Transoral thyroid and parathyroid surgery in Brazil: where are we?

INTRODUCTION: thyroid surgery through the transoral vestibular approach is a reality in many countries. While several competing remote access techniques have been developed in the last 20 years, many were not reproducible. Transoral Endoscopic Neck Surgery (TNS) has been shown to be reproducible in different centers around the world, and approximately five years after its description it has been adopted relatively quickly for various reasons. To date, there are at least 7 Brazilian studies published, including a series of more than 400 cases. The aim of this work is to study the progression of Transoral Neck Surgery in Brazil and describe the profile of surgeons involved in this new approach. METHODS: this is a retrospective study with descriptive statistics. A REDCap based survey about transoral endoscopic thyroidectomy and parathyroidectomy vestibular approach (TOETVA/TOEPVA) was done with 66 Brazilian surgeons regarding surgeon profile, numbers of cases performed by geographic region, what kind of training was necessary prior to the first case and behavior of the surgeon proposing these new approaches. RESULTS: response rate of this survey was 53%. To date, 1275 TOETVA/TOEPVA cases had been performed in Brazil, 1229 thyroidectomies (96.4%), 42 parathyroidectomies (3.3%) and 4 combined procedures (0.3%). Most of the cases were done in the southeast region (821, 64.4%), 538 (42.2%) cases in the State of São Paulo and 283 (22.2%) cases in the State of Rio de Janeiro. CONCLUSIONS: TOETVA is becoming popular in Brazil. Younger surgeons, especially those between 30 and 50 years old were more likely to adopt this approach.

Transoral endoscopic thyroidectomy vestibular approach: Experience from a multicenter national group with 412 patients.

BACKGROUND: Well-established conventional thyroidectomy has satisfactory outcomes; however, robotic and endoscopic thyroid surgery can avoid visible anterior neck scars. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is the most recent of these techniques. METHODS: This was a retrospective review of 412 patients who underwent TOETVA from 2017 to 2020 in 13 Brazilian centers. RESULTS: The study included 359 (87.1%) females and 53 (12.9%) males, with a mean age of 40 years. There were 231 (56.1%) total thyroidectomies. The conversion rate was 0.7%. The transient vocal cord palsy rate was 7.6% (30 patients). Temporary and persistent hypocalcemia rates were 4.0% and 0.8%, respectively. There were two cases of infection (0.5%). DISCUSSION: This is a large multi-institute TOETVA study, with one of the largest cohorts published to date that; despite its retrospective nature and selection bias, reached outcomes comparable to previously reported series, this study reinforced safeness, feasibility, and nationwide reproducibility for this technique.

Safely performing percutaneous dilatational tracheostomies on COVID-19 patients in the intensive care unit: A standardized approach.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the resulting coronavirus disease 2019 (COVID-19) have afflicted hundreds of millions of people in a worldwide pandemic. During this pandemic, otolaryngologists have sought to better understand risk factors associated with COVID-19 contamination during surgical procedures involving the airways such as tracheostomies. OBJECTIVE: This study provides a standardized technique of performing an ultrasound (US)-guided percutaneous dilatational tracheostomy (PDT) on COVID-19 patients in the intensive care unit (ICU). It also outlines safety strategies for health care providers that includes proper use of personal protective equipment (PPE) and regular testing of otolaryngologists for COVID-19 contamination. METHODS: This study analyzed data from 44 PDT procedures performed on COVID-19 patients in the ICU of hospitals in Sao Paulo and Santos, Brazil. The PDT procedures were conducted between April 2020 and August 2020, which coincided with a peak of the COVID-19 pandemic in São Paulo, Brazil. Surgeons were tested for COVID-19 using a two-stage serological enzyme-linked immunosorbent assay specific for SARS-CoV-2 antigens. CONCLUSION: This study describes a safe standardized technique of US-guided PDT for COVID-19 patients in the ICU using a method that also decreases the risk of surgeon contamination.

Trans Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in Brazil: Safety and complications during learning curve.

OBJECTIVE: The aim of this study was to address the first cases of TOETVA done in Brazil, by TOETVA-Bra study group, regarding safety and complications. METHODS: Series of the first 93 TOETVAs cases in Brazil. All authors except LPK, AJG JOR and RPT received TOETVA training including cadaveric hands-on in Thailand or United States (Johns Hopkins Medicine) during 2017. After they came back to Brazil and started doing their first TOETVA cases in the cities of Rio de Janeiro, Sao Paulo and Chapecó they agreed to collaborate and gather data using an online spreadsheet. All patients were submitted to the technique described by Anuwong. RESULTS: A total of 93 patients underwent TOETVA. Most patients (58.1%) were submitted to total thyroidectomy and 59.1% had benign disease. Two patients (2.2%) needed conversion to open surgery. Five patients (9.3%) developed transient hypoparathyroidism and there were 3 (2.0%) temporary recurrent laryngeal nerve palsy. There was one (0.7%) permanent unilateral palsy. Twenty patients had some sort of complication, 16.1% were minor and 5.4% were major. A total of 73 patients (78.5%) had an uneventful recovery. CONCLUSION: The technique is reproducible with a low complication rate. While further studies are needed to confirm equivalency, early efforts suggest that TOETVA is not inferior to traditional open thyroidectomy in appropriately selected patients.

Selective neck dissection for treating node-positive necks in cases of squamous cell carcinoma of the upper aerodigestive tract.

CONTEXT AND OBJECTIVE: Modified radical neck dissection (MRND) is the classical treatment for neck metastases of squamous cell carcinoma (SCC) of the upper aerodigestive tract. However, it may still be accompanied by significant sequelae. One alternative for this treatment would be selective neck dissection (SND), which has a lower incidence of sequelae. The aim of this study was to define which neck metastasis cases would really be suitable candidates for SND. DESIGN AND SETTING: Retrospective clinical-surgical trial at the Division of Head and Neck Surgery, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP). METHODS: We retrospectively studied 67 patients with SCC of the upper aerodigestive tract, divided into two groups: 1) 47 patients treated by means of SND (node-negative or node-positive), 2) 20 patients treated by means of MRND (all node-positive). RESULTS: Our results demonstrated that there was no difference between the patients treated with SND or MRND in relation to disease evolution, and that the main prognostic factor was lymph node involvement. We observed that patients with pharyngeal SCC and older patients presented worse evolution and would probably not be suitable candidates for SND. CONCLUSIONS: SND may be a good option for treating node-positive necks in selected cases.

Transoral thyroid and parathyroid surgery in Brazil: where are we? / Cirurgia transoral de tireóide e paratireóide no Brasil: onde estamos?

ABSTRACT Introduction: thyroid surgery through the transoral vestibular approach is a reality in many countries. While several competing remote access techniques have been developed in the last 20 years, many were not reproducible. Transoral Endoscopic Neck Surgery (TNS) has been shown to be reproducible in different centers around the world, and approximately five years after its description it has been adopted relatively quickly for various reasons. To date, there are at least 7 Brazilian studies published, including a series of more than 400 cases. The aim of this work is to study the progression of Transoral Neck Surgery in Brazil and describe the profile of surgeons involved in this new approach. Methods: this is a retrospective study with descriptive statistics. A REDCap based survey about transoral endoscopic thyroidectomy and parathyroidectomy vestibular approach (TOETVA/TOEPVA) was done with 66 Brazilian surgeons regarding surgeon profile, numbers of cases performed by geographic region, what kind of training was necessary prior to the first case and behavior of the surgeon proposing these new approaches. Results: response rate of this survey was 53%. To date, 1275 TOETVA/TOEPVA cases had been performed in Brazil, 1229 thyroidectomies (96.4%), 42 parathyroidectomies (3.3%) and 4 combined procedures (0.3%). Most of the cases were done in the southeast region (821, 64.4%), 538 (42.2%) cases in the State of São Paulo and 283 (22.2%) cases in the State of Rio de Janeiro. Conclusions: TOETVA is becoming popular in Brazil. Younger surgeons, especially those between 30 and 50 years old were more likely to adopt this approach.

RESUMO Introdução: a cirurgia de tireoide por via transoral vestibular é uma realidade em muitos países. Embora várias outras técnicas de acesso remoto tenham sido desenvolvidas nos últimos 20 anos, muitas não eram reprodutíveis. A cirurgia endoscópica cervical transoral (TNS - Transoral Neck Surgery) tem se mostrado reprodutível em diferentes centros ao redor do mundo sendo que, aproximadamente cinco anos após sua descrição, foi adotada de forma relativamente rápida por vários motivos. Até o momento, existem pelo menos 7 estudos brasileiros publicados, incluindo uma série de mais de 400 casos. O objetivo deste trabalho é estudar a evolução da Cirurgia Transoral do Pescoço (TNS) no Brasil e descrever o perfil dos cirurgiões envolvidos nesta nova abordagem. Métodos: trata-se de um estudo descritivo. Uma pesquisa online hospedada no REDCap sobre tireoidectomia e paratireoidectomia endoscópica transoral por abordagem vestibular (TOETVA/TOEPVA) foi realizada com 66 cirurgiões brasileiros. Foram levantados dados sobre o perfil do cirurgião, número de casos realizados por região geográfica, que tipo de treinamento foi necessário antes do primeiro caso e comportamento do cirurgião durante o relacionamento com o paciente ao abordar essas novas técnicas. Resultados: a taxa de resposta desta pesquisa foi de 53%. Até o momento, 1.275 casos de TOETVA/TOEPVA foram realizados no Brasil, sendo 1.229 tireoidectomias (96,4%), 42 paratireoidectomias (3,3%) e 4 procedimentos combinados (0,3%). A maioria dos casos foi realizada na região sudeste (821, 64,4%), 538 (42,2%) casos no estado de São Paulo e 283 (22,2%) casos no estado do Rio de Janeiro. Conclusões: a TOETVA está se popularizando no Brasil. Cirurgiões mais jovens, especialmente aqueles entre 30 e 50 anos, são mais propensos a adotar essa abordagem.

[Fine needle aspiration in salivary gland tumors: specificity and sensitivity]. / Punção aspirativa nos tumores das glândulas salivares: especificidade e sensibilidade.

UNLABELLED: Neoplasms of salivary glands represent almost 3% of all head and neck tumors. Proper surgical treatment depends upon accurate histological findings, especially in the case of malignant lesions. As such, knowledge of correct cytological findings prior to surgery is important for therapeutic planning. This is not easily established since it is usually based only on the patients' clinical history and imaging exams OBJECTIVE: To evaluate results obtained from fine needle aspiration biopsy (FNAB), comparing them to the histological findings of the respective surgical specimens and analyzing the sensitivity, specificity and accuracy of this method in relation to the diagnosis of malignancy or benignancy. METHODS: Retrospective study with the medical records of 73 patients who had salivary gland neoplasms and were submitted to FNAB and surgical treatment. RESULTS: Data disclosed that values of sensitivity were 87.9 % and specificity 85.7 % for diagnosis of benign tumors. For malignant tumors 42.5 % of sensitivity and 98.3 of specificity, were observed. Overall values of accuracy were, respectively, 85.7 % and 87.8 % for positive and negative predictive values in the diagnosis of malignancy by FNAB. CONCLUSIONS: It was shown that FNAB, as supplementary diagnostic method, can be useful for preoperative evaluation and surgical planning especially for malignant neoplasms.

Trans Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in Brazil: Safety and complications during learning curve

ABSTRACT Background: The aim of this study was to address the first cases of TOETVA done in Brazil, by TOETVA-Bra study group, regarding safety and complications. Materials and Methods: Series of the first 93 TOETVAs cases in Brazil. All authors except LPK, AJG JOR and RPT received TOETVA training including cadaveric hands-on in Thailand or United States (Johns Hopkins Medicine) during 2017. After they came back to Brazil and started doing their first TOETVA cases in the cities of Rio de Janeiro, Sao Paulo and Chapecó they agreed to collaborate and gather data using an online spreadsheet. All patients were submitted to the technique described by Anuwong. Results: A total of 93 patients underwent TOETVA. Most patients (58.1%) were submitted to total thyroidectomy and 59.1% had benign disease. Two patients (2.2%) needed conversion to open surgery. Five patients (9.3%) developed transient hypoparathyroidism and there were 3 (2.0%) temporary recurrent laryngeal nerve palsy. There was one (0.7%) permanent unilateral palsy. Twenty patients had some sort of complication, 16.1% were minor and 5.4% were major. A total of 73 patients (78.5%) had an uneventful recovery. Conclusion: The technique is reproducible with a low complication rate. While further studies are needed to confirm equivalency, early efforts suggest that TOETVA is not inferior to traditional open thyroidectomy in appropriately selected patients.

BRAF mutation in the elderly submitted to thyroidectomy.

OBJECTIVE: To evaluate the frequency of the BRAF V600E mutation in patients over 65 years of age undergoing thyroidectomy, correlating its presence or absence with the different histologic lesions, their variants and with prognostic factors of papillary carcinoma. METHODS: We evaluated 85 patients over 65 years of age who underwent thyroidectomy, analyzing the BRAF V600E mutation by RT-PCR performed after DNA extraction from the paraffin blocks. RESULTS: The study detected the presence or absence of BRAF V600E mutation in 47 patients (55.3%). Among the 17 papillary carcinomas studied, seven had the mutation (41.2%). There was a statistical association between the presence of this mutation and the classic variant of papillary carcinoma, and a trend of association with thyroid extravasation. CONCLUSION: BRAF mutation in the elderly is also exclusive of papillary carcinoma and is often significant. Furthermore, it is related to the classic variant and possibly to thyroid extravasation.

[Thyroid gland primary leiomyosarcoma]. / Leiomiossarcoma primário da glândula tireoide.

Despite the fact that 15% to 20% of sarcomas occur in the head and neck and 80% in adults, only 0.014% are primary thyroid leiomyosarcomas. To the best of our knowledge, only 16 cases have been reported around the world, none in South America. Cytologic diagnosis is challenging and these tumors may be mistaken by more common ones such as anaplastic or medullary carcinomas. The treatment of choice for thyroid leiomyosarcomas is not well established yet because of its poor prognosis. Radical surgery associated with chemoradiotherapy has not been effective and did not improve survival rates. The authors report a case of primary thyroid leiomyosarcoma in a young male, who has been submitted to total thyroidectomy and selective neck dissection. Extensive literature review was performed by the authors. The patient received adjuvant radiotherapy, presenting good postoperative course. After four years evolution, there was no local recurrence or distant metastasis.

Metástase gigante de carcinoma papilífero / Giant metastasis of thyroid papillar carcinoma

O carcinoma papilífero da tireoide, o mais comum deste órgão, geralmente se apresenta como lesões parenquimatosas pequenas e, eventualmente, com metástases cervicais numerosas, raramente volumosas. É descrito um caso raro de uma paciente do gênero feminino, 44 anos, com um tumor cervical anterior, nodular e volumoso há nove anos. Após o tratamento cirúrgico, o anatomopatológico mostrou tratar-se de metástases linfonodais de carcinoma papilífero. O objetivo deste estudo é relatar um caso clínico de apresentação incomum de carcinoma papilífero da tireoide, de diagnóstico inicial difícil e apresentando-se com metástases linfonodais volumosas. Arq Bras Endocrinol Metab. 2014;58(9):967-9 Papillary thyroid carcinoma, the most common type of thyroid cancer is usually presented as small parenchymatous lesions and, eventually, with cervical lymph node metastasis, rarely voluminous. Here we describe a rare case of a 44-year-old woman presenting a visible anterior cervical tumor, nodullary and voluminous, for nine years. After surgical treatment, the anatomical pathology sample revealed that the mass was composed of several cervical lymph node metastatic lesions of a papillary thyroid carcinoma. We report the discovery of an uncommon papillary thyroid carcinoma manifestation, with a difficult initial diagnosis and presenting voluminous lymph node metastases.

Mutação BRAF em pacientes idosos submetidos à tireoidectomia / BRAF mutation in the elderly submitted to thyroidectomy

OBJETIVO: Avaliar a frequência da mutação V600E do gene BRAF em pacientes com mais de 65 anos de idade submetidos à tireoidectomia, correlacionando sua presença ou ausência com as diferentes lesões histológicas, com as variantes e com fatores prognósticos do carcinoma papilífero. MÉTODOS: Foram avaliados 85 pacientes com mais de 65 anos de idade submetidos à tireoidectomia, analisando a mutação BRAF V600E através de reação de PCR-RT realizada após a extração do DNA dos blocos de parafina. RESULTADOS: Detectou-se ausência ou presença da mutação BRAF V600E em 47 pacientes (55,3%). Entre os 17 carcinomas papilíferos estudados, sete apresentavam a mutação (41,2%). Demonstrou-se associação estatística entre a presença desta mutação e a variante clássica do carcinoma papilífero, além de tendência de associação com o extravasamento tireoideano. CONCLUSÃO: A mutação BRAF nos pacientes idosos também é exclusiva do carcinoma papilífero e tem frequência expressiva. Além disso, está relacionada à variante clássica e, possivelmente, ao extravasamento tireoideano.

OBJECTIVE: To evaluate the frequency of the BRAF V600E mutation in patients over 65 years of age undergoing thyroidectomy, correlating its presence or absence with the different histologic lesions, their variants and with prognostic factors of papillary carcinoma. METHODS: We evaluated 85 patients over 65 years of age who underwent thyroidectomy, analyzing the BRAF V600E mutation by RT-PCR performed after DNA extraction from the paraffin blocks. RESULTS: The study detected the presence or absence of BRAF V600E mutation in 47 patients (55.3%). Among the 17 papillary carcinomas studied, seven had the mutation (41.2%). There was a statistical association between the presence of this mutation and the classic variant of papillary carcinoma, and a trend of association with thyroid extravasation. CONCLUSION: BRAF mutation in the elderly is also exclusive of papillary carcinoma and is often significant. Furthermore, it is related to the classic variant and possibly to thyroid extravasation.

Leiomiossarcoma primário da glândula tireoide / Thyroid gland primary leiomyosarcoma

Aproximadamente 15 por cento a 20 por cento dos sarcomas ocorrem na região da cabeça e pescoço, 80 por cento em adultos, sendo apenas 0,014 por cento leiomiossarcomas primários de tireoide. Existem apenas 16 casos relatados no mundo, dos quais não há nenhum em nosso meio. São tumores com diagnóstico citológico pré-operatório difícil e podem ser confundidos com outras lesões mais comuns da tireoide, como carcinomas anaplásicos e medulares. O tratamento ideal ainda não está bem definido, visto que o prognóstico é ruim e a cirurgia radical associada à quimioterapia e à radioterapia adjuvantes não demonstra melhora nas taxas de recorrência e sobrevida. Relatou-se um caso de leiomiossarcoma primário da glândula tireoide em um paciente jovem, submetido a tireoidectomia total e esvaziamento cervical, associado à radioterapia adjuvante e realizou-se uma extensa revisão da literatura existente sobre o tema. Houve boa evolução pós-operatória, sem sinais de recidiva após quatro anos de seguimento.

Despite the fact that 15 percent to 20 percent of sarcomas occur in the head and neck and 80 percent in adults, only 0.014 percent are primary thyroid leiomyosarcomas. To the best of our knowledge, only 16 cases have been reported around the world, none in South America. Cytologic diagnosis is challenging and these tumors may be mistaken by more common ones such as anaplastic or medullary carcinomas. The treatment of choice for thyroid leiomyosarcomas is not well established yet because of its poor prognosis. Radical surgery associated with chemoradiotherapy has not been effective and did not improve survival rates. The authors report a case of primary thyroid leiomyosarcoma in a young male, who has been submitted to total thyroidectomy and selective neck dissection. Extensive literature review was performed by the authors. The patient received adjuvant radiotherapy, presenting good postoperative course. After four years evolution, there was no local recurrence or distant metastasis.

Tratamento seletivo do hipoparatireoidismo após tireoidectomia total baseado nos valores de PTH / Selective treatment for hypoparathyroidism after total thyroidectomy based on PTH levels

Introdução: A hipocalcemia é a complicação mais comum após a tireoidectomia total e responsável por um maior tempo de internação. A fim de evitar manifestações da hipocalcemia, alguns autores rotineiramente fazem suplementação oral de cálcio, outros, por sua vez, prolongam a estadia do doente aguardando dosagens séricas de cálcio para indicar a reposição. Objetivo: Avaliar a eficácia da suplementação de cálcio/calcitriol baseado em valores pós operatórios de paratormônio(PTH) , afim de evitar manifestações clínicas de hipocalcemia em pacientes submetidos à tireoidectomia total. Materiais e Métodos: Estudo prospectivo com 31 pacientes submetidos à tireoidectomia total ou totalização, com ou sem esvaziamento recorrencial. O PTH foi colhido após 1 hora de pós operatório. A suplementação seletiva foi determinada pelo valor do PTH com cálcio (PTH >5 e <15pg/ml), cálcio e calcitriol (PTH <5pg/ml) e foram correlacionadas com sintomas de hipocalcemia durante 10 dias de pós operatório. Resultados: Nenhum paciente com PTH>15pg/ml desenvolveu sintomas (p=0,007). Dentre os pacientes com PTH <15pg/ml, 9 (52,84%) permaneceram assintomáticos com uso da medicação. Cinco pacientes (29,41%) não fizeram uso da suplementação prescrita e todos apresentaram sintomas. Três pacientes apresentaram sintomas, apesar do uso correto da suplementação.(p=0,009). Conclusão: A suplementação seletiva de cálcio ou cálcio associada ao calcitriol, baseada no PTH, é eficaz para evitar os sintomas de hipocalcemia.

Background: Hypocalcemia is the most common complication after total thyroidectomy and the major determinant in delay of discharge. Because of this, some authors routinely use oral supplementation of oral calcium, while others postpone hospital discharge waiting of multiple calcium dosages. Objectives: To test a selective oral calcium/calcitriol supplementation to avoid clinical manifestations of hypocalcemia based on parathyroid hormone levels after total thyroidectomy. Methods: Prospective study with 31 patients undergoing total thyroidectomy or completion, with or without central neck dissection. Parathyroid hormone (PTH) was measured 1 hour postoperative period. Selective supplementation was determined by serum PTH levels with oral calcium (PTH>5pg/ ml and <15pg/ml) or oral calcium plus calcitriol (PTH<5pg/ml) and correlated with symptoms of hypocalcemia during 10 days postthyroidectomy. Results: None of the patients (14/31) with PTH levels > 15pg/ml developed symptoms (p=0,007). Among seventeen patients with PTH<15pg/ml, 9 (52,84%) patients had adequate supplementation and remained asymptomatic. Five patients (29,41%) had clinical manifestations without correct supplementation. Three patients developed symptoms taking correct supplementation. (p=0,009). Conclusions: The selective supplementation based on postthyroidectomy PTH levels can be used safely to avoid clinical manifestations of hypocalcemia.

Avaliação da efetividade e dos custos da sutura mecânica nas laringectomias totais comparados ao fechamento tradicional / Mechanical versus manual suture in total laryngectomy: Costs and effectiveness

Introdução: A ocorrência de fístulas faringocutâneas apóslaringectomias totais é um fator de grande impacto no tempode internação do doente enquanto a demora no fechamentoda faringe é significativa no tempo de permanência em salacirúrgica. Ambos afetam o custo final do procedimento cirúrgico.O uso da sutura mecânica pode reduzir estes tempos e,consequentemente, dos custos do procedimento. Objetivos:Comparar os custos resultantes do fechamento manual emecânico da faringe. Método: estudo retrospectivo, avaliandoo tempo de permanência em sala cirúrgica e permanênciahospitalar de pacientes submetidos a laringectomia total, quantoaos dois tipos de fechamento da faringe: Manual ou mecânico.Resultados: A fístulas faringocutâneas ocorreram apenas noscasos de fechamento manual (17,3%), resultando em uma maiorpermanência hospitalar neste grupo (12,23 x 6,5 dias da suturamecânica). O tempo operatório também foi maior naquele grupo(2h20min maior). A média dos custos do fechamento manual foramR$5.799,24. Isto supera o custo do grampeador, de R$ 1033,00.Conclusão: O fechamento da faringe com grampeador deve serpreferido, sempre que possível, pois apresenta menores índicesde complicações e custos menores, apesar do preço do mesmo.

Selective neck dissection for treating node-positive necks in cases of squamous cell carcinoma of the upper aerodigestive tract / Esvaziamento cervical seletivo para o tratamento do pescoço positivo em carcinomas epidermóides do trato aerodigestório alto

CONTEXT AND OBJECTIVE: Modified radical neck dissection (MRND) is the classical treatment for neck metastases of squamous cell carcinoma (SCC) of the upper aerodigestive tract. However, it may still be accompanied by significant sequelae. One alternative for this treatment would be selective neck dissection (SND), which has a lower incidence of sequelae. The aim of this study was to define which neck metastasis cases would really be suitable candidates for SND. DESIGN AND SETTING: Retrospective clinical-surgical trial at the Division of Head and Neck Surgery, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP). METHODS: We retrospectively studied 67 patients with SCC of the upper aerodigestive tract, divided into two groups: 1) 47 patients treated by means of SND (node-negative or node-positive), 2) 20 patients treated by means of MRND (all node-positive). RESULTS: Our results demonstrated that there was no difference between the patients treated with SND or MRND in relation to disease evolution, and that the main prognostic factor was lymph node involvement. We observed that patients with pharyngeal SCC and older patients presented worse evolution and would probably not be suitable candidates for SND. CONCLUSIONS: SND may be a good option for treating node-positive necks in selected cases.

CONTEXTO E OBJETIVO: O esvaziamento cervical radical modificado (ECRM) é o tratamento clássico para as metástases cervicais do carcinoma espinocelular (CEC) do trato aerodigestório alto (TADA). Este procedimento é considerado oncologicamente satisfatório, porém pode ser acompanhado de seqüelas significativas devido à extensão do procedimento e a grande manipulação de estruturas nobres, especialmente as nervosas. Assim, tem sido proposto o esvaziamento cervical seletivo (ECS) para o tratamento de casos selecionados, pN1, pN2 sem ruptura capsular, minimizando, ou mesmo evitando, deste modo, as seqüelas do ECRM. O grande questionamento atual é a definição de quais casos seriam eleitos para este procedimento, sem alterar o resultado oncológico de médio e longo prazo. TIPO DE ESTUDO E LOCAL: Estudo clínico retrospectivo realizado na Disciplina de Cirurgia de Cabeça e Pescoço do Departamento de Cirurgia da Faculdade de Ciências Médicas da Santa Casa de São Paulo. MÉTODOS: Estudamos 67 doentes portadores de CEC do TADA de 1990 a 2001 dividindo-os em dois grupos: 1) 47 doentes tratados com ECS e 2) 20 doentes tratados com ECRM (todos N+). Os casos do grupo 1 eram clinicamente N0 e, 11 tornaram-se pN+, após o exame histopatológico. Assim, no grupo 1 obtivemos doentes pN+ tratados com ECS e seguimos estes grupos por, no mínimo, 2 anos. O grupo 2 serviu como controle da evolução dos doentes pN+. RESULTADOS: Nossos resultados mostraram que na comparação do ECS com o ECRM, não houve diferença significativa quanto à evolução (sobrevivência ou recidiva), no entanto, foi possível evidenciar uma pior evolução nos doentes N+ quando comparados aos N0, demonstrando que o principal fator prognóstico é o comprometimento linfonodal. Além disso, apesar do pequeno número de doentes, observamos que os doentes mais idosos e com CEC de faringe tiveram pior evolução e, por isto, talvez não sejam candidatos ao ECS. CONCLUSÕES: Concluímos, portanto, que o ECS pode...