shown that in patients with digestive fistulae there is a rapid growth and maintaining of increased values of serum PCR and of the leukocytes from the peritoneal cavity, values to which we associated also an increase in blood leukocytes. The modifications appear with approx. two days before the appearance of clinical signs or their confirmation through imagery (ultrasound, computed tomography). The regular and standardized follow-up in days 1, 3 and 5 postoperatively of the PCR value in blood, of the number of leukocytes in the abdominal cavity and of the serum leucocytosis, increasing the value of these parameters, could allow the early identification of the patients with a risk of fistula and the rapid selection of those which need supplementary investigations and/or surgical intervention.

Residents entering Complex General Surgical Oncology fellowship lack confidence with pelvic MRI for rectal cancer: Results of a needs assessment survey

BackgroundMagnetic resonance imaging (MRI) is essential for the multidisciplinary treatment of rectal cancer. However, baseline experience of surgical residents with MRI is unknown. Therefore, a needs assessment survey was conducted to examine confidence with pelvic MRI for residents entering Complex General Surgical Oncology (CSGO) fellowships. MethodsA multi-institutional survey evaluated incoming CGSO fellows’ experience with pelvic MRI for rectal cancer in residency. Additionally, confidence was assessed for essential components of pelvic MRI including T- and N-stage, circumferential resection margin (CRM), extramural venous invasion (EMVI), and pelvic anatomy. ResultsOf the twenty-four incoming fellows who completed the survey (response rate = 44%), 20 reported frequent use of pelvic MRI for rectal cancer in residency, but 16 reported rarely/never interpreting images themselves for staging or operative planning. Most respondents reported low confidence for T-stage, N-stage, CRM, EMVI, as well as pelvic anatomy, particularly for lateral and posterior pelvis. ConclusionsThe development of a pelvic MRI curriculum for residents entering CGSO fellowships could enhance their clinical training in the multidisciplinary management of patients with rectal cancer.

ASO Author Reflections: Complex General Surgical Oncology Fellowships: What Are Programs Looking For?

ASO Author Reflections: Complex General Surgical Oncology Fellowships: What Are Programs Looking For?

ASO Author Reflections: A Glimpse of Complex General Surgical Oncology Practice After Fellowship.

ASO Author Reflections: A Glimpse of Complex General Surgical Oncology Practice After Fellowship.

Complex General Surgical Oncology Fellowship Applicants: Trends over Time and the Impact of Board Certification Eligibility.

Complex general surgical oncology (CGSO) fellowships recently obtained Accreditation Council for Graduate Medical Education (ACGME) accreditation and board certification eligibility. We aimed to characterize the applicant pool and identify factors predictive of matching into our program. We conducted a retrospective review of CGSO fellowship applications to a major cancer center from 2008 to 2018. Data were analyzed for trends over time, including a comparison of pre- versus post-American Board of Surgery (ABS) certification eligibility. A total of 846 applications were reviewed. Most applicants (86.2%) trained in a US residency program; 58.4% performed ≥ 1 research year during residency; 29.6% had a dual degree. Fewer applicants (34.5%) were female, a trend which did not change over time. Post-ABS, applicants were more likely to complete ≥ 1year between residency and fellowship (20.9% versus 13.2%, p = 0.003), to be in practice at the time of application (12.2% versus 6.6%, p = 0.005), and to reapply (5.5% versus 1.0%, p < 0.001). Post-ABS applicants listed more peer-reviewed publications (8 [interquartile range (IQR) 4, 15] versus 5 [IQR 2, 10]; p < 0.001). On multivariable analysis, factors associated with matching into our program included: US allopathic medical school graduation [odds ratio (OR) 4.6, 95% confidence interval (CI) 1.8-11.7], Alpha Omega Alpha (AOA) Honor Medical Society distinction (OR 2.7, 95% CI 1.6-4.7), dual degree (OR 2.0, 95% CI 1.1-3.4), and performance of a clinical/research rotation at our institution (OR 4.9, 95% CI 2.2-10.7). After establishment of CGSO board certification eligibility, applicants were more likely to apply while in practice and to reapply. A number of factors, including having a dual degree and rotating at our institution, were associated with matriculation.

Defining a Leader—Characteristics That Distinguish a Chair of Surgery

BackgroundChair of the Department of Surgery, sometimes known as the Chief, holds a title that has significant historical connotations. Our goal was to assess a group of objectively measurable characteristics that unify these individuals as a group. MethodsUtilizing publicly available data for all US teaching hospitals, demographic information was accumulated for the named chiefs/chairs of surgery. Information collected included location of their program, their medical/surgical training history, their surgical specialty, previous chair/chief titles held, and academic productivity. ResultsOf the 259 programs listed, data were available on 244 individuals who were trained in 19 different specialties. The top three specialties of these practitioners are General Surgery (40, 16.3%), Surgical Oncology (38, 15.5%), and Vascular Surgery (33, 13.5%). There were only 14 female chairs (5.7%) and only one chair with a doctor of osteopathic medicine degree. The majority (62.3%) had been a previous chief of a surgical subdivision with only 26% having been a previous chair/chief of the surgical department.The average chair had 72 peer-reviewed manuscripts with 28 published book chapters. Chair's at academic institutions with university affiliation had a significantly higher number of peer-reviewed manuscripts (P < 0.0001) as well as were more likely to be trained at academic institutions (P = 0.013). ConclusionsThere are no set characteristics that define the Chair of a Department of Surgery. By understanding a group of baseline characteristics that unify these surgical leaders, young faculty and trainees with leadership aspirations may begin to understand what is necessary to fill these roles in the future.

A Survey of the Complex General Surgical Oncology Fellowship Programs Regarding Applicant Selection and Rank.

There is significant demand for training in Complex General Surgical Oncology (CGSO) fellowships. Previous work has explored objective quantitative metrics of applicants that matriculated to CGSO fellowships; however, ambiguity remains concerning academic benchmarks and qualitative factors that impact matriculation. A web-based survey was sent to each ACGME/SSO-approved CGSO fellowship training program. The survey was comprised of 24 questions in various forms, including dichotomous, ranked, and five-point Likert scale questions. Twenty-nine of 30 program directors (97%) submitted complete survey responses, representing 64 of the 65 CGSO fellowship positions (99%) currently offered. Programs received a mean of 73 applications per cycle (range 50-125) and granted a mean of 26 interviews (range 2-45). Seventy-two percent of programs had an established benchmark for ABSITE score percentile before offering a candidate an interview, with 62% of those programs setting that benchmark above the 50th percentile. The majority of programs also had established benchmarks for quantity of first author publications (mean: 2.3) and all publications of any authorship (mean: 4.4). An applicant's interview was ranked as the most important factor in determining inclusion on the program's rank list. The ability to work as part of a team, interpersonal interaction/communication abilities, and operative skills were rated as most important applicant characteristics, whereas an applicant's personal statement was ranked as least important. After established academic benchmarks have been met, a multitude of factors influences ranking of applicants to the CGSO fellowship, most of which are assessed at the interview.

Prognostic value of the nodal yield in head and neck squamous cell carcinoma: A systematic review.

ObjectiveLiterature analysis on the prognostic factor of the nodal yield (NY) in neck dissections (NDs), which in general surgical oncology is a strong prognosticator and quality‐of‐care marker.MethodsWe performed a systematic review of all PubMed and Embase publications until June 30, 2018 screening for data on NY as prognosticator and overall survival (OS) as outcome in patients with head and neck squamous cell carcinoma (HNSCC). Risk for bias was asserted by application of the Quality In Prognosis Studies tool.ResultsOf the 823 screened publications, 15 were included in this analysis. Five out of seven that compared NY ≥18 vs <18 as prognosticator, showed significantly improved survival if NY ≥18. Six studies used other cutoffs and three reported improved survival with each additionally harvested lymph node.ConclusionIncreased NY in ND specimen for HNSCC, most commonly described as ≥18 lymph nodes, is associated with improved OS and could be used as a prognosticator and quality‐of‐care marker.

Survey of Surgical Oncology Fellowship Graduates 2005-2016: Insight into Initial Practice.

Despite burgeoning interest in Complex General Surgical Oncology (CGSO) fellowship training, little is reported about postgraduate employment. The goal of this study was to characterize CGSO graduates' first employment and to identify factors that influenced this decision. The National Cancer Institute (NCI) and Society of Surgical Oncology developed and distributed an electronic survey to CGSO fellows who graduated from 2005 to 2016. The survey response rate was 47% (237/509). Fifty-seven percent of respondents were first employed as faculty surgeons at a university-based/affiliated hospital, with 15% returning to their residency institution. The distribution of respondents' current employment across the United States mirrored the locations of their hometowns. Eighty-five percent of respondents care for patients across at least three disease types, most commonly hepatopancreatobiliary (81%), esophagus/gastric (75%), and sarcoma (74%). Twenty-seven percent of respondents spend the majority of their time in one area of surgical oncology; melanoma, breast, and head/neck were the most common. Two-thirds of respondents (67%) reported that they performed either clinical or basic science research as part of their current position. Multiple factors influenced the decision of first faculty position. Most CGSO graduates are employed at academic medical centers across the country in proximity to NCI-designated centers, treat a variety of disease types, and spend a percentage of their time dedicated to clinical research.

Correction to: Evolution of a Novel Robotic Training Curriculum in a Complex General Surgical Oncology Fellowship.

In the XML of the original article, L. Mark Knab's first name was tagged incorrectly.

Robotic surgery trends in general surgical oncology from the National Inpatient Sample.

Robotic surgery is offered at most major medical institutions. The extent of its use within general surgical oncology, however, is poorly understood. We hypothesized that robotic surgery adoption in surgical oncology is increasing annually, that is occurring in all surgical sites, and all regions of the US. We identified patients with site-specific malignancies treated with surgical resection from the National Inpatient Sample 2010-2014 databases. Operations were considered robotic if any ICD-9-CM robotic procedure code was used. We identified 147,259 patients representing the following sites: esophageal (3%), stomach (5%), small bowel (5%), pancreas (7%), liver (5%), and colorectal (75%). Most operations were open (71%), followed by laparoscopic (26%), and robotic (3%). In 2010, only 1.1% of operations were robotic; over the 5-year study period, there was a 5.0-fold increase in robotic surgery, compared to 1.1-fold increase in laparoscopy and 1.2-fold decrease in open surgery (< 0.001). These trends were observed for all surgical sites and in all regions of the US, they were strongest for esophageal and colorectal operations, and in the Northeast. Adjusting for age and comorbidities, odds of having a robotic operation increased annually (5.6 times more likely by 2014), with similar length of stay (6.9 ± 6.5 vs 7.0 ± 6.5, p = 0.52) and rate of complications (OR 0.91, 95% CI 0.83-1.01, p = 0.08) compared to laparoscopy. Robotic surgery as a platform for minimally invasive surgery is increasing over time for oncologic operations. The growing use of robotic surgery will affect surgical oncology practice in the future, warranting further study of its impact on cost, outcomes, and surgical training.