The impact of treatment on quality of life of patients with head and neck cancer and its association with prognosis.

BACKGROUND: Information is scarce regarding the impact of treatment on Health-Related Quality of Life (HRQL) of patients with Head and Neck (H&N) cancers. We assessed the effect of treatment on HRQL and its association with prognosis in H&N cancer. PATIENTS AND METHODS: Patients with H&N cancer in whom HRQL was assessed before and after treatment. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-H&N35 instruments were used. Association of changes in patients' HRQL after treatment with Loco-Regional Recurrence (LRR) and Overall Survival (OS) was investigated. RESULTS: One hundred sixty patients were included; scales of the baseline assessment of HRQL were moderately associated with LRR and OS, but the impact of treatment on most HRQL scales was strongly associated with OS. By multivariate analysis, baseline assessment of Global Health, Physical, HN Teeth, HN Dry mouth, and HN Cough scales, and impact of treatment on the Physical and Pain scales comprised independent variables associated with LRR. Male gender, positive lymph nodes, baseline assessment of Role, HN Pain, HN Cough, and impact of treatment on Emotion, Pain, Financial, HN Swallowing, HN Social contact, and the interaction of HN Pain-change in Pain scales were associated with OS. Both multivariate models were adjusted by the neoplasm's site of origin. CONCLUSION: Aside from well-known clinical-pathologic prognostic factors in H&N cancers, HRQL assessment, both prior to and after treatment, provides significant prognostic information and should be measured. Design of therapeutic clinical trials in patients with H&N cancers should consider these novel prognostic factors.

Schwannomas múltiples de nervio mediano: descripción de un caso / Multiple median nerve schwannoma: a case report

Introducción: el abultamiento y las parestesias que originan los schwannomas múltiplessuelen confundirse con otras enfermedades más frecuentes en la mano: lipoma, ganglión,síndrome de túnel carpiano.Caso clínico: presentamos un caso poco frecuente de schwannomas múltiples del nerviomediano en un varón de 20 años. Este tipo de tumores no se manifi esta con défi cit neurológicosimportantes.Conclusiones: la resonancia magnética es muy útil en el diagnóstico preoperatorio y en laplanifi cación de la cirugía. La disección intracapsular microquirúrgica fue realizada deforma satisfactoria, y en la actualidad no hay recidiva del tumor(AU)

Introduction: The bulging masses and paresthesias caused by multiple schwannomas areoften confused with the symptoms of other more common pathologies of the hand:lipoma, ganglion, carpal tunnel syndrome.Clinical case: We present a rare case of multiple median nerve schwannomas in a 20-year-old male. These tumors are not accompanies by signifi cant neurologicalimpairment.Conclusions: Magnetic resonance imaging (MRi) is very useful in preoperative diagnosisand surgical planning. Microsurgical intracapsular dissection was performed satisfactorilyand the tumor has so far not recurred(AU)

Accuracy of fine-needle aspiration biopsy of the thyroid combined with an evaluation of clinical and radiologic factors.

Fine-needle aspiration biopsy (FNAB) of thyroid nodules is an operator-interpreter-dependent procedure whose diagnostic accuracy has deficiencies, especially concerning indeterminate and negative results. There are reports in the literature of up to a 15% definitive diagnosis of carcinoma in the first category of cytology and an 11% false-negative rate in the second category. With these facts in mind, a prospective study was done at the Instituto Nacional de Cancerología, Mexico City, to determine whether one or several clinicoradiologic factors were associated with a final pathologic diagnosis of carcinoma, thereby increasing the diagnostic accuracy of thyroid FNAB. In total, 200 cases were reviewed, and 159 patients underwent surgery. Our study group comprises these 159 patients. The only clinical factor associated with false-negative results was size > or = 4 cm, with no statistical significance for the other factors analyzed. A comparison was done between clinical factors of patients who had indeterminate results in the aspirate and those of patients who had a definitive diagnosis by permanent section of the thyroid carcinoma, where an association was found between malignancy and tumor size > or = 4 cm, irregular borders, fixed lesions, and heterogeneity on ultrasound. We conclude that in the presence of a negative cytology result, with tumor size > or = 4 cm, close follow-up is indicated, and a new thyroid FNAB should be performed in 6 months. If the nodule persists or grows, a surgical procedure should be considered. In the case of an indeterminate cytology result and in the absence of those factors associated more frequently with a pathologic result of carcinoma, a conservative approach could be indicated with clinical follow-up and repeat thyroid FNAB in 6 months to 1 year.

Mandibular reconstruction with the free vascularized fibular flap: utility of three-dimensional computerized tomography.

Oncologic management in the mandibular area leaves important osseous defects, that require reconstructive procedures with vascularized osseous tissues. Mandibular reconstructions with free vascularized fibular flaps have well-defined indications and some advantages over various other types of vascularized osseous grafts, because the fibular graft permits the reconstruction of large mandibular defects. This study demonstrates the usefulness of three-dimensional (3D) tomography as a tool to determine the size of the defect, and with angiotomography, to define the anatomic pattern of the vascular pedicle. Five patients with varying mandibular tumors and osseous defects were evaluated with 3D tomography in the pre- and postoperative periods. Two patients were immediately reconstructed with vascularized fibular flaps. 3D preoperative tomography showed the dimensions of the tumor, the dimensions of the mandibular resection, and the graft vascular pattern. Three patients were secondarily reconstructed, two of them with partial mandibular defects, and one patient with total mandibular reconstruction. In the preoperative period, 3D tomography was used to determine the dimensions of the mandibular defect, as well as the area of the osteotomies. The technology permits an exact knowledge of the dimension of mandibular defects, allowing better planning of reconstructive procedures.

The impact of preoperative tracheotomy on T3 transglottic carcinomas of the larynx.

To evaluate the impact of the practice of a preoperative tracheotomy and different prognostic factors reported in the literature in patients with transglottic carcinoma of the larynx, a retrospective study was performed in the Instituto Nacional de Cancerologia, Mexico City. In all, 90 cases with T3 transglottic squamous cell carcinoma requiring a total laryngectomy as primary treatment were studied. Prognostic factors such as the Karnofsky index, tumor differentiation, surgical margins and preoperative tracheotomy were analyzed by a Cox's proportional hazards model. The Kaplan-Meier method and log rank test were used to evaluate the disease-free intervals and survival curves. Thirty-two patients had preoperative tracheotomies, while 58 did not. Eighty percent of the patients in the non-preoperative tracheotomy group were alive after 5 years versus 20% of those with preoperative tracheotomies (P < 0.001). Although possibly controversial, our findings indicate that a pretreatment tracheotomy should be avoided in T3 transglottic obstructive lesions. In patients with these lesions and a subglottic extension < or = 3 cm we recommend an emergency total laryngectomy when possible to increase survival and decrease surgical morbidity.

Malignant melanoma of the oral cavity: diagnosis and treatment experience in a Mexican population.

Oral malignant melanoma is uncommon, accounting for 1-8% of all malignant melanomas. All previous papers have reported small numbers of cases or have retrospectively reviewed case reports from the literature. The following case reports concern malignant melanoma of the oral cavity seen at the Instituto Nacional de Cancerología, Mexico City, during the period of 1982-96. Demographic, clinical and histopathological data were collected. Our 15 patients consisted of 6 males and 9 females. The mean age was 52.6 years (range: 35 to 80 years). The hard palate was the most common area affected with 11 cases (73%). At the time of the initial examination, a pigmented mass was apparent in 100% of the patients. All our surgical cases were treated with wide resection; 8 patients received adjuvant radiation, 4 were treated with surgery alone and 1 case received radiation and chemotherapy before the surgery. Local control of the primary lesion was possible in 14 of the 15 cases. Some patients received therapeutic or elective lymph node dissection. The median survival was 16.9 months (mean: 12.5 months). The 2- and 5-year survival rates were 26.6 and 6.6%, respectively.

[Gastric cancer]. / Cáncer gástrico.

Gastric cancer (GC) is a frequent neoplasm with high mortality. Most patients in occidental countries show advanced stages of the disease, and low resectability rates. In this paper, some epidemiological items are detailed. The morphologic classifications, TNM stages and risk factors for GC are defined. Clinical manifestations are described, focused in the necessity of early diagnosis as it is the only way to reduce mortality. The usefulness of diagnostic methods in preoperative staging are discussed in relation to the role of these methods in the prediction of resectability and the evaluation of new therapeutic regimens. The role of radical surgery and extended lymphadenectomy as definitive treatment is analyzed as well the role of adjuvant and palliative interventions. The experience in Instituto Nacional de Cancerología is briefly described.

[Cholangiocarcinoma]. / Colangiocarcinoma.

Cholangiocarcinoma, are uncommon cancers, and the least common of those categorized as liver and biliary tract cancers. May occur anywhere in the biliary tree. Patients typically present with painless jaundice and pruritus, cholangitis is uncommon. They are classified into three broad anatomic groups: Intrahepatic, perihilar and distal lesions. This classification system is useful for monitoring outcome, since intrahepatic tumors are usually managed as hepatocellular carcinoma with liver resection, and distal tumors are treated as pancreatic cancer with pancreatoduodenectomy. Perihilar lesions may be treated with a variety of operative and nonoperative therapies. Surgery is the only potentially curative treatment. Prognosis and resectability depend on tumor location along the biliary tree, the extent of hepatic parenchymal involvement and the invasion of major blood vessels by the tumor.

Angiocentric lymphomas of the palate: clinico-pathological considerations in 12 cases.

Angiocentric lymphomas (AL) involving the mid-face are infrequent lesions. Their incidence seems to be higher in certain Asian and Latin American countries, where most of the reported series reveal a predominance of T-cell lineage and a high frequency of EBV-positive cells. The clinical and pathological features of 12 AL that affected the palate are presented. Immunophenotypic studies were performed in nine of these cases. Seven (77%) demonstrated T-cell lineage, one was of B-cell origin and one could not be classified. The high incidence of T-cell lesions in this and other studies supports the existence of geographical and possibly of etiological differences in these neoplasms.

[Hepatocellular carcinoma. Experience at the Instituto Nacional de Cancerología]. / Carcinoma hepatocelular. Experiencia en el Instituto Nacional de Cancerología.

BACKGROUND: Hepatocellular carcinoma (HCC) is a rare tumor in Mexico. Stands in the 21st place, corresponding to 1.4% of all malignant tumors. However in Southeast Asia, Japan and Sub-Sahara Africa, its incidence is very high. Frequently this tumor is diagnosed in late clinical stages and curative surgery is difficult to perform. OBJECTIVES: To analyze the general features of patients with HCC, and its management in our hospital. METHODS: An observational, transversal retrospective study was performed with 63 patients with histological proved HCC. RESULTS: Thirty-two were male (50.7%) and 31 female, the mean age was 56 years, 18 had history of alcohol abuse. Liver enlargement, abdominal pain and weight loss were the most common clinical manifestations. The alpha-fetoprotein (AFP) was positive in 55% of the patients, ultrasonography and computed tomography were the most useful studies. Fifty-six percent had associated chronic liver pathology, of which 51% had alcoholic cirrhosis, 43% had cirrhosis of other undetermined origin, and 6% had chronic hepatitis. Seventy percent were diagnosed in clinical stage II, 17% in stage III. Only 31% were taken to surgery, of which laparotomy and liver biopsy was performed in 70%, liver resection in 15%, liver dearterialization in 15%. Fifty-four percent of all cases did not received any kind of treatment. Postoperative complications occurred in 25% and the operative mortality was 20%, with a mean survival time of 10 months. CONCLUSIONS: HCC is a rare tumor in our country. All cases were diagnosed in late clinical stages. The male-female ratio was 1:1. AFP was positive in only 55% of cases. Due to the late stages at presentation or poor clinical conditions, most tumors were considered irresectable, thereby other forms of management need to be evaluated in order to define its place. It is important to identify patients with higher risk of HCC for an early detection and management.

Staging and treatment of nasopharyngeal angiofibroma.

To analyze the prognostic value of clinical-radiologic staging, morbidity, mortality and results of treatment used in the Instituto Nacional de Cancerologia, Mexico, a retrospective study of angiofibroma was performed. Charts were reviewed from patients who attended the institute from 1977 to 1993. History and physical examination, rhinoscopy and fiber-optic nasopharyngolaryngoscopy were done in every patient. Radiologic evaluation was done with computed tomography, after which Chandler's staging system was used. Disease-free interval curves were estimated for patients who had presented with stage III or IV tumors. Thirty-one patients were treated with surgery and/or radiotherapy. Most of the patients had stage III (70.9%) or stage JV (25.8%) disease. Surgical procedures included lateral rhinotomies (15 cases), transpalatal dissections (11 cases), transantral degloving (3 cases), median rhinotomies (2 cases), infratemporal transzygomatic dissections (2 cases), frontotemporal craniotomy (1 case) and suprahyoid pharyngotomy (1 case). Radiotherapy (as 3000-5500 cGy) was administered to 16 patients: 7 patients with stage III persistent or recurrent tumor and 8 patients as initial treatment for stage IV disease. The disease-free interval of patients with stage III and IV disease was 80.3% and 19%, respectively, after 36 months of follow-up. Findings demonstrated that surgery was the treatment chosen in patients with stage II and III disease, with low morbidity and mortality, and good results in disease control. In contrast, radiotherapy was usually the treatment in stage IV disease, but had low effectiveness, indicating the need to carefully investigate the value of craniofacial approaches in these tumors.

Cancer of the mobile tongue in Mexico. A retrospective study of 170 patients.

Histological reports of 170 patients with cancer of the mobile tongue between 1977 and 1989 were identified at the Instituto Nacional de Cancerología (INCan), in Mexico City. Demographic, clinical and histological information was retrospectively reviewed. Chi-square, Student's t-test and Wilcoxon rank-sum test were applied for comparisons, and Kaplan-Meier curves, log-rank test and Cox proportional hazards for survival analysis. Of the 161 patients with mobile tongue squamous cell carcinoma (MTSCC), 104 (65%) were males and 57 (35%) were females. The mean age was 60 years old (range 19-91). T1 and T2 lesions comprised 35%, T3 and T4 lesions 65%. There was a statistically significant association between size of the tumour and lymph node involvement (P < 0.0001). The proportion of cases with advanced disease was 80% for males and 57% for females (P = 0.008). The 5-year survival rate was 16% (CI 10.2-22.8%). Cancer of the mobile tongue in Mexico still has a poor prognosis. Efforts should be made to reduce the delay in diagnosis of MTSCC, in order to increase the cure rates and improve the quality of life of the patients.

Uteruslike mass of the ovary: endomyometriosis or congenital malformation? A case with a discussion of histogenesis.

We describe an 18-year-old woman with a mass in the region of the right ovary. The mass, which had a central cavity lined by endometrium and surrounded by smooth muscle, extraordinarily resembled a uterus. Review of the literature disclosed only one such case in which this change was considered to arise from endomyometriosis of the ovary, a phenomenon characterized by smooth-muscle metaplasia in a focus of endometriosis. Although this possibility is interesting and plausible, we believe that a congenital malformation, possibly caused by a defect in fusion of müllerian ducts, should strongly be considered in explaining the pathogenesis of this kind of lesion.