Factors of local recurrence and organ preservation with transoral laser microsurgery in laryngeal carcinomas; CHAID decision-tree analysis.

BACKGROUND: Indications of transoral laser microsurgery (TLM) are conditioned by the risk of local relapse. OBJECTIVE: To evaluate prognostic factors of local relapse and local control with TLM (LC-TLM). METHODS: Local relapse and LC-TLM were evaluated in 1119 patients. Logistic regression and CHAID decision tree analysis were performed. RESULTS: Local relapse correlated to previous radiotherapy failure (8.45, CI 95%: 2.64-27.03; P < .001), paraglottic involvement (2.42, CI: 1.41-4.15; P = .001), anterior commissure involvement (2.12, CI: 1.43-3.14; P < .001), grade of differentiation (1.74, CI: 1.18-2.57; P = .005), and alcohol consumption (1.4, CI: 0.99-1.98; P = .057). Local relapse tended to inversely correlate with experience (0.73, CI: 0.51-1.03; P = .078). The most important factors for local relapse were previous radiotherapy failure and anterior commissure involvement. LC-TLM inversely correlated with previous radiotherapy failure (0.09, CI: 0.03-0.28; P < .001), paraglottic involvement (0.25, CI: 0.14-0.43; P < .001), anterior commissure involvement (0.49, CI: 0.32-0.77; P = .007), margins (0.56, CI: 0.30-1.04; P = .068), and differentiation (0.68, CI: 0.44-1.05; P = .087). LC-TLM correlated with experience (1.71, CI: 1.13-2.55; P = .010). The most important factors for LC-TLM were previous radiotherapy failure and paraglottic involvement. CONCLUSION: Previous radiotherapy failure is the most important factor for local relapse and LC-TLM. In primary treatments, anterior commissure involvement and paraglottic involvement are the most important factors for local relapse and LC-TLM, respectively.

Narrow band imaging for head and neck malignancies: Lessons learned from mistakes.

BACKGROUND: The accuracy of white light endoscopy in combination with narrow band imaging (WLE + NBI) for diagnosis of squamous cell carcinoma (SCC) does not reach 100%. We evaluated the characteristics of the false-negative and false-positive cases. METHODS: Five hundred thirty lesions of the upper airways were evaluated. The WLE was followed by NBI examination before performing a biopsy. RESULTS: The false-negative lesions (7.36%) were represented by submucosal and non-SCC tumors. Among the 25 non-SCC tumors, 72% did not show any suspicious vascular pattern under NBI. The false-positive lesions (6.04%) were mainly represented by postradiotherapy mucosal changes, ulcers, and infections. Regarding papillomas, NBI accuracy reached 95.32%, although cases with dysplasia were difficult to distinguish from SCC. CONCLUSION: The WLE + NBI improved diagnostic accuracy, but not all lesions were ideally evaluated with current defined patterns. An accurate anamnesis is mandatory, because, in some cases, it may be more relevant than the NBI pattern.

Usefulness of office examination with narrow band imaging for the diagnosis of head and neck squamous cell carcinoma and follow-up of premalignant lesions.

BACKGROUND: The purpose of this study was to evaluate the value of narrow band imaging (NBI) examination in the office for the diagnosis and follow-up of upper airway premalignant and malignant lesions. METHODS: Four hundred eighty lesions were evaluated with white light endoscopy (WLE) and NBI before a biopsy/excision. Additionally, 151 premalignant lesions were followed up without proven biopsy. Carcinoma-free survival was calculated. The learning curve was analyzed. RESULTS: Overall, the accuracy improved from 74.1% with WLE to 88.9% with NBI, being relevant in all anatomic subsites. The accuracy of NBI increased significantly with increasing experience (area under the curve [AUC] >0.9). After a follow-up of 25 months, 14 of 151 lesions (9.3%) converted into carcinoma. The 4-year carcinoma-free survival rate was 86.4%. The 4-year carcinoma-free survival rate differed significantly between lesions classified as benign/mild dysplasia versus those presenting as moderate/severe dysplasia (88.9% vs 73.5%; P = .018). CONCLUSION: The NBI provided a greater accuracy than WLE and showed promising usefulness for the follow-up of premalignant lesions.

The Role of Audiometry prior to High-Dose Cisplatin in Patients with Head and Neck Cancer.

OBJECTIVES: To analyze the role of audiometry in considering change to a less ototoxic treatment in head and neck cancer (HNC) patients. METHODS: Consecutive patients prescribed high-dose cisplatin (100 mg/m2) between January 2013 and February 2015 were enrolled. Audiometry was performed at baseline and before cisplatin. Change to a less ototoxic agent or reduced cisplatin dose was considered with audiometric decreases >25 dB. RESULTS: A total of 103 patients were included; the median age of the patients was 59 years (range 18-75). Cisplatin was intended curative (58%), adjuvant (32%), or palliative (10%). Forty-two participants (41%) did not commence high-dose cisplatin because of baseline audiometric alterations. Of 61 patients treated with high-dose cisplatin, 40 (66%) showed marked ototoxicity at the end of treatment. The mean hearing loss between initial and final audiometries showed a hearing loss at 4 and 8 kHz in both ears (p = 0.002). Thirteen patients switched to carboplatin and 15 to a lower dose of cisplatin. The outcome was not significantly altered when cisplatin was replaced with carboplatin or cetuximab. CONCLUSIONS: Audiometric alterations are common in HNC with high-dose cisplatin, and switching to a less ototoxic regimen does not adversely affect outcome. Audiometric examination could help to prevent hearing loss in this population.

Long-term quality of life after transoral laser microsurgery for laryngeal carcinoma.

BACKGROUND AND OBJECTIVES: Previous studies showed good short-term Quality of life (QOL) after Transoral Laser Microsurgery (TLM) for laryngeal cancer. Here, we aimed to evaluate QOL after TLM in the long-term. METHODS: Prospective longitudinal study. Sixty-two consecutive disease-free patients were evaluated using UW-QOL v4 and SF-12 questionnaires, 1 and 5 years after TLM. Changes over time were assessed according to age, location, and tumor size. Long-term VHI-10 was also evaluated. RESULTS: The mean follow-up time was 5.41 ± 2.02 years. No differences in the global UW-QOL score were observed between 1 and 5 years after TLM (1135.00 vs. 1127.20; P = 0.4). Activity worsened slightly in the long-term (93.03 vs. 87.70; P = 0.02). Forty-two and 58% of the patients reported that their health 1 and 5 years after treatment was much better than prior to diagnosis. Initially, 3.3% considered their health much worse, which was reduced to 1.7% at 5 years. SF-12 scores remained unchanged for both physical and mental aspects (P > 0.05). The VHI-10 was 3.81 ± 5.7 for supraglottic and 7.2 ± 9.6 for glottic tumors. CONCLUSION: Patients treated with TLM present a very good long-term QOL. Only activity deteriorates over time, while voice and swallowing remain satisfactory in the majority of patients. J. Surg. Oncol. 2016;114:789-795. © 2016 2016 Wiley Periodicals, Inc.

Electrochemotherapy as palliative treatment in patients with thyroid papillary carcinoma / Eletroquimioterapia como tratamento paliativo em pacientes com carcinoma papilar da tireoide

ABSTRACT INTRODUCTION: Local progression of papillary thyroid carcinoma (PTC) after failure of standard therapies may cause pain, ulceration, and bleeding. As patients are fully aware of the tumor growth, they might suffer high grade anxiety. Electrochemotherapy (ECT) is a new local palliative treatment for skin metastases of malignant melanoma or other tumors, including squamous head e neck cancer patients. OBJECTIVE: To evaluate the impact of ECT in patients with local progression of PTC. METHODS: Four patients with local progression of PTC were treated with ECT based on Bleomycin, and evaluated according to tumor response, local pain and side effects. RESULTS: In all cases, some grade of tumor response was observed, lasting 6, 7, 12 and 8 months, respectively. Also, reduction of local pain and anxiety was registered in all patients. Tumor infiltrated skin necrosis was the only collateral effect of the treatment. ECT induced a tumor response in all PTC patients with improvement of symptoms. CONCLUSIONS: ECT may be an option for local palliative treatment in PTC patients with local tumor progression.

Resumo Introdução: A progressão local do carcinoma papilífero de tireoide (CPT) após a falha da terapia de rotina pode causar dor, ulceração e sangramento. Considerando que os pacientes estão perfeitamente cientes do crescimento tumoral, podem apresentar um alto grau de ansiedade. A eletroquimioterapia (EQT) é um novo tratamento paliativo para metástases de pele de melanoma maligno ou de outros tumores, inclusive em pacientes com carcinoma escamoso de cabeça e pescoço. Objetivo: Avaliar o impacto da EQT em pacientes com progressão local de CPT. Método: Quatro pacientes com progressão local de CPT foram tratados com EQT com base em bleomicina, e avaliados em relação ao grau de resposta tumoral, dor local, efeitos colaterais. Resultados: Em todos os casos, foi observado algum grau de resposta tumoral, que perdurou por 6, 7, 12 e 8 meses, respectivamente. Da mesma forma, foi registrada diminuição da dor local e da ansiedade em todos os pacientes. Necrose cutânea na infiltração tumoral foi o único efeito colateral do tratamento. EQT induziu resposta tumoral em todos os pacientes com CPT, com melhora dos sintomas. Conclusões: EQT pode ser uma opção para o tratamento paliativo tópico em pacientes com CPT com progressão tumoral local.

Alcohol consumption in upper aerodigestive tract cancer: Role of head and neck surgeons' recommendations.

This study aims to describe the prevalence of alcohol consumption in patients diagnosed with an upper aerodigestive tract cancer (UADTC) and evaluate the clinical impact of head and neck surgeons' recommendations on alcohol intake. An observational, retrospective, and cross-sectional study was conducted. Socio-demographic data, type of cancer, psychiatric history, substance-use history, and DSM-IV-TR criteria for alcohol dependence were recorded. Patients were asked to report their alcohol consumption before UADTC diagnosis and during their follow-up. All patients were asked if they had received from the specialist any recommendation to reduce or stop their alcohol consumption. One hundred ninety-one patients were included. Laryngeal cancer was the most frequent. 85.3% of patients were alcohol consumers before being diagnosed, 39.8% were risky drinkers, and 13.1% had alcohol dependence. The prevalence of alcohol use decreased by 16.7% after the UADTC was diagnosed. The proportion of risky drinkers decreased from 46.6% to 24.5%. Almost half of the patients did not recall having received any recommendation regarding alcohol consumption. Receiving a recommendation was independently associated with a positive response (reduced or stopped alcohol consumption) with an Odds Ratio 3.7; p < 0.001. Prevalence of alcohol dependence and risky drinking (39.8%) is high in UADTC patients, compared to the general population. Otorhinolaryngologists and head and neck surgeons frequently provide recommendations about alcohol consumption, which has a relevant impact on the reduction of alcohol intake. Further prospective studies focused on brief advice should be performed in order to demonstrate effectiveness in this population.

Transoral laser microsurgery for locally advanced (T3-T4a) supraglottic squamous cell carcinoma: Sixteen years of experience.

BACKGROUND: Controversy exists regarding treatment of advanced laryngeal cancer. The purpose of this study was to evaluate the oncologic and functional outcomes of T3 to T4a supraglottic squamous carcinomas treated with transoral laser microsurgery (TLM). METHODS: We conducted a retrospective analysis from an SPSS database. Primary outcomes were: locoregional control, overall survival (OS), disease-specific survival (DSS), laryngectomy-free survival, and function-preservation rates. Secondary objectives were: rate of tracheostomies and gastrostomies according to age. Risk factors for local control and larynx preservation were also evaluated. RESULTS: One hundred fifty-four consecutive patients were chosen for this study. Median follow-up was 40.7 + /- 32.8 months. Five and 10-year OS, DSS, and laryngectomy-free survival were 55.6% and 47%, 67.6% and 58.6%, and 75.2% and 59.5%, respectively. Paraglottic involvement was an independent factor for larynx preservation. Six patients (3.9%) needed a definitive tracheostomy, a gastrostomy, or both. The gastrostomy rate was higher in the group of patients above 65 years of age (p = .03). Five-year laryngectomy-free survival with preserved function was 74.5%. CONCLUSION: TLM constitutes a true alternative for organ preservation in locally advanced supraglottic carcinomas with good oncologic and functional outcomes. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1050-1057, 2016.

Electrochemotherapy as palliative treatment in patients with thyroid papillary carcinoma.

INTRODUCTION: Local progression of papillary thyroid carcinoma (PTC) after failure of standard therapies may cause pain, ulceration, and bleeding. As patients are fully aware of the tumor growth, they might suffer high grade anxiety. Electrochemotherapy (ECT) is a new local palliative treatment for skin metastases of malignant melanoma or other tumors, including squamous head e neck cancer patients. OBJECTIVE: To evaluate the impact of ECT in patients with local progression of PTC. METHODS: Four patients with local progression of PTC were treated with ECT based on Bleomycin, and evaluated according to tumor response, local pain and side effects. RESULTS: In all cases, some grade of tumor response was observed, lasting 6, 7, 12 and 8 months, respectively. Also, reduction of local pain and anxiety was registered in all patients. Tumor infiltrated skin necrosis was the only collateral effect of the treatment. ECT induced a tumor response in all PTC patients with improvement of symptoms. CONCLUSIONS: ECT may be an option for local palliative treatment in PTC patients with local tumor progression.

Prognostic factors of quality of life after transoral laser microsurgery for laryngeal cancer.

We aimed to evaluate factors influencing quality of life (QOL) after transoral laser microsurgery (TLM) of laryngeal cancer. Four hundred and one consecutive disease-free patients were evaluated 1 year after treatment using the University of Washington-QOL v4, the SF-12 (short form of SF-36), and a questionnaire about self-rated health status. The importance of age, gender, tumor location, tumor size, tumor stage, neck dissection and adjuvant treatment were evaluated. One year after TLM patients had a good QOL, with only 6 % of patients reporting a worsening in their health status. Radiation therapy (p = 0.000) and neck dissection (p = 0.000) were negative factors for disease-specific QOL, whereas age ≥ 70 (p = 0.01) was a positive independent factor for mental score of SF-12. Speech was negatively influenced by tumor size (p = 0.001) as was swallowing by age (p = 0.001) and postoperative radiation (p = 0.000). Patients treated with TLM present a good QOL 1 year after surgery. Radiation and neck dissection negatively impact QOL. Elderly patients cope better with their disabilities.

Prognostic significance and association of Helicobacter pylori infection in pharyngolaryngeal cancer.

The aim of this study is to assess the correlation between the Helicobacter pylori (H. pylori) serologic status of patients who underwent for curative resection for squamous cell carcinoma of the larynx and hypopharynx and their prognosis. From April 2004 to March 2005, we included eighty patients with laryngeal and hypopharyngeal cancer. Control group consisted of 20 healthy patients and 10 patients with Reinke's edema. Serologic status was assessed using an enzyme-linked immunosorbent assay kit for immunoglobulin G. Patients were followed for 5 years. H. pylori-positive serologic status was statistically significant for the case subjects (70.6 v/s 29.4 %; p < 0.001). Mean overall and disease-free survival were 50.7 months (range 46.9-54.5) and 52.1 months (range 48.3-55.7), respectively. H. pylori-positive serologic status was not associated with a poor prognosis in the Cox regression model (p = 0.77). We observed a positive association between H. pylori infection and laryngeal and hypopharyngeal cancer. But we fail to confirm that the presence of H. pylori infection is associated with poor outcome or a higher recurrence rate.

Quality of life after transoral laser microresection of laryngeal cancer: a longitudinal study.

BACKGROUND AND METHODS: In the treatment of early to moderate laryngeal carcinoma, both, transoral laser surgery and radiation-based protocols have demonstrated good survival and preservation rates. In this scenario, quality of life (QOL) may become an important tool for treatment planning. We aimed to evaluate QOL changes after transoral laser microsurgery (TLM). Prospective longitudinal study. Ninety-three consecutive disease-free patients were evaluated using UW-QOL v4 and SF-12, before and 12 months after treatment. Changes over time were assessed according to age, gender, location, tumor size, and adjuvant treatment. RESULTS: UW-QOL improved from 1,051.5 ± 133.7 to 1,121.7 ± 92.1 (P = 0.000), suggesting that the impact of the treatment was favorable in most of the patients. Voice quality significantly improved after TLM, but speech was still the most important variable for 46% of the patients. Tumor location (P = 0.002) was an independent factor for preoperative total score of UW-QOL, whereas adjuvant radiation (P = 0.03) and neck dissection (P = 0.02), were the only postoperative negative factors. CONCLUSION: One year after TLM patients present a very good QOL. Relevant voice impairment is detected especially in locally advanced tumors, reinforcing the necessity of preoperative counseling and postoperative rehabilitation. Adjuvant radiotherapy and neck dissection negatively influenced disease-specific QOL.

The learning curve in transoral laser microsurgery for malignant tumors of the larynx and hypopharynx: parameters for a levelled surgical approach.

The goal of the study was to identify parameters helpful to define a learning curve for laser microsurgery (TLM). 587 patients with malignant tumors of larynx and hypopharynx treated with TLM were divided into groups depending on the number of interventions their surgeons had performed. Outcome measures were obtained for the number of revision surgeries and complications, rates for tumor-free margins, tumor relapse and disease-specific survival rates for early and advanced tumors, serving to evaluate their potential influence on the learning curve. Surgery of early tumors was not influenced by the grade of experience. For locally advanced tumors the learning curve was statistically related to the number of surgeries needed per patient (p = 0.018). The number of overall complications (p = 0.000) and the disease-specific survival rate (p = 0.019) was significantly lower in the "expert" group. The percentage of postoperative bleedings was similar between all groups. Tumor-free margins and tumor relapse were not influenced by experience. In TLM, a learning curve could be observed for locally advanced tumors.

Transoral laser surgery for hypopharyngeal carcinomas.

PURPOSE OF REVIEW: Organ preservation strategies are a major focus of interest in head and neck cancer. There are two ways to preserve the function in the treatment of squamous cell carcinomas of the hypopharynx: organ-sparing surgery or neoadjuvant or concomitant chemoradiotherapy. From the surgical point of view, the possibilities of organ sparing have been increased with the use of transoral carbon dioxide laser surgery. Our purpose is to review this technique as a preservation surgical strategy for hypopharyngeal carcinomas. RECENT FINDINGS: The role of primary surgery in the initial treatment of head and neck carcinomas is being reviewed. The transoral laser resection of hypopharyngeal carcinomas is the least established of the transoral laser surgical approaches. Recent data suggest that selected hypopharyngeal tumors may be treated with transoral laser surgery, achieving very good oncologic and functional outcomes. SUMMARY: Transoral carbon dioxide laser surgery is an alternative to treat hypopharyngeal carcinomas. Early tumors may be removed by a transoral approach with high local control rates and function preservation in most of the patients. For more advanced tumors experience is still limited, and the role of this technique has not yet been defined.

Outcome of transoral laser microsurgery for T2-T3 tumors growing in the laryngeal anterior commissure.

BACKGROUND: To evaluate the outcomes of transoral laser microsurgery (TLM) in the treatment of T2 to T3 laryngeal carcinomas growing in the laryngeal anterior commissure. METHODS: This study was a retrospective analysis of 107 patients. Overall survival, disease-specific survival, and laryngectomy-free survival were analyzed. Technical difficulties, postoperative complications, influence of the learning curve, and the number of surgeries were evaluated. RESULTS: Five-year overall survival, disease-specific survival, and laryngectomy-free survival were 71%, 79.5%, and 71.4%, respectively. The probability of tumor relapse was related to the status of the margins (p = .01) and to surgical experience (p = .02), but not to tumor exposure (p = .78) or pT category (p = .36). Disease-specific survival differed significantly between the group of patients treated in the early period of surgical experience and those treated in the advanced period of surgical experience (71% vs 94%; p = .02) CONCLUSION: TLM is a useful treatment for T2 to T3 laryngeal carcinomas growing in the laryngeal anterior commissure when it is performed under an advanced learning curve.

Deep vein thrombosis: rare cases of diagnoses in a pediatric emergency department.

Deep vein thrombosis (DVT) has an estimated annual incidence of 0.07/10,000 children. Early diagnosis suspicion in the emergency department is important because it is a serious disease that, if untreated, can lead to a postthrombotic disease or a pulmonary thromboembolism. We report 2 cases of DVT whose diagnosis was made in the pediatric emergency department. Case 1 is a 9-year-old boy, evaluated with corticodependent nephrotic syndrome, who presented with pain in the lower left limb and increase in size of 48 hours' evolution suggestive of DVT. The elevation of D-dimer in the blood analysis and images from the Doppler ultrasound confirmed the diagnosis. His clinical evolution was good after beginning treatment with low molecular weight heparin. Case 2 is a 16-year-old adolescent, mother of a 1-year-old infant, who took oral contraceptives and was an occasional smoker, showed increased size and had pain in the lower left limb of a few hours' evolution. Deep vein thrombosis was suspected, and the diagnosis was confirmed by Doppler ultrasound. The evolution was favorable after beginning treatment with low molecular weight heparin. Although DVT is rare in children, early detection is important, requiring a detailed case history in the presence of edematous, painful, and hot limbs that are keys to the diagnostic suspicion. The imaging test and the laboratory tests will confirm the diagnosis, and anticoagulant treatment will prevent complications.

A Cuban NGO perspective on disabilities: José Blanch MD MPH, National Association of Blind Persons. Interview by Gail Reed.

Dual specialties in epidemiology and labor medicine, as well as an advanced degree in public health, gave Dr José Blanch expertise on disabilities in Cuba from a population health perspective. However, when he began losing his sight due to a diabetic retinopathy while serving in Africa, he also began a difficult journey that would transform his life and career, giving him new personal and professional perspectives on disability and the potential of disabled persons. Active for the past several years in the National Association of Blind Persons (ANCI, its Spanish acronym), in 2010 Dr Blanch was elected President of the non-governmental organization. He spoke with MEDICC Review about ANCI's role and challenges in the context of Cuba today.

Transoral laser microsurgery for T3 laryngeal tumors: Prognostic factors.

BACKGROUND: The objective of this study was to evaluate the outcomes of transoral laser microsurgery (TLM) in T3 laryngeal carcinomas and to identify prognostic factors for survival and laryngeal preservation. METHODS: This study aimed to provide a retrospective analysis of 147 consecutive patients, evaluating their overall survival, disease-specific survival, laryngectomy-free survival, and function preservation rate. RESULTS: Five-year overall, disease-specific, and laryngectomy-free survivals were 53.1%, 70.2%, and 62.3%, respectively. Disease-specific survival differed between glottic and supraglottic tumors (86.3% vs 61.8%; p = .015). Function preservation was 65.5% in supraglottic and 49.1% in glottic tumors (p = .002). Disease-specific survival was not related to pre-epiglottic involvement, cord fixation, or focal cartilage infiltration (p > .05). Vocal cord fixation and cartilage infiltration were independent negative prognostic factors for organ preservation (odds ratio [OR] = 0.184; 95% confidence interval [CI] = 0.082-0.411; p = .000 and OR = 0.331; 95% CI = 0.139-0.789; p = .013, respectively). CONCLUSION: Our conclusion is that TLM is a good alternative in a large number of T3 laryngeal tumors, with adequate survival and organ preservation rates above 60%.