Bullous Melanoma: should the thickness of the bullous lesion be included in Breslow depth measurement?

Abstract Bullous melanoma represents a rare variant of melanoma, especially in patients without underlying bullous cutaneous disease. Few cases have been described in the literature, including cases of melanoma in patients with bullous epidermolysis or Hailey-Hailey disease. The histopathological diagnosis of bullous melanoma does not show any difficulties, except for the measurement of the Breslow index. The rarity of this case, the dilemma of how to measure the Breslow index and the importance of an early diagnosis motivated this report.

Jaw osteosarcoma and pregnancy: a rare coexistence.

Osteosarcoma of the jaw represents less than 1% of all head and neck malignancies. This malignancy in pregnant women occurs in one per 1000 deliveries. We report a case of a 29-year-old woman, in the 33rd week of gestation, who presented with an expansive tumor destroying the maxillary alveolar bone, histologically composed of pleomorphic, round, spindle, or epithelioid cells and osteoid/chondroid matrix. Upon final diagnosis of osteosarcoma, the lesion was excised. To the best of our knowledge, only 10 cases of jaw osteosarcoma in pregnant women have been reported to date in the English language literature. The use of ancillary examinations, malignancy diagnosis, and cancer treatment can be challenging during pregnancy. Knowledge about jaw osteosarcoma in pregnancy can increase healthcare providers' awareness, avoid delays and misdiagnosis and potentially improve maternal and neonatal outcomes.

Bullous Melanoma: should the thickness of the bullous lesion be included in Breslow depth measurement?

Bullous melanoma represents a rare variant of melanoma, especially in patients without underlying bullous cutaneous disease. Few cases have been described in the literature, including cases of melanoma in patients with bullous epidermolysis or Hailey-Hailey disease. The histopathological diagnosis of bullous melanoma does not show any difficulties, except for the measurement of the Breslow index. The rarity of this case, the dilemma of how to measure the Breslow index and the importance of an early diagnosis motivated this report.

Jaw osteosarcoma and pregnancy: a rare coexistence

Osteosarcoma of the jaw represents less than 1% of all head and neck malignancies. This malignancy in pregnant women occurs in one per 1000 deliveries. We report a case of a 29-year-old woman, in the 33rd week of gestation, who presented with an expansive tumor destroying the maxillary alveolar bone, histologically composed of pleomorphic, round, spindle, or epithelioid cells and osteoid/chondroid matrix. Upon final diagnosis of osteosarcoma, the lesion was excised. To the best of our knowledge, only 10 cases of jaw osteosarcoma in pregnant women have been reported to date in the English language literature. The use of ancillary examinations, malignancy diagnosis, and cancer treatment can be challenging during pregnancy. Knowledge about jaw osteosarcoma in pregnancy can increase healthcare providers' awareness, avoid delays and misdiagnosis and potentially improve maternal and neonatal outcomes.

Functional outcomes and survival of patients with oral and oropharyngeal cancer after total glossectomy / Resultados funcionais e sobrevida de pacientes com câncer de cavidade oral e orofaringe submetidos à glossectomia total

Abstract Introduction: Cancer of the oral cavity and oropharynx presents aggressive behavior and its diagnosis is, in most cases, performed in advanced stages. Total glossectomy is a therapeutic option in locally advanced cancer, and the only one in the recurrent or residual disease, after chemoradiotherapy. Objective: To evaluate the clinical-epidemiological profile, postoperative complications, survival rates and functional aspects of patients with oral cavity and oropharynx cancer after total glossectomy. Methods: It was a retrospective study where 22 patients were included with oral cavity and oropharyngeal cancer after total glossectomy at the Hospital Regional do Vale do Paraíba, em Taubaté, São Paulo. Results: All patients were male, with a median age of 57 years, most of tumors are located in the tongue and floor of the mouth and classified as stage IVa. Total glossectomy as initial treatment was performed in 18 and as salvage in four patients. The major pectoralis myocutaneous flap was used for reconstruction in all cases. The main postoperative complication was wound infection and salivary fistula. Conclusion: Overall survival was 19% and cancer-specific survival was 30.8% in five years. Eight patients were rehabilitated for exclusive oral feeding without the dependence tracheostomy and enteral tube, all with an overall survival greater than 15 months.

Resumo Introdução: O câncer da cavidade oral e da orofaringe apresenta comportamento agressivo e seu diagnóstico é, na maioria dos casos, realizado em fases avançadas. A glossectomia total é uma opção terapêutica no câncer localmente avançado e a única no resgate de pacientes com doença residual ou recorrente, após a quimiorradioterapia. Objetivo: Avaliar o perfil clínico-epidemiológico, as complicações pós-operatórias, as taxas de sobrevida e os aspectos funcionais de pacientes com câncer da cavidade oral e da orofaringe submetidos à glossectomia total. Método: Estudo retrospectivo em que foram incluídos 22 pacientes com câncer de cavidade oral e orofaringe submetidos à glossectomia total no Hospital Regional do Vale do Paraíba, em Taubaté, São Paulo. Resultados: Todos os pacientes eram do gênero masculino, com mediana de 57 anos, com tumores principalmente na língua e no assoalho da boca e classificados, em sua maioria, como estádio clínico IVa. A glossectomia total como tratamento inicial foi realizada em 18 e como resgate em quatro pacientes. O retalho miocutâneo peitoral maior foi utilizado para a reconstrução em todos os casos. A principal complicação pós-operatória foi a infecção da ferida operatória e a fístula salivar. Conclusão: A sobrevida global foi de 19% e a específica por câncer de 30,8% em cinco anos. Oito pacientes foram reabilitados para alimentação oral exclusiva sem a dependência de traqueostomia e ou de dieta enteral, todos com sobrevida global maior do que 15 meses.

Functional outcomes and survival of patients with oral and oropharyngeal cancer after total glossectomy.

INTRODUCTION: Cancer of the oral cavity and oropharynx presents aggressive behavior and its diagnosis is, in most cases, performed in advanced stages. Total glossectomy is a therapeutic option in locally advanced cancer, and the only one in the recurrent or residual disease, after chemoradiotherapy. OBJECTIVE: To evaluate the clinical-epidemiological profile, postoperative complications, survival rates and functional aspects of patients with oral cavity and oropharynx cancer after total glossectomy. METHODS: It was a retrospective study where 22 patients were included with oral cavity and oropharyngeal cancer after total glossectomy at the Hospital Regional do Vale do Paraíba, em Taubaté, São Paulo. RESULTS: All patients were male, with a median age of 57 years, most of tumors are located in the tongue and floor of the mouth and classified as stage IVa. Total glossectomy as initial treatment was performed in 18 and as salvage in four patients. The major pectoralis myocutaneous flap was used for reconstruction in all cases. The main postoperative complication was wound infection and salivary fistula. CONCLUSION: Overall survival was 19% and cancer-specific survival was 30.8% in five years. Eight patients were rehabilitated for exclusive oral feeding without the dependence tracheostomy and enteral tube, all with an overall survival greater than 15 months.

Parotidectomy under sedation and locoregional anesthesia with monitoring of brain activity.

BACKGROUND: Parotidectomy is usually performed while the patient is under general anesthesia, however, sedation with locoregional anesthesia could be an alternative. METHODS: Fifteen adult patients with parotid tumors of the superficial lobe were included in this study. Anesthetic procedure consisted of sedation associated with cervical plexus and auriculotemporal nerve block. Sedation was managed based on the bispectral index. RESULTS: Superficial parotidectomies were performed in 13 patients, and combined partial resections were performed in 2 patients. The mean operative time was 118.2 ± 16.4 minutes. Conversion to general anesthesia was necessary in only 1 patient. Ten surgeries were performed on an outpatient basis. Definitive facial paralysis occurred in 1 patient. All patients reported total satisfaction with the procedure. CONCLUSION: In selected cases, parotidectomy under sedation plus locoregional anesthesia is feasible and safe. The careful selection of patients and the close collaboration with an anesthesiologist is the key to a successful procedure. © 2016 Wiley Periodicals, Inc. Head Neck 39: 744-747, 2017.

Diagnosis of second primary tumor and long-term survival after single initial triple endoscopy in patients with head and neck cancer.

Patients with squamous cell carcinoma of the upper aerodigestive tract (UADT) have a high risk of developing second primary tumors (SPTs). Most of the studies concerning triple endoscopy (laryngoscopy, digestive tract endoscopy and bronchoscopy) describe the frequency and stage of the SPT, but not its impact on survival. This study is a matched pair analysis that included patients with squamous cell carcinoma of the UADT who were subjected to a triple endoscopy before the first treatment, matched with patients who did not undergo triple endoscopy. One hundred and thirty-five patients were included in each group. The diagnosis of an SPT was more frequent in the initial triple endoscopy group than in the control group (34 and 20 cases, respectively). In the initial triple endoscopy group, 50.0 % of these tumors were diagnosed simultaneously, whereas in the control, only 5.0 %. No significant differences in the survival rates or in clinical stage of the SPTs were found in the two groups. There was no difference in the clinical stage of the SPT and the survival rates of the patient groups who underwent triple endoscopy at the initial evaluation and those subjected to only a routine evaluation and follow-up.

Second primary tumors in patients with head and neck cancer.

This is a review on second primary tumors in patients with head and neck cancer. These patients have a high risk of developing other cancers simultaneously or subsequently. The incidence of multiple primary tumors in this population can be as high as 27%. Recurrences are the most common cause of treatment failure within the first 2 years of follow-up. After the third year the diagnosis of a second primary tumor becomes the most important cause of morbimortality in head and neck cancer patients, especially in those treated for cancers early diagnosed. Most second primary tumors occur in the upper aerodigestive tract (40%-59%), lung (31%-37.5%), and esophagus (9%-44%). Patients who develop second primary tumor have a significant reduction of survival expectancy.

Second primary tumor in patients with upper aerodigestive tract cancer.

UNLABELLED: In the first three years after treatment of patients with squamous cell carcinoma of upper aerodigestive tract (UADT), there is a high incidence of recurrences. After the third year, the occurrence of second primary tumor (SPT) is an important cause of morbimortality. AIM: To evaluate the incidence and the characteristics of the SPT in patients with squamous cell carcinoma of UADT, treated with curative intention. METHODS: Retrospective study where the incidence, localization and treatment of SPT had been analyzed and survival rates were calculated. RESULTS: Of the 624 analyzed cases, 59 (9.4%) had SPT during follow-up (4 synchronous and 55 metachronous). The SPT free survival rate ranged from 2 to 191.3 months (median of 42.5 months). In 20 cases (33.9%) the SPT was diagnosed after the fifth year of follow-up. The most frequent site of STP was the UADT mucosa (49.1%), followed by the lungs (22.0%) and the esophagus (11.9%). The best survival after-SPT occurred in cases of UADT STP (32.2% in 5 years, median 16.2 months). CONCLUSION: The STP incidence was 9.4%. In 33.9% of the cases, the SPT was diagnosed after the fifth year of follow-up. The most frequent localization of STP was the UADT mucosa.

Segundo tumor primário em pacientes com câncer de vias aerodigestivas superiores / Second primary tumor in patients with upper aerodigestive tract cancer

Nos primeiros três anos após o tratamento dos pacientes com carcinomas epidermoides de vias aerodigestivas superiores (VADS), observa-se elevada incidência de recidivas. Depois do terceiro ano, o aparecimento de um segundo tumor primário (STP) torna-se importante causa de morbi-mortalidade. OBJETIVO: Avaliar a incidência e o perfil dos STP em pacientes com carcinoma epidermoide de VADS tratados com intenção curativa. MATERIAL E MÉTODO: Estudo retrospectivo em que foram analisadas a incidência, localização e tratamento dos STP e calculada sobrevida. RESULTADOS: Dos 624 casos analisados, 59 (9,4 por cento) tiveram STP durante o seguimento (4 sincrônicos e 55 metacrônicos). A sobrevida livre de STP variou de 2 a 191,3 meses (mediana, 42,5 meses). Em 20 casos (33,9 por cento) o STP foi diagnosticado após o quinto ano de seguimento. O local mais acometido por STP foi a mucosa das VADS (49,1 por cento), seguida pelo pulmão (22,0 por cento) e pelo esôfago (11,9 por cento). A melhor sobrevida pós-STP foi dos casos de STP nas VADS (32,2 por cento em 5 anos, mediana 16,2 meses). CONCLUSÃO: Nos pacientes avaliados a incidência de STP foi de 9,4 por cento. Em 33,9 por cento dos casos o STP foi diagnosticado após o quinto ano de seguimento. A localização mais frequente dos STP foi a mucosa das VADS.

In the first three years after treatment of patients with squamous cell carcinoma of upper aerodigestive tract (UADT), there is a high incidence of recurrences. After the third year, the occurrence of second primary tumor (SPT) is an important cause of morbimortality. AIM: To evaluate the incidence and the characteristics of the SPT in patients with squamous cell carcinoma of UADT, treated with curative intention. METHODS: Retrospective study where the incidence, localization and treatment of SPT had been analyzed and survival rates were calculated. RESULTS: Of the 624 analyzed cases, 59 (9.4 percent) had SPT during follow-up (4 synchronous and 55 metachronous). The SPT free survival rate ranged from 2 to 191.3 months (median of 42.5 months). In 20 cases (33.9 percent) the SPT was diagnosed after the fifth year of follow-up. The most frequent site of STP was the UADT mucosa (49.1 percent), followed by the lungs (22.0 percent) and the esophagus (11.9 percent). The best survival after-SPT occurred in cases of UADT STP (32.2 percent in 5 years, median 16.2 months). CONCLUSION: The STP incidence was 9.4 percent. In 33.9 percent of the cases, the SPT was diagnosed after the fifth year of follow-up. The most frequent localization of STP was the UADT mucosa.

A importância da tríplice endoscopia no diagnóstico de neoplasias primárias múltiplas em pacientes com carcinoma epidermóide de vias aerodigestivas superiores / Importance of triple endoscopy in the diagnosis of multiple primary tumors in patients with upper aerodigestive tract squamous cell carcinoma

INTRODUÇÃO: Pacientes com carcinomas das vias aerodigestivas superiores (VADS) apresentam um alto risco de desenvolver outros cânceres tanto simultaneamente quanto subsequentemente. A maioria destes tumores ocorre nas VADS, pulmões ou esôfago. A tríplice endoscopia (laringoscopia, endoscopia digestiva alta e broncoscopia) possibilita o diagnostico de lesões precursoras e de tumores invasivos. No entanto, a maioria dos estudos limita-se a descrever a frequência de diagnósticos, mas não os resultados do tratamento e o impacto na sobrevida. OBJETIVOS: Avaliar a importância da tríplice endoscopia para o diagnóstico de neoplasias primárias múltiplas e as diferenças no estadiamento e nas taxas de sobrevida de pacientes com carcinoma epidermóide de VADS. Caracterizar o perfil e analisar fatores de risco para neoplasias primárias múltiplas. MÉTODOS: Trata-se de estudo caso-controle retrospectivo em que foram incluídos pacientes com carcinoma epidermóide de VADS, submetidos à tríplice endoscopia antes do início do tratamento (grupo tríplice endoscopia), pareados, por sexo, idade e localização, estádio clínico e tratamento do tumor primário, com pacientes não submetidos à tríplice endoscopia na avaliação inicial (grupo controle). RESULTADOS: Foram incluídos 135 pacientes em cada grupo. No grupo tríplice endoscopia ocorreram mais diagnósticos de segundo tumor primário (STP), 34 (17 simultâneos e 17 metacrônicos), do que no grupo controle, 20 (1 simultâneo e 19 metacrônicos). Não foi identificada diferença significativa entre o estadiamento dos tumores de grupo tríplice endoscopia e do grupo controle. As curvas de sobrevida global, específica por câncer, livre de doença e pós-STP foram semelhantes nos dois grupos. A sobrevida livre de STP foi maior no grupo controle. Na análise multivariada foram identificados como fatores prognósticos independentes para a sobrevida, o sexo (feminino, RR 0,51, IC 0,30 0,88), a idade (maior que 57 anos, RR 1,73, IC 1,29 2,31),...

INTRODUCTION: Patients with upper aerodigestive tract (UADT) carcinomas have a high risk of developing others cancers simultaneously or subsequently. Most of these tumors occur in UADT, lungs or esophagus. Triple endoscopy (laryngoscopy, endoscopy and bronchoscopy) enables the diagnosis of premalignant and invasive tumors. However, most of the studies describe only the frequency of the diagnosis, but not the results of treatment and its impact on survival. OBJECTIVES: To evaluate the importance of triple endoscopy for the diagnosis of multiple primary tumors and the differences in clinical stage and survival rates of patients with squamous cell carcinoma of the UADT. To characterize and to analyze the risk factors for multiple primary tumors. METHODS: This is a case-control study that included patients with squamous cell carcinoma of the UADT, that were submitted to a triple endoscopy before the first treatment (triple endoscopy group), matched by sex, age and location, clinical stage and treatment of primary tumor, with patients not undergoing triple endoscopy in the initial evaluation (control group). RESULTS: One hundred and thirty five patients were included in each group. The diagnosis of second primary tumor (SPT) was more frequent in the triple endoscopy group than in the control group, 34 (17 simultaneous and 17 metachronous) and 20 cases (1 simultaneous and 19 metachronous), respectively. No significant difference was found between the clinical stage of triple endoscopy group and the control group. The curves of overall survival, cancer specific, disease-free and after SPT were similar in both groups. The SPT free survival was higher in the control group. In the multivariate analysis were identified as independent prognostic factors for survival, sex (women, RR 0.51, CI 0.30 - 0.88), age (older than 57 years, RR 1.73, CI 1.29 - 2.31), the primary tumor site (larynx, RR 0.60, CI 0.39 - 0.93), N stage (N2 and N3, RR 1.78, CI 1.26 - 2.51) ...

The importance of long-term follow-up of head and neck cancer patients for reliable survival analysis.

OBJECTIVE: Analyze the influence of patients lost to follow-up in estimated survival rates calculated by the Kaplan-Meier method. STUDY DESIGN: Only patients with previously untreated squamous cell carcinoma of the upper aerodigestive tract were selected. For the patients lost to follow-up anytime, the last medical evaluation date was collected to calculate the "estimate A" survival time. If the same patient returned to our outpatient clinic or further health information was obtained, the updated last information/evaluation date was also collected to calculate "estimate B" survival time. The survival curves considering "estimate A" and "B" survival rates were compared. RESULTS: The overall 5 and 10-years survival rates for all patients calculated for "estimate A" were 54.0% and 46.0%, respectively; compared with 42.8% and 28.2% when were calculated considering "estimate B" (P < 0.001). CONCLUSION: Close follow-up of the head and neck cancer patients is essential for an accurate estimate of survival by Kaplan-Meier method.

Long-term quality-of-life evaluation after head and neck cancer treatment in a developing country.

OBJECTIVE: To evaluate the long-term quality of life of patients treated for head and neck cancer at a single institution in a developing country. DESIGN: Cross-sectional analysis of a consecutive series of patients. SETTING: Tertiary cancer center hospital in Brazil. PATIENTS: Eligible subjects included patients treated between 1974 and 1999 for head and neck carcinoma who had a minimum disease-free survival of 2 years and who completed a Portuguese version of the University of Washington Quality of Life (UW-QOL) questionnaire. MAIN OUTCOME MEASURES: Descriptive analyses of the results and comparisons of the scores for each UW-QOL domain, stratified by tumor site, were performed using nonparametric tests. RESULTS: Findings from 344 patients were analyzed. Of the study population, 140 (41%) had survived 2 to 5 years, 125 (36%) had survived 5 to 10 years, and 79 (23%) had survived more than 10 years since treatment. Primary tumor sites were in the oral cavity in 43.3% of cases, the oropharynx in 20.9%, the larynx in 32.0%, and the hypopharynx in 3.8%. In terms of treatment, 33.1% underwent surgery alone; 16.9%, radiotherapy alone; and 50% underwent combined treatment. Overall, 78.5% of the patients classified their own health as good or excellent. Stratified analysis showed that impairment in chewing and swallowing was more common in patients with oral and oropharyngeal tumors than in those with larynx and hypopharynx tumors, and speech impairment was more frequently related to patients with larynx and hypopharynx tumors than to those with oral and oropharynx tumors. In all tumor sites, the composite scores were significantly worse in advanced tumors than early stage tumors, but the use of combined treatment had the greatest negative impact on quality-of-life scores, after we adjusted for T and N stage with multivariable analyses (P<.001). CONCLUSIONS: The Portuguese version of the UW-QOL questionnaire was an effective tool to evaluate quality of life in a Brazilian population. Although many patients reported some limitations, most reported a good to excellent long-term quality of life.

Transtornos neurológicos mais frequentes: contribuição para a definição de temas do conteúdo programático do curso de Neurologia, para a graduação médica / The most frequent neurologic disturbances: a contribution to the definition of topics for the programmatic content to the program of Neurology in medical graduation

INTRODUÇÃO: O acúmulo de conhecimentos tem sobrecarregado o conteúdo curricular do curso de graduação médica. As escolas médicas devem estar preocupadas em definir um conteúdo temático mínimo, relacionado com os transtornos mais frequentes; buscamos sugerir o conteúdo temático mínimo, para o curso de Neurologia na graduação médica. MÉTODO: 1. Identificamos os locais de trabalho dos médicos jovens, fora do Hospital Escola(HE) pela análise de resposta às cartas enviadas a 6415 médicos residentes (MR) do Estado de São Paulo e de 201 entrevistas pessoais com MR; 2. Verificamos quais os transtornos neuro-psiquiátricos (TNP) mais frequentes na população, através da análise dos registros diagnósticos de pacientes que procuraram o Pronto Socorro (PS) de três instituições: Municipal de Taubaté-SP, Municipal de São José dos Campos-SP e Faculdade de Medicina da Santa Casa de Misericórdia de São Paulo-SP. RESULTADOS: 1. Os MR são jovens e, fora do HE, trabalham em PS. 2.Os diagnósticos mais frequentes nas três instituições foram: alcoolismo, cefaléia, coma, demência, desmaio, doença encéfalo-vascular, epilepsia, hemiplegias ou paraplegias, meningite, neuropatia periférica, paralisia facial, tontura, transtornos psíquicos e traumatismo craniencefálico. CONCLUSÃO: Estes diagnósticos mais frequentes são os temas relevantes para o conteúdo programático do curso de Neurologia na graduação médica.