Efficacy of surgical comprehensive therapy for 456 cases of hypopharyngeal carcinoma / 中华耳鼻咽喉头颈外科杂志

Objective: To retrospectively analyse the efficacy of surgerical comprehensive treatment for hypopharyngeal cancer. Methods: Four hundred and fifty-six cases of hypopharyngeal squamous cell carcinoma treated from Jan 2014 to Dec 2019 were analyzed retrospectively, including 432 males and 24 females, aged 37-82 years old. There were 328 cases of pyriform sinus carcinoma, 88 cases of posterior pharyngeal wall carcinoma, and 40 cases of postcricoid carcinoma. According to American Joint Committe on Cancer(AJCC) 2018 criteria, 420 cases were of stage Ⅲ or Ⅳ; 325 cases were of T3 or T4 stage. Treatment methods included surgery alone in 84 cases, preoperative planned radiotherapy plus surgery in 49 cases, surgery plus adjuvant radiotherapy or concurrent chemoradiotherapy in 314 cases, and inductive chemotherapy plus surgery and adjuvant radiotherapy in 9 cases. The primary tumor resection methods included transoral laser surgery in 5 cases, partial laryngopharyngectomy in 74 cases, of them 48 cases (64.9%) presented with supracricoid hemilaryngopharyngectomy, total laryngectomy with patial pharyngectomy in 90 cases, total laryngopharyngectomy or with cervical esophagectomy in 226 cases, and total laryngopharyngectomy with total esophagectomy in 61 cases. Among 456 cases, 226 cases received reconstruction surgery with free jejunum transplantation, 61 cases with gastric pull-up, and 32 cases with pectoralis myocutaneous flaps. All patients underwent retropharyngeal lymph node dissection, and high-definition gastroscopy was performed during admission and follow-up. SPSS 24.0 software was used to analyze the data. Results: The 3-year and 5-year overall survival rates were respectively 59.8%, and 49.5%. The 3-year and 5-year disease specific survival rates were respectively 69.0% and 58.8%. Total metastasis rate of retropharyngeal lymph nodes was 12.7%. A total of 132 patients (28.9%) suffered from simultaneous and metachronous multiple primary carcinoma of the hypopharynx. Multivariate Logistic regression analysis showed that T3-4 disease, cervical lymph node metastasis, retropharyngeal lymph node metastasis and postoperative adjuvant radiotherapy were independent factors affecting the prognosis of patients (all P<0.05). As of April 30, 2022, a total of 221 patients died during follow-up, of 109 (49.3%) with distant metastases, which were the main cause of death. Conclusions: The efficacy of comprehensive treatment for hypopharyngeal cancer can be improved by accurate preoperative evaluation, improved surgical resection, active retropharyngeal lymph node dissection and full process intervention of the second primary cancer.

A retrospective comparative study between robotic thyroidectomy through transoral vestibular approach and bilateral breast-axillary approach / 中华外科杂志

Objective: To compare the surgical outcome of robotic thyroidectomy through transoral approach and the bilateral breast-axillary approach. Methods: Retrospective analysis was made on the clinical data of patients who performed transoral robotic thyroidectomy (TORT group) or bilateral breast-axillary approach (BABA group) in the Department of Thyroid and Breast Surgery, the 960th Hospital of People's Liberation Army from July 2020 to May 2022. Both groups received lobectomy with lymph node dissection of the central region. A total of 100 cases were included in the study, including 48 cases in the TORT group and 52 cases in the BABA group. The propensity score matching method was used for 1∶1 matching of patients between the 2 groups, with a match tolerance of 0.03. There were 31 patients in each group successfully matched. In the TORT group, there were 5 males and 26 females, aged (33.2±7.9) years (range: 21 to 53 years). While there were 4 males and 27 females in the BABA group, aged (34.6±9.2) years (range: 19 to 58 years). The t test, Mann-Whitney U test, χ2 test or Fisher exact test were used to compare the clinical efficacy between the two groups. Results: All the patients successfully completed robotic thyroid surgery without conversion to open surgery. Compared with BABA group, the TORT group had longer operation time ((211.3±57.2) minutes vs. (126.2±37.8) minutes, t=6.915, P<0.01), shorter drainage tube retention time ((5.4±1.0) days vs. (6.4±1.2) days, t=-3.544, P=0.001), shorter total hospital stay ((6.6±1.2) days vs. (7.4±1.3) days, t=-2.353, P=0.022), and higher cosmetic score (9.46±0.25 vs. 9.27±0.26, t=2.925, P=0.005). There was no significant difference between the two groups in the number of lymph nodes dissection, metastasis in the central compartment, and the incidence of postoperative complications (all P>0.05). Conclusions: Compared with the bilateral breast-axillary approach, the transoral vestibular approach of robotic thyroidectomy is also safe and effective. It shows similar surgical results to the bilateral breast-axillary approach in strictly selected patients, but the postoperative recovery speed is much faster, and the hospital stay is shorter. Transoral robotic thyroidectomy is a more recommended surgical method for patients with high aesthetic demand.

Retropharyngeal lymph node dissection in head and neck cancers treated with transoral robotic surgery / 中华肿瘤杂志

Objective: To evaluate the indications, safety, feasibility, and surgical technique for patients with head and neck cancers undergoing transoral robotic retropharyngeal lymph node (RPLN) dissection. Methods: The current study enrolled 12 consecutive head and neck cancer patients (seven males and four females) who underwent transoral robotic RPLN dissection with the da Vinci surgical robotic system at the Sun Yat-sen University Cancer Center from May 2019 to July 2020. Seven patients were diagnosed as nasopharyngeal carcinoma with RPLN metastasis after initial treatments, 4 patients were diagnosed as thyroid carcinoma with RPLN metastasis after initial treatments, and one patient was diagnosed as oropharyngeal carcinoma with RPLN metastasis before initial treatments. The operation procedure and duration time, intraoperative blood loss volume and complications, nasogastric feeding tube dependence, tracheostomy dependence, postoperative complications, and hospitalization time were recorded and analyzed. Results: All patients were successfully treated by transoral robotic dissection of the metastatic RPLNs, none of which was converted to open surgery. RPLNs were completely resected in 10 patients, and partly resected in 2 patients (both were nasopharyngeal carcinoma patients). The mean number of RPLN dissected was 1.7. The operation duration time and intraoperative blood loss volume were (191.3±101.1) min and (150.0±86.6) ml, respectively. There was no severe intraoperative complication such as massive haemorrhage or adjacent organ injury during surgery. Nasogastric tube use was required in all patients with (17.1±10.6) days of dependence, while tracheotomy was performed in 8 patients with (11.6±10.7) days of dependence. The postoperative hospitalization stay was (8.5±5.7) days. Postoperative complications occurred in 4 patients, including 2 of retropharyngeal incision and 2 of dysphagia. During a follow-up of (6.5±5.1) months, disease-free progression was observed in all patients, 10 patients were disease-free survival and other 2 patients were survival with tumor burden. Conclusions: The transoral robotic RPLN dissection is safety and feasible. Compared with the traditional open surgical approach, it is less traumatic and safer, has fewer complications and good clinical application potentiality. The indications for transoral robotic RPLN dissection include thyroid carcinoma, oropharyngeal carcinoma, and some selected nasopharyngeal carcinoma and other head and neck cancers. Metastatic RPLNs from some nasopharyngeal carcinoma with incomplete capsule, unclear border and adhesion to the surrounding vessels are not suitable for transoral robotic RPLN dissection.

How pathological criteria can impact prognosis of tongue and floor of the mouth squamous cell carcinoma

Abstract Pathological parameters have been indicated as tumor prognostic factors in oral carcinoma. Objective: The objective of this study was to investigate the impact of pathological parameters on prognosis of patients affected only by tongue and/or floor of the mouth squamous cell carcinoma (SCC). Methodology: In total, 380 patients treated in the Brazilian National Cancer Institute (INCA) from 1999 to 2006 were included. These patients underwent radical resection followed by neck dissection. The clinical and pathological characteristics were recorded. The Kaplan-Meier method and Cox proportional hazards model were used in survival analysis. Overall survival (OS), cancer-specific survival (CSS) and disease-free interval (DFI) were estimated. Cox residuals were evaluated using the R software version 3.5.2. Worst OS, CSS and DFI were observed in patients with tumors in advanced pathological stages (p<0.001), with the presence of perineural invasion (p<0.001) and vascular invasion (p=0.005). Results: Advanced pathological stage and the presence of a poorly differentiated tumor were independent prognostic factors for OS and CSS. However, advanced pathological stage and perineural invasion were independent predictors of a shorter OS, DFI and CSS. Conclusion: Pathological stage and perineural invasion were the most significant pathological variables in survival analysis in tongue and/or floor of the mouth SCC.

Prophylactic central neck dissection and local recurrence in papillary thyroid microcarcinoma: a meta-analysis / Esvaziamento cervical central profilático e recidiva local de microcarcinoma papilífero de tireoide: uma metanálise

Abstract Introduction: For papillary thyroid microcarcinoma patients, the reported incidence of lymph node metastasis is as high as 40%, and these occur mainly in the central compartment of the neck. Because these metastases are difficult to detect using ultrasonography preoperatively, some authors advocate routine central neck dissection in papillary thyroid microcarcinoma patients at the time of initial thyroidectomy. Objective: To evaluate whether prophylactic central neck dissection can decrease the local recurrence rate of papillary thyroid microcarcinoma after thyroidectomy. Methods: The publicly available literature published from January 1990 to December 2017 concerning thyroidectomy plus prophylactic central neck dissection versus thyroidectomy for papillary thyroid microcarcinoma was retrieved by searching the national and international online databases. A meta-analysis was performed after the data extraction process. Results: Four studies were finally included with a total of 727 patients, of whom, 366 cases underwent thyroidectomy plus prophylactic central neck dissection and 361 cases received thyroidectomy only. As shown by the meta-analysis results, the recurrence rates in cases of thyroidectomy plus prophylactic central neck dissection were approximately 1.91% and were significantly lower than those with thyroidectomy only (OR = 0.24, 95% CI [0.10, 0.56], p = 0.0009). Conclusion: For patients with papillary thyroid microcarcinoma, thyroidectomy plus prophylactic central neck dissection is a safe and efficient procedure and it results in lower recurrence rate. Since the evidences are of low quality (non-randomized studies), further randomized trials are needed.

Resumo Introdução: A incidência relatada de metástases linfonodais chega a 40% em pacientes com microcarcinoma papilífero de tireoide e essas ocorrem principalmente no compartimento cervical central. Como essas metástases são difíceis de ser detectadas com o uso de ultrassonografia no pré-operatório, alguns autores defendem o esvaziamento cervical central de rotina em pacientes portadores de microcarcinoma papilífero de tireoide no momento da tireoidectomia inicial. Objetivo: Avaliar se o esvaziamento cervical central profilático pode diminuir a taxa de recorrência local de microcarcinoma papilífero de tireoide após a tireoidectomia. Método: A literatura disponível, publicada de janeiro de 1990 a dezembro de 2017, sobre tireoidectomia com esvaziamento cervical central profilático versus tireoidectomia somente para microcarcinoma papilífero de tireoide foi obtida através de busca nas bases de dados online nacionais e internacionais. A metanálise foi feita após o processo de extração de dados. Resultados: Quatro estudos foram finalmente incluídos na metanálise, com 727 pacientes, dos quais 366 foram submetidos à tireoidectomia com esvaziamento cervical central profilático e 361 só receberam tireoidectomia. Como mostrado pelos resultados da metanálise, as taxas de recorrência com tireoidectomia com esvaziamento cervical central profilático foram de 1,91% e foram significantemente menores do que aquelas em pacientes submetidos somente à tiroidectomia (OR = 0,24, IC95% [0,10-0,56], p = 0,0009). Conclusão: Para pacientes com microcarcinoma papilífero de tireoide, o esvaziamento cervical central profilático é um procedimento seguro e eficiente e resulta em menor taxa de recorrência. Como as evidências são de baixa qualidade (estudos não randomizados), mais estudos randomizados são necessários.

Efficacy of Drainless Total Thyroidectomy in Intrathyroidal Lesions of Thyroid

Abstract Introduction There is difference of opinion about the placement of the drain in thyroid surgeries, and, to the best of our knowledge, the efficacy of drainless total thyroidectomy regarding various parameters of thyroid lesions has not been well-established. Objective To report our experience with drainless total thyroidectomy, and to define an appropriate patient population for its performance. Methods This is a retrospective case analysis of the patients who underwent total thyroidectomy for intrathyroidal lesions with or without central neck dissection in a tertiary referral hospital (number = 74). The patients, who had undergone total thyroidectomy without any drain insertion, were analyzed, and the relationships among various parameters of thyroid lesions were noted in relation to seroma and hematoma formation. Results Seroma formation was noted only in 5 out of 74 patents (6.75%). All of the seromas that occurred were observed in patients with thyroid lesions < 4 cm, and 4 out of 5 seromas were observed in patients with a malignant pathology. There was no statistically significant difference in seroma formation between patients younger or older than 50 years of age. The nature of the lesion, whether benign or malignant, did not affect the formation of seroma. Of interest is the fact that none of the 10 patients who had central neck dissection performed as part of their treatment developed seroma. Conclusions Drainless total thyroidectomy is safe across all age groups for patients harboring either benign or malignant thyroid pathologies. However, caution is to be observed in opting for drainless total thyroidectomy in patients with large lesions (> 5 cm)

Single transverse extended incision for radical neck dissection / Esvaziamento cervical radical por incisão transversa única estendida

ABSTRACT Objective: to assess the efficacy of the single transverse extended cervical incision in radical neck dissection. Method: we conducted a prospective study, from January 2008 to January 2009, with 18 patients undergoing surgical treatment of malignant tumors of the upper aero-digestive tract. The primary lesion was located in the oral cavity in eight cases, in the oropharynx in three, in the hypopharynx in three, in the larynx in two, in the maxillary sinus, and in one case, the primary injury was hidden. There were 29 neck dissections, eight bilateral and 10 unilateral (26 radical and three selective). Staging revealed nine patients with T4 tumor, one T3, six T2, one T1 and one Tx. Five patients were N0, nine N2b, one N2c and three N3. The average number of dissected lymph nodes was 34.25. We performed the neck dissection through a single incision located in the middle neck, coincident with the skinfold, with a length of about 2 to 3 cm behind the anterior edge of the trapezius muscle and 3 to 4 cm from the midline for the unilateral neck dissections. Results: as complications, there were myocutaneous flap necrosis in one patient with prior radiation therapy, one lymphatic fistula, one dehiscence of the tracheostomy, one cervical abscess, one salivary fistula and one suture dehiscence. Conclusions: the single extended incision provides adequate exposure of the neck structures, without compromising surgical time, even in bilateral dissections. It does not compromise the resection of all cervical lymph nodes; it has excellent aesthetic and functional results and is easily associated with other approaches to resection of the primary tumor.

RESUMO Objetivo: verificar a eficácia da incisão cervical única, transversa e estendida, para o esvaziamento cervical radical. Método: estudo prospectivo, de janeiro de 2008 a janeiro de 2009, de 18 pacientes submetidos a tratamento cirúrgico de tumores malignos da via aero-digestiva superior. A lesão primária se situava na cavidade oral em oito casos, na orofaringe em três, no seio piriforme em três, na laringe em dois, no seio maxilar em um e em um caso a lesão primária era oculta. Houve 29 esvaziamentos, sendo oito bilaterais e 10 unilaterais (26 radicais e três seletivos). O estadiamento revelou nove pacientes com tumor T4, um T3, seis T2, um T1 e um Tx. Cinco pacientes eram N0, nove N2b, um N2c e três N3. A média de linfonodos dissecados foi de 34,25. O esvaziamento cervical foi realizado por meio de uma única incisão localizada no terço médio do pescoço, coincidente com dobra cutânea, com extensão de cerca de 2 a 3 cm para trás da borda anterior do músculo trapézio e 3 a 4 cm da linha média para os esvaziamentos cervicais unilaterais. Resultados: como complicações houve necrose de retalho miocutâneo em um paciente com radioterapia prévia, uma fistula linfática, uma deiscência do traqueostoma, um abscesso cervical, uma fístula salivar e uma deiscência de sutura. Conclusões: a incisão única e estendida proporciona exposição adequada das estruturas do pescoço, sem comprometer o tempo cirúrgico, mesmo em esvaziamentos bilaterais. Não compromete a ressecção de todos os linfonodos cervicais, apresenta excelentes resultados estéticos e funcionais e é facilmente associada com outras abordagens para ressecção do tumor primário.

Quantitative analysis of lymph nodes in neck dissection specimens. Morphologic study

ABSTRACT PURPOSE: To quantify the amount of lymph nodes harvested in modified radical neck dissection. METHODS: Cross-sectional anatomical study conducted in 28 non-preserved cadavers. RESULTS: The mean number of lymph nodes found in each nodal level of the 56 modified radical neck dissections performed were: level IA - 1.5 (95% CI: 1.1 - 1.8), level IB - 2.5 (95% CI: 2.1 - 2.9), level IIA - 7.2 (95% CI: 6.0 - 8.5), IIB level - 6.5 (95% CI: 5.5 - 7.4), level III - 6.6 (95% CI: 5.7 - 7.4), level IV - 8.6 (95% CI: 7.1 - 10.1), level V - 11 (95% CI: 9.2 - 12.7), totalizing 43.8 lymph nodes (95% CI: 40.3 - 47.4). CONCLUSION: The results defined a parameter in relation to the minimum recommended nodal yield in a modified radical neck dissection, as well as the number of lymph nodes in each level of this dissection, performed in clinical practice.

The Role of Virtual Surgical Planning in the Era of Robotic Surgery

Among various surgical methods introduced to optimize esthetic results, robotic surgery has gradually expanded in scope. As incision, approach, and operation view in robotic surgery differ from existing surgical methods, we should consider reconstruction from a different perspective. We recently experienced two mandibular reconstruction cases after tumor ablative surgery with robotic neck dissection using the conventional reconstruction method and virtual surgical planning (VSP), respectively. We found that the conventional reconstruction method is inappropriate in modified facelift incision in robotic neck dissection because it provides limited surgical scope, restricts access to the defect area, and therefore, consumes considerable time before anastomosis. For these reasons, the authors consider VSP far more viable in the era of robotic surgery.

Preservación de la glándula submandibular en las disecciones linfonodulares de cuello / Preservation of the submandibular gland in lymph node neck dissections

Introducción: el desarrollo acelerado de la oncología ha condicionado recientes modificaciones terapéuticas que pudieran incluir la preservación de la glándula submandibular en las disecciones de cuello. Objetivos: identificar los criterios para preservar quirúrgicamente la glándula submandibular y exponer los fundamentos científico-teóricos que permitan plantear una modificación actual a la técnica de disección de cuello para conservar esta glándula. Métodos: se realizó una búsqueda exhaustiva retrospectiva de artículos publicados en las bases de datos electrónicas Pubmed, Medline, Cochrane e Hinari desde enero de 2009 hasta julio de 2014, en las revistas Head and Neck, Otolaryngology and Head and Neck Surgery y The Laryngoscope con los términos: preservación glándula submandibular, criterios oncológicos conservar glándula submandibular, modificaciones disecciones linfonodulares cervicales, sin restricciones idiomáticas. Se incluyeron solo los artículos publicados durante los últimos cinco años, cuyo material y método reflejara: estudios poblacionales, disecciones de cuello como tratamiento oncoespecífico y confirmación anatomo-patológica para concluir el diagnóstico. Análisis e integración de la información: de 3 estudios que conformaron una metapoblación de 829 pacientes, donde se preservó la glándula submandibular en un grupo de pacientes con tumores de cavidad bucal y orofaringe y disecciones de cuello simultáneas, se evidenció que no hubo diferencias en cuanto a recaída local, regional, a distancia ni sobrevida al compararlos con otro grupo de pacientes donde la disección de cuello no incluyó este proceder. Conclusión: los estudios coinciden en el bajo riesgo de metástasis ocultas a la glándula por carcinomas escamosos de cabeza y cuello, xerostomía posquirúrgica y factibilidad de la técnica quirúrgica como fundamentos para preservar la submandibular, de igual manera en que la ausencia de terapia oncoespecífica anterior, linfonódulos positivos en el subnivel IB y relación entre el tumor primario y la glándula son criterios necesarios en la selección de candidatos para realizar este proceder(AU)

Introduction: as a result of the swift development of oncology, some therapeutic modifications have recently been considered, among them the potential preservation of the submandibular gland in neck dissections. Objectives: identify the criteria to surgically preserve the submandibular gland and expound the theoretical scientific foundations allowing to set forth a modification to neck dissection technique with a view to preserving this gland. Methods: an exhaustive retrospective search was conducted of papers published in the databases Pubmed, Medline, Cochrane and Hinari from January 2009 to July 2014. The journals surveyed were Head and Neck, Otolaryngology and Head and Neck Surgery, and The Laryngoscope. The search terms used were submandibular gland preservation, oncological criteria preserve submandibular gland, modifications cervical lymph node dissections, without any language restrictions. Only papers published in the last five years were included. On the other hand, their materials and methods section should make reference to population studies, neck dissection as an onco-specific treatment, and anatomopathological confirmation of the diagnosis. Data analysis and integration: three studies with a metapopulation of 829 patients referred to a group of patients with oral and oropharyngeal tumors and simultaneous neck dissections whose submandibular gland had been preserved. These studies do not report any difference as to local, regional or distant relapse or survival when compared with another group of patients in whom neck dissection did not include such a procedure. Conclusion: all studies referred to the following aspects: the low risk of occult metastasis to the gland from head and neck squamous cell carcinomas, postsurgical xerostomia, and the feasibility of the surgical technique as foundations for the preservation of the submandibular gland. They also referred to the fact that absence of prior onco-specific therapy, positive lymph nodes in sublevel IB, and the relationship between the primary tumor and the gland are all required criteria for the selection of candidates for the procedure(AU)

Oral cavity squamous cell carcinoma: factors related to occult lymph node metastasis / Carcinoma espinocelular da cavidade oral: fatores relacionados à presença de metástases linfonodais ocultas

INTRODUCTION: Elective neck dissection is recommended in cases of oral cavity squamous cell carcinoma without lymph node metastasis because of the risk of occult metastasis. OBJECTIVE: The present study aimed to evaluate predictive factors for occult lymph node metastasis in patients with oral cavity squamous cell carcinoma treated with elective neck dissection and their impact on overall and disease-free survival. METHODS: Forty surgically treated patients were retrospectively included. RESULTS: Ten cases (25%) had lymphatic metastasis. Of the studied variables, perineural and angiolymphatic invasion in addition to tumor thickness were statistically associated with lymph node metastasis. Only angiolymphatic invasion was identified as an independent risk factor for occult metastasis in the logistic regression (OR = 39.3; p = 0.002). There was no association between overall and disease-free survival with the presence of occult lymph node metastasis. CONCLUSION: Metastatic disease rate was similar to that found in the literature. Perineural and angiolymphatic invasion and tumor thickness were associated with occult metastasis, but only angiolymphatic invasion showed to be an independent risk factor .

INTRODUÇÃO: O esvaziamento cervical eletivo é realizado de maneira sistemática nos casos de carcinoma espinocelular da cavidade oral sem linfonodos clinicamente comprometidos devido à alta incidência de metástases ocultas. OBJETIVO: Avaliar pacientes com carcinoma espinocelular de cavidade oral tratados com esvaziamento cervical eletivo quanto a fatores preditivos para ocorrência de metástases ocultas e o impacto das mesmas na sobrevivência global e livre de progressão destes pacientes. MÉTODO: Quarenta pacientes cirurgicamente tratados foram avaliados em estudo retrospectivo. RESULTADOS: Dez casos (25%) apresentaram metástases ocultas. Das variáveis analisadas, invasão perineural e angiolinfática e também a espessura tumoral foram estatisticamente significantes à análise univariada. Apenas a invasão angiolinfática foi fator independente de risco de metástases ocultas pela regressão logística (OR = 39,3; p = 0,002). A presença de metástase oculta não apresentou diferença estatisticamente significante em relação às taxas de sobrevivência global e livre de progressão. CONCLUSÃO: A incidência de metástase oculta foi semelhante à literatura. A invasão perineural, angiolinfática e a espessura tumoral foram fatores associados à presença de metástase oculta, porém apenas a invasão angiolinfática apresentou-se como um fator de risco independente para ocorrência do fenômeno. .

Neck Dissection in Verrucous Carcinoma: A Surgical Dilemma.

Oral verrucous carcinoma (OVC) is a distinct low grade variant of squamous cell carcinoma (SCC) of the oral cavity. OVC is a rare tumor representing only 3-4% of all carcinoma. OVC is characterized by a slow growing, painless, broad based verrucous or wart like papillary lesion. Th e lesion lacks ulceration and has a propensity for local invasion rather than metastatic spread. Transformation of VC to anaplastic or poorly diff erentiated SCC is about 30-40%. Surgical excision with adequate margins of resection seems to be the clear preference for treatment. Th e need for neck dissection is an important consideration in planning therapy for OVC. Th e aggressive clinical presentation of the tumor often sways clinical judgment in favor of performing lymph node dissection, especially in the presence of clinical lymphdenopathy. It is reasonable to consider a selective neck dissection such as supra-omohyoid neck dissection in situations where there is uncertainty regarding the pathological diagnosis in the phase of clinically suspicious lymphdenopathy. Here we are presenting a case report of OVC in 65-year-old male patient treated with surgical excision and right side supra-omohyoid neck dissection.

Cáncer de tiroides: En búsqueda del tratamiento individualizado / Thyroid cancer: In search of individualized treatment

La incidencia de cáncer de tiroides, principalmente carcinoma papilar, aumentó exponencialmente en todo el mundo. Este incremento podría reflejar los efectos combinados de las prácticas de detección , sumados a cambios en los factores de riesgo. A pesar de este aumento, la mortalidad específica se mantuvo estable en las últimas tres décadas. Dado que los pacientes con carcinoma papilar de tiroides a menudo tienen un muy buen pronóstico, con elevada supervivencia en el seguimiento a largo plazo en comparación con otro tipo de carcinomas, no ha habido una necesidad de cambiar el tratamiento convencional por mucho tiempo. Los pilares del tratamiento, cirugía (tiroidectomía total o casi total) y la terapia con radioyodo (131I), se encuentran en este momento en el centro de discusión en los foros mundiales. La tendencia actual es garantizar el tratamiento más eficaz y menos deletéreo para el paciente. En este momento lo más importante es individualizar el enfoque terapéutico considerando cuál es el estadio tumoral y el riesgo de recurrencia, para determinar qué pacientes se beneficiarán de una terapia más agresiva y cuáles podrán ser tratados con un enfoque más conservador.

The incidence of thyroid cancer has increased exponentially around the world (mostly papillary thyroid carcinoma). This growth may reflect the combined effects of increased screening practices, together with changes in risk factors for thyroid cancer. In spite of this, disease specific mortality remained stable in the last three decades. Due to the fact that patients with papillary thyroid carcinoma often have a very good prognosis, with high survival in the long term follow-up compared with other types of carcinomas, there has been no need to change the standard treatment. The mainstays of thyroid cancer treatment are surgery (total or near-total thyroidectomy) with or without the additional administration of radioiodine (131I). These approaches are now in the center of discussion in all global forums. The current trend is to ensure the most effective and less harmful treatment and the most important issue at this point is to individualize patients according to tumor stage and risk of recurrence, to define which patients will benefit of more aggressive therapy and who could be handled with a more conservative approach.

Esvaziamento cervical em níveis II e III para câncer de laringe em pacientes N0 / Levels II and III neck dissection for larynx cancer with N0 neck

A remoção dos níveis II, III e IV assumiram importância no tratamento do pescoço no carcinoma espinocelular (CEC) da laringe. Este estudo propõe a remoção dos níveis II e III, devido à baixa probabilidade de metástases linfáticas para nível IV. OBJETIVO: Estudar a prevalência de metástases linfáticas no nível IV em CEC da laringe. MÉTODO:Estudo prospectivo de pacientes consecutivos com CEC de laringe submetidos a esvaziamentos cervicais. Níveis cervicais foram identificados e marcados para posterior avaliação histopatológica. RESULTADOS: 6% (3/54) dos espécimes cirúrgicos apresentaram metástases linfáticas para nível IV. Todos os espécimes cirúrgicos cN0 (42) foram isentos de metástases para nível IV. Nos espécimes de pescoços cN (+) (12), 25% foram histopatologicamente positivos no nível IV. Esta diferença entre pescoços cN0 e cN (+) foi estatisticamente significativa (p = 0,009). Não houve metástases isoladas para o nível IV, sempre relacionado a nível II ou III comprometido (p = 0,002). CONCLUSÃO: A prevalência de metástases linfáticas para o nível IV em CEC da laringe no pescoço cN0 foi 0%. Metástase linfática no nível IV foi correlacionada com pescoço de cN (+). Metástases para nível IV foram relacionadas com metástases para o nível II ou III.

The removal of level II, III, and IV metastases has gained importance in the treatment of squamous cell carcinomas (SCC) of the neck and larynx. This study assessed the possibility of removing level II and level III metastases only, given the low likelihood of occurrence of metastatic lymph nodes on level IV in SCCs of the larynx. OBJECTIVE: This study aimed to analyze the prevalence rates of metastatic lymph nodes on level IV in laryngeal SCC patients. METHODS: This prospective study enrolled consecutive patients with laryngeal SCC submitted to neck lymph node dissection. Neck levels were identified and marked for future histopathology testing. RESULTS: Six percent (3/54) of the necks had level IV metastatic lymph nodes. All cN0 necks (42) were free from level IV metastasis. Histopathology testing done in the cN (+) necks (12) revealed that 25% of the level IV specimens were positive for SCC. The difference between cN0 and cN (+) necks was statistically significant (p = 0.009). Level IV metastases never occurred in isolation, and were always associated with level II or level III involvement (p = 0.002). CONCLUSION: The prevalence rate for lymph node metastasis in cN0 necks was 0%. Level IV metastatic lymph nodes were correlated to cN (+) necks. Level IV metastasis was associated with the presence of metastatic lymph nodes in levels II or III.

Esvaziamento cervical no carcinoma epidermoide de laringe: indicação de esvaziamento eletivo contralateral / Neck dissection in squamous cell carcinoma of the larynx: indication of elective contralateral neck dissection

O planejamento terapêutico dos tumores da laringe inclui a possibilidade de esvaziamento cervical uni ou bilateral. OBJETIVO: Avaliar a prevalência e localização de metástases linfonodais bilaterais ou contralaterais nos tumores de laringe. CASUÍSTICA E MÉTODO: Estudo longitudinal retrospectivo de 272 prontuários de pacientes com carcinoma epidermoide de laringe tratados entre 1996 e 2004, selecionados 104 submetidos à cirurgia com esvaziamento cervical. Avaliada a incidência de metástases bilaterais ou contralaterais, de acordo com a localização e extensão do tumor primário, considerando os subsítios anatômicos e a linha mediana. RESULTADOS: A prevalência de metástases contralaterais nos tumores lateralizados foi de 3,5% nas lesões glóticas e 26% nas lesões supraglóticas. As metástases contralaterais foram infrequentes nos casos N0. Tanto no esvaziamento eletivo como no terapêutico, os níveis linfonodais IIa e III foram os mais acometidos. CONCLUSÃO: Nas lesões glóticas lateralizadas, mesmo nos tumores transglóticos, não há necessidade de esvaziamento contralateral eletivo. Nas lesões da supraglote sem metástases ipsilaterais, a incidência de metástases ocultas não justifica o esvaziamento eletivo contralateral. A linha mediana não é um indicador fidedigno do risco de metástases contralaterais nos tumores da laringe.

Unilateral or bilateral neck dissection must be considered in the treatment of laryngeal cancer AIM: To evaluate the prevalence of contralateral metastases in larynx cancer and distribution of these metastases according to lymph node levels in the neck. METHOD: Retrospective longitudinal study of 272 charts from patients with squamous cell cancer of the larynx treated between 1996 and 2004; and we selected 104 surgical cases submitted to neck dissection. We evaluated the incidence of bilateral or contralateral metastases, according to the location and extension of the primary tumor, considering the anatomical sub-sites and the midline. RESULTS: Contralateral metastases in lateral tumors were observed in 3.5% of glottic lesions and in 26% of supraglottic lesions. Contralateral metastases were uncommon in N0 patients. Lymph nodes levels IIa and III were the most commonly involved in the neck. CONCLUSION: In lateral glottic tumors there is no need for elective contralateral neck dissection. In supraglottic lesions without ipsilateral metastases, the incidence of hidden metastasis does not justify elective contralateral dissection. The midline is not a reliable indicator of the risk of contralateral laryngeal tumors.

Linfogammagrafía con SPECT/CT en neoplasias cutáneas de cabeza y cuello / Lymphogammagraphy with SPECT/CT in head and neck cutaneous neoplasms

Las neoplasias cutáneas son un motivo de consulta cada día mayor; especialmente, en las regiones del trópico. Para los profesionales que atienden a pacientes con este tipo de patologías, resulta de vital importancia tener claro el manejo de ellas; sobre todo, el melanoma y el carcinoma escamocelular de piel de cabeza y cuello. No solo se debe tratar el sitio primario, sino también los relevos ganglionares que podrían estar afectados, dependiendo de los factores de riesgo de la enfermedad. Como no está claro el uso de intervenciones conservadoras para tratar los ganglios del cuello en estos pacientes, ha surgido en el Instituto Nacional de Cancerología (INC) la necesidad de implementar el uso de la linfogammagrafía con tomografía computarizada de emisión de fotón único más tomografía computada (SPECT/CT), para definir cuáles grupos ganglionares del cuello deben ser retirados. Con el fin de aclarar tópicos de esta técnica, se revisa el tema.

According to medical statistics, the frequency of cutaneous neoplasms is on the rise, particularly in tropical regions. It is highly important for physicians who treat these pathologies to have extensive knowledge on their control, especially for melanoma and head and neck squamous cell carcinoma. Not only should the primary site be treated, but so too should the relay lymph nodes, since these could be affected, depending upon the risk factors of the disease. Due to the fact that no clear conclusions exist on the effects of using conservative interventions to treat neck ganglia in these patients, the National Cancer Institute of Colombia (INC) has initiated the use of lymphogammagraphy with computed tomography single photon emission plus computed tomography (SPECT/CT) to define which neck nodal groups should be removed. Aspects of this topic are reviewed below.

Immunomorphological assessment of regional lymph nodes for predicting metastases in oral squamous cell carcinoma.

Background: Oral squamous cell carcinoma is the most common neoplasm and comprises of approximately 80% of the cancers occurring in the oral cavity. The role of the host response to this neoplasm has been recognized, and for many years the regional lymph node in tumor-bearing hosts has been considered as an anatomic barrier to the systematic dissemination of tumor cells. Morphological evaluation of the regional nodes has aided in understanding the immune response. Aim: The current study was carried out to observe the morphological changes occurring in the regional lymph nodes and to evaluate whether these features could be helpful in assessing the immunological status of the patient, and thereby, the prognosis of the patient. Materials and Methods: The study was based on lymph nodes from 63 patients with oral squamous cell carcinoma, who underwent radical neck dissection or modified neck dissection. In the lymph node, four morphological patterns were observed that included lymphocyte predominance, germinal center predominance, mixed pattern (sinus Histiocytosis), and an unstimulated pattern. The cases were then divided into four groups according to the predominant immunoreactivity pattern based on the World Health Organization (WHO) standardized system for reporting human lymph node morphology. Results: Revealed that risk of metastases to cervical lymph nodes in patients with lymphocyte predominance was less (28.6%) when compared to the high risk of metastases with germinal center predominance (68%), and these results were statistically significant (P < 0.05). Patients with a mixed pattern showed less risk of metastases (45.4%), while those with an unstimulated pattern had increased risk of metastases (66.6%), but the results were not statistically significant. It was also found that in the positive nodes, germinal center hyperplasia (50.2%) was the predominant pattern. Conclusion: The present study revealed that patients with lymphocyte predominance had less risk of metastases and patients with germinal center predominance had a high risk of metastases to the lymph node.

Comparison of the complication between the radical neck dissection and selective neck dissection for the patient of oral squamous cell carcinoma

To compare the outcome of the radical neck dissection and selective neck dissection for control of the disease in those patients who have their nodal involvement localized to level I, II, III. Prospective Randomizing Study. This study was conducted in Oral and Maxillofacial Surgery Department, Mayo Hospital, Lahore from 1[st] January to 31[st] December 2001. The study was conducted in dental section, Mayo hospital, Lahore. Thirty patients of squamous cell carcinoma of oral cavity were selected and randomly divided into two groups. Group I was subjected to selective dissection of the tumour while group I was subjected to radical neck dissection. Postoperative complications were recorded each follow up visit. Post operatively, in group I secondary hemorrhage occurred in 26.7% while in group II, it occurred in 40.0%, group I showed delayed healing due to infection in 46.7% while in group II, it was 73.3%. In group I and group II, there was no recurrence after 1 month, 3 month and 6 month. After 9 months recurrence was noted in groups. It was 20% in group I while 6.7% in group II. Selective-neck dissection should be preferred in the patient of oral squamous cell carcinoma with level I, II, III lymph node involvement as compared to radical neck dissection however recurrence rate is higher in patients undergoing selective neck dissection as compared to patients undergoing radical neck dissection

Histological description of the interaction between muscle fibers and connective tissue of the fascia of the human trapezius muscle / Descripción histológica de la interacción entre las fibras musculares y tejido conectivo de la fascia del músculo trapecio humano

The skeletal muscle fascia corresponds to a condensation of connective tissue. Fascias are highly innervated and sensitive, and can cover non-expandable structures as well as musculature. It is suggested that fascias have a pivotal role in functions such as postural regulation, peripheral motor coordination and proprioception. Also, the presence of inflammation and microcalcification in fascia of patients with localized muscle pain has been described, suggesting a pathogenic role in pain. The aim was to describe the histological structure of the external deep fascia of the trapezius muscle, with emphasis on the content and arrangement of muscle fibers, type I collagen, and adipose tissue. Sample material was obtained from a male cadaver (60-70 years old), by dissection of the posterior cervical region of the superficial fascia of the trapezius muscle and fixed in buffered formalin. Samples were processed by routine histological techniques and embedded in paraffin, obtaining 5 µm-thick sections that were stained according to the van Gieson technique. The trapezius fascia is composed of type I collagen, organized into high-density collagen bundles and oriented in different directions, and by adipocytes disposed in longitudinal groups on the main axis of the fascia. Muscle fibers are organized into bundles that are inserted laterally on the thickness of the fascia. It is possible that lateral transmission of tensional forces between the fibers might be present.

La fascia del músculo esquelético corresponde a una condensación de tejido conectivo. Las fascias están inervadas y son sensibles y pueden cubrir estructuras no distensibles, así como las fibras musculares esqueléticas. Tienen un rol importante en la regulación de la postura, la coordinación motora periférica y la propiocepción. Además, se ha descrito la presencia de inflamación y microcalcificaciones en la fascia de los pacientes con dolor muscular localizado, lo que sugiere un rol patogénico en el dolor. El objetivo del trabajo fue describir la estructura histológica de la fascia externa profunda del músculo trapecio, con énfasis en el contenido y la disposición de las fibras musculares, colágeno tipo I y el tejido adiposo. Material y métodos: El material de la muestra fue obtenido de un cadáver de sexo masculino (60-70 años), por la disección de la región cervical posterior de la fascia superficial del músculo trapecio e inmediatamente fijado en formalina tamponada (pH 7,2) durante 48 horas. La muestra fue procesada por técnicas histológicas e impregnada en parafina (punto de fusión 56-58 C). Secciones de 5 µm de espesor fueron montadas en láminas silanizada para el desarrollo del protocolo de la técnica de van Gieson. Resultados y discusión: Se observa que la fascia del trapecio está compuesta por tejido conectivo denso irregular con abundante colágeno tipo I, organizado en paquetes grandes como verdaderos haces de colágeno de alta densidad orientada en diferentes direcciones; y por adipocitos dispuestos en grupos longitudinales en el eje principal de la fascia. Las fibras musculares estriadas están organizadas en paquetes que se insertan lateralmente en el espesor de la fascia. Es posible que la transmisión lateral de la tensión entre las fibras esté presente.

Who are the low-risk patients that could benefit from watch-and-wait regarding the neck? / Quem são os pacientes de baixo risco que poderiam beneficiar-se de conduta expectante do pescoço?

CONTEXT AND OBJECTIVE: The management of clinically negative neck is controversial, with an ongoing debate on the indication criteria and prognostic impact of different types of therapy. The aim here was to compare the results from neck dissection and watch-and-wait, among oral cancer patients who, clinically, did not show any evidence of neck metastasis. DESIGN AND SETTING: Retrospective analysis in a tertiary cancer center hospital. METHODS: Patients with epidermoid oral carcinoma were assessed. The inclusion criteria were: primary tumor restricted to the oral/oropharyngeal cavity, no previous treatment, surgical treatment as the first option, clinical/radiological stage N0 and no distant metastasis. RESULTS: Two hundred and sixty-two patients were analyzed. The length of follow-up ranged from four to 369.6 months and, at the end, 118 patients were alive, 53 had died due to cancer, 84 had died from other causes and 7 had died after the operation. Among the patients who underwent neck dissection, lymphatic vascular embolization (P = 0.009) and tumor thickness (P = 0.002) were significant for regional recurrence, while for the watch-and-wait group, only tumor thickness was significant (P = 0.018). Through recursive partitioning, the patients without adverse prognostic factors and tumor thickness < 2 mm presented compatible results in the two groups. CONCLUSION: Elective neck dissection seems to be the best treatment option. Patients who are eligible for watch-and-wait constitute a small group that, ideally, is categorized according to the postoperative pathological findings.

CONTEXTO E OBJETIVO: O manejo do pescoço clinicamente negativo é controverso, havendo um debate corrente sobre os critérios de indicação bem como o impacto prognóstico das diferentes modalidades terapêuticas. O objetivo foi comparar os resultados do esvaziamento cervical com a observação em pacientes com câncer de boca e clinicamente sem evidência de metástases cervicais. TIPO DE ESTUDO E LOCAL: Análise retrospectiva em hospital terciário, especializado em oncologia. MÉTODOS: Pacientes com diagnóstico de carcinoma epidermoide de boca foram analisados. Os critérios de inclusão foram: tumor primário restrito à cavidade oral/orofaringe, ausência de tratamento prévio, tratamento cirúrgico como primeira opção, estádio clínico e radiológico N0 e ausência de metástases a distância. RESULTADOS: Duzentos e sessenta e dois pacientes foram analisados. O tempo de acompanhamento variou de 4 a 369.6 meses e, ao final, havia 118 pacientes vivos, 53 óbitos pela neoplasia, 84 óbitos por outras causas e 7 óbitos pós-operatórios. Nos pacientes submetidos a esvaziamento cervical, a embolização vascular linfática (P = 0,009) e a espessura tumoral (P = 0,002) foram associados significativamente com a recidiva regional, enquanto que nos pacientes somente observados, apenas a espessura tumoral se associou significativamente (P = 0,018). Por meio do particionamento recursivo, aqueles pacientes sem fatores adversos prognósticos e espessura tumoral menor que 2 mm apresentaram resultados compatíveis em ambos os grupos. CONCLUSÃO: O esvaziamento cervical eletivo parece ser a melhor opção de tratamento. Pacientes candidatos a observação constituem um pequeno grupo e a sua categorização ideal depende de achados patológicos pós-operatórios.