Mudanças no perfil de atendimento do departamento de cirurgia de cabeça e pescoço em um hospital de referência para câncer / Changes in the attending profile of the department of head and neck surgery in a reference hospital to cancer

Introdução: Serviços especializados em Cirurgia de Cabeça ePescoço até o fim do século passado era praticamente exclusividadede hospitais terciários localizados em grandes centros. Nos anosmais recentes eles vêm se difundindo não só nos grandes centros,mas também em cidades menores, acompanhando o fenômenoda interiorização da medicina especializada. Em hospitais dereferência para câncer, o perfil de atendimento tem se modificadodrasticamente nos últimos anos. Objetivo: Analisar de formadescritiva o perfil atual de atendimento de um departamento decirurgia de cabeça e pescoço e otorrinolaringologia de um hospitalde referência no tratamento do câncer e comparar os números atuaiscom os dos anos de 1990 e 2000. Material: Foram analisados 23910atendimentos ambulatoriais e 1285 cirurgias consecutivas realizadaspelos médicos do Departamento de Cirurgia de Cabeça e Pescoçoe Otorrinolaringologia de um hospital oncológico no período de 1 deJaneiro a 31 de Dezembro de 2010. Método: Revisão do prontuárioeletrônico de todos os pacientes atendidos através do sistema MV2000. Análise descritiva de dados hospitalares e de atendimentoambulatorial do departamento. Resultados: Em 2010, foramrealizados 23910 atendimentos ambulatoriais no departamento, comuma média mensal de 1993 atendimentos, sendo 1692 pacientesatendidos pela primeira vez na instituição. No mesmo período, 1285cirurgias foram realizadas, sendo 1115 (86,8%) delas por cirurgiõesde cabeça e pescoço, 91 (7%) por cirurgiões plásticos e 79 (6,2%)por otorrinolaringologistas. 138 cirurgias foram indicadas comotratamento de resgate. As doenças da tireoide foram responsáveispela indicação 38% das cirurgias. Em divisão por porte cirúrgico217 cirurgias foram consideradas de grande porte, 703 de médioporte e 365 de pequeno porte. Em relação às complicações, asmais frequentes foram: infecção de ferida operatória (57 casos)e o hipocalcemia (81 casos). No período houve nove óbitos pósoperatórios, dos quais 8 após cirurgias de grande porte. Conclusão:Esta análise do ano de 2010, mostra que em um mesmo hospitalde referência para câncer, vêm crescendo a parcela de pacientestireoideopatias tratadas, o que provavelmente reflete o aumento daincidência do câncer de tireoide detectado nas últimas décadas. Domesmo modo, observou-se um aumento no número de pacientessubmetidos a cirurgias de resgate.

Gingival squamous cell carcinoma mimicking periodontal disease.

Gingival squamous cell carcinoma (GSCC) is relatively rare, representing less than 10% of oral cavity squamous cell carcinomas. Because of its proximity to the teeth and periodontium, the tumor can mimic tooth-related benign inflammatory conditions. In this article, a case of GSCC with clinical features very similar to those of periodontal disease in an 86-year-old nonsmoking woman is presented. Consequently, clinicians should be aware of this pathology to play an important role in the early detection of gingival cancer.

Total glossectomy in the organ preservation era.

PURPOSE OF REVIEW: Total or subtotal glossectomy is considered a highly morbid procedure. However, in some institutions and in selected cases of unsuccessful chemoradiation regimens, it is performed with acceptable oncological and functional outcomes. RECENT FINDINGS: Chemoradiation for advanced oral and oropharyngeal cancers is also highly morbid and some authors reported reasonable functional results after major glossectomies. Also, there is a lack of prospective trials comparing the long-term outcome between chemoradiation and major glossectomies. SUMMARY: Total and/or subtotal glossectomies with immediate reconstruction can be performed in highly selected patients with advanced oral or base of the tongue carcinomas, as a primary or salvage procedure, with acceptable outcomes.

Validation of the Washington University Head and Neck Comorbidity Index in a cohort of older patients.

OBJECTIVES: To validate the prognostic ability of the Washington University Head and Neck Comorbidity Index (WUHNCI) relative to 5-year survival in a cohort of older patients with head and neck cancer and to compare it with that of the Adult Comorbidity Evaluation 27 (ACE-27). DESIGN: Validation study. SETTING: Academic research. PATIENTS: Three hundred twenty-one patients older than 70 years with head and neck cancer in a tertiary cancer center. Comorbidity was measured using the ACE-27, WUHNCI, and National Cancer Institute (NCI) comorbidity index. MAIN OUTCOME MEASURE: Five-year overall survival. RESULTS: Five-year overall and cancer-specific survival, respectively, were as follows: Using the WUHNCI, 52.2% and 62.9% for a score of 0; 25.1% and 41.7% for a score of 1; 39.3% and 64.9% for a score of 2; and 19.5% and 45.0% for a score of 3 or higher. Using the ACE-27, 54.4% and 61.7% for a score of 0 (no comorbidity); 46.8% and 61.7% for a score of 1 (mild comorbidity); 31.7% and 51.6% for a score of 2 (moderate comorbidity); and 13.8% and 43.7% for a score of 3 (severe comorbidity). The C statistics were 0.641 for the NCI comorbidity index, 0.656 for the ACE-27, and 0.686 for the WUHNCI. CONCLUSIONS: The WUHNCI did not demonstrate good discriminative power compared with the ACE-27 in a cohort of older patients. To be widely used, instruments developed to measure comorbidities must be reliable in any population. We believe that the ACE-27 is still the best index to assess comorbidities and that it should be used in studies evaluating the prognostic effect of comorbidities.

Giant pleomorphic adenoma of the parotid gland.

Pleomorphic adenoma is the most common type of all benign and malignant salivary gland tumors, involving more frequently the parotid gland. It is a benign tumor with a slow and continuous growth that without treatment can reach an enormous size. We present a case of a giant pleomorphic adenoma in a 78-year-old man with a history of more than 30 years of a growing lesion in the parotid gland. Clinical examination revealed a giant mass on the right side of the face, however without any sign of facial nerve damage. The tumor was completely resected by total parotidectomy and preservation of the facial nerve. Macroscopically, the tumor measured 28 cm and weighed 4.0 Kg. On the histological examination there was a predominance of epithelial and myoepithelial cells in a hyaline and myxoid stroma. It was not found any area of malignant transformation. In the post-operatory the aesthetic and functional results were excellent.

Giant pleomorphic adenoma of the parotid gland

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Pleomorphic adenoma is the most common type of all benign and malignant salivary gland tumors, involving more frequently the parotid gland. It is a benign tumor with a slow and continuous growth that without treatment can reach an enormous size. We present a case of a giant pleomorphic adenoma in a 78-year-old man with a history of more than 30 years of a growing lesion in the parotid gland. Clinical examination revealed a giant mass on the right side of the face, however without any sign of facial nerve damage. The tumor was completely resected by total parotidectomy and preservation of the facial nerve. Macroscopically, the tumor measured 28cm and weighed 4.0 Kg. On the histological examination there was a predominance of epithelial and mioepithelial cells in a hyaline and mixoid stroma. It was not found any area of malignant transformation. In the post-operatory the aesthetic and functional results were excellent (AU)

Preservation of the internal jugular vein in the radical treatment of node-positive neck--is it safe?

BACKGROUND: The aim of this study was to evaluate risk factors of neck recurrence in patients with pN+ necks submitted to a modified or a classic radical neck dissection and the safety of preserving the internal jugular vein in the treatment of a subgroup of these patients. METHODS: The medical records of 311 untreated patients with squamous cell carcinoma of the oral cavity (106 cases), oropharynx (95 cases), larynx (49 cases), and hypopharynx (61 cases) were reviewed. Their clinical stages (CS) were CS II in 1%, CS III in 19.9%, CS IVA in 76.2%, and CS IVB in 19.6% of the cases. All patients were pN+. RESULTS: Ipsilateral neck recurrence occurred in 18 cases (5.8%), 14 cases (4.5%) where the internal jugular vein was resected, and 4 cases (1.3%) where the internal jugular vein was preserved. Neck recurrence did not have significant correlation with tumor site (P = .852), T stage (P = .369), N stage (P = .963), adjuvant radiotherapy (P = .701), number of positive lymph nodes (P = .886), jugular vein preservation (P = .240), and extracapsular spread (P = .670). There was significant correlation between neck recurrence and the lymph node size (.040). CONCLUSIONS: Modified radical neck dissection with internal jugular vein preservation can be performed in selected patients with lymph node metastases, with no significant increase in the risk of neck recurrence.

Predictive factors for complications in elderly patients who underwent head and neck oncologic surgery.

BACKGROUND: Postoperative complications are relevant outcomes in patients with head and neck tumor who have undergone surgery. Few trials have assessed predictive factors in older patients. We assessed the predictive effect of preoperative clinical factors on postoperative complications. METHODS: We conducted a cohort study with 242 patients older than 70 years with head and neck cancer who underwent surgery. Logistic regression identified predictive factors for postoperative complications. Significant variables were used to build a predictive index. RESULTS: Comorbidities were present in 87.6% of patients, and 56.6% had some type of complication (44.6% local and 28.5% systemic). Male sex, bilateral neck dissection, presence of 2 or more comorbidities, reconstruction, and clinical stage IV were associated with postoperative complications. The predictive index showed a receiver operating characteristics curve (ROC) area of 0.69. CONCLUSION: It is possible to predict postoperative complications in older patients with head and neck tumors who underwent oncologic surgery using clinical preoperative variables.

Internal jugular vein preservation in neck dissection for pN1-N2c oral and oropharyngeal carcinoma.

PURPOSE: The aim of this study is to evaluate risk factors of neck recurrence in patients with pN1-N2 neck stage, submitted to a modified radical neck dissection with preservation of the internal jugular vein. MATERIALS AND METHODS: We reviewed the medical records of 72 patients with squamous cell carcinoma of the oral cavity (43 cases) and oropharynx (29 cases). The clinical stage of the neck was N1 in 23 cases and N2a-c in 49. RESULTS: Neck recurrences occurred in 6 cases at the side in which the internal jugular vein was preserved. Neck recurrence did not have significant correlation with tumor site (P = .391), T stage (P = .999), N stage (P = .203), adjuvant radiotherapy (P = .999), number of positive lymph nodes (P = .180), lymph nodes size (P = .429), and extracapsular spread (P = .400). CONCLUSIONS: Modified radical neck dissection with internal jugular vein preservation can be performed in selected patients with lymph node metastases, with no significant increase on the risk of neck recurrence.

Multiple cutaneous metastases from a parotid adenoid cystic carcinoma.

Cutaneous metastasis from salivary gland adenoid cystic carcinoma is extremely rare. We report a case of a 39-year-old man that presented multiple cutaneous metastases from a parotid salivary gland adenoid cystic carcinoma. The clinical, histopathological and immunohistochemical features are described and discussed. This case shows the importance of a detailed and periodical skin examination in patients treated for salivary gland adenoid cystic carcinoma.

Is galectin-3 a good method for the detection of malignancy in patients with thyroid nodules and a cytologic diagnosis of "follicular neoplasm"? A critical appraisal of the evidence.

BACKGROUND: Thyroid nodules are the most common surgical disease of the thyroid. Fine-needle aspiration biopsy (FNAB) is the most commonly employed tool for establishing a diagnosis. However, 15% to 25% of FNAB reports yield inconclusive results. Immunostaining of cytological smears from FNAB with galectin-3 has been proposed as a tool for differentiating between benign and malignant nodules. We performed a systematic review to evaluate the utility of galectin-3. METHODS: Prospective studies of nodules with FNAB reports of "follicular neoplasm" and with a definitive diagnosis confirmed by histopathology were selected. Calculations of individual sensitivity, specificity, and positive and negative likelihood ratios were made. RESULTS: The articles selected were those with the best methodological quality. CONCLUSION: Galectin-3 could be a good tool to guide therapeutic decision in patients with thyroid nodules and FNAB results of follicular neoplasm, but available information has methodological flaws that precludes a definitive answer about galectin-3 utility in the clinical setting.

Factors that influence treatment decision in older patients with resectable head and neck cancer.

OBJECTIVES: To find clinical factors related to administration of substandard treatment in older patients with head and neck cancer. STUDY DESIGN: Historic cohort. METHODS: Patients of 70 years of age of older with diagnosis of resectable head and neck cancer were included. Treatment offered to patients was classified as standard or substandard by experienced surgeons. Relation of age, clinical stage, comorbidities, performance status, and treatment with substandard treatment was explored. The effect of substandard treatment on survival was assessed. RESULTS: Three hundred twelve patients were included. Substandard treatment was offered to 19.9% of patients. Associated factors related to selection of substandard treatment were higher age, oro/hypopharynx tumor site, severe comorbidity, advanced clinical stage, and low Karnofsky Index. Patients submitted to substandard treatment had lower overall and cancer-specific survival (45.9% vs. 19.9% and 63.0% vs. 33.1%, respectively). CONCLUSION: Selection of substandard treatment decreases overall and cancer-specific survival. Selecting substandard treatment for reasons such as chronologic age, tumor site, or moderate or mild comorbidities worsen patient prognosis.

Shorter CAG repeat length in the AR gene is associated with poor outcome in head and neck cancer.

OBJECTIVE: Alterations in the size of the [CAG](n) repeats of the AR gene have been described in several types tumors. The purpose of this study was to evaluate if there is an association between the AR [CAG](n) repeat alleles and the relative risk for head and neck cancer and to analyse microsatellite instability (MSI) and loss of heterozygosity (LOH) in these tumors. DESIGN: Matched samples of blood and head and neck tumors were evaluated using two methodologies, silver-stained gels to perform the analyses of MSI and LOH, and automated analysis to confirm these results and for genotyping of the AR [CAG](n) repeat length. Sixty-nine individuals without cancer were used as a control group for both procedures. The Log-rank test was used to compare overall survival and disease-free survival curves. The Cox proportional hazards regression models were performed to determine the [CAG](n) repeats as an independent prognostic factor. RESULTS: Patients with alleles

Comorbidity is a prognostic factor in elderly patients with head and neck cancer.

BACKGROUND: The number of aged patients with head and neck cancer is increasing. Comorbidities are common in this population. It is necessary to evaluate the effect of comorbidities as measured with the ACE-27 index on recurrence and survival of elderly patients with head and neck cancer, adjusting by other prognostic factors as age, clinical stage and functional status index. PATIENTS: Three hundred and ten patients greater than 70 years of age with head and neck cancer in a referral cancer center were studied. Comorbidity measured with the ACE-27 index was the main independent variable. The outcomes were recurrence and survival. RESULTS: Comorbidities were present in 75% of patients. Five-year disease-free survival, overall survival and cancer-specific survival were 63.1, 42.8 and 55.8%, respectively. Advanced clinical stage and Karnofsky index < or =70 were associated with recurrence. Age >80 years, male gender, Karnofsky index < or =80, advanced clinical stage, and ACE value > or =2 were independently associated with overall survival. The ACE-27 value was not associated with cancer-specific survival. The Karnofsky performance index was associated with overall survival and mortality and acted as a confounding factor on multivariable analysis on overall and cancer-specific survival. CONCLUSIONS: Comorbidity measured with ACE-27 was a prognostic factor for overall survival in patients older than 70 years with head and neck cancer. The Karnofsky performance index could be included in multivariable analysis of survival for older patients with head and neck cancer.

Platysma Myocutaneos Flap in Head and Neck Reconstruction

Background: Platysma myocutaneous flap is one of the methods currently available for reconstruction of small and moderate size defects after head neck cancer resection. Objectives: To investigate the long term results of head and neck reconstruction using platysma myocutaneous flap. Patients and methods: 23 consecutive patients with malignant head and neck neoplasms who underwent radical surgical resections and immediate reconstructions using a platysma myocutaneous flap were reviewed. The flaps were used to repair defects of the following sites: oral cavity in 15 cases and larynx, lip commissure, parotid gland and oropharynx in 2 cases each. Results: In fourteen cases (60.8) there were no flap-related complications. Flap necrosis occurred in 9 (39.1) patients [4 (17.3) partial flap necrosis]. There was no correlation of complications with previous irradiation or facial artery ligation. Conclusion: Platysma myocutaneous flap can be considered among the alternatives for small and moderate size reconstructions after oral cavity, oropharynx and larynx cancer resections, even in patients previously submitted to radiotherapy.

Prognostic factors in salvage surgery for recurrent oral and oropharyngeal cancer.

BACKGROUND: Therapeutic decisions in recurrent oral and oropharyngeal squamous carcinoma (SCC) remain controversial. METHODS: Two hundred forty-six consecutive patients who underwent salvage surgery for recurrent squamous cell carcinoma (SCC) of the oral cavity and oropharynx were studied. The tumor sites were lip, 33 cases; oral cavity, 143; oropharynx, 70. The previous treatment was surgery in 73 patients, radiotherapy in 96, combined surgery and radiotherapy in 76, and chemotherapy in one. The clinical stage of recurrence was I/II in 51 cases and III/IV in 195 cases. The disease-free interval (DFI) was less than 1 year in 156 cases and greater than 1 year in 90 cases. RESULTS: The rate of recurrence was 54.9%, and the overall 5-year actuarial survival rate was 32.3%. The significant prognostic factors in multivariate analysis were restage (p = .049) and DFI (p = .045). CONCLUSION: Patients with recurrent oral and oropharyngeal SCC at initial clinical stages (rCS I and II) and with a DFI greater than 1 year had a favorable prognosis.

H19-DMR allele-specific methylation analysis reveals epigenetic heterogeneity of CTCF binding site 6 but not of site 5 in head-and-neck carcinomas: a pilot case-control analysis.

Aberrant methylation of seven potential binding sites of the CTCF factor in the differentially methylated region upstream of the H19 gene (H19-DMR) has been suggested as critical for the regulation of IGF2 and H19 imprinted genes. In this study, we analyzed the allele-specific methylation pattern of CTCF binding sites 5 and 6 using methylation-sensitive restriction enzyme PCR followed by RFLP analysis in matched tumoral and lymphocyte DNA from head-and-neck squamous cell carcinoma (HNSCC) patients, as well as in lymphocyte DNA from control individuals who were cancer-free. The monoallelic methylation pattern was maintained in CTCF binding site 5 in 22 heterozygous out of 91 samples analyzed. Nevertheless, a biallelic methylation pattern was detected in CTCF binding site 6 in a subgroup of HNSCC patients as a somatic acquired feature of tumor cells. An atypical biallelic methylation was also observed in both tumor and lymphocyte DNA from two patients, and at a high frequency in the control group (29 out of 64 informative controls). Additionally, we found that the C/T transition detected by HhaI RFLP suppressed one dinucleotide CpG in critical CTCF binding site 6, of a mutation showing polymorphic frequencies. Although a heterogeneous methylation pattern was observed after DNA sequencing modified by sodium bisulfite, the biallelic methylation pattern was confirmed in 9 out of 10 HNSCCs. These findings are likely to be relevant in the epigenetic regulation of the DMR, especially in pathological conditions in which the imprinting of IGF2 and H19 genes is disrupted.