Head & neck cancer. Its impact on the history of mankind.

Squamous cell carcinoma is the most common head & neck malignancy, and its first descriptions date from the pharaonic era. It has impacted humanity by affecting labor, scientific and cultural productivity and, sometimes, it has influenced the course of history. Head & neck cancer is more common in economically impoverished countries and individuals; however, it can affect any socioeconomic stratum; it has been suffered by known, famous, economically powerful celebrities, intellectuals and artists. Head & neck cancer treatment has been controversial since its initial description up to the present day. Therapeutic decisions have been influenced not only by the stage but by the patient's environment and, sometimes, in an effort to reduce the morbidity resulting from the various oncological treatments, erroneous decisions have been made that have implied the loss of the patient's life. Unfortunately, currently we continue to see these behaviors. A synthesis of cases of renowned celebrities that suffered from this cancer is presented, and the impact this implied in the society of their times is described.

El cáncer epidermoide es el más frecuente en cabeza y cuello y sus primeras descripciones datan de la época faraónica. Ha impactado en la humanidad al afectar la productividad laboral, científica y cultural y, en ocasiones, ha influido en el derrotero de la historia. El cáncer de cabeza y cuello es más frecuente en países e individuos depauperados económicamente, sin embargo, puede afectar cualquier estrato socioeconómico; lo han padecido personajes conocidos, famosos, económicamente poderosos, intelectuales y artistas. El tratamiento del cáncer de cabeza y cuello ha sido motivo de controversia desde su descripción inicial hasta la actualidad. En la decisión terapéutica ha influido no solo el estadio del cáncer sino el entorno del paciente; en ocasiones, en un afán de disminuir la morbilidad derivada de los diversos tratamientos oncológicos, se han tomado decisiones erróneas que han implicado la pérdida de la vida del enfermo. Infortunadamente, en la actualidad seguimos viendo estas conductas. Se presenta una síntesis de casos de connotados personajes que presentaron este cáncer y se describe el impacto que ello implicó en la sociedad de ese momento.

Aspectos fundamentales del nódulo tiroideo y el cáncer bien diferenciado de tiroides para los médicos general y familiar.

The physician that has the first contact with the patient is the general or family doctor, on whose initial assessment patient treatment success often depends. National and international treatment guidelines are designed for specialists in the area, and the primary care physician often finds them difficult to interpret. The purpose of this document is to offer primary care physicians the fundamentals for the diagnostic and reference process of patients with thyroid nodules and possibly with well-differentiated thyroid cancer, from an objective and pragmatic point of view. Not all thyroid nodules require the same approach, and not all nodules are associated with cancer and neither should they be removed. The bases for a proper diagnosis of a thyroid tumor are patient history, physical examination and ultrasound. The results of these three initial assessment methods shall support the decision on the diagnostic-therapeutic process. This article explains the appropriate way to approach the diagnosis of a thyroid tumor, which studies are unnecessary, and which are the principles of thyroid cancer treatment.

El galeno de primer contacto con el paciente es el médico general o familiar, de cuya evaluación inicial muchas veces depende el éxito en el tratamiento de los pacientes. Las guías terapéuticas nacionales e internacionales están diseñadas para especialistas en el área y el médico de primer contacto suele encontrarlas difíciles de interpretar. El objetivo del presente documento es ofrecer al médico de primer contacto los fundamentos para el diagnóstico y proceso de referencia de los pacientes con nódulos tiroideos y eventualmente con cáncer bien diferenciado de tiroides, un punto de vista objetivo y pragmático. No todos los nódulos tiroideos requieren la misma aproximación diagnóstica y no todos los nódulos están asociados con cáncer ni deben ser retirados. Las bases para el adecuado diagnóstico de un tumor tiroideo son la historia clínica, la exploración física y el ultrasonido; los resultados de estos tres métodos iniciales de exploración serán los que orienten el proceso diagnóstico-terapéutico. En el presenta artículo se explica la forma adecuada para el diagnóstico de un tumor tiroideo, los estudios innecesarios y los principios del tratamiento del cáncer de tiroides.

[Melanoma cutáneo. Etapificación ganglionar con base en la evidencia actual].

Most patients with cutaneous melanoma present with clinical stage 1 at diagnosis, i.e., with no evidence of lymph node or systemic metastases. However, since this is a type of neoplasm with high affinity to lymphatic tissue, between 30 and 60% of patients are estimated to have occult metastases on the lymph nodes of the area that drains the primary tumor site at the moment of diagnosis. This possibility depends on several histologic factors, especially thickness of the neoplasm. Historically, in order to reduce the rate of regional recurrence, lymphadenectomy was an essential part of cutaneous melanoma treatment, which has associated morbidity. In the decade of 1990, Morton et al. reported that lymph is initially received by a single lymph node in the lymphatic basin and that its histological status predicts the status of the others and that, therefore, in patients with sentinel lymph node free of metastases lymphadenectomy is not necessary, which reduces morbidity. In the present manuscript, indications, contraindications and requirements for sentinel lymph node identification are described, as well as its current value in cutaneous melanoma diagnostic and therapeutic process.

La mayoría de los pacientes con melanoma cutáneo se presenta en etapa clínica 1, es decir, sin evidencia de metástasis ganglionares ni sistémicas, sin embargo, al ser una neoplasia con alta linfofilia, se estima que al momento del diagnóstico entre 30 y 60 % de los pacientes tiene metástasis ocultas en los ganglios linfáticos de la zona que drena el sitio del tumor primario. Esta posibilidad depende de varios factores histológicos, principalmente el grosor de la neoplasia. Históricamente y con objeto de lograr disminuir la tasa de recurrencias regionales, la linfadenectomía, con la morbilidad asociada, era parte esencial del tratamiento. En la década de 1990, Morton et al. reportaron que un solo ganglio de la zona linfoportadora recibe la linfa inicialmente y que su estado histológico predice el estado de los demás, de tal manera que la linfadenectomía no es necesaria en pacientes con ganglio centinela sin metástasis, lo que disminuye la morbilidad. En el presente manuscrito se describen las indicaciones, contraindicaciones y requisitos para efectuar la identificación del ganglio centinela, así como su valor actual en el proceso diagnóstico terapéutico del melanoma cutáneo.

[Evaluación funcional de deglución-aspiración en pacientes sometidos a laringectomía subtotal supracricoidea con cricohioidoepiglotopexia].

INTRODUCTION: Cardiovascular disease is the main cause of mortality worldwide. In women, its incidence increases at the sixth decade of life, coinciding with postmenopause. Whether this effect is due to menopause-related hormonal changes is not known. OBJECTIVE: To evaluate the differences in cardiovascular risk in pre- and postmenopausal women by means of the Globorisk risk scale, the triglyceride/high-density lipoproteinsHDL cholesterol (Tg/HDL-C) ratio and metabolic syndrome (MS) criteria. METHOD: Cross-sectional study that included 408 women from 40 to 60 years of age; anthropometric measurements and biochemical determinations were performed. The participants were classified as premenopausal and postmenopausal. Cardiovascular risk was assessed using the MS criteria, the Globorisk risk calculator and the Tg/HDL-C ratio. RESULTS: Postmenopausal women showed a significant increase in waist circumference, total cholesterol and triglycerides Tg in comparison with premenopausal women. Significant associations were found between hormonal state and Globorisk-measured cardiovascular risk (OR = 2.50; 95 % CI = 1.67-3.74) and the Tgtriglyceride/HDL-C ratio (OR = 1.66; 95 % CI = 1.09-2.52). CONCLUSION: Cardiovascular risk factors have a higher prevalence in postmenopause. The Globorisk scale and Tg/HDL-C ratio identify cardiovascular risk in postmenopausal women.

INTRODUCCIÓN: La laringectomía subtotal supracricoidea asociada con cricohioidoepiglotopexia es la técnica quirúrgica conservadora más eficiente para preservar las funciones laríngeas de los pacientes con carcinoma localmente avanzado de la laringe. La complicación más temida de esta intervención es la aspiración en el momento de la deglución y la neumonía secundaria; existen diversas formas de evaluar la aspiración y el grado de esta. Presentamos una novedosa forma de identificar incluso pequeñas cantidades de aspiración traqueobronquial. MÉTODO: Se incluyeron pacientes sometidos a laringectomía subtotal y cricohioidoepiglotopexia por cáncer laríngeo; todos evaluados con trago radiactivo posoperatorio. Con base en la sintomatología y resultado del gammagramma se decidió prolongar el tiempo de alimentación por sonda. RESULTADOS: Se incluyeron 37 pacientes, cuatro habían recibido radioterapia; la tasa de aspiración fue de 29.7 %; 50 % de los pacientes que habían recibido radioterapia presentó aspiración y 18 % de los pacientes con aspiración requirió prolongación del tiempo de alimentación por sonda nasogástrica; ninguno necesitó laringectomía total por aspiración que no permitiera la deglución. CONCLUSIONES: La evaluación posoperatoria de pacientes sometidos a laringectomía subtotal con trago radiactivo permite identificar líquido aspirado al árbol bronquial, incluso en cantidades mínimas, y planear el momento para iniciar la deglución.

[Mandibular osteoradionecrosis (ORN) as a side effect of head and neck cancer treatment: Factors that induce it]. / Osteoradionecrosis (ORN) mandibular como efecto colateral del tratamiento del cáncer de cabeza y cuello: factores que la inducen.

INTRODUCTION: Osteoradionecrosis of the mandible is a relatively common complication in patients with head and neck cancer undergoing radiotherapy or concomitant chemoradiotherapy, characterized by exposure of the mandibular bone either in the mouth or in the facial skin, with no improvement with conservative treatment for six months. The risk factors are radiotherapy in head and neck region, lack of dental prophylaxis before treatment and dental extraction. MATERIAL AND METHODS: Retrospective observational study analyzing incidence and etiologic factors of osteoradionecrosis in 250 patients undergoing radiotherapy or combined treatment of cervicofacial area between 2002 and 2010. RESULTS: 25 patients were included; the horizontal branch was the most affected area, followed by the anterior arch. Associated factors were: stage (T4a and T4b), tumor location (oral cavity), dental extraction pre or post-radiotherapy, and radiotherapy time (pre-or postoperative); 72% had association with tooth extraction. Only five patients had control with conservative measures, and 20 required some type of mandibulectomy, only three of them were candidates for reconstruction with fibular free flap; none received treatment in a hyperbaric chamber. CONCLUSIONS: The data suggest that osteoradionecrosis has a multifactorial origin, and prevention is the best alternative and includes pretreatment dental prophylaxis to avoid tooth extractions and close monitoring and surveillance in order to identify early osteoradionecrosis. Most patients require mandible resection as definitive treatment.

[Subtotal-supracrioid laryngectomy (SCSL): the importance of the histopathological analysis]. / Laringectomía subtotal supracricoidea (LSSC): la importancia del análisis histopatológico.

The purpose of conservative surgical treatment of laryngeal cancer is to obtain cancer control with preservation of laryngeal function, and in turn, the preservation of laryngeal function should be understood as the preservation of the patient's ability to ventilate in the normal way without tracheostomy and without aspiration and maintaining intelligible speech. This objective is achieved by maintaining a balance between two fundamental aspects: proper patient selection (based on tumor extension and preoperative laryngeal function) and an adequate histopathological analysis of the surgical specimen. Supracricoid subtotal laryngectomy (SCSL) is the voice conservative surgical technique which offers the best possibility of control in patients with locally advanced laryngeal cancer, and the proper histopathological analysis allows staging and selecting patients eligible for adjuvant therapy, avoiding unnecessary therapies, and allows design of a monitoring and surveillance program based on risk factors. The aim of this manuscript is to highlight key points in the histopathological evaluation of the surgical specimen of SCSL. The proper communication between the surgeon and pathologist, offering complete information on preoperative clinical evaluation and the knowledge of the key points in the evaluation of the surgical specimen (sites of tumor leakage and surgical resection margins) are fundamental parameters to achieve a proper histopathologic evaluation of the surgical specimen.

[Cutaneous Melanoma (CM): Current Diagnosis and Treatment]. / Melanoma cutáneo (MC): diagnóstico y tratamiento actuales.

Cutaneous melanoma (CM) is the third most common cancer of the skin, but it is the neoplasia with the greatest impact on mortality. Its etiology is multifactorial and it has been reported that its prevalence has increased in the last two decades. In Mexico, CM ranks seventh in frequency among all malignancies and 80% of cases are in locally advanced stages. The prognosis depends on the stage. The prognostic factors with greatest impact in survival are nodal status, tumor thickness or Breslow depth, ulceration, and in thin melanomas (< 1 mm thickness, without ulceration and Clarck level III), the mitotic index. The diagnostic approach is of great importance to achieve adequate treatment. Adherence to global guidelines of treatment allows us to obtain the best rates of locoregional control, which is the first target to be achieved in patients with CM. The goal of this manuscript is to provide a synthesis of the most important aspects in the diagnosis and treatment of CM, based on current evidence obtained in the literature.

[Drainage time in patients submitted to radical neck dissection. Influence of peri-operative intravenous liquid perfusion]. / Tiempo de drenaje en pacientes sometidos a disección radical de cuello. La influencia de la perfusión de líquidos en el periodo perioperatorio.

INTRODUCTION: Drainage after radical neck dissection (RND) is routine and several factors impact the postoperative drainage number of days (PODND). OBJECTIVE: to determine the impact of trans-operative intravenous fluid management (TOFM) in in PODND. METHODS: Retrospective analysis of patients subjected to some type of radical neck dissection. Variables analyzed: blood loss volume, radical neck dissection type, surgical time, anesthesia time, and trans-operative intravenous fluid management volume. RESULTS: 120 patients included: average age 58.3 years; 60 males and 60 females. Radical neck dissection most frequent indications: thyroid cancer (36.6%), laryngeal cancer (15.8%) and tongue cancer (7.5%). Radical neck dissection most frequent types: 47 modified radical (39.2%), 22 lateral (18.3%) and 16 supra-omohyoid (13.3%). Median surgical time 3.55 hours, median anesthesia time 4.3 hours, median blood loss 278 ml, related to transoperative intravenous fluid management. Classical radical neck dissection was performed in 13 patients in whom postoperative drainage number of days was greater than in the other types (p = 0.08). No difference in postoperative drainage number of days among the different types of radical neck dissection. An apparent association was found between trans-operative intravenous fluid management volume and postoperative drainage number of days: the greater the quantity of fluids, the greater the number of days (p = 0.001). Patients who had drain removed during the first seven days had an average of 1,500 ml infused. Patients who had an average of 3,000 ml of fluid had drainage of 10 days. Perfusion > 3,500 ml = postoperative drainage number of days ≥ 10 días. CONCLUSIONS: In the present series a statistically significant relationship was found between the TOFM and PODND. A meticulous surgical technique and an anesthesia procedure that carefully assesses fluid balance could decrease PODND.

[Unsual clinical signs of primary hyperparathroidism]. / Manifestaciones clínicas inusuales del hiperparatiroidismo primario.

BACKGROUND: A growing number of patients with primary hyperparathyroidism (PHPT) are diagnosed in the absence of symptoms following routine biochemical screening. However, in some countries, overt manifestations and osteitis fibrosa cystica (OFC) still dominate the clinical profile of PHPT patients. METHODS: We retrospectively studied clinical and biochemical manifestations of 47 consecutive patients with primary hyperparathyroidism who were treated with parathyroidectomy from October 1993 to June 2005. RESULTS: Mean age was of 51.3 years. Our sample included 40 women (85%) and 7 men (15%). Seventy eight percent of cases had radiological features of OFC, namely subperiosteal bone resorption, cortical cysts and osteopenia. Pathological fracture occurred in nine patients (19.1%). Fifteen (32%) patients had clinically evident bony deformities or brown tumors mostly located in the mandible and maxilla. CONCLUSIONS: Our results indicate that symptomatic osteitis fibrosa cystica and severe decrease of bone mineral density were the primary manifestations of primary hyperparathyroidism. Most patients were referred to an oncology hospital for treatment due to a suspected malignant neoplasm. A comprehensive clinical evaluation with biochemical markers, imaging studies and histological results is needed to establish a possible diagnosis of primary hyperparathyroidism.

[Fibular free-flap for mandibular reconstruction in patients undergoing mandibulectomy for oral cavity and bone tumors: 10-year experience]. / Trasplante de peroné para reconstrucción mandibular en pacientes sometidos a mandibulectomía por tumores óseos y de la cavidad bucal. Experiencia de 10 años.

BACKGROUND: Fibular-free-flap is currently considered the optimum choice in mandible reconstruction. OBJECTIVE: Assess our results using this technique after 10 years-experience. MATERIAL AND METHODS: Patients underwent mandibulectomy and primary or secondary reconstruction with fibular-free-flap between 1995 and 2005. Variables analyzed included: surgical time, time of micro-vascular anastomosis, bleeding, tobacco history, comorbidity, chemo-radiotherapy background, flap type and primary or secondary reconstruction. RESULTS: We included, 60 patients and performed 62 flaps. We included 27 women and 33 men; mean age was 43 years, 30 had malignant tumors and 30 benign. Diabetes was the most frequent co-morbid pathology. In 49 subjects reconstruction was primary and secondary in 11; in 38 the flap was osseous and in 22 osteocutaneous. In 52 patients (87%) the flap was successful and 8 showed total loss. The most frequent complications were osteosynthesis material exposure, pseudoarthrosis and cervical abscess. Four patients were subjected to re-exploration but the flap was preserved in all. No acssociation was found among any of the variables studied and flap viability. The functional result was considered adequate in 90% of cases and was associated with time of reconstruction. CONCLUSION: Fibular-free-flap is a safe alternative in mandible reconstruction. Primary reconstruction offers better functional results.

[Incisión cervical transversa en disección radical de cuello]. / Transverse incision in radical neck dissection.

ANTECEDENTES: La disección radical de cuello es la única forma de estadificar a pacientes con neoplasias con riesgo de metástasis ganglionares. Se han efectuado diversos tipos de incisiones a lo largo de la historia, con el objetivo de obtener una exposición suficiente que permita la resección completa de los grupos ganglionares en riesgo. Es importante combinar la seguridad oncológica con unas adecuadas estética, funcionalidad y calidad de vida. MÉTODO: Evaluación retrospectiva del resultado obtenido con la incisión transversa en el cuello en pacientes sometidos a disección radical. El parámetro utilizado para saber si esta incisión es adecuada es el número de ganglios disecados. RESULTADOS: Son 35 pacientes, 30 con metástasis de carcinoma epidermoide y 5 con metástasis de melanoma. La media de ganglios disecados fue de 25. Una sola incisión permitió la disección de los cinco niveles ganglionares; no se requirió convertir la incisión ni hacer ampliaciones verticales. El resultado cosmético fue satisfactorio en todos los pacientes, y no hubo complicaciones mayores. CONCLUSIÓN: La incisión cervical única transversa permite el acceso a los cinco niveles cervicales y puede ser ampliada bilateralmente. En la presente serie, la media de ganglios disecados fue de 25, número suficiente para considerar al procedimiento completo. El resultado estético fue satisfactorio. BACKGROUND: Radical neck dissection is the only way to stage patients with neoplasms at risk of lymph node metastases; various types of incisions have been made throughout history, the goal: to obtain sufficient exposure to allow complete resection of the nodal groups at risk. It is important to combine oncological safety with adequate aesthetics, functionality and quality of life. METHODS: Retrospective evaluation of the result obtained with the transverse neck incision in patients submitted to radical neck dissection, the parameter used to know if this incision is adequate is the number of dissected lymph nodes. RESULTS: There are 35 patients, 30 with metastasis of squamous cell carcinoma and 5 with melanoma metastasis. The average of dissected lymph nodes was 25. A single incision allowed the dissection of the five nodal levels, it was not necessary to convert the incision or make vertical enlargements; the cosmetic result was satisfactory in all patients, there were no major complications. CONCLUSION: The unique transverse cervical incision allows access to the five cervical levels, it can be enlarged bilaterally; in the present series, the mean number of dissected lymph nodes was 25 enough to consider the procedure as complete. The aesthetic result was satisfactory.

[Human papillomavirus: association with head and neck cancer]. / Virus del papiloma humano asociado a cáncer de cabeza y cuello.

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) is the 6th most common cancer worldwide. In 2005, 400,000 cases of HNSCC were diagnosed worldwide. The most frequently affected site is the oral cavity. Alcohol/tobacco consumption is the most important risk factor for this neoplasia; nevertheless, since 1983 it has been suggested that human papilloma viruses (HPV) have a role in HNSCC, mainly in the oropharynx (level 1 evidence). We undertook this study to determine HPV prevalence and types in patients with HNSCC. METHODS: Presence of HPV was determined by polymerase chain reaction and staged by in situ hybridization. We analyzed stage, tumor site of origin, sexual practices, and alcohol/tobacco consumption. Fisher's exact test and Student's t-test were used for statistical analysis. We performed a multiple regression analysis for adjustment of variables. RESULTS: There were 118 patients were HPV positive and oropharyngeal and laryngeal cancer patients were the most frequently affected (55% and 50%, respectively). HPV-16 was most frequently isolated (70%). Laryngeal cancer patients suffered the highest ratio of HPV-16 infection (68.7%). Factors associated with HPV (univariate analysis) were age >50 years, tobacco/alcohol consumption and male gender. In multivariate analysis, none of the variables showed importance (p >0.5); HPV infection was more frequent in patients with history of alcohol/tobacco consumption (p = 0.6). CONCLUSIONS: There was HPV presence in 42% of HNSCC patients, HPV-16 in 70%, with the oropharynx and larynx being the most affected sites. No variables are associated with the virus presence. HPV is a co-factor in HNSCC etiology.

[Lymphatic mapping and sentinel node biopsy in penis cancer. Feasibility study and preliminary report]. / Mapeo linfático y biopsia del ganglio centinela en cáncer de pene. Estudio de factibilidad y reporte preliminar.

Most patients with invasive squamous cell carcinoma of the penis do not have inguinal node metastasis at the time of diagnosis and 50% of those having palpable nodes are inflammatory. Penis cancer (PC) treatment implies resection of the primary tumor and inguinal lymphadenectomy; nevertheless, morbidity related to this procedure is high and its usefulness may be questioned in patients without metastasis in dissected nodes. Lymphatic mapping with sentinel node biopsy (LMSNB) is a valid alternative, useful in other neoplasias. The objective of this study is to determine if it is possible to identify a sentinel node (SN) in patients with PC. Patients with T1-2 PC without palpable nodes (N0) were included. LMSNB was carried out with the combined technique (blue dye and radiocolloid). All patients underwent an elective bilateral inguinal lymphadenectomy. Sensitivity and false negative index were calculated. SNs were sent for transoperative study with imprint technique and, definitively, with serial cuts and hematoxylin/eosin staining. Nine patients showed results with 32 lymph carrier zones and SN was identified in all of them, 4 regions had metastasis, in 3 the SN was metastatic and in one patient was metastasis-negative (false negative); sensitivity = 80%; false negatives index = 20%. Seven patients (77%) did not have node metastasis. LMSNB is an alternative for staging PC patients and could prevent unnecessary inguinal lymphadenectomies. A larger number of patients is required to validate the sturdy. The combined technique offers a high rate of success in SN identification.

[Concomitant treatment with gemcitabine and radiotherapy in patients with advanced stages of epidermoid carcinoma originating in the head and neck. A phase II sutdy]. / Tratamiento concomitante con gemcitabina y radioterapia en pacientes con carcinoma epidermoide locorregionalmente avanzado de cabeza y cuello. Estudio fase II.

BACKGROUND: Surgery, radiotherapy or radiotherapy alone (RTA) constitute conventional treatment regimes for advanced stages of squamous cell carcinoma originating in the head and neck mucosa. Nevertheless, the results in advanced regional carcinoma (ARC) are disappointing. The chemotherapy-radiotherapy (CHT-RT) association has shown to be superior to RTA in irresectable disease and in resectable disease it could substitute initial surgery as a rescue alternative. OBJECTIVE: Our objective is to report the response rate and toxicity of concurrent treatment with Gemcitabine and Radiotherapy (GRT) in patients with ARC. In a prospective design, patients with ARC received concurrent GRT; the global, complete and partial response rate as well as toxicity were assessed. MATERIAL AND METHODS: 15 patients were included, 5 women and 10 men, 73% in stage IVa; 13/15 showed a global response (87%), a complete response was observed in 9 cases (60%) (RC) and 2 showed progress. RESULTS: All patients included showed toxicity, the most frequent one was level 4 mucositis in 46%, of this 40% required nutritional support by catheter or gastrostomy. One patient in RC died due to sepsis. None of them suspended treatment. CONCLUSION: The GRT association offers a complete response rate of 60%; nevertheless morbidity was not insignificant; randomized studies with a larger number of patients will be required to allow us to outline the optimal therapeutic scheme.

[Lymphatic mapping and sentinel node biopsy in squamous cell carcinoma of head and neck mucosa]. / Mapeo linfático y biopsia del ganglio centinela en carcinoma epidermoide originado en mucosas de cabeza y cuello.

BACKGROUND: Lymphatic mapping with sentinel node biopsy (LMSNB) is a staging alternative in melanoma and breast cancer. In oral cavity cancer (OCC) without palpable nodes, the recommended surgical treatment is elective-selective neck dissection; nevertheless, 70% will not show metastasis. LMSNB might be a staging alternative. Our objective was to determine if this technique allows the identification of sentinel node. METHODS: Characteristics were T1-2, N0, OCC patients >4 mm of tumor thickness. We injected 3 mCi of rhenium and 2 cc of blue dye around the tumor and performed a lymphogammagraphy. Sentinel node (SN) was identified by color and radioactivity, and all patients were submitted to suprahyoid dissection. Index of success, false negative, and negative predictive values were calculated. RESULTS: Of 41 patients, there were 20 females and 21 males. Lymphogammagraphy showed a SN in each patient. SN was identified in all patients during surgery: in 10 patients the SN was "hot" (24%) and in 31 (75%) "hot and blue"; 13/41 (31.7%) showed metastasis, 4 had negative SN (false negative); in 3/13 metastatic SN. Diagnosis was made by definite analysis. All patients with false negative had tumors >2 cm. CONCLUSIONS: LMSNB in oral cavity cancer has a high index of success and radical neck dissection could be avoided in 80% of patients with T1-2 tumors.

[Head and neck cancer. Risk factors and prevention]. / El cáncer de cabeza y cuello. Factores de riesgo y prevención.

The frequency of squamous cell carcinoma originating in head and neck mucosae has increased worldwide in the last decade, particularly in countries with emerging economies; oral cavity cancer is ranked in 6th place for all neoplasias. We conducted a literature review related to epidemiology and risk factors in head and neck cancer in order to analyze the most significant etiological factors and to emphasize prevention of carcinoma originating in head and neck mucosae. The prognosis in head and neck cancer patients depends on the clinical stage at time of diagnosis; therefore, identification of high-risk populations, precancerous lesions and early diagnosis decrease mortality. Nevertheless, the major effort must be on primary prevention.

[Laryngeal conservative surgery in patients candidates for combined treatment with chemo-radiotherapy]. / Cirugía conservadora de laringe en pacientes candidatos a tratamiento combinado con quimio-radiación por cáncer laríngeo.

BACKGROUND: The standard of care for advanced-stage laryngeal cancer is combined treatment (chemo-radiotherapy). However, the complications with this treatment are not few, mainly in swallowing. Conservative laryngeal surgery remains an effective alternative for cancer control without the complications of chemo-radiotherapy. MATERIAL AND METHODS: Retrospective study was conducted on patients with laryngeal cancer cT3, cN0 with paraglottic infiltration, fixation of the vocal cord, minimal invasion of the hyo-thyroepiglottic space, but with normal arytenoid mobility and no sub-glottic extension, were treated with subtotal supracricoid laryngectomy. Complications, sequels of treatment, and local recurrence were evaluated. Bronchial aspiration was studied with radioactive swallow. RESULTS: There were 25 patients, 22 with negative surgical margins, one had tumour contact with the surgical margins, and 2 were positive. Two patients received postoperative radiotherapy. The mean decannulation was 15 days and removal of nasogastric tube 25 days. During the mean follow-up of 26 months, none of the patients had tumour recurrence or required conversion to total laryngectomy. In all patients swallowing has been normal and none required permanent or temporary tracheotomy or definitive gastrostomy. The voice is considered intelligible in all patients. Radioactive swallow showed aspiration in 15/25 patients, with none being clinically relevant. There were postoperative complications in 5 patients, and 4 patients required re-intervention but no conversion to total laryngectomy. CONCLUSION: Conservative surgery is an effective surgical-alternative to chemo-radiotherapy in patients with locally advanced laryngeal cancer, providing oncological control, acceptable complications and minimal sequels. Although most patients have aspiration, this does not affect functional status.

The number of sentinel nodes identified as prognostic factor in oral epidermoid cancer.

In patients with oral cavity epidermoid cancer without palpable nodes, the standard cervical treatment is supraomohyoid dissection; nevertheless, lymphatic mapping with sentinel node (SN) biopsy has been useful and allows the identification of a group of patients where neck dissection may be prevented. The objective of this study was to examine which factors diagnose the possibility of metastasis in SN. A non-randomized prospective study was performed during a two year period and included patients with T1-2, N0 oral cavity cancer >4 mm thick, SN was identified by blue dye and Rhenium colloid. All patients underwent pre-operatory lymphogammagraphy and elective-selective neck dissection. Age, gender, tumor site, T, tumor thickness and number of sentinel nodes found were evaluated. In 48 patients, at least one sentinel node was found, 2 per patient on average. 10.4% showed drainage outside the supraomohyoid region, 13/48 had nodular metastasis, 4 with negative SN(8.3%). T, location, thickness and number of SN are related to non-SN metastasis. Identification of 3SN or more was related to the possibility of SN metastasis p=0 (RR 10.1, I. C. 95% 1.1 91.2). The combined technique (dye-colloid) offers a high index of success in the identification of SN in patients with oral cavity cancer, while lymphogammagraphy identifies patients with anatomically unexpected drainage. Patients with T1 less than 2cm, not located on the tongue with thickness <5 mm and more than 2 SN were less likely to have metastasis in non-sentinel nodes. The identification of at least 3 sentinel nodes decreases the possibility of identifying patients with hidden metastasis (p=0.04).

[Breast cancer associated with pregnancy]. / Cáncer de mama asociado a embarazo.

Invasive breast carcinoma diagnosed during pregnancy and even one year after delivery is known as breast cancer associated with pregnancy. There are many controversies surrounding this entity concerning diagnosis and therapeutics as well as to the behavior regarding the fetus. There is broad information in the existing literature. We can find authors who do not change the diagnostic-therapeutic approach to the neoplasia and those who even advise pregnancy interruption and consider greater aggressiveness in treatment, in comparison to the same cancer in a non-pregnant woman. The prognosis of breast cancer associated with pregnancy has also been a controversial issue. Historically, it has been considered to have the worst evolution. Nevertheless, evidence recently has shown that the known prognosis factors in breast cancer (stage, nodular status, receptors, etc.) are those associated with the prognosis and not the pregnancy itself. The objective of this article is to analyze, based on the existing evidence in the literature, which is the best diagnostic-therapeutic route for breast cancer associated with pregnancy, which procedures must be followed with the mother and the fetus and which is the ideal therapeutic sequence, analyzing at the same time the possibilities of axillary preservation by means of lymphatic mapping and sentinel node biopsy in these patients.