Eugene Nicholas Myers' Lecture on Head and Neck Cancer, 2020: The Surgeon as a Prognostic Factor in Head and Neck Cancer Patients Undergoing Surgery

Abstract This paper is a transcript of the 29th Eugene N. Myers, MD International Lecture on Head and Neck Cancer presented at the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in 2020. By the end of the 19th century, the survival rate in treated patients was 10%. With the improvements in surgical techniques, currently, about two thirds of patients survive for > 5 years. Teamwork and progress in surgical reconstruction have led to advancements in ablative surgery; the associated adjuvant treatments have further improved the prognosis in the last 30 years. However, prospective trials are lacking; most of the accumulated knowledge is based on retrospective series and some real-world data analyses. Current knowledge on prognostic factors plays a central role in an efficient treatment decision-making process. Although the influence of most tumor- and patient-related prognostic factors in head and neck cancer cannot be changed by medical interventions, some environmental factors—including treatment, decision-making, and quality—can be modified. Ideally, treatment strategy decisions should be taken in dedicated multidisciplinary team meetings. However, evidence suggests that surgeons and hospital volume and specialization play major roles in patient survival after initial or salvage head and neck cancer treatment. The metrics of surgical quality assurance (surgical margins and nodal yield) in neck dissection have a significant impact on survival in head and neck cancer patients and can be influenced by the surgeon's expertise. Strategies proposed to improve surgical quality include continuous performance measurement, feedback, and dissemination of best practice measures.

Impact of the COVID-19 Pandemic on Physicians Working in the Head and Neck Field

Abstract Background With the COVID-19 pandemic, the clinical practice of physicians who work in the head and neck field in Brazil dropped dramatically. The sustained impact of the pandemic is not known. Methods An anonymous online survey was distributed to Brazilian otolaryngologists, head and neck surgeons, medical and radiation oncologists, asking about their clinical practice in the third to fourth months of the pandemic. Results The survey was completed by 446 specialists. About 40 % reported reduction of more than 75 % in outpatient care. A reduction of 90 % to 100 % in airway endoscopies was reported by 50 % of the responders, and the same rate of reduction regarding surgeries (pediatric or nasosinusal) was reported by 80 % of them. Family income decreased by 50 %, and the psychological burden on physicians was considerable. The availability of personal protective equipment and safety precautions were limited, especially in the public sector. Conclusion COVID-19 is still impacting the head and neck field, and safety concerns may hinder the prompt resumption of elective care.

Trismus and oral health conditions during diagnosis of malignant oral neoplasms / Trismo e condições de saúde bucal no diagnóstico de neoplasias malignas da cavidadeoral

Abstract Introduction: Trismus has been considered a late complication of cancer treatment. It can occur prior to treatment, mainly caused by tumor invasion or muscle spasms induced by the presence of the tumor. Objective: In this study, we evaluated the incidence of trismus and its effect on oral health in patients with malignant neoplasms of the oral cavity before performing the cancer treatment. Methods: This review was carried out via interviews, visual clinical inspection and objective measurement of maximal mouth opening in 35 consecutive patients. Trismus was defined as a maximal mouth opening <35 mm. Results: Trismus was observed in 15 patients, with a total incidence of 42%. A high rate of tooth loss was recorded, and trismus association with tooth loss was statistically verified using the Chi-square and Fisher's exact tests, the t-student test and Mann-Whitney non-parametric test. All tests were performed at p < 0.05. Conclusion: Edentulous patients are eight times more likely to have trismus compared to patients that are partially and fully dentate. Trismus was demonstrated to be correlated with tooth loss; however other oral health conditions were not shown to be a modifying factor.

Resumo Introdução: O trismo tem sido considerado uma complicação tardia do tratamento do câncer, pode ocorrer antes do tratamento, causado principalmente por invasão tumoral ou espasmos musculares induzidos pela presença do tumor. Objetivo: Avaliar a incidência do trismo e seu efeito sobre a saúde bucal em pacientes com neoplasias malignas da cavidade bucal antes de se submeterem ao tratamento do câncer. Método: Esta revisão foi realizada por meio de entrevistas, inspeção clínica visual e mensuração objetiva da abertura bucal máxima em 35 pacientes consecutivos. O trismo foi definido como abertura bucal máxima < 35 mm. Resultados: O trismo foi observado em 15 pacientes, com uma incidência de 42%. Uma alta taxa de perda dentária foi registrada e a associação do trismo com a perda dentária foi verificada estatisticamente com os testes qui-quadrado, exato de Fisher, t de Student e não paramétrico de Mann-Whitney. Todos os testes foram realizada com p < 0,05. Conclusão: Pacientes edêntulos são oito vezes mais propensos a ter trismo do que os pacientes parcial e totalmente dentados. O trismo demonstrou estar correlacionado com a perda dentária. Entretanto, as outras condições de saúde bucal não se mostraram um fator modificador.

Recommendations for head and neck surgical procedures during the COVID-19 pandemic

The coronavirus disease (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread exponentially worldwide. In Brazil, the number of infected people diagnosed has been increasing and, as in other countries, it has been associated with a high risk of contamination in healthcare teams. For healthcare professionals, the full use of personal protective equipment (PPE) is mandatory, such as wearing surgical or filtering facepiece class 2 (FFP2) masks, waterproof aprons, gloves, and goggles, in addition to training in care processes. A reduction in the number of face-to-face visits and non-essential elective procedures is also recommended. However, surgery should not be postponed in the case of the most essential elective indications (mostly associated with head and neck cancers). As malignant tumors of the head and neck are clinically time sensitive, neither consultations for these tumors nor their treatment should be postponed. Postponing surgical treatment can result in a change in the disease stage and alter an individual's chance of survival. In this situation, planning of all treatments must begin with the request for, in addition to routine examinations, a nasal swab polymerase chain reaction for SARS-CoV-2 and chest computed tomography. Only if the results of these tests are positive or if fever or other symptoms suggestive of COVID-19 are present should the surgical procedure be postponed until the patient completely recovers. This is mandatory not only because of the risk of contamination of the surgical team but also because of the increased risk of postoperative complications and high risk of death. During this pandemic, the most effective safety measures are social distancing for the general public and the adequate availability and use of PPE in the healthcare field. The treatment of other chronic diseases, such as cancer, should be continued, as the damming of cases of these diseases will have a deleterious effect on the public healthcare system.

Oral health, hygiene practices and oral cancer

OBJETIVO: Avaliar a associação entre saúde e higiene bucal na ocorrência de câncer oral. MÉTODOS: Estudo caso-controle de base hospitalar, realizado entre 1998 e 2002 na área metropolitana de São Paulo, SP. Foram incluídos 309 pacientes com carcinoma epidermóide de boca e orofaringe e 468 controles, pareados com os casos por sexo e idade. Os casos foram levantados em sete hospitais que concentram a assistência médica a pacientes com a doença e os controles rastreados em cinco hospitais gerais dentre os sete. Informações pormenorizadas sobre tabagismo, consumo de álcool, escolaridade, saúde bucal e práticas de higiene bucal foram obtidas por entrevista. Por meio de análise de regressão logística não condicional foram calculados odds ratios (OR) e intervalos com 95 por cento de confiança (IC 95 por cento), ajustados por sexo, idade, nível educacional, tabagismo e consumo de álcool, bem como para as demais variáveis de saúde e higiene bucal. RESULTADOS: Uso de prótese bucal total não se associou a câncer oral, mas sangramento gengival freqüente apresentou alta associação (OR=3,1; IC 95 por cento: 1,2;7,9). Nunca ter consultado dentista mostrou associação com câncer oral (OR=2,5; IC 95 por cento: 1,3;4,8). Uso diário de enxaguatórios bucais apresentou associação mais intensa com tumores de faringe (OR=4,7; IC 95 por cento: 1,8;12,5) do que com tumores de boca (OR=3,2; IC 95 por cento: 1,6;6,3). CONCLUSÕES: Sangramento gengival, ausência de consultas com dentistas e uso regular de enxaguatórios bucais foram fatores associados com câncer oral, independentemente de tabagismo e consumo de bebidas alcoólicas.

Carcinoma mucoepidermóide de cabeça e pescoço: estudo clínico-patológico de 173 casos / Head and neck mucoepidermoid carcinoma: clinicopathologic study of 173 cases

Introduçäo: Carcinoma mucoepidermóide (CME) é o tumor maligno mais comum de glândulas salivares, entretanto poucos estudos em populaçöes brasileiras têm sido relatados na literatura. Objetivo: Reportar os dados clínico-patológicos de 173 CME de cabeça e pescoço do Centro de Tratamento e Pesquisa Hospital do Câncer A. C. Camargo em Säo Paulo. Forma de estudo: Clínico randomizado. Material e Método: Cento e setenta e três casos de CME tratados entre 1953 e 1997, obtidos dos arquivos do Centro de Tratamento e Pesquisa Hospital do Câncer A. C. Camargo foram utilizados no estudo. Os dados foram obtidos a partir dos prontuários e da revisäo histológica de todos os casos. Resultados: A idade média dos pacientes foi de 44 anos e 93 (53,8 por cento) eram homens. Parótida foi acometida em 61 casos (35,2 por cento) e as glândulas salivares menores intra-orais em 75 (43,4 por cento), TNM revelou 50,3 por cento dos casos em estádios I e II, e a gradaçäo histológica revelou 45,2 por cento, 18,5 por cento e 36,3 por cento tumores de baixo grau, grau intermediário e alto grau de malignidade, respectivamente. Tratamento cirúrgico foi utilizado em 80,3 por cento dos casos, complementado por esvaziamento cervical em 52 casos (30,1 por cento) e radioterapia em 73 (42,2 por cento). Recidiva local, recidiva regional e metástase a distância foram encontradas em 12,7 por cento, 9,8 por cento e 9,2 por cento dos pacientes, respectivamente, e a sobrevida global dos pacientes em 5 e 10 anos foi de 70 por cento e 60 por cento, respectivamente. Conclusöes: A avaliaçäo dos 173 casos de CME de cabeça e pescoço mostrou que estes tumores ocorreram preferencialmente na glândula parótida e no palato de indivíduos adultos, sem predileçäo por sexo. Metade dos casos encontravam-se em estádios clínicos iniciais e 64 por cento dos tumores eram de grau baixo ou intermediário de malignidade. O tratamento de escolha foi cirúrgico e o prognóstico dos pacientes foi bom

Tumores benignos das glândulas parótidas: análise retrospectiva de uma série de 222 casos / Benign tumors of the parotid glands: retrospective analysis of a series of 222 cases

A experiência do Hospital do Câncer com tumores benignos da glândula parótida tratados cirurgicamente num período de 25 anos, totalizando 222 pacientes, foi submetida a estudo retrospectivo, avaliando-se dados demográficos, clínicos e histológicos, além dos resultados do tratamento empregado. Houve predominância do sexo feminino, com 126 casos (56,7%), sendo o maior número observado entre os 31 e 50 anos de idade, na faixa etária de 1 a 80 anos. O adenoma pleomórfico predominou, com 165 casos (74,3%), seguido pelo tumor de Warthin, com 38 casos (17,1%). A principal modalidade cirúrgica utilizada foi a parotidectomia parcial com conservação do nervo facial, realizada em 182 casos. A taxa de recidiva local foi de 4,8%, sendo todos esses casos de adenoma pleomórfico. A disfunção do nervo facial no pós-operatório, a síndrome de Frey, a presença de seroma, de necrose e infecção foram observadas em 25,2%, 7,2%, 2,2% e 1,3%, respectivamente. A radioterapia foi empregada como tratamento complementar em 12 casos. Doze pacientes apresentaram segundas neoplasias durante o período de seguimento, que variou de 16 dias a 234 meses. Na instituição, consideramos atualmente que a cirurgia mínima para o tratamento dos tumores benignos da parótida é a parotidectomia parcial com conservação do nervo facial; e, sempre que o nervo é sacrificado, procedimentos de reanimação facial são realizados. O uso da radioterapia deve ser reservado ao pós-operatório de cirurgias de resgate, em casos de recidiva local.

A 25-year experience of the Hospital do Cancer with benign parotid tumours surgically treated in a consecutive series of 222 patients has been reviewed, evaluating demographic, clinic and histopathological data as well as results of treatment. The female gender predominated with 126 cases (56,7%). Age ranged from 1 to 80 years old with the highest incidence from 31 to 50 years old (42 patients). Pleomorphic adenoma was the predominant histopathological type observed in 165 (74,3N) cases, followed by Warthin's tumor with 38 (17,1%) cases. Partial parotidectomy with facial nerve preservation was the main and minimal procedure performed. Local recurrences ocurred in 4,8% of the pleomorfic adenomas. Postoperative facial disfunction, Frey's syndrome, seroma, necrosis and infection were observed irk 25,2%, 7,2%, 2,2% and 1,3%, respectively. Radiotherapy was used as postoperative adjuvant treatment in 12 cases. Twelve patients presented other neoplasms during the follow-up period which ranged from 16 days to 234 months. We consider that partial parotidectomy with facial nerve preservation is the minimal surgical procedure to treat benign parotid tumors and facial reanimation must be tried whenever the facial nerve is sacrificed. Radiotherapy must be reserved to- postoperative period after salvage surgery for local recurrences.

Treatment planning, total rehabilitation and quality of life of the head and neck cancer patient

Head and neck cancers are devastating diseases for which there are numerous therapeutic options that will result in a high cure rate, but with significant physical and psychosocial sequelae. The ultimate goal of treatment is disease eradication an rehabilitation of physiological, psychological and social status. To achieve this objective it is necessary to avoid fragmented care. Good medical care involves a concerted effort of several medical disciplines, as well as collaboration of dentists, speech therapists, physiotherapists, psychologists, nurses, nutrition specialists and social workers. The rehabilitation program should start when cancer treatment is planned. With the increase in rehabilitation measures and consequent decrease in morbidity the improvement in the quality of life of the head and neck cancer patient becomes a realistic possibility. Several developments in plastic surgery (myocutaneous flaps, microsurgery) and maxillofacial prosthesis have resulted in great improvement in function and cosmetic appearance. Self concept, self-esteem, and body image immediately follow survival in order of in importance. The patient's self-image is crucial for his/her reintegration and adaptation to family, social life and work. Several recent publications have introduced quality of life parameters as an integral part of the evaluation process in clinical practice. The quality of life concept in the health sciences is used to describe aspects of health status as physical symptoms, daily activity level, psychological well-being, and social functioning. Finally, some highlights of the quality of life measurement are reviewed.

Lymph node metastasis as a prognostic factor in laryngeal cancer

The authors reviewed the prognostic importance of several lymph node metastasis-related factors. The presence of lymph node metastasis from laryngeal cancer significantly reduces the probability of regional control and survival. Proper management of the neck remains a therapeutic dilemma because there are no precise means for evaluating lymph nodes. A comprehensive neck dissection adjuvant radiotherapy has been relied as the proper treatment for cases with positive lymph nodes. On the other hand, there is no consensus over whether or not and how to perform an elective neck treatment in patients with laryngeal carcinoma. Several variables related to cervical lymph node involvement and their implication on prognosis were studied in the literature (site, size, extracapsular extensión, number). In an analysis of 3-year survival rates showed that patients with clincially detectable regional metastasis (N stage) exhibited poorer disease free interval (DFI) and overall survival (OS) than those classified as N-. Also patients with high number, or larger, or ruptured metastatic nodes experienced poor prognosis (marginally significant statistically). The highest impact on survival were exhibited by the involvement of contralateral lymph nodes adn extracapsular extension. It is our opinion tha cases with clinically positive nodes should be submitted to a comprehensive neck dissection (either classical or modified); at least a selective dissection as a staging procedure when the supraglottis is involved. It is a advisable to perform an elective comprehensive neck dissection when a satisfactory clinical assessment cannot be made or when ther are factors would prevent adequade follow-up

Advances in the management of cancer of the paranasal sinuses

Tumores malignos dos seios paranasias säo incomuns e geralmente diagnosticados em estádios avançados da doença. Os fatos mais inportantes que ocorreram nesta área nos últimos 20 anos foram: 1) acumulou-se significativo número de informaçöes epidemiológicas com respeito a alguns dos fatores de risco envolvidos na etiologia destes tumores, 2) desenvolvimento da tomografia computadorizada de alta resoluçäo e ressonância nuclear magnética, que permitem excelente avaliaçäo da extensäo tumoral antes do tratamento, 3) sistema de estadiamento que permite a comparaçäo de resultados do tratamento, 4) a cirurgia craniofacial é método seguro e potencialmente curativo para alguns casos selecionados que eram consideraçöes inoperáveis ou eram operados inadequadamente há apenas alguns poucos anos, 5) preservaçäo do conteúdo orbitário quando isso é oncologicamente seguro, 6) avanços em reabilitaçäo protética permiten melhores resultados funcionais e estéticos, 7) desenvolvimento de técnicas de transferências de tecido com anastomose microvascular tem estimulado o desenvolvimento de ressecçöes mais radicais, 8) terapêutica combinada incluindo cirurgia, radioterapia e quimioterapia tem mostrado melhora nos resultados a curto prazo

Risk factors for oral cancer in Brazil: a case-control study

A case-control study of risk factors for carcinomas of the tongue, gum, floor, and other specified parts of the mouth was conduced in three metropolitan areas in Brazil; Säo Paulo (Southeast), Curitiba (South), and Goiânia (Central-West). We analyzed information on demographics, occupational history, environmental exposures, tabacco smoking and alcohol drinking habits, diet, oral and other health characteristics obtained from interviews with 232 cases and 464 hospital non-cancer controls matched on 5-year age group, sex hospital catchment area, and trimester of admission. Tobacco and alcohol consuption were the strongest risk factors irrespective of the anatomical site. The adjusted relative risks (RR) for ever vs. never smokers were: 6.3, 13.9, and 7.00, for industrial-brand cigarrettes, pipe and hand-rolled cigarrettes, respectively. A strong correlation was seen between number of pack-years and risk. The RR for the heaviest vs. the lowest consumption categories (>100 vs. <1 pack-years) was 14.8 Risk levels generally decreased to that of never smokers after 10 years since smoking cessation. The risk associated with alcohol was mostly evident for wine (cancer of the tongue) and "cachaça" (all sites), a hard liquor distilled from sugar cane. Other important risk factors were "chimarräo" drinking (a type of mate), use of a wood stove for cooking, and frequent consumption of charcoal-grilled meat and manioc. Oral hygiene chacarcteristics represented correlates of disease risk