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1.
J Surg Oncol ; 124(6): 967-976, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34599762

RESUMO

This review explores how human papillomavirus-related oropharyngeal cancer affects health-related quality of life (HR-QoL) and the role patient-reported outcomes (PROs) can play in optimizing treatment. PRO measures (PROMs) are comprehensive, subjective assessments of patients' day-to-day HR-QoL. Developed through a scientifically robust, multistage process, PROMs offer insight into patients' symptoms, function, and satisfaction with care. The use of PROMs can increase symptom awareness, stimulate discussion, and enhance shared decision-making between patients and healthcare providers.


Assuntos
Neoplasias Orofaríngeas/terapia , Neoplasias Orofaríngeas/virologia , Papillomaviridae/isolamento & purificação , Infecções por Papillomavirus/patologia , Ensaios Clínicos Fase II como Assunto , Ensaios Clínicos Fase III como Assunto , Humanos , Neoplasias Orofaríngeas/patologia , Infecções por Papillomavirus/virologia , Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto
2.
J Surg Oncol ; 124(5): 731-739, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34236707

RESUMO

OBJECTIVES: Sinonasal and skull base tumors are rare, making it difficult to identify trends in surgical outcome. This study examines complications in a large cohort of patients undergoing surgery for sinonasal malignancy. METHODS: Following IRB approval, an institutional database was reviewed to identify patients who underwent surgery for sinonasal or skull base malignancies from 1973 to 2016 at our institution. Charlson comorbidity index score and Clavien-Dindo grade were calculated. The main study endpoint was subgroup analysis of Clavien-Dindo Grade 0, Grades 1-2, and Grades 3-5 complications. An ordinal logistic regression model was constructed to assess the association between comorbidities, demographics, tumor characteristics, and surgical complications. RESULTS: In total, 448 patients met inclusion criteria. Perioperative mortality rate at 30 days was 1.6% (n = 7). The rate of severe complications (Clavien-Dindo 3 or higher) was 13.6% (n = 61). Multivariate analysis using an ordinal logistic regression model showed no association between Charlson comorbidity index score and Clavien-Dindo grade of postoperative complication. Advanced T-stage was significantly associated with complications (p = 0.0014; odds ratio: 3.442 [95% confidence interval: 1.615, 7.338]). CONCLUSION: Surgery for sinonasal and skull base tumors is safe with a low mortality rate. Advanced T-stage is associated with postoperative complications. These findings have implications for preoperative risk stratification. Key Points Surgery for sinonasal malignancy is safe with a 30 mortality of 1.6% and rate of severe complications of 12.8%. There is no association between patient comorbidity and post operative complication. On multivariate analysis, only advanced T stage was associated with increased rate of surgical complication.


Assuntos
Neoplasias Nasais/cirurgia , Neoplasias dos Seios Paranasais/cirurgia , Complicações Pós-Operatórias/patologia , Neoplasias da Base do Crânio/cirurgia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Nasais/patologia , Neoplasias dos Seios Paranasais/patologia , Complicações Pós-Operatórias/etiologia , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Neoplasias da Base do Crânio/patologia , Taxa de Sobrevida , Adulto Jovem
3.
Artigo em Inglês | MEDLINE | ID: mdl-34323968

RESUMO

Importance: Pharyngocutaneous fistula (PCF) results in an inflammatory reaction, but its association with the rate of locoregional and distant control, disease-free survival, and overall survival in laryngeal cancer remains uncertain. Objective: To determine if pharyngocutaneous fistula after salvage laryngectomy is associated with locoregional and distant control, disease-free survival, and/or overall survival. Design, Setting, and Participants: A multicenter collaborative retrospective cohort study conducted at 5 centers in Canada and the US of 550 patients who underwent salvage laryngectomy for recurrent laryngeal cancer from January 1, 2000, to December 31, 2014. The median follow-up time was 5.7 years (range, 0-18 years). Main Outcomes and Measures: Outcomes examined included locoregional and distant control, disease-free survival, and overall survival. Fine and Gray competing risk regression and Cox-proportional hazard regression models were used for outcomes. Competing risks and the Kaplan-Meier methods were used to estimate outcomes at 3 years and 5 years. Results: In all, 550 patients (mean [SD] age, 64 [10.4] years; men, 465 [85%]) met inclusion criteria. Pharyngocutaneous fistula occurred in 127 patients (23%). The difference in locoregional control between the group of patients with PCF (75%) and the non-PCF (72%) group was 3% (95% CI, -6% to 12%). The difference in overall survival between the group with PCF (44%) and the non-PCF group (52%) was 8% (95% CI, -2% to 20%). The difference in disease-free survival between PCF and non-PCF groups was 6% (95% CI, -4% to 16%). In the multivariable model, patients with PCF were at a 2-fold higher rate of distant metastases (hazard ratio, 2.00; 95% CI, 1.22 to 3.27). Distant control was reduced in those with PCF, a 13% (95% CI, 3% to 21%) difference in 5-year distant control. Conclusions and Relevance: This multicenter retrospective cohort study found that development of PCF after salvage laryngectomy is associated with an increased risk for the development of distant metastases.

4.
JAMA Surg ; 156(8): 740-746, 2021 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-34076691

RESUMO

Importance: Increasingly complex surgical procedures are being performed in the outpatient setting, increasing the burden on patients and caregivers to manage their postoperative symptoms. Electronic patient-reported symptom tracking may reduce this burden and help patients distinguish between expected symptoms and those requiring intervention. Objective: To determine whether electronic symptom reporting with clinical alerts for 10 days after ambulatory cancer surgery is associated with a reduction in potentially avoidable urgent care visits, defined as a visit not leading to admission. Design, Setting, and Participants: This retrospective cohort study was conducted at the Josie Robertson Surgery Center (JRSC), Memorial Sloan Kettering Cancer Center's ambulatory surgery center with overnight stay capacity from September 20, 2016, to December 31, 2018. Patients undergoing prostatectomy, nephrectomy, mastectomy with or without immediate reconstruction, hysterectomy, or thyroidectomy at the surgery center before (n = 4195) and after (n = 2970) implementation of the Recovery Tracker (RT) electronic postoperative symptom survey were included. Data analyses were conducted from February 1 to November 24, 2020. Exposures: A short electronic survey assessing symptoms daily for 10 days after surgery, administered via the patient portal, with alerts to the clinical team and follow-up for concerning responses. Main Outcomes and Measures: The main outcome was Memorial Sloan Kettering urgent care center visits with and without readmission and any readmission within 30 days after surgery. Nursing workload was measured by patient phone calls, emails, and secure messages as documented in the electronic medical record. Results: A total of 7165 patients were analyzed, including 4195 (median age, 53 [interquartile range (IQR), 44-63] years; 3490 women [83%]) from the pre-RT implementation period and 2970 (median age, 56 [IQR, 46-65] years; 2221 women [75%]) from after full implementation. On multivariable, intent-to-treat analysis by study period, having surgery in the post-RT period was associated with a 22% decrease in the odds of an urgent care center visit without readmission (OR, 0.78; 95% CI, 0.60-1.00; P = .047). Having responded to at least 1 survey was associated with a 42% reduction in the odds of an urgent care center visit without readmission (OR, 0.58; 95% CI, 0.39-0.87; P = .007). There was no change in the risk of admission. Nursing calls increased by a mean of 0.86 (95% CI, 0.75-0.98) calls per patient after RT implementation (P < .001), a 34% increase. Conclusions and Relevance: In this cohort study, electronic symptom reporting with nursing follow-up for clinical alerts was associated with a reduction in potentially avoidable urgent care visits. The low risk and high benefit of this intervention suggest that these systems should be more broadly implemented.

5.
Head Neck ; 43(8): 2497-2509, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33893750

RESUMO

AIMS: In the era of precision medicine, accurate pathologic diagnoses are crucial for appropriate management. METHODS: We herein described the histologic features and clinical impacts of 66 salivary gland epithelial neoplasms in which the diagnosis was altered after expert review. RESULTS: The most common revised diagnosis was that of salivary duct carcinoma (SDC, n = 12), adenoid cystic carcinoma (n = 12), and myoepithelial carcinoma (n = 10). The most common initial diagnosis was mucoepidermoid carcinoma (n = 19) with SDC being the most common revised diagnosis (7/19). Thirteen salivary gland carcinomas were initially diagnosed as benign entities, whereas five benign tumors were initially interpreted as carcinoma. The change in diagnosis was considered to be clinically significant in 65 (97%) cases. CONCLUSIONS: Given their rarity, salivary gland neoplasms are prone to diagnostic inaccuracy and discrepancy. A constellation of histologic features and ancillary studies are useful in reaching the correct diagnosis, which can have significant clinical impacts.


Assuntos
Carcinoma Adenoide Cístico , Carcinoma Mucoepidermoide , Neoplasias Epiteliais e Glandulares , Neoplasias das Glândulas Salivares , Carcinoma Adenoide Cístico/diagnóstico , Humanos , Encaminhamento e Consulta , Neoplasias das Glândulas Salivares/diagnóstico , Glândulas Salivares , Centros de Atenção Terciária
6.
Endocr Relat Cancer ; 28(6): 391-402, 2021 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-33890869

RESUMO

Constitutive MAPK activation silences genes required for iodide uptake and thyroid hormone biosynthesis in thyroid follicular cells. Accordingly, most BRAFV600E papillary thyroid cancers (PTC) are refractory to radioiodide (RAI) therapy. MAPK pathway inhibitors rescue thyroid-differentiated properties and RAI responsiveness in mice and patient subsets with BRAFV600E-mutant PTC. TGFB1 also impairs thyroid differentiation and has been proposed to mediate the effects of mutant BRAF. We generated a mouse model of BRAFV600E-PTC with thyroid-specific knockout of the Tgfbr1 gene to investigate the role of TGFB1 on thyroid-differentiated gene expression and RAI uptake in vivo. Despite appropriate loss of Tgfbr1, pSMAD levels remained high, indicating that ligands other than TGFB1 were engaging in this pathway. The activin ligand subunits Inhba and Inhbb were found to be overexpressed in BRAFV600E-mutant thyroid cancers. Treatment with follistatin, a potent inhibitor of activin, or vactosertib, which inhibits both TGFBR1 and the activin type I receptor ALK4, induced a profound inhibition of pSMAD in BRAFV600E-PTCs. Blocking SMAD signaling alone was insufficient to enhance iodide uptake in the setting of constitutive MAPK activation. However, combination treatment with either follistatin or vactosertib and the MEK inhibitor CKI increased 124I uptake compared to CKI alone. In summary, activin family ligands converge to induce pSMAD in Braf-mutant PTCs. Dedifferentiation of BRAFV600E-PTCs cannot be ascribed primarily to activation of SMAD. However, targeting TGFß/activin-induced pSMAD augmented MAPK inhibitor effects on iodine incorporation into BRAF tumor cells, indicating that these two pathways exert interdependent effects on the differentiation state of thyroid cancer cells.

7.
Int J Cancer ; 149(1): 139-148, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33586179

RESUMO

High-dose (HD) cisplatin remains the standard of care with chemoradiation for locally advanced oropharyngeal cancer (OPC). Cooperative group trials mandate bolus-HD (100 mg/m2 × 1 day, every 3 weeks) cisplatin administration at the beginning of the week to optimize radiosensitization-a requirement which may be unnecessary. This analysis evaluates the impact of chemotherapy administration day of week (DOW) on outcomes. We also report our institutional experience with an alternate dosing schedule, split-HD (50 mg/m2 × 2 days, every 3 weeks). We retrospectively reviewed 435 definitive chemoradiation OPC patients from 10 December 2001 to 23 December 2014. Those receiving non-HD cisplatin regimens or induction chemotherapy were excluded. Data collected included DOW, dosing schedule (bolus-HD vs split-HD), smoking, total cumulative dose (TCD), stage, Karnofsky Performance Status, human papillomavirus status and creatinine (baseline, peak and posttreatment baseline). Local failure (LF), regional failure (RF), locoregional failure (LRF), distant metastasis (DM), any failure (AF, either LRF or DM) and overall survival (OS) were calculated from radiation therapy start. Median follow-up was 8.0 years (1.8 months-17.0 years). DOW, dosing schedule and TCD were not associated with any outcomes in univariable or multivariable regression models. There was no statistically significant difference in creatinine or association with TCD in split-HD vs bolus-HD. There was no statistically significant association between DOW and outcomes, suggesting that cisplatin could be administered any day. Split-HD had no observed differences in outcomes, renal toxicity or TCD compared to bolus-HD cisplatin. Our data suggest that there is some flexibility of when and how to give HD cisplatin compared to clinical trial mandates.


Assuntos
Quimiorradioterapia/mortalidade , Cisplatino/uso terapêutico , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Neoplasias/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/uso terapêutico , Esquema de Medicação , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/patologia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
8.
J Surg Oncol ; 123(1): 149-155, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33063318

RESUMO

BACKGROUND AND OBJECTIVES: Total laryngectomy in thyroid cancer is controversial. Functional and oncologic outcomes are needed to inform surgical indications in this population. METHODS: A retrospective cohort study was performed at a tertiary referral center from 1997 to 2018 to identify patients with a diagnosis of thyroid carcinoma who underwent total laryngectomy. Complications, survival outcomes, and functional outcomes were analyzed. RESULTS: Thirty patients met the inclusion criteria. The mean age was 62 years (range, 30-88 years) and the male-to-female ratio was 1:2.75. The most common diagnosis was well-differentiated thyroid cancer (53.3%), followed by poorly differentiated (30%) and anaplastic (16.7%). Total laryngectomy was performed with a 10% rate of Clavien-Dindo Grade III-V complications. The median overall survival was 40 months (range, 1-237). Five-year overall survival was 39.5% and disease-specific survival was 51.1%. Locoregional control was achieved in 80.0% of patients. Twelve months postoperatively, 100% of surviving patients were taking oral intake and 86.4% had a self-reported functional voice. CONCLUSION: Total laryngectomy for locally advanced thyroid cancer is safe and provides acceptable rates of locoregional control. While the risk of distant metastases remains high, advances in systemic therapy may justify aggressive local control strategies to improve the quality of life.


Assuntos
Neoplasias Laríngeas/mortalidade , Laringectomia/mortalidade , Recidiva Local de Neoplasia/mortalidade , Complicações Pós-Operatórias/mortalidade , Qualidade de Vida , Neoplasias da Glândula Tireoide/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Neoplasias Laríngeas/patologia , Neoplasias Laríngeas/cirurgia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/cirurgia , Complicações Pós-Operatórias/patologia , Complicações Pós-Operatórias/cirurgia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/cirurgia
9.
Cancer ; 127(3): 359-371, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33107986

RESUMO

BACKGROUND: Patient-reported outcomes (PROs) allow for the direct measurement of functional and psychosocial effects related to treatment. However, technological barriers, survey fatigue, and clinician adoption have hindered the meaningful integration of PROs into clinical care. The objective of the authors was to develop an electronic PROs (ePROs) program that meets a range of clinical needs across a head and neck multidisciplinary disease management team. METHODS: The authors developed the ePROs module using literature review and stakeholder input in collaboration with health informatics. They designed an ePROs platform that was integrated as the standard of care for personalized survey delivery by diagnosis across the disease management team. Tableau software was used to create dashboards for data visualization and monitoring at the clinical enterprise, disease subsite, and patient levels. All patients who were treated for head and neck cancer were eligible for ePROs assessment as part of the standard of care. A descriptive analysis of ePROs program implementation is presented herein. RESULTS: The Head and Neck Service at Memorial Sloan Kettering Cancer Center has integrated ePROs into clinical care. Surveys are delivered via the patient portal at the time of diagnosis and longitudinally through care. From August 1, 2018, to February 1, 2020, a total of 4154 patients completed ePROs surveys. The average patient participation rate was 69%, with a median time for completion of 5 minutes. CONCLUSIONS: Integration of the head and neck ePROs program as part of clinical care is feasible and could be used to assess value and counsel patients in the future. Continued qualitative assessments of stakeholders and workflow will refine content and enhance the health informatics platform. LAY SUMMARY: Patients with head and neck cancer experience significant changes in their quality of life after treatment. Measuring and integrating patient-reported outcomes as a part of clinical care have been challenging given the multimodal treatment options, vast subsites, and unique domains affected. The authors present a case study of the successful integration of electronic patient-reported outcomes into a high-volume head and neck cancer practice.


Assuntos
Neoplasias de Cabeça e Pescoço/terapia , Medidas de Resultados Relatados pelo Paciente , Padrão de Cuidado , Registros Eletrônicos de Saúde , Humanos
11.
Otolaryngol Head Neck Surg ; 165(2): 267-274, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33320788

RESUMO

OBJECTIVE: To address the lack of validated patient-reported outcome (PRO) instruments that define and quantify patient expectations in thyroid cancer surgery, we developed and initially validated ThyroidEx, a novel disease-specific PRO instrument. STUDY DESIGN: Survey study. SETTING: Single-institution tertiary care cancer center. METHODS: An expert panel drafted an initial set of thyroid cancer-specific concepts, which was used in semistructured concept elicitation interviews with patients with thyroid cancer 4 weeks before and 8 weeks after surgery. Candidate items were generated per patient responses and refined via cognitive interviewing and additional review by the expert panel. The draft ThyroidEx was then preoperatively administered to a separate cohort undergoing thyroid cancer surgery to establish a final item set and initial psychometric evidence. RESULTS: Prospective concept elicitation interviews generated 358 patient-elicited concepts (n = 15 patients). These were then placed into 70 unique subcategories from which 41 items were generated for cognitive interviews with 20 patients preoperatively and 28 postoperatively. After expert panel review, ThyroidEx included 18 items across 2 scales (Expectations and Concerns), with an additional item about beliefs. In the preoperative cohort in phase 2 (n = 67), internal consistency Cronbach's α values ranged from 0.81 to 0.89. Descriptive analysis showed significant differences between patients' concerns and expectations and clinicians' perceptions. CONCLUSION: Defining expectations represents an important modifier in the measurement of PROs. Preliminary validation of ThyroidEx revealed incongruent expectations between expert opinion and patients. Future development and implementation of ThyroidEx may affect preoperative consultation and the consent process.


Assuntos
Motivação , Medidas de Resultados Relatados pelo Paciente , Neoplasias da Glândula Tireoide/psicologia , Neoplasias da Glândula Tireoide/cirurgia , Adulto , Tomada de Decisões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Preferência do Paciente , Psicometria , Qualidade de Vida , Reprodutibilidade dos Testes , Tireoidectomia
12.
Artigo em Inglês | MEDLINE | ID: mdl-33151192

RESUMO

Oral cancer treatment involving the maxilla and/or mandible often results in esthetic and functional deficits that can diminish the patient's quality of life. As a result, expeditious reconstruction of the defect and dental rehabilitation is desirable. Dental rehabilitation shortly after reconstruction with an osteocutaneous free flap and resection prosthesis is a persistent challenge for patients with oncologic defects where immediate dental rehabilitation is not a possibility. Additionally, conventional prosthesis fabrication techniques are impractical or impossible due to postoperative anatomical changes and limitations in clinical armamentarium. To address these limitations, a technique and a novel implant-supported prosthetic workflow for the oncologic patient were developed to provide interim dental rehabilitation for such clinical situations. This article describes the prosthesis fabrication technique, reports short-term outcomes, and evaluates patient-reported quality-of-life outcomes using the FACE-Q Head and Neck Cancer Module.


Assuntos
Implantes Dentários , Retalhos de Tecido Biológico , Reconstrução Mandibular , Implantação Dentária Endo-Óssea , Prótese Dentária Fixada por Implante , Fíbula/cirurgia , Humanos , Qualidade de Vida
13.
Head Neck ; 42(11): 3316-3325, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32737953

RESUMO

BACKGROUND: Sinonasal mucosal melanoma (SNMM) is an aggressive cancer with high mortality. Identifying patients at risk of distant metastasis assists with management and prognostication. We aimed to define the relationship between volume, survival, and risk of distant metastases. METHODS: A retrospective review of all patients with SNMM treated at a single institution over a 21-year period was conducted. Tumor volume was calculated using cross-sectional imaging and survival analysis was performed. RESULTS: Sixty-one patients were included. Tumor volume was predictive of local progression-free survival (P = .03), distant metastases-free survival (DMFS) (P = .002), and overall survival (OS) (P = .02). It was a better predictor than AJCC stage and T-classification. Tumor volume equal to or greater than 5 cm3 was associated with a significantly worse DMFS and OS (P = .02 and .009, respectively). CONCLUSION: Calculation of tumor volume assists in quantifying the risk of distant metastases and death in SNMM.


Assuntos
Melanoma , Neoplasias dos Seios Paranasais , Humanos , Melanoma/patologia , Mucosa Nasal/patologia , Estadiamento de Neoplasias , Neoplasias dos Seios Paranasais/diagnóstico por imagem , Neoplasias dos Seios Paranasais/patologia , Neoplasias dos Seios Paranasais/terapia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Carga Tumoral
14.
Cancer ; 126(18): 4092-4104, 2020 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-32639615

RESUMO

Because of the national emergency triggered by the coronavirus disease 2019 (COVID-19) pandemic, government-mandated public health directives have drastically changed not only social norms but also the practice of oncologic medicine. Timely head and neck cancer (HNC) treatment must be prioritized, even during emergencies. Because severe acute respiratory syndrome coronavirus 2 predominantly resides in the sinonasal/oral/oropharyngeal tracts, nonessential mucosal procedures are restricted, and HNCs are being triaged toward nonsurgical treatments when cures are comparable. Consequently, radiation utilization will likely increase during this pandemic. Even in radiation oncology, standard in-person and endoscopic evaluations are being restrained to limit exposure risks and preserve personal protective equipment for other frontline workers. The authors have implemented telemedicine and multidisciplinary conferences to continue to offer standard-of-care HNC treatments during this uniquely challenging time. Because of the lack of feasibility data on telemedicine for HNC, they report their early experience at a high-volume cancer center at the domestic epicenter of the COVID-19 crisis.


Assuntos
COVID-19 , Neoplasias de Cabeça e Pescoço/radioterapia , Telemedicina/métodos , COVID-19/transmissão , Procedimentos Cirúrgicos Eletivos , Neoplasias de Cabeça e Pescoço/diagnóstico por imagem , Neoplasias de Cabeça e Pescoço/terapia , Humanos , Equipamento de Proteção Individual , Guias de Prática Clínica como Assunto , Radioterapia (Especialidade)/organização & administração , Telemedicina/organização & administração
15.
J Surg Oncol ; 121(7): 1167-1168, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32153021
16.
J Surg Oncol ; 120(8): 1456-1461, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31680250

RESUMO

BACKGROUND AND OBJECTIVES: Remifentanil infusion is used as an intraoperative anesthetic for thyroidectomy, but has been associated with acute opioid tolerance and hyperalgesia. A national shortage of remifentanil provided an opportunity to study postoperative pain in patients undergoing thyroidectomy. METHODS: Retrospective review of prospectively collected data from an outpatient surgery center. Primary analysis compared patients treated before and after remifentanil shortage. RESULTS: Median postoperative opioid consumption was 20 morphine milligram equivalents (MMEs) among those treated in the high-dose period and 15 MMEs in the low-dose period. Remifentanil/weight received was a significant predictor of requiring a postoperative narcotic (P = .006). Total non-remifentanil narcotics administered were equivalent but patients in the low dose period received higher amounts of intraoperative long-acting narcotics. CONCLUSIONS: Remifentanil infusion for thyroid surgery is associated with higher postoperative pain and postoperative narcotics requirement. While a hyperalgesia state is possible, shifting of longer-acting narcotics from intraoperative to postoperatively is also supported.


Assuntos
Analgésicos Opioides/administração & dosagem , Uso de Medicamentos/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico , Remifentanil/administração & dosagem , Tireoidectomia , Adulto , Procedimentos Cirúrgicos Ambulatórios , Feminino , Humanos , Infusões Intravenosas , Cuidados Intraoperatórios , Masculino , Pessoa de Meia-Idade , Medição da Dor , Alta do Paciente , Período Pós-Operatório , Estudos Retrospectivos
17.
J Surg Oncol ; 120(7): 1259-1265, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31549410

RESUMO

BACKGROUND AND OBJECTIVES: The reported risk of nodal metastasis in hard palate and upper gingival squamous cell carcinoma (SCC) has been inconsistent with inadequate consensus regarding the utility of neck dissection in the clinically negative (cN0) neck. MATERIALS AND METHODS: Using the National Cancer Database, cN0 patients diagnosed with SCC of the head and neck with the subsites of the hard palate and upper gingiva were identified from 2004 to 2014. RESULTS: A total of 1830 patients were identified, and END was performed on 422 patients with cN0 tumors. Pathologically positive nodes occurred in 14% (59/422) of patients in this cohort. Higher tumor stage, academic hospital type, and large hospital volume (>28 cancer-specific cases/year) were associated with a higher likelihood of END both in univariate and multivariate analyses (P < .05). Patients >80 years of age were less likely to receive END on multivariate analysis (OR 0.52, 0.32-0.84). No variables, including advanced T stage, predicted occult metastases. Cox proportional hazards regression analysis showed that patients who underwent END demonstrated improved OS over an 11-year period (hazard ratio 0.75, P = .002). On subgroup analysis, this improvement was significant in patients with both stage T1 and T4 tumors. CONCLUSIONS: Tumor stage, hospital type, and hospital volume were associated with higher rates of END for patients with cN0 hard palate SCC and after controlling for clinical factors, END was associated with improved overall survival.


Assuntos
Carcinoma de Células Escamosas/mortalidade , Procedimentos Cirúrgicos Eletivos/mortalidade , Neoplasias Gengivais/mortalidade , Neoplasias Maxilares/mortalidade , Esvaziamento Cervical/mortalidade , Palato Duro/cirurgia , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Bases de Dados Factuais , Feminino , Seguimentos , Neoplasias Gengivais/patologia , Neoplasias Gengivais/cirurgia , Humanos , Masculino , Neoplasias Maxilares/patologia , Neoplasias Maxilares/cirurgia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Palato Duro/patologia , Estudos Retrospectivos , Taxa de Sobrevida
18.
Head Neck ; 41(11): 3906-3915, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31433540

RESUMO

BACKGROUND: Despite advances in treatment, the recurrence rates for laryngeal cancer range from 16% to 40%. METHODS: Patients with recurrent laryngeal cancer treated at Memorial Sloan Kettering (MSK) from 1999 to 2016 were reviewed. Survival outcomes were analyzed. RESULTS: Of 241 patients, 88% were male; the median age was 67 years; 71% had primary glottic tumors. At initial treatment, 72% of patients were seen with early stage disease; primary treatment was radiation (68%), chemoradiation (29%), and surgery (3%). The most common salvage surgery was total laryngectomy (74%). Forty-seven percentage were upstaged at salvage surgery. The 2- and 5-year disease-specific survival (DSS) was 74% and 57%, respectively. Patients with cT4 disease treated with nonsurgical primary management had a 0% 5-year DSS. Independent predictors of DSS were tumor location, perineural invasion, margin, and stage. CONCLUSIONS: Salvage surgery results in acceptable oncologic outcomes. Stage, disease site, perineural invasion, and margins are associated with inferior DSS.


Assuntos
Carcinoma de Células Escamosas/terapia , Neoplasias Laríngeas/terapia , Laringectomia , Recidiva Local de Neoplasia/terapia , Terapia de Salvação , Idoso , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/patologia , Intervalo Livre de Doença , Feminino , Humanos , Neoplasias Laríngeas/mortalidade , Neoplasias Laríngeas/patologia , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Estudos Retrospectivos , Taxa de Sobrevida
19.
J Neurol Surg B Skull Base ; 80(4): 371-379, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31316883

RESUMO

Objectives Determining surgical trends and outcomes for sinonasal tumors is challenging given their low incidence and heterogeneous pathology. This study utilized the National Cancer Database (NCDB) to identify trends and outcomes associated with surgical management of sinonasal tumors. Design Retrospective database analysis. Setting National Cancer Database. Participants Patients with sinonasal malignancies identified from the NCDB between 2010 and 2015. Main Outcome Measures The primary outcome was the choice of surgical therapy used for sinonasal tumor resection: endoscopic versus open approach. Each was cohort analyzed with respect to various demographic and clinicopathologic factors. A treatment effect model was used to identify potential differences between surgical approaches. Survival was evaluated using Kaplan-Meier analysis. Results A total of 10,193 patients with sinonasal malignancies were identified in the NCDB database; of these, 2,292 had a documented subsite, histology, and definitive surgical treatment with documented surgical approach and were included in the analysis. About 71.9% of patients had an open approach and 28.1% a purely endoscopic procedures. Tumor histology, treatment facility type, margin status, and length of stay were all variables that were associated with significant differences between the open and endoscopic cohort. Five-year survival rates for the open and endoscopic cohorts were not significantly different (59.6 and 60.8%, respectively). Conclusions Assessment of the NCDB revealed that 28% patients with sinonasal malignancy were selected for endoscopic surgery. These patients had comparable oncologic outcomes to open resection.

20.
Head Neck ; 41(10): 3551-3563, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31294897

RESUMO

BACKGROUND: Timely postoperative radiation therapy (RT) within 50 days of surgery for head and neck cancers provides a survival advantage. METHODS: Using the National Cancer Database, we performed a propensity score-matched analysis comparing patients undergoing open or endoscopic surgery for squamous cell carcinoma (SCC) of the nasal cavity and paranasal sinuses from 2010 to 2015. RESULTS: Among 168 pairs, patients undergoing endoscopic surgery had shorter time to surgery (24.2 vs 36.7 days, P < .001) and shorter postoperative time to RT (PTTR, 51.2 vs 58.4 days, P = .02). On multivariable linear regression, endoscopic surgery predicted shorter PTTR (ß = -7.6, P = .01). Using the Kaplan-Meier method, patients in the longest PTTR quartile had decreased overall survival (OS; Q1 vs Q4, 3-year OS 76.5% vs 53.3%, P = .007), a durable finding when adjusted for covariates (Q1 vs Q4, HR 0.50, P = .008). CONCLUSIONS: Patients undergoing endoscopic surgery for sinonasal SCC experience shorter PTTR. Shorter PTTR is associated with extended OS.


Assuntos
Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/cirurgia , Endoscopia/métodos , Neoplasias dos Seios Paranasais/mortalidade , Neoplasias dos Seios Paranasais/cirurgia , Adulto , Idoso , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/radioterapia , Terapia Combinada , Bases de Dados Factuais , Intervalo Livre de Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Otorrinolaringológicos/métodos , Neoplasias dos Seios Paranasais/patologia , Neoplasias dos Seios Paranasais/radioterapia , Pontuação de Propensão , Radioterapia Adjuvante , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Fatores de Tempo
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