Marcação pré-operatória com carvão nas metástases linfonodais não palpáveis da região cervical, guiada pela ultrassonografia / Preoperative marking with activated charcoal suspension for the ultrasound-guided localization of nonpalpable metastatic lymph nodes

Introdução: A incidência de recorrência não palpável delinfonodos cervicais detectada por ultrassonografia no pósoperatóriode tireoidectomia tem aumentado com uso do examede ultrassom no seguimento desses pacientes. Desta forma,uma eficiente e segura marcação pré-operatória da lesão énecessária a fim de colaborar para o sucesso da segunda cirurgia,reduzindo as complicações. Objetivo: Estudar a segurança e aeficácia da marcação pré-cirúrgica com carvão ativado guiadapor ultrassonografia para a localização de linfonodos cervicaisnão palpáveis durante o ato cirúrgico. Método: Entre agosto de2010 e maio de 2011 foram avaliados 18 pacientes com 24 lesõescervicais não palpáveis que foram submetidas à marcação cominjeção de carvão ativado guiada por ultrassonografia. Todosos pacientes foram submetidos à ressecção cirúrgica logo apósa marcação. A eficácia e as complicações da marcação e dadetecção cirúrgica foram avaliadas através de ultrassonografia,cirurgia e estudo histopatológico. Resultados: Todas as 24lesões foram evidenciadas no ato cirúrgico e posteriormenteenviadas para avaliação histopatológica. O tamanho médio daslesões localizadas foi de 0,9 cm. Linfonodos cervicais foram aslesões mais marcadas, nos níveis IV, VI e VII. A taxa de sucessotécnico da marcação e da detecção ultrassonográfica para aslesões suspeitas foi de 100% (24/24). Não se observou nenhumacomplicação. Conclusão: O uso da marcação pré-operatóriacom carvão ativado mostrou ser um método seguro e eficaz noscasos de lesões não palpáveis da região cervical, em pacientespreviamente submetidos à cirurgia.

Management of the N0 neck in moderately advanced squamous carcinoma of the larynx.

OBJECTIVE: To assess the oncological efficacy of selective neck dissection (SND) in patients with T3-4 N0 laryngeal squamous carcinoma. SUBJECTS AND METHODS: A total of 327 patients underwent 654 neck dissections; each side of the neck was individually evaluated. RESULTS: Three percent of patients who had SND developed regional recurrence (RR) in comparison with 11.7 percent of patients who underwent modified radical neck dissection (MRND) (P=0.005). Only 3 (0.9%) patients developed RR outside the field of SND. The presence of extracapsular extension (P=0.002) in node-positive (pN+) group and of microvascular invasion (P=0.007), together with the type of neck dissection (ND) (P=0.0003) in node-negative (pN0) group had statistical impact on RR. The development of RR significantly affected disease-specific survival (P=0.0001). Equivalent rates of RR were found in pN+ (2.6%) or pN0 (3.2%) patients treated with SND (P=0.98) as well as in pN+ patients who underwent SND (2.6%) or MRND (4.7%) (P=0.85). CONCLUSION: This study confirmed the adequacy of SND as a satisfactory staging and therapeutic procedure, and suggests its use in the treatment of limited node-positive (N+) neck.

Impact of previous tracheotomy as a prognostic factor in patients with locally advanced squamous cell carcinoma of the larynx submitted to concomitant chemotherapy and radiation.

HYPOTHESIS: The combination of chemotherapy and radiotherapy is a standard nonsurgical treatment for locally advanced laryngeal cancer. Nevertheless, there are no validated markers to predict the outcome of nonsurgical therapies. The impact of previous tracheotomy is not clear in patients submitted to concomitant chemoradiotherapy. STUDY DESIGN: A non-randomized prospective study. Prognostic factors such as stage, age, performance status, number of chemotherapy cycles, radiotherapy dose, stage VIb disease, and previous tracheotomy were analyzed using the Cox's proportional hazard model. The Kaplan-Meier and log rank tests were used to evaluate the progression-free and overall survival. PATIENTS AND METHODS: Patients with stage III/IV laryngeal carcinoma were prospectively selected. Treatment consisted of cisplatin 100 mg/m(2) every 3 weeks for 3 cycles, radiotherapy to a total dose of 70.2 Gy and salvage surgery. RESULTS: Forty-nine patients were analyzed; tracheotomy was performed in 12 patients (24.5%) before therapy. Patients who had previous tracheotomy had a lower rate of complete response (41.7 vs. 75%, p = 0.034, HR 0.55, CI 95% 0.27-1.11), shorter progression free-survival (HR 2.83, CI 95% 1.60-4.88, p < 0.001), and median overall survival (12 vs. 56 months, HR 2.37, CI 95% 1.43-3.93, p < 0.001), in comparison to those without a tracheotomy. Moreover a significant difference was observed in 3-year survival rates (6 vs. 61%, p = 0.001), in favor of the group without tracheotomy. Interestingly, the impact of previous tracheotomy was not altered when adjusted by other prognostic factors (HR 8.7, CI 95% 3.1-24.0, p < 0.001). CONCLUSIONS: Previous tracheotomy is a negative prognostic factor for patients submitted to chemotherapy combined with radiotherapy and should be considered as a negative clinical prognostic factor in the selection of patients for more aggressive treatment strategies.

Impact of previous tracheotomy as a prognostic factor in patients with locally advanced squamous cell carcinoma of the larynx submitted to concomitant chemotherapy and radiation

HYPOTHESIS: The combination of chemotherapy and radiotherapy is a standard nonsurgical treatment for locally advanced laryngeal cancer. Nevertheless, there are no validated markers to predict the outcome of nonsurgical therapies. The impact of previous tracheotomy is not clear in patients submitted to concomitant chemoradiotherapy. STUDY DESIGN: A non-randomized prospective study. Prognostic factors such as stage, age, performance status, number of chemotherapy cycles, radiotherapy dose, stage VIb disease, and previous tracheotomy were analyzed using the Cox's proportional hazard model. The Kaplan-Meier and log rank tests were used to evaluate the progression-free and overall survival. PATIENTS AND METHODS: Patients with stage III/IV laryngeal carcinoma were prospectively selected. Treatment consisted of cisplatin 100 mg/m(2) every 3 weeks for 3 cycles, radiotherapy to a total dose of 70.2 Gy and salvage surgery.RESULTS: Forty-nine patients were analyzed; tracheotomy was performed in 12 patients (24.5%) before therapy. Patients who had previous tracheotomy had a lower rate of complete response (41.7 vs. 75%, p = 0.034, HR 0.55, CI 95% 0.27-1.11), shorter progression free-survival (HR 2.83, CI 95% 1.60-4.88, p < 0.001), and median overall survival (12 vs. 56 months, HR 2.37, CI 95% 1.43-3.93, p < 0.001), in comparison to those without a tracheotomy. Moreover a significant difference was observed in 3-year survival rates (6 vs. 61%, p = 0.001), in favor of the group without tracheotomy. Interestingly, the impact of previous tracheotomy was not altered when adjusted by other prognostic factors (HR 8.7, CI 95% 3.1-24.0, p < 0.001). CONCLUSIONS: Previous tracheotomy is a negative prognostic factor for patients submitted to chemotherapy combined with radiotherapy and should be considered as a negative clinical prognostic factor in the selection of patients for more aggressive treatment strategies

Metástase cervical nos tumores malignos da parótida / Neck metastasis in malignant parotid tumors

OBJETIVO: Analisar fatores que influenciam a ocorrência de metástase linfática cervical e a sobrevida nos tumores malignos epiteliais da glândula parótida. MÉTODO: Analisamos retrospectivamente os prontuários de 150 pacientes tratados em nossa instituição de 1974 a 1998. Vinte e quatro pacientes foram excluídos do estudo por não terem sido tratados primariamente por cirurgia. O 126 pacientes restantes foram submetidos a parotidectomia e incluídos neste estudo. Setenta e quatro pacientes tiveram sua cirurgia complementada por radioterapia pós-operatória. Trinta e quatro pacientes foram submetidos ao esvaziamento cervical associado a parotidectomia. A idade média foi de 49 anos. Todos os pacientes foram estadiados pela Classificação TNM da UICC de 1997, sendo 49 pacientes estágio I, 27 estágio II, 22 estágio III, and 28 estágio IV. A influência dos fatores analisados na ocorrência de metástase cervical foi estabelecida pelo teste do chi quadrado e por análise multivariada. A influência de fatores prognósticos na sobrevida específica de doença (SED) em 5 e 10 anos foi estabelecida pelo método de Kaplan-Meier e pelo teste log-rank. RESULTADOS: O tipo histopatológico de 40 pacientes foi o carcinoma mucoepidermóide, de 18 pacientes o adenocarcinoma (SOE), de 18 pacientes o carcinoma de células acinares, de 15 pacientes o carcinoma adenóide cístico, de 11 pacientes o carcinoma exadenoma pleomórfico, de 11 pacientes o carcinoma de ducto salivares, e de 13 pacientes outras histopatologias. Vinte e cinco pacientes apresentaram recidivas, 17 recidivas locais, quatro recidivas regionais, e quatro recidivas loco-regionais. A incidência geral de metástase linfática cervical foi de 17,5 por cento. Metástases linfáticas cervicais ocultas ocorreram em cinco pacientes daqueles submetidos a esvaziamento cervical profilático. A presença de paralisia facial no diagnóstico, a idade, o estágio T, e o grau de malignidade foram relacionados a ocorrência de metástase...

BACKGROUND: Factors influencing the occurrence of neck metastasis and survival in patients with parotid malignant epithelial tumors are analyzed. METHODS: One hundred fifty patients treated at our institution from 1974 to 1998 were retrospectively reviewed. Twenty four patients were not treated by surgery and were excluded from this study. The remaining 126 patients were operated on and 74 patients had postoperative radiotherapy. Thirty four patients were treated with parotidectomy plus neck dissection. The mean age was 49 years old. According to the UICC/1997 TNM Classification 49 patients were Stage I, 27 were Stage II, 22 were Stage III, and 28 were Stage IV. The influence of selected factors on 10 years disease-specific survival was analyzed using Kaplan-Meier actuarial method and log-rank test. RESULTS: Forty patients had mucoepidermoid carcinoma, 18 patients adenocarcinoma, 18 patients acinic cell carcinoma, 15 patients adenoid cystic carcinoma, 11 patients carcinoma ex pleomorphic adenoma, 11 patients salivary duct carcinoma, and 13 patients other pathology. Recurrences occurred on 27 patients, 17 local, 4 had neck recurrences, and 4 loco-regional recurrences. Overall incidence of neck metastasis was 17.5 percent. Occult neck metastasis occurred in 5 patients who underwent elective neck dissection. Facial nerve dysfunction, age, T stage, grade, and histology were related to the recurrence of neck metastasis in univariate analysis. Prognoses were negatively influenced by five factors: T3- T4 stage, high malignancy grade, presence of cervical metastases, facial nerve palsy at first presentation and age higher then 50 years old. Ten years disease-specific survival was 97 percent for stage I, 81 percent for stage II, 56 percent for stage II, and 20 percent for stage IV. CONCLUSION: Tumor grade and stage were the most important prognostic factors. In spite of lack of prospective randomized published studies, recommendations to do elective...

Supracricoid laryngectomy with cricohyoidoepiglottopexy for advanced glottic cancer.

BACKGROUND: Supracricoid laryngectomy with cri-cohyoidoepiglottopexy (CHEP) is a conservative surgical procedure indicated in selected cases of advanced glottic carcinoma. METHODS: This study is a review of our experience with 43 patients with T3/T4 glottic squamous cell carcinoma who underwent CHEP in our institution. All but two patients underwent selective neck dissections. All patients were staged on the basis of the 2002 TNM classification. Rates of recurrence and death were estimated by the Kaplan-Meier method. RESULTS: The 5-year disease-specific survival and 5-year relapse-free survival rates were 78% and 83%, respectively. Neck metastases were found in three patients. Cartilage invasion occurred in 11 cases. The average length of hospital stay was 5.7 days. The mean time of enteral feeding tube was 33.8 days, and the mean time for tracheotomy was 29.6 days. Overall, normal swallowing was achieved in 74.4% of patients. Eleven patients had mild and major complications. Laryngeal stenosis emerged as the most frequent major complication. Three patients (6.9%) had local recurrences. Two patients (4.6%) had neck metastases. CONCLUSIONS: On the basis of this study, over a 7-year period with 43 patients with advanced glottic cancer, a successful on-cologic outcome is confirmed.

Relevance of skip metastases for squamous cell carcinoma of the oral tongue and the floor of the mouth.

OBJECTIVE: To analyze the therapeutic implications of the distribution of neck metastases (NM) in patients with squamous cell carcinoma (SCC) of the tongue and the floor of the mouth (FOM). PATIENTS AND METHODS: From January 1987 through December 1997, 339 previously untreated patients with T1-2 N0 M0 SCC of the tongue and the FOM underwent primary surgical treatment in our institution. A retrospective review of the pathology reports and outcome of these patients was made to ascertain the prevalence and distribution of NM. Patients were grouped by clinical neck status at the time of neck dissection: elective neck dissection (END) in the NO neck and subsequent therapeutic dissection (STD) in the neck observed which converted clinically to N+ or regional recurrences after END. All patients were classified according to the American Joint Committee on Cancer (AJCC)/UICC 2002 TNM classification. RESULTS: All patients underwent surgical treatment of the primary cancer and had negative margins at frozen section. Overall incidence of NM was 41.3%. Twenty-seven point eight percent of T1 N0 M0 and 48.2% of T2 N0 M0 patients developed NM (P = .0004). Occult neck metastases occurred in 24.1% of patients. Clinically, N+ metastases occurred in 23.6% of patients. The overall incidence of NM in levels IV and V was 8.5%. Neck level IV nodes were involved in only 1.5% of patients in the END group versus 23.7% in the STD group (P < 0.001). Level V was always associated to nodal metastases in other neck levels. Only 2% of patients in our study presented "skip metastases" in the neck. CONCLUSIONS: Neck levels I and II were at great risk for the development of NM (46.9% and 75.3% respectively). Levels IV (6.5%) and V (2%) were rarely involved in our group of patients. The results found in this study support the indication of supraomohyoid neck dissection for N0 and a more comprehensive neck dissection (levels I-V) for N+ patients in Stage I-II SCC of the tongue and FOM. EBM RATING: C-4.

Therapeutic options in advanced laryngeal cancer: an overview.

Historically, patients with advanced laryngeal cancer have been treated with radical surgery and adjuvant radiation therapy. Intensive surgical research has allowed surgeons to deal with almost any local extension and to propose an appropriate surgical procedure for each case. Several function-sparing surgical options are available to treat moderately advanced/advanced laryngeal cancer. Better understanding of the anatomy and biology of cancer in this anatomical site has enabled us to devise effective oncological strategies associated with a great effort to preserve laryngeal function. Numerous efforts have been made to augment the therapeutic armamentarium with the addition of chemotherapeutic agents combined with radiation therapy. For advanced laryngeal cancer, the debate is still open between partial/subtotal surgical procedures, which are more efficient but sacrifice parts of the larynx, and radiotherapy/chemoradiation protocols which can preserve the larynx and its function even though it requires radical surgery for salvage. Efforts should be made to select patients properly, in an individual basis, based on tumor characteristics, clinical aspects, patient's expectations, and the expertise of the head and neck oncologic team for the various therapeutic strategies in order to get better oncological results in association with the preservation of the laryngeal form and function, when possible.

Clinical prognostic factors in malignant parotid gland tumors.

OBJECTIVE: To analyze the factors in parotid malignant epithelial tumors influencing recurrences and disease-specific survival. METHODS: We retrospectively reviewed the files of 150 patients treated at our institution, from 1974 to 1998. Twenty-four patients were not treated by surgery and were excluded from this study. The remaining 126 patients were treated with surgery and 74 patients had postoperative radiotherapy. Thirty-three patients were treated with parotidectomy plus neck dissection. Neck lymph node metastasis was found in 22 patients, 5 patients had occult neck metastasis, and 4 periparotid lymph nodes metastasis. The mean age was 49 years old. According to the UICC/1997 TNM Classification, 49 patients were stage I, 27 stage II, 22 stage III, and 28 stage IV. The influence of selected factors on the 10 year disease-specific survival was analyzed using the Kaplan-Meier actuarial method and the log-rank test. RESULTS: Forty patients had mucoepidermoid carcinoma, 18 patients adenocarcinoma NOS, 18 patients acinic cell carcinoma, 15 patients adenoid cystic carcinoma, 11 patients malignant mixed tumor, 11 patients salivary duct carcinoma, and 13 patients other pathology. Twenty-five patients had recurrences: 17 had local recurrences, 4 patients had neck recurrences, and 4 were loco-regional recurrences. Five factors influenced negatively the prognosis: 1) T stage (p.00001), 2) grade (p.00001), 3) + lymph nodes (p.0007), 4) facial nerve dysfunction (p.0001), and 5) age (p.004). Patients with high-grade tumors and high-stage tumors had the worst prognosis according to the multivariate analysis. The 10-year disease-specific survival was 97% for stage I, 81% for stage II, 56% for stage III, and 20% for stage IV. CONCLUSION: The grade of the tumor and stage were the most important prognostic factor. EBM RATING: C.

Patterns of failure and outcome in esthesioneuroblastoma.

OBJECTIVES: To evaluate the results of standardized treatment of esthesioneuroblastoma (ENB) during a 17-year period and to identify pertinent factors for clinical outcome. DESIGN: Review of clinical and radiographic data and retrospectively staging ENB according to 3 staging systems: Kadish, Biller, and Dulguerov and Calcaterra. SETTING: Hospital do Cancer I-Instituto Nacional de Cancer, Rio de Janeiro, Brazil. PATIENTS: Thirty-six patients with histologically confirmed ENB treated between January 1, 1983, and December 31, 2000; 35 fulfilled study inclusion criteria. INTERVENTIONS: Treatment included gross tumor resection through a transfacial approach with postoperative radiotherapy (RT) in 11 patients, craniofacial resection (CFR) and postoperative RT in 7, exclusive RT in 14, CFR alone in 1, and a combination of chemotherapy and RT in 2. Histopathological slides were reviewed and graded using the Hyams staging system. Analysis of prognostic factors was performed. MAIN OUTCOME MEASURES: Evaluation of survival rates using the Kaplan-Meier method. Analysis of prognostic factors carried out with the Fisher exact test and the log-rank test. RESULTS: Analysis of survival showed that the Kadish classification best predicted disease-free survival (P =.046). The presence of regional and distant metastases adversely affected prognosis (P<.001 and P =.01, respectively). Craniofacial resection plus postoperative RT provided a better 5-year disease-free survival rate (86%) compared with the other therapeutic options used (P =.05). The 5-year disease-specific survival rate was 64% and 43% for the low- and high-grade tumors, respectively (P =.20). Disease-free survival for this cohort of 35 patient was 46% and 24% at 5 and 10 years, respectively. Overall survival was 55% and 46% at 5 and 10 years of follow-up, respectively. CONCLUSIONS: The development of cervical nodal metastases and distant metastases had a significant adverse impact on prognosis. The value of the Kadish staging system was confirmed in our study, significantly correlating with prognosis. Tumor grade according to the Hyams staging system also seems to be an important factor in determining prognosis for tumor recurrence and survival. Aggressive multimodality therapeutic strategies, particularly CFR and adjuvant RT, yielded the best treatment outcome.

Prognostic factors and outcome for nasopharyngeal carcinoma.

BACKGROUND: Nasopharyngeal cancer (NPC) is a distinct form of cancer of the upper respiratory or digestive tract in which the epidemiologic features, origin, histopathologic types, treatment, and prognosis are different from those associated with other malignant neoplasms of this anatomical area. Recent publications have demonstrated the advantage of aggressive multimodality treatment for advanced NPC. OBJECTIVES: To evaluate the results of standardized treatment of NPC during 11 years and to identify pertinent factors for clinical outcome. METHODS: Between January 1, 1989, and December 31, 2000, 173 patients with newly diagnosed NPC were treated at Instituto Nacional de Cancer. Clinical records and radiographic studies of the patients were retrospectively reviewed. Documented data of the initial presenting symptoms, head and neck examination, radiotherapy protocols, chemotherapy regimens, and surgical technique were analyzed. To determine important prognostic factors, we correlated survival rates with age, clinical stage, tumor extent, histopathological type, and therapeutic approach. The major end point used for assessment was relapse-free survival. Survival curves were estimated by the Kaplan-Meier product-limit method. Multivariate analysis was performed using the Wilcoxon signed rank and Cox proportional hazards regression tests. RESULTS: Most patients (88.5%) had locoregional advanced disease, mostly (53.4%) of the nonkeratinizing subtype. Forty-seven percent of patients had clinical cervical nodal metastases at first consultation. Gross extension of the primary tumor involving the facial bones and skull base was observed in 39.3% and 20.8%, respectively. Just under 75% of patients were treated with radiotherapy (median dose, 6600 cGy), and 25.4% underwent concomitant chemoradiotherapy with adjuvant chemotherapy (cisplatin plus 5-fluorouracil) (median dose, 6800 cGy). The 5-year disease-specific survival for the 173 patients was 32.3%. The disease-specific survival for the radiotherapy group was 22.5%, compared with 61.4% for the chemoradiotherapy plus adjuvant chemotherapy group (P =.004). Factors associated with adverse outcomes were age older than 40 years at treatment (P =.001), advanced TNM stage (P =.002), skull base invasion (P =.004), and facial bone invasion (P<.001). CONCLUSIONS: Compared with radiotherapy alone, concomitant chemoradiotherapy with adjuvant chemotherapy improved the treatment outcome of patients with NPC treated in our institution. Advanced age, local extension, and stage of the disease adversely affected the prognosis in our patients. Compared with reirradiation, salvage brachytherapy and radical neck dissection for local and regional residual or recurrent NPC were associated with increased rates of locoregional control and survival.