Quality of life after total laryngectomy: impact of different vocal rehabilitation methods in a middle income country.

INTRODUCTION: The impact of advanced laryngeal cancer and its extensive surgical treatments cause significant morbidity for these patients. Total laryngectomy impacts essential functions such as breathing, communication and swallowing, and may influence the quality of life as well as affecting the social life of laryngeal cancer patients. OBJECTIVE: Describe the quality of life and analyze the factors associated with the reduced quality of life in patients who have undergone total laryngectomy. METHOD: Observational cross-sectional study was carried out to evaluate the quality of life of patients who had undergone total laryngectomy due to laryngeal cancer. The fourth version of the UW-QOL Quality of Life Assessment Questionnaire from Washington University, validated for Portuguese, was used. RESULTS: The study population was 95 patients, and the mean composite score of the QOL was 80.4. In the subjective domains the majority of the patients (38.9%) reported they felt much better at present compared to the month before being diagnosed with cancer. When questioned about how they evaluated their health-related quality of life, there was a predominance of those who considered it good (43.2%), and most considered they had a good quality of life (46.3%) considering personal well-being. The overall quality of life was considered good to excellent by 83.2% of the patients. Patients with tracheoesophageal prosthesis reported a better quality of life, compared to patients using an electrolarynx or esophageal voice. CONCLUSION: The high mean value of the composite score for quality of life revealed that the patients assessed their quality of life positively. The absence of vocal emission was the only variable associated with a lower quality of life within the composite score according to the UW-QOL questionnaire.

Gender differences in prognostic factors for oral cancer.

The aim of this study was to assess gender differences in prognostic factors among patients treated surgically for oral squamous cell carcinoma (OSCC). The medical records of 477 eligible patients (345 males, 132 females) obtained from the Brazilian Cancer Institute were reviewed. Survival was calculated by Kaplan-Meier method. Cox regression models were used to obtain adjusted hazard ratios (aHR) for males and females. Multivariate analysis showed that past tobacco use (aHR 0.2, 95% confidence interval (CI) 0.1-0.7) and regional metastasis (aHR 2.3, 95% CI 1.5-3.5) in males, and regional metastasis (aHR 2.2, 95% CI 1.2-4.3), distant metastasis (aHR 6.7, 95% CI 1.3-32.7), and hard palate tumours (aHR 11.8, 95% CI 3.3-47.7) in females, were associated with a higher risk of death. There were no differences in survival between males and females. Regional metastasis was found to be a negative prognostic factor in OSCC for both genders. Past tobacco use was an independent prognostic factor for worse survival among males, while distant metastasis and hard palate tumours were independent prognostic factors for worse survival among females. Further studies are necessary to corroborate the relationships found in this study.

Adenoid cystic carcinoma of the maxillary sinus: a clinical-pathological report of 10 years of experience from a single institution.

Adenoid cystic carcinoma (ACC) is the most common malignant salivary gland tumour of the maxillary sinus. The present study describes 24 cases seen over a period of 10 years at the Brazilian National Cancer Institute. Socio-demographic, clinical, pathological, and follow-up data were retrieved from the medical files for the period 1997-2006. The mean age of the patients was 51.1 years. Twenty-one (87.5%) presented advanced tumours. The main signs and symptoms found were a tumour mass (87.5%), pain (50%), nasal obstruction (25%), and epistaxis (20.8%). Most cases (62.5%) were treated with surgery and radiation therapy. Follow-up data showed two patients (8.3%) with residual disease, local recurrences in four (16.7%) patients, and distant metastasis in five (20.8%). The overall 5- and 10-year survival rates were 72.61% and 62.11%, respectively. Maxillary sinus ACC has an aggressive but indolent behaviour, typically presenting at an advanced T stage that reflects a poor prognosis for patients.

Development and characterization of microsatellite loci for genetic studies of the sugarcane borer, Diatraea saccharalis (Lepidoptera: Crambidae).

We present polymorphic microsatellite markers isolated for genetic studies of the sugarcane borer, Diatraea saccharalis (Fabricius). We isolated 16 microsatellite loci through an enriched genomic library protocol. After characterization, 12 markers showed polymorphic information expressed in the observed number of alleles (ranging from 2 to 7; 5 on average) and in the polymorphism information content (ranging from 0.292 to 0.771; 0.535 on average). These markers can be used in further studies to understand the basic ecological characteristics of the sugarcane borer, e.g., dispersion patterns and population genetic differentiation, associated with distinct geographic scales and host plants.

Analysis of the cytogenetic response in peripheral blood lymphocytes from breast cancer patients following chemotherapy.

The presence of chromosomal aberrations induced in circulating lymphocytes from breast cancer patients during chemotherapy was analyzed. Ten breast cancer patients undergoing neoadjuvant chemotherapy and ten healthy women (controls) were evaluated. Metaphases were obtained from cultures of peripheral lymphocytes stimulated with phytohemaglutinin and metaphase blockage was achieved with colchicine. One hundred metaphases were analyzed for chromosomal aberrations and 1,000 cells for the mitotic index. No significant differences were observed regarding the frequency of chromosomal aberrations, number of cells with chromosomal aberrations and mitotic index between the controls and patients before chemotherapy. However, after the first chemotherapy cycle, the numbers of chromosomal aberrations and cells with them was greater. After the third cycle, the mitotic index was lower, but the fifth cycle produced an increase in relation to the third and fourth cycles. The results suggest that chemotherapy raises the number of chromosomal aberrations and favors persistence of stable chromosomal abnormalities.

Anterior vocal commissure invasion in laryngeal carcinoma diagnosis.

BACKGROUND: Laryngeal carcinoma involving anterior vocal commissure (AVC) represents a great challenge for staging and treatment. OBJECTIVES: To compare laryngoscopy and computed tomography (CT) scan efficiency in staging tumors extending to the AVC. We also analyzed the helicoidal axial CT scan accuracy in recognizing this larynx subregion invasion. MATERIAL AND METHODS: Fifty-two glottic and supraglottic laryngeal squamous cell carcinoma patients with tumoral extension to the AVC were prospectively studied from August 2001 to August 2003 at the National Cancer Institute (Rio de Janeiro, Brazil). All patients underwent videolaryngoscopic examination and direct laryngoscopy for lesion extension analysis and biopsy. After AVC helicoidal axial CT scan with sagittal and coronal 1.0 mm thick reconstruction, patients were submitted to surgical treatment. The same pathologist analyzed all surgical specimens. RESULTS: When compared with pathologic stage, clinical endoscopic classification was correct in 40.38% of cases (40% for T1, 29.41% for T2, 46.43% for T3, and 50% in T4). Helicoidal axial CT scan accuracy for AVC tumors was 75% (P = .0001), being more important for T2 (62.50%), T3 (73.91%), and T4 (88.24%) lesions. Identification of radiologic signs described as gross radiologic anterior commissure involvement (GRACI) increased radiologic image staging accuracy to over 96%. CONCLUSIONS: Endoscopic evaluation understaged tumors in all clinical stages but really T1. Helicoidal axial CT scan reformatted to 1.0 mm thick played an important role in correctly staging more advanced AVC laryngeal tumors. Radiologic signs, here identified as GRACI, may be very helpful for tomographic staging and patient treatment.

Depression levels in chronic orofacial pain patients: a pilot study.

The assessment of depressive behaviour in chronic pain patients is especially important, because depression is commonly associated with chronic pain. The aim of this pilot study was to compare depression levels between patients with head and neck cancer pain and temporomandibular disorders (TMD), and to determine whether there is an association between depression levels and chronic pain severity. This study was an observational and sectional study and the sample consisted of 40 patients, uniformly divided into those with chronic orofacial pain related to cancer and those with painful TMD classified with research diagnostic criteria for temporomandibular disorders (RDC/TMD) axis I. Depression levels, pain intensity and severity were assessed with RDC/TMD axis II. The study demonstrated statistically significant differences in depression levels present in the head and neck cancer pain group and the painful TMD group, with the occurrence of a moderate statistically significant correlation between depression levels and chronic pain severity.

Assessment of the ability of Imazaquin herbicide to induce chromosomal aberrations in vitro in cultured Chinese hamster ovary cells and micronuclei in vivo in mice.

The agricultural chemicals marketed to increase food production may not only combat pests and weeds but also present toxic properties and cause genetic damage to the fauna and flora. The Imazaquin herbicide (Scepter 70 DG-Cyanamid) has been widely used in soybean fields in Paraná (Brazil), but information on its genotoxicity is scarce. Thus, in vivo and in vitro studies were carried out to assess the possible clastogenic effect of this herbicide on eukaryote cells. In the in vitro studies, the Chinese hamster ovarian cell lines CHO-K1 (wild) and CHO xrs-5 (mutant) were treated at the three phases of the cell cycle (G1, S and G2) for chromosome aberration (CA) analysis. The in vivo assessment was carried out by the micronucleus test (MN) on Swiss mice (Mus musculus) bone marrow cells. The herbicide did not induce a significant increase in the CA frequency in any of the treatments. No statistically significant differences were observed in the MN frequencies among the groups treated with the herbicide and the negative control. From the test system used in this study, we can conclude that the Imazaquin herbicide did not act as a clastogenic agent either in vitro or in vivo.

Chromosomal aberrations induced by 5-azacytidine combined with VP-16 (etoposide) in CHO-K1 and XRS-5 cell lines.

A cytogenetic study was carried out with 5-azacytidine (5-azaC) and etoposide (VP-16) in CHO-K1 and XRS-5 (mutant cells deficient for double-strand break rejoining) cell lines to verify the interaction effects of the drugs in terms of induction of chromosomal aberrations. 5-azaC is incorporated into DNA causing DNA hypomethylation, and VP-16 (inhibitor of topoisomerase II enzyme) is a potent clastogenic agent. Cells in exponential growth were treated with 5-azaC for 1 h, following incubation for 7 h, and posttreatment with VP16 for the last 3 h. In K1 cells, the combined treatments induced a significant reduction in the aberrations induced in the X and "A" (autosome) chromosomes, which are the main target for 5-azaC. However, in XRS-5 cells, the drug combination caused a significant increase in the aberrations induced in those chromosomes, but with a concomitant reduction in the randomly induced-aberrations. In addition, each cell line presented characteristic cell cycle kinetics; while the combined treatment induced an S-arrest in K1 cells, alterations in cell cycle progression were not found for XRS-5, although each drug alone caused a G2-arrest. The different cell responses presented by the cell lines may be explained on the basis of the evidence that alterations in chromatin structure caused by 5-aza-C probably occur to a different extent in K1 and XRS-5 cells, since the mutant cells present a typical hyper-condensed chromosome structure (especially the X- and "A" chromosomes), but, alternatively, 5-aza-C could induce reactivation of DNA repair genes in XRS-5 cells.

Elective neck dissection versus observation in stage I squamous cell carcinomas of the tongue and floor of the mouth.

A retrospective study was undertaken of patients with T1N0M0 squamous cell carcinoma of the oral tongue and floor of the mouth who underwent surgical treatment between 1985 and 1995. Evaluation of two groups of patients (neck dissection versus observation) was made according to the management of the neck. Results were obtained regarding the presence of occult metastases, recurrence in the neck, treatment failure, results of salvage treatment, and disease-free survival. Forty-nine patients underwent surgical treatment: 25 resection of primary and 24 resection plus neck dissection. Overall incidence of regional metastases was 24.5%. Eight patients (16%) developed recurrence of the disease. Seven (14%) had regional recurrences (including 1 with distant metastases) and 1(2%) had local recurrence. Twenty-four percent of patients from the resection of primary group developed neck recurrences in comparison with 4% of the resection plus neck dissection group (P = 0.05). Overall salvage rate was 37.5%. Second primary tumors developed in 16% of patients. Patients who underwent elective neck dissection had a 23% higher disease-free survival rate compared with those who underwent resection of the tumor alone (P = 0.03). The findings of this study stress the importance of control of the neck in early oral cancer. Elective neck dissection significantly improved regional control of the disease.

Supracricoid laryngectomy with CHEP: functional results and outcome.

OBJECTIVES: To assess whether supracricoid laryngectomy with cricohiodoepiglottopexy could successfully reach the cure and preserve the voice in glottic laryngeal cancer, we studied 27 patients with T2/T3 squamous cell carcinoma of the larynx treated in our institution with cricohiodoepiglottopexy. STUDY DESIGN: A retrospective analysis has been carried out between 1995 through 1997. We classified 11 patients as T2N0M0 and 16 patients as T3N0M0. Nineteen patients had bilateral selective lateral neck dissection, 3 patients had unilateral lateral neck dissection, and 5 patients had undissected neck. Survival was analyzed under the Kaplan-Meyer method. RESULTS: Five patients had postoperative complications, 2 were treated with a total laryngectomy. The remaining 25 patients kept the normal airway, swallowing, and speech. None of the patients in the neck dissection group had neck metastasis. Two patients had recurrences, 1 with local recurrence was treated with a total laryngectomy and is alive without disease; the other patient had neck recurrence, was treated with radical neck dissection plus radiotherapy, and is dead of the disease. One patient had a second tumor in oropharynx treated with palliative radiotherapy and is dead of the disease. Three years disease-free survival was 75% for T2 and 79% for T3. CONCLUSIONS: This technique is useful in the treatment of selected cases of T3/T2 glottic cancer regarding the extent of disease. The incidence of complications in need of a complete laryngectomy does not compromise the functionality of this technique. The survival is comparable to patients who submitted to total laryngectomy and near-total laryngectomy, regarding the extent of the lesion.

Potentiation by turmeric and curcumin of gamma-radiation-induced chromosome aberrations in Chinese hamster ovary cells.

The effect of turmeric and curcumin, two natural antioxidants, on the frequencies of chromosome aberrations induced in Chinese hamster ovary (CHO) cells by gamma-radiation was investigated. Cells were treated with three concentrations of each drug, turmeric (100, 250, and 500 microg/ml) and curcumin (2.5, 5, and 10 microg/ml), and then irradiated (2.5 Gy) during different phases of the cell cycle. Turmeric was not clastogenic by itself, whereas curcumin at 10 microg/ml enhanced the chromosomal damage frequency. Neither of the two antioxidants showed protective effect against the clastogenicity of gamma-radiation. Instead, an obvious increase in the frequencies of chromosome aberrations was observed when turmeric at 500 microg/ml was associated with gamma-radiation during G2/S phase, and curcumin at 10 microg/ml plus gamma-radiation during S and G2/S phases of the cell cycle. The results clearly indicate the exacerbated effect of turmeric and curcumin on radiation-induced clastogenicity, suggesting that these antioxidants are also potentiating agents depending on the experimental conditions.

Modulatory effects of curcumin on the chromosomal damage induced by doxorubicin in Chinese hamster ovary cells.

Curcumin, a natural phenolic compound, is gaining importance as a free radical scavenger. This study was undertaken to investigate the modulatory effects of curcumin on the chromosomal damage induced by the antitumoral doxorubicin (DXR), a known free radical generator, in Chinese hamster ovary cells in culture. Cells were treated with three concentrations of curcumin (2.5, 5, or 10 microg/ml) and then treated with DXR (1.0 microg/ml) during different phases of the cell cycle. The results show that curcumin induces chromosomal damage in CHO at the highest concentration when compared to the untreated control. Neither treatment with curcumin shows a reduction in the clastogenicity of DXR. Instead, a statistically significant increase in the frequency of chromosomal damage was observed when the middle and the highest concentrations of curcumin were associated with DXR during the G1/S, S, and S/G2 phases of the cell cycle. The results clearly indicate the potentiating effect of curcumin on DXR-induced chromosomal damage.

Complications of anterior craniofacial resection.

BACKGROUND: The complications associated with anterior craniofacial resections for benign and malignant tumors were reviewed in 104 patients treated between January 1981 and June 1996. METHODS: Information regarding patient characteristics, histologic type, history of prior therapy, extent of the disease, extent of surgical procedure, and type of reconstruction were entered in a microcomputer database. To better understand and stage postoperative complications, we divided them into early (<14 days) and late (>14 days) according to the time of presentation, into major and minor depending on the morbidity potential of complication, and into local and systemic ones. Comparison between risk factors associated with complications was made using chi-square analysis with Yates' correction for continuity. Survival analysis was performed using the Kaplan-Meier product limit method. RESULTS: There were 8 (7.6%) postoperative deaths, with only 1 occurring from systemic complications. Complications occurred in 53 (48.6%) patients. Local major complications occurred in 49 (45%) patients, local minor in 29 (26.6%), and systemic in 11 (10%). Early complications occurred in 40 (38.5%) patients and late complications in 13 (12.5%) patients. These complications developed during a period ranging from 1 day to 5 months. More than one complication occurred in a number of patients. Bacterial contamination leading to local septic complications was the principal cause of morbidity, accounting for 54.7% (29/53) of complications. Major complications included meningitis in 8 patients associated with cerebrospinal fluid leak in 7, cerebral abscess in 2, sepsis in 1, and subdural hemorrhage in 1, all of which resulted in death except for one case. The extent of the craniofacial resection (p = .011) was the most important factor associated with major complications. Invasion of the dura and the type of reconstruction of the anterior skull base were the most important factors related to cerebrospinal fluid leakage (p = .048 and p = .032) and meningitis (p = .011). CONCLUSION: Contemporary surgical approaches and methods of reconstruction have enabled skull base surgeons to extend their cranial base resections and increase the 5-year survival rates of patients. Nevertheless, significant complications persist. Knowledge and high index of suspicion together with early recognition of these complications are essential for effective management of patients undergoing craniofacial resection. The factors related to major complications found in this study stressed the need to develop more effective methods to prevent contamination of intracranial structures.

Near-total laryngectomy for treatment of advanced laryngeal cancer.

BACKGROUND: In order to assess whether near-total laryngectomy (NTL) could successfully reach the cure and preserve the voice in advanced laryngeal cancer, we studied 28 patients with T3/T4 squamous cell carcinoma of the larynx treated with NTL in our institution. METHODS: A retrospective analysis has been carried out from 1990 through 1994. We classified 24 patients as Stage III and 4 patients as Stage IV. All patients had lateral neck dissection. Survival was analyzed under the Kaplan-Meier method. RESULTS: Twenty-six patients achieved voice preservation. Two patients in the bilateral neck dissection group had a metastatic lymph node on the opposite side. No patient had local recurrence. Three patients died of the disease, and 1 patient was salvaged with neck dissection. Three-year disease-free survival was 85%. CONCLUSION: This technique is useful in the treatment of selected cases of advanced laryngeal cancer and achieves local control of the lesion in all cases. The survival is comparable with that of patients submitted to total laryngectomy, regarding the extent of lesion. Voice preservation can be achieved in most cases.

Prognostic factors and outcome in craniofacial surgery for malignant cutaneous tumors involving the anterior skull base.

BACKGROUND: We retrospectively reviewed the medical charts of 57 patients with advanced malignant cutaneous tumors involving the anterior skull base who underwent combined craniofacial resection in our department from January 1, 1981, to December 31, 1994. METHODS: The data regarding histological results, demographic aspects, clinical presentation, previous treatment, extent of the disease, extent of surgical procedure, type of reconstruction, complications, and follow-up were analyzed using the chi 2 method. Survival analysis was performed using the Kaplan-Meier method. RESULTS: We found prevalence of the male sex (60%) and white race (86%), with a mean age of 62 years. Thirty-five patients (61%) showed extensive lesions directly invading the anterior skull base (type II); 46 patients (81%) had been treated previously; 10 patients (18%) had dural invasion; 29 patients (51%) could not have the eyeball preserved; 32 patients (56%) underwent microsurgical reconstruction; and 45 patients (79%) underwent pericranial or galeal-pericranial flap reconstruction for the anterior skull base defect. Postoperative complications occurred in 29 patients (51%). The most common complication was postoperative infection (17 patients [59%]). Thirty-two patients (56%) were free of disease, and 4 (7%) were alive with disease at the time of our study. CONCLUSIONS: The extent of facial disease (P = .005) and the type of facial reconstruction (P = .01) were the most important risk factors in the development of infectious complications. Invasion of the dura and the type of reconstruction of the anterior skull base were the most important factors related to cerebrospinal fluid leakage (P = .003) and meningoencephalitis (P = .06). Invasion of the dura mater significantly affected survival (P = .005).

Elective neck dissection in the treatment of T3/T4 N0 squamous cell carcinoma of the larynx.

BACKGROUND: This study analyzed pathologic findings of clinically occult cervical lymph nodes of T3/T4 N0 squamous cell laryngeal carcinoma and their impact on locoregional failures and overall survival. PATIENTS AND METHODS: A retrospective analysis of 76 patients with T3/T4 N0 laryngeal carcinoma was carried out between 1981 and 1989. Sixty-seven patients had transglottic tumor, 31 patients had extralaryngeal spread, 56 patients were T3 N0, and 20 patients were T4 N0. Seventy-five patients had total laryngectomy and 1 had near total laryngectomy. All patients had bilateral elective neck dissection. The chi-square test was applied to factors related to neck metastasis and locoregional failure. Survival was analyzed using the Kaplan-Meier actuarial method; differences were tested using the Wilcoxon signed-rank test. RESULTS: Eighteen patients had positive surgical margins. Occult neck metastasis was observed in 30%. Univariate analysis showed that cancer stage and cartilage status were not significant to predict neck metastasis. Locoregional recurrence was observed in 28% of patients. Surgical margins, cervical metastasis, lesion extension, and cartilage invasion had significant impact on disease-free survival. The 5-year overall survival was 52%; disease-free survival was 57%. CONCLUSION: The elective bilateral neck dissection performed in T3/T4 N0 patients yielded a 30% incidence of occult neck metastasis. Classification of transglottic carcinomas into endolaryngeal and exolaryngeal provides a better parameter for predicting neck metastasis than does T status. Disease-free and overall survival were significantly affected by neck metastasis, T stage, exolaryngeal tumor, cartilage infiltration, and surgical margins.

Supraomohyoid neck dissection in the treatment of T1/T2 squamous cell carcinoma of oral cavity.

BACKGROUND: Recent studies in patients with previously untreated T1 and T2 squamous cell carcinoma (SCC) of the tongue and floor of the mouth have shown a relationship between tumor thickness, neck metastasis, and survival. Our study was conducted to determine the indication of elective neck dissection in patients with early oral cavity SCC. PATIENTS AND METHODS: Sixty-seven patients were stratified by stage (T1 and T2 NO), and those in each stage were randomized to receive one of two types of treatment; resection alone (RA) or resection plus elective supraomohyoid neck dissection (RSOND). Fifty-two patients (78%) were men and 15 (22%) were women. The median age was 57 years old (range 34 to 95). RESULTS: Twenty-six (39%) patients had tumor in the floor of the mouth and 41 (61%), in the tongue. Using the criteria of the Union Internationale Contre le Cancer (UICC), 1987, we classified 31 tumors (46%) as T1 lesions and 36 (54%) as T2 lesions. Thirty patients had a tumor thickness < or = 4 mm and 37 had a tumor thickness > 4 mm. Thirty-three (49%) patients were treated with RA, and 34 patients (51%) were treated with RSOND. Seven (21%) patients of the RSOND group had occult cervical metastasis. There were recurrences in 14 (42%) patients of the RA group and 8 (24%) patients of the RSOND group. The disease-free survival rates at 3.5 years for RA and RSOND patients were 49%, and 72%, respectively. The impact of sex, age, site, cancer stage, and tumor thickness was assessed by the Mantel-Haenszel chi-square procedure. Later stage (P = 0.05) and increased tumor thickness (P = 0.005) were significantly associated with treatment failures. CONCLUSION: Neck dissection remains mandatory in the early stage of oral SCC, because of better survival rates compared to RA and the poor salvage rate. In particular, patients with tumor thickness > 4 mm treated with RSOND had significant benefit on disease-free survival.