Head & neck cancer. Its impact on the history of mankind.

Squamous cell carcinoma is the most common head & neck malignancy, and its first descriptions date from the pharaonic era. It has impacted humanity by affecting labor, scientific and cultural productivity and, sometimes, it has influenced the course of history. Head & neck cancer is more common in economically impoverished countries and individuals; however, it can affect any socioeconomic stratum; it has been suffered by known, famous, economically powerful celebrities, intellectuals and artists. Head & neck cancer treatment has been controversial since its initial description up to the present day. Therapeutic decisions have been influenced not only by the stage but by the patient's environment and, sometimes, in an effort to reduce the morbidity resulting from the various oncological treatments, erroneous decisions have been made that have implied the loss of the patient's life. Unfortunately, currently we continue to see these behaviors. A synthesis of cases of renowned celebrities that suffered from this cancer is presented, and the impact this implied in the society of their times is described.

El cáncer epidermoide es el más frecuente en cabeza y cuello y sus primeras descripciones datan de la época faraónica. Ha impactado en la humanidad al afectar la productividad laboral, científica y cultural y, en ocasiones, ha influido en el derrotero de la historia. El cáncer de cabeza y cuello es más frecuente en países e individuos depauperados económicamente, sin embargo, puede afectar cualquier estrato socioeconómico; lo han padecido personajes conocidos, famosos, económicamente poderosos, intelectuales y artistas. El tratamiento del cáncer de cabeza y cuello ha sido motivo de controversia desde su descripción inicial hasta la actualidad. En la decisión terapéutica ha influido no solo el estadio del cáncer sino el entorno del paciente; en ocasiones, en un afán de disminuir la morbilidad derivada de los diversos tratamientos oncológicos, se han tomado decisiones erróneas que han implicado la pérdida de la vida del enfermo. Infortunadamente, en la actualidad seguimos viendo estas conductas. Se presenta una síntesis de casos de connotados personajes que presentaron este cáncer y se describe el impacto que ello implicó en la sociedad de ese momento.

Cáncer de cabeza y cuello. Su impacto en la historia de la humanidad / Head & neck cancer. Its impact on the history of mankind

Resumen El cáncer epidermoide es el más frecuente en cabeza y cuello y sus primeras descripciones datan de la época faraónica. Ha impactado en la humanidad al afectar la productividad laboral, científica y cultural y, en ocasiones, ha influido en el derrotero de la historia. El cáncer de cabeza y cuello es más frecuente en países e individuos depauperados económicamente, sin embargo, puede afectar cualquier estrato socioeconómico; lo han padecido personajes conocidos, famosos, económicamente poderosos, intelectuales y artistas. El tratamiento del cáncer de cabeza y cuello ha sido motivo de controversia desde su descripción inicial hasta la actualidad. En la decisión terapéutica ha influido no solo el estadio del cáncer sino el entorno del paciente; en ocasiones, en un afán de disminuir la morbilidad derivada de los diversos tratamientos oncológicos, se han tomado decisiones erróneas que han implicado la pérdida de la vida del enfermo. Infortunadamente, en la actualidad seguimos viendo estas conductas. Se presenta una síntesis de casos de connotados personajes que presentaron este cáncer y se describe el impacto que ello implicó en la sociedad de ese momento.

Abstract Squamous cell carcinoma is the most common head and neck malignancy, and its first descriptions date from the pharaonic era. It has impacted humanity by affecting labor, scientific and cultural productivity and, sometimes, it has influenced the course of history. Head and neck cancer is common in economically impoverished countries and individuals; however, it can affect any socioeconomic stratum; it has been suffered by known, famous, economically powerful celebrities, intellectuals and artists. Head and neck cancer treatment has been controversial since its initial description up to the present day. Therapeutic decisions have been influenced not only by the stage but by the patient's environment and, sometimes, in an effort to reduce the morbidity resulting from the various oncological treatments, erroneous decisions have been made that have implied the loss of the patient's life; unfortunately, currently we continue to see these behaviors. A synthesis of cases of renowned celebrities that suffered from this cancer is presented, and the impact this implied in the society of their times is described.

Aspectos fundamentales del nódulo tiroideo y el cáncer bien diferenciado de tiroides para los médicos general y familiar.

The physician that has the first contact with the patient is the general or family doctor, on whose initial assessment patient treatment success often depends. National and international treatment guidelines are designed for specialists in the area, and the primary care physician often finds them difficult to interpret. The purpose of this document is to offer primary care physicians the fundamentals for the diagnostic and reference process of patients with thyroid nodules and possibly with well-differentiated thyroid cancer, from an objective and pragmatic point of view. Not all thyroid nodules require the same approach, and not all nodules are associated with cancer and neither should they be removed. The bases for a proper diagnosis of a thyroid tumor are patient history, physical examination and ultrasound. The results of these three initial assessment methods shall support the decision on the diagnostic-therapeutic process. This article explains the appropriate way to approach the diagnosis of a thyroid tumor, which studies are unnecessary, and which are the principles of thyroid cancer treatment.

El galeno de primer contacto con el paciente es el médico general o familiar, de cuya evaluación inicial muchas veces depende el éxito en el tratamiento de los pacientes. Las guías terapéuticas nacionales e internacionales están diseñadas para especialistas en el área y el médico de primer contacto suele encontrarlas difíciles de interpretar. El objetivo del presente documento es ofrecer al médico de primer contacto los fundamentos para el diagnóstico y proceso de referencia de los pacientes con nódulos tiroideos y eventualmente con cáncer bien diferenciado de tiroides, un punto de vista objetivo y pragmático. No todos los nódulos tiroideos requieren la misma aproximación diagnóstica y no todos los nódulos están asociados con cáncer ni deben ser retirados. Las bases para el adecuado diagnóstico de un tumor tiroideo son la historia clínica, la exploración física y el ultrasonido; los resultados de estos tres métodos iniciales de exploración serán los que orienten el proceso diagnóstico-terapéutico. En el presenta artículo se explica la forma adecuada para el diagnóstico de un tumor tiroideo, los estudios innecesarios y los principios del tratamiento del cáncer de tiroides.

[Melanoma cutáneo. Etapificación ganglionar con base en la evidencia actual].

Most patients with cutaneous melanoma present with clinical stage 1 at diagnosis, i.e., with no evidence of lymph node or systemic metastases. However, since this is a type of neoplasm with high affinity to lymphatic tissue, between 30 and 60% of patients are estimated to have occult metastases on the lymph nodes of the area that drains the primary tumor site at the moment of diagnosis. This possibility depends on several histologic factors, especially thickness of the neoplasm. Historically, in order to reduce the rate of regional recurrence, lymphadenectomy was an essential part of cutaneous melanoma treatment, which has associated morbidity. In the decade of 1990, Morton et al. reported that lymph is initially received by a single lymph node in the lymphatic basin and that its histological status predicts the status of the others and that, therefore, in patients with sentinel lymph node free of metastases lymphadenectomy is not necessary, which reduces morbidity. In the present manuscript, indications, contraindications and requirements for sentinel lymph node identification are described, as well as its current value in cutaneous melanoma diagnostic and therapeutic process.

La mayoría de los pacientes con melanoma cutáneo se presenta en etapa clínica 1, es decir, sin evidencia de metástasis ganglionares ni sistémicas, sin embargo, al ser una neoplasia con alta linfofilia, se estima que al momento del diagnóstico entre 30 y 60 % de los pacientes tiene metástasis ocultas en los ganglios linfáticos de la zona que drena el sitio del tumor primario. Esta posibilidad depende de varios factores histológicos, principalmente el grosor de la neoplasia. Históricamente y con objeto de lograr disminuir la tasa de recurrencias regionales, la linfadenectomía, con la morbilidad asociada, era parte esencial del tratamiento. En la década de 1990, Morton et al. reportaron que un solo ganglio de la zona linfoportadora recibe la linfa inicialmente y que su estado histológico predice el estado de los demás, de tal manera que la linfadenectomía no es necesaria en pacientes con ganglio centinela sin metástasis, lo que disminuye la morbilidad. En el presente manuscrito se describen las indicaciones, contraindicaciones y requisitos para efectuar la identificación del ganglio centinela, así como su valor actual en el proceso diagnóstico terapéutico del melanoma cutáneo.

[Evaluación funcional de deglución-aspiración en pacientes sometidos a laringectomía subtotal supracricoidea con cricohioidoepiglotopexia].

INTRODUCTION: Cardiovascular disease is the main cause of mortality worldwide. In women, its incidence increases at the sixth decade of life, coinciding with postmenopause. Whether this effect is due to menopause-related hormonal changes is not known. OBJECTIVE: To evaluate the differences in cardiovascular risk in pre- and postmenopausal women by means of the Globorisk risk scale, the triglyceride/high-density lipoproteinsHDL cholesterol (Tg/HDL-C) ratio and metabolic syndrome (MS) criteria. METHOD: Cross-sectional study that included 408 women from 40 to 60 years of age; anthropometric measurements and biochemical determinations were performed. The participants were classified as premenopausal and postmenopausal. Cardiovascular risk was assessed using the MS criteria, the Globorisk risk calculator and the Tg/HDL-C ratio. RESULTS: Postmenopausal women showed a significant increase in waist circumference, total cholesterol and triglycerides Tg in comparison with premenopausal women. Significant associations were found between hormonal state and Globorisk-measured cardiovascular risk (OR = 2.50; 95 % CI = 1.67-3.74) and the Tgtriglyceride/HDL-C ratio (OR = 1.66; 95 % CI = 1.09-2.52). CONCLUSION: Cardiovascular risk factors have a higher prevalence in postmenopause. The Globorisk scale and Tg/HDL-C ratio identify cardiovascular risk in postmenopausal women.

INTRODUCCIÓN: La laringectomía subtotal supracricoidea asociada con cricohioidoepiglotopexia es la técnica quirúrgica conservadora más eficiente para preservar las funciones laríngeas de los pacientes con carcinoma localmente avanzado de la laringe. La complicación más temida de esta intervención es la aspiración en el momento de la deglución y la neumonía secundaria; existen diversas formas de evaluar la aspiración y el grado de esta. Presentamos una novedosa forma de identificar incluso pequeñas cantidades de aspiración traqueobronquial. MÉTODO: Se incluyeron pacientes sometidos a laringectomía subtotal y cricohioidoepiglotopexia por cáncer laríngeo; todos evaluados con trago radiactivo posoperatorio. Con base en la sintomatología y resultado del gammagramma se decidió prolongar el tiempo de alimentación por sonda. RESULTADOS: Se incluyeron 37 pacientes, cuatro habían recibido radioterapia; la tasa de aspiración fue de 29.7 %; 50 % de los pacientes que habían recibido radioterapia presentó aspiración y 18 % de los pacientes con aspiración requirió prolongación del tiempo de alimentación por sonda nasogástrica; ninguno necesitó laringectomía total por aspiración que no permitiera la deglución. CONCLUSIONES: La evaluación posoperatoria de pacientes sometidos a laringectomía subtotal con trago radiactivo permite identificar líquido aspirado al árbol bronquial, incluso en cantidades mínimas, y planear el momento para iniciar la deglución.

[Incisión cervical transversa en disección radical de cuello]. / Transverse incision in radical neck dissection.

ANTECEDENTES: La disección radical de cuello es la única forma de estadificar a pacientes con neoplasias con riesgo de metástasis ganglionares. Se han efectuado diversos tipos de incisiones a lo largo de la historia, con el objetivo de obtener una exposición suficiente que permita la resección completa de los grupos ganglionares en riesgo. Es importante combinar la seguridad oncológica con unas adecuadas estética, funcionalidad y calidad de vida. MÉTODO: Evaluación retrospectiva del resultado obtenido con la incisión transversa en el cuello en pacientes sometidos a disección radical. El parámetro utilizado para saber si esta incisión es adecuada es el número de ganglios disecados. RESULTADOS: Son 35 pacientes, 30 con metástasis de carcinoma epidermoide y 5 con metástasis de melanoma. La media de ganglios disecados fue de 25. Una sola incisión permitió la disección de los cinco niveles ganglionares; no se requirió convertir la incisión ni hacer ampliaciones verticales. El resultado cosmético fue satisfactorio en todos los pacientes, y no hubo complicaciones mayores. CONCLUSIÓN: La incisión cervical única transversa permite el acceso a los cinco niveles cervicales y puede ser ampliada bilateralmente. En la presente serie, la media de ganglios disecados fue de 25, número suficiente para considerar al procedimiento completo. El resultado estético fue satisfactorio. BACKGROUND: Radical neck dissection is the only way to stage patients with neoplasms at risk of lymph node metastases; various types of incisions have been made throughout history, the goal: to obtain sufficient exposure to allow complete resection of the nodal groups at risk. It is important to combine oncological safety with adequate aesthetics, functionality and quality of life. METHODS: Retrospective evaluation of the result obtained with the transverse neck incision in patients submitted to radical neck dissection, the parameter used to know if this incision is adequate is the number of dissected lymph nodes. RESULTS: There are 35 patients, 30 with metastasis of squamous cell carcinoma and 5 with melanoma metastasis. The average of dissected lymph nodes was 25. A single incision allowed the dissection of the five nodal levels, it was not necessary to convert the incision or make vertical enlargements; the cosmetic result was satisfactory in all patients, there were no major complications. CONCLUSION: The unique transverse cervical incision allows access to the five cervical levels, it can be enlarged bilaterally; in the present series, the mean number of dissected lymph nodes was 25 enough to consider the procedure as complete. The aesthetic result was satisfactory.

[Mandibular osteoradionecrosis (ORN) as a side effect of head and neck cancer treatment: Factors that induce it]. / Osteoradionecrosis (ORN) mandibular como efecto colateral del tratamiento del cáncer de cabeza y cuello: factores que la inducen.

INTRODUCTION: Osteoradionecrosis of the mandible is a relatively common complication in patients with head and neck cancer undergoing radiotherapy or concomitant chemoradiotherapy, characterized by exposure of the mandibular bone either in the mouth or in the facial skin, with no improvement with conservative treatment for six months. The risk factors are radiotherapy in head and neck region, lack of dental prophylaxis before treatment and dental extraction. MATERIAL AND METHODS: Retrospective observational study analyzing incidence and etiologic factors of osteoradionecrosis in 250 patients undergoing radiotherapy or combined treatment of cervicofacial area between 2002 and 2010. RESULTS: 25 patients were included; the horizontal branch was the most affected area, followed by the anterior arch. Associated factors were: stage (T4a and T4b), tumor location (oral cavity), dental extraction pre or post-radiotherapy, and radiotherapy time (pre-or postoperative); 72% had association with tooth extraction. Only five patients had control with conservative measures, and 20 required some type of mandibulectomy, only three of them were candidates for reconstruction with fibular free flap; none received treatment in a hyperbaric chamber. CONCLUSIONS: The data suggest that osteoradionecrosis has a multifactorial origin, and prevention is the best alternative and includes pretreatment dental prophylaxis to avoid tooth extractions and close monitoring and surveillance in order to identify early osteoradionecrosis. Most patients require mandible resection as definitive treatment.

[Laryngeal conservative surgery in patients candidates for combined treatment with chemo-radiotherapy]. / Cirugía conservadora de laringe en pacientes candidatos a tratamiento combinado con quimio-radiación por cáncer laríngeo.

BACKGROUND: The standard of care for advanced-stage laryngeal cancer is combined treatment (chemo-radiotherapy). However, the complications with this treatment are not few, mainly in swallowing. Conservative laryngeal surgery remains an effective alternative for cancer control without the complications of chemo-radiotherapy. MATERIAL AND METHODS: Retrospective study was conducted on patients with laryngeal cancer cT3, cN0 with paraglottic infiltration, fixation of the vocal cord, minimal invasion of the hyo-thyroepiglottic space, but with normal arytenoid mobility and no sub-glottic extension, were treated with subtotal supracricoid laryngectomy. Complications, sequels of treatment, and local recurrence were evaluated. Bronchial aspiration was studied with radioactive swallow. RESULTS: There were 25 patients, 22 with negative surgical margins, one had tumour contact with the surgical margins, and 2 were positive. Two patients received postoperative radiotherapy. The mean decannulation was 15 days and removal of nasogastric tube 25 days. During the mean follow-up of 26 months, none of the patients had tumour recurrence or required conversion to total laryngectomy. In all patients swallowing has been normal and none required permanent or temporary tracheotomy or definitive gastrostomy. The voice is considered intelligible in all patients. Radioactive swallow showed aspiration in 15/25 patients, with none being clinically relevant. There were postoperative complications in 5 patients, and 4 patients required re-intervention but no conversion to total laryngectomy. CONCLUSION: Conservative surgery is an effective surgical-alternative to chemo-radiotherapy in patients with locally advanced laryngeal cancer, providing oncological control, acceptable complications and minimal sequels. Although most patients have aspiration, this does not affect functional status.

[Clinical characteristics of malignant tumours originating in the external ear]. / Características clínicas de los tumores malignos originados en el pabellón auricular.

BACKGROUND: Skin tumours that originate in the external ear are common in individuals with type 1 skin and phenotype 1 and 2. The skin cancer is associated with chronic or intermittent, but intense sunlight. The most common malignant tumour is basal cell carcinoma, followed by squamous cell carcinoma and melanoma. The diagnosis of squamous cell skin cancer in head and neck area is usually made in the advanced stages and has a poor prognosis. MATERIAL AND METHODS: A cross-sectional, retrospective analysis was performed on the database of patients with skin cancer of the external ear treated between 2011 and 2014. Histology type, stage, rate of clinical and occult metastases, and rate of loco-regional recurrence were evaluated. RESULTS: Of the 42 patients included there were, 25 squamous cell carcinomas, 11 basal cell carcinomas, and 6 invasive melanomas. The rate of lymph node metastases in patients with squamous cell carcinoma was 32%, mostly in the parotid and peri-parotid region, 7% of them with capsular rupture, 2/17 were staged as cN0, and 11.7% had occult metastases. All patients with nodal metastasis were classified as T2 with ulceration. None of the patients with basal cell carcinoma had lymph node metastases. All melanomas were superficial extension type with mean level of Breslow of 3 mm. All underwent lymphatic mapping and sentinel node biopsy, with only one having metastases in the sentinel node. CONCLUSION: The most frequent tumour in the external ear in this series was squamous cell carcinoma. The possibility of lymph node metastases is associated with tumour size (T). Node dissection should be systematic in patients with T2 or greater.

[Histopathological evaluation of the subtotal laryngectomy specimen]. / Evaluación histopatológica del espécimen de laringectomía subtotal.

INTRODUCTION: The goal of conservative surgical treatment of laryngeal cancer is to obtain oncological control with preservation of laryngeal function. The concept of laryngeal function preservation should be understood as the preservation of the patient's ability to breathe normally with neither tracheostomy nor aspiration, and maintaining intelligible speech. This can be achieved by a balance between two fundamental aspects, proper patient selection (based on tumour extension and preoperative laryngeal function), and an adequate histopathological analysis of the surgical specimen. Supracricoid subtotal laryngectomy is the voice conservative surgical technique that offers the best possibility of control in patients with locally advanced laryngeal cancer. The proper histopathological analysis allows staging and selecting patients for adjuvant therapy, avoiding unnecessary ones as well as designing monitoring and surveillance programs based on risk factors. OBJECTIVE: To highlight key points in the histopathological evaluation of the surgical specimen of a subtotal laryngectomy. CONCLUSION: The proper communication between the surgeon and pathologist, offering complete information on preoperative clinical evaluation and the knowledge of the key points in the evaluation of the surgical specimen (sites of tumour leakage and surgical resection margins) are fundamental parameters to achieve a proper histopathological evaluation of the surgical specimen.

[Dermoscopy in cutaneous melanoma]. / Dermatoscopia en melanoma cutáneo.

BACKGROUND: The mortality of cutaneous melanoma has not declined over the past 50 years. The only interventions that can reduce mortality are primary prevention and early diagnosis, and the dermoscopic evaluation is essential to achieve this. Dermoscopy identifies characteristics of melanoma that would go unnoticed to the naked eye. The aim of this paper is to report the most frequent dermoscopic findings in patients diagnosed with in situ and invasive melanoma. MATERIAL AND METHODS: An observational and retrospective study of contact dermoscopy was performed using LED DermliteTM and camera DermliteTM dermoscope. The findings evaluated were: asymmetry in two axes, association of colours, lack of pigment, irregular points, atypical network, pseudopods, blue veil, ulceration, and peri-lesional pink ring. These dermoscopic findings were compared with the histological diagnosis. RESULTS: The study included 65 patients with cutaneous melanoma; 10 in situ, and 55 invasive. The mean Breslow in invasive melanoma was 3 mm. Most patients (35) had localization in extremities. In all patients, the most frequent dermoscopic finding was asymmetry in two axes, followed by association of two or more colours; in melanoma in situ, asymmetry was the most frequent, followed by atypical-irregular points. In invasive melanoma asymmetry in two axes, the association of two or more colours, and pseudopods, were the most frequent findings. CONCLUSION: Asymmetry in two axes is the most common dermoscopic finding in in situ and invasive melanoma. The presence of two or more colours in a pigmented lesion should be suspected in an invasive melanoma.

[Cutaneous malignant melanoma and the new drugs]. / La cirugía en melanoma cutáneo maligno y las nuevas drogas.

The treatment of cutaneous melanoma has historically been essentially surgical. Much progress has been made in this area, and the resection margins have been established based on tumour depth. Candidates are also identified for lymphadenectomy, avoiding the morbidity of the procedure in patients who do not require it. But little progress has been made in systemic treatment, since the 70's when the use of dacarbazine was introduced for the treatment of patients with tumour progression or distant metastasis, with disappointing results. Despite this, Dacarbazine has been the most used drug to the present. Three years ago, two new drugs were introduced, one of them based on the target therapy and other one in the immunotherapy, offering, with the obtained results, an alternative in the treatment of cutaneous melanoma The objectives of this article are to show the pathways of these drugs, to describe the current role of surgery in cutaneous melanoma, with the arrival of these drugs, as well as to know the therapeutic alternatives that are emerging for the cutaneous melanoma based on scientific evidence.

[Subtotal-supracrioid laryngectomy (SCSL): the importance of the histopathological analysis]. / Laringectomía subtotal supracricoidea (LSSC): la importancia del análisis histopatológico.

The purpose of conservative surgical treatment of laryngeal cancer is to obtain cancer control with preservation of laryngeal function, and in turn, the preservation of laryngeal function should be understood as the preservation of the patient's ability to ventilate in the normal way without tracheostomy and without aspiration and maintaining intelligible speech. This objective is achieved by maintaining a balance between two fundamental aspects: proper patient selection (based on tumor extension and preoperative laryngeal function) and an adequate histopathological analysis of the surgical specimen. Supracricoid subtotal laryngectomy (SCSL) is the voice conservative surgical technique which offers the best possibility of control in patients with locally advanced laryngeal cancer, and the proper histopathological analysis allows staging and selecting patients eligible for adjuvant therapy, avoiding unnecessary therapies, and allows design of a monitoring and surveillance program based on risk factors. The aim of this manuscript is to highlight key points in the histopathological evaluation of the surgical specimen of SCSL. The proper communication between the surgeon and pathologist, offering complete information on preoperative clinical evaluation and the knowledge of the key points in the evaluation of the surgical specimen (sites of tumor leakage and surgical resection margins) are fundamental parameters to achieve a proper histopathologic evaluation of the surgical specimen.

[Cutaneous Melanoma (CM): Current Diagnosis and Treatment]. / Melanoma cutáneo (MC): diagnóstico y tratamiento actuales.

Cutaneous melanoma (CM) is the third most common cancer of the skin, but it is the neoplasia with the greatest impact on mortality. Its etiology is multifactorial and it has been reported that its prevalence has increased in the last two decades. In Mexico, CM ranks seventh in frequency among all malignancies and 80% of cases are in locally advanced stages. The prognosis depends on the stage. The prognostic factors with greatest impact in survival are nodal status, tumor thickness or Breslow depth, ulceration, and in thin melanomas (< 1 mm thickness, without ulceration and Clarck level III), the mitotic index. The diagnostic approach is of great importance to achieve adequate treatment. Adherence to global guidelines of treatment allows us to obtain the best rates of locoregional control, which is the first target to be achieved in patients with CM. The goal of this manuscript is to provide a synthesis of the most important aspects in the diagnosis and treatment of CM, based on current evidence obtained in the literature.

[Adnexal neoplasms in the context of skin cancer: trichilemmal carcinoma. Apropos of a case]. / Neoplasias de anexos en el contexto del cáncer de piel: el carcinoma triquilemal. A propósito de un caso.

BACKGROUND: The trichilemmal carcinoma is a rare malignant neoplasm, whose origin lies in the annexes of the skin, because of its low prevalence often confused with other dermal tumors, the differential diagnosis is not easy and is usually made by exclusion; in theory, its behavior is slow with little tendency to send both regional lymph node metastasis and systemic. Due to the limited number of cases there is no consensus on the prognosis, although it is generally considered good. The aim of this report is to show a case that, contrary to previous reports, the clinical presentation is aggressive with large soft tissue tumor infiltration around the site of origin in a patient without risk factors for skin cancer. CLINICAL CASE: Male patient, 65 years old with cytologic diagnosis of carcinoma in a preprarotideal facial tumor, characteristics at diagnosis were infiltration of the facial skin, ear, and parotid gland. Complete block resection was performed, radical parotiroidectomy and radical neck dissection; the soft tissue defect was covered with a pediculated flap. The evolution was satisfactory it follow-up short though. We evaluated the experience in the literature regarding the prognosis and treatment of these patients. CONCLUSION: Trichilemmal carcinoma can be fully invasive behavior prognosis is difficult to know and probably depends on the clinical stage at diagnosis.

Antecedente: el carcinoma triquilemal es una neoplasia maligna poco frecuente originada en los anexos de la piel. Debido a su escasa prevalencia suele confundirse con otros tumores dérmicos, su presentación clínica no favorece el diagnóstico diferencial y generalmente éste se hace por exclusión. En teoría, su comportamiento es lento, con poca tendencia a enviar metástasis regionales ganglionares y sistémicas. Debido al escaso número de casos no existe consenso en relación con el pronóstico, aunque generalmente se estima bueno. El objetivo de este reporte es mostrar un caso que, contrario a lo informado, es de manifestación agresiva en un paciente sin factores de riesgo para cáncer de piel, con gran infiltración tumoral de los tejidos blandos alrededor del sitio de origen. Caso clínico: paciente masculino de 65 años de edad que acudió con diagnóstico citológico de carcinoma en un tumor facial preparotídeo; al momento del diagnóstico motraba infiltración de la piel de la cara, del pabellón auricular y de la glándula parótida. Se efectuó resección completa de la neoplasia en bloque con isla de piel facial, parotidectomía total y disección radical del cuello; el defecto de partes blandas fue cubierto con un colgajo pediculado. La evolución ha sido satisfactoria; sin embargo, el seguimiento es corto. Se evalúa la experiencia asentada en la bibliografía en relación con el pronóstico y tratamiento de estos pacientes. Conclusión: el carcinoma triquilemal puede tener comportamiento localmente invasor lo que hace difícil determinar el pronóstico, que quizá dependa de la etapa clínica al momento del diagnóstico.

[Drainage time in patients submitted to radical neck dissection. Influence of peri-operative intravenous liquid perfusion]. / Tiempo de drenaje en pacientes sometidos a disección radical de cuello. La influencia de la perfusión de líquidos en el periodo perioperatorio.

INTRODUCTION: Drainage after radical neck dissection (RND) is routine and several factors impact the postoperative drainage number of days (PODND). OBJECTIVE: to determine the impact of trans-operative intravenous fluid management (TOFM) in in PODND. METHODS: Retrospective analysis of patients subjected to some type of radical neck dissection. Variables analyzed: blood loss volume, radical neck dissection type, surgical time, anesthesia time, and trans-operative intravenous fluid management volume. RESULTS: 120 patients included: average age 58.3 years; 60 males and 60 females. Radical neck dissection most frequent indications: thyroid cancer (36.6%), laryngeal cancer (15.8%) and tongue cancer (7.5%). Radical neck dissection most frequent types: 47 modified radical (39.2%), 22 lateral (18.3%) and 16 supra-omohyoid (13.3%). Median surgical time 3.55 hours, median anesthesia time 4.3 hours, median blood loss 278 ml, related to transoperative intravenous fluid management. Classical radical neck dissection was performed in 13 patients in whom postoperative drainage number of days was greater than in the other types (p = 0.08). No difference in postoperative drainage number of days among the different types of radical neck dissection. An apparent association was found between trans-operative intravenous fluid management volume and postoperative drainage number of days: the greater the quantity of fluids, the greater the number of days (p = 0.001). Patients who had drain removed during the first seven days had an average of 1,500 ml infused. Patients who had an average of 3,000 ml of fluid had drainage of 10 days. Perfusion > 3,500 ml = postoperative drainage number of days ≥ 10 días. CONCLUSIONS: In the present series a statistically significant relationship was found between the TOFM and PODND. A meticulous surgical technique and an anesthesia procedure that carefully assesses fluid balance could decrease PODND.

Human papilloma virus in patients with epidermoid head and neck carcinoma: a prognostic factor?

BACKGROUND: The three most important prognostic factors in patients with head and neck squamous cell carcinoma (HNSCC) are tumor size, nodular histological condition and tumor origin. Recently, human papilloma virus (HPV), particularly HPV-16, has been acknowledged as a prognostic factor. HPV+ patients have better survival than HPV-. This has created a controversy because other factors may influence the prognosis. The objective of this study was to investigate whether HPV has prognostic value in patients with HNSCC. METHODS: We carried out a retrospective evaluation of patients with HNSCC and the following variables were analyzed: survival, tumor location, stage, general condition according to Eastern Cooperative Oncology Group (ECOG) status, treatment and HPV association identified by PCR. We used a descriptive analysis of simple frequencies and central tendency and dispersion measures according to the type of variables. We used descriptive analysis for overall survival with Kaplan- Meier and Cox regression with 95% confidence interval. RESULTS: There were 179 patients included: 119 (66.5%) were male. Average age of patients was 64 years; 34% of the tumors were located in the oral cavity and 33% were located in the larynx. Factors associated with survival were ECOG (RR = 11.3; 2.6-48), clinical stage (RR = 7.8; 1.7-34), age >70 years (RR = 3.5, 1.4-8.5) and nonsurgical treatment (RR = 2.3; 1.4-3.8). Average overall survival for patients with HPV16 was 22 months vs. 28 months in those with other types of viruses. HPV infection was not associated with the prognosis in this series. CONCLUSIONS: ECOG at the time of the diagnosis and clinical stage were the most significant prognostic factors in this series. HPV did not show any prognostic value.

Diagnostic-therapeutic approach to breast cancer associated with pregnancy: update 2010.

Breast cancer associated with pregnancy (defined as the presence of breast cancer during gestation extending until a year after the resolution of the pregnancy) represents controversial ethical dilemmas and contradictions in its diagnostic and therapeutic approach. Diagnostic methods and the role of pregnancy interruption are controversial subjects for prognosis. Our objective was to discuss the recommendations for diagnosis and treatment for these patients using evidence-based medicine and to discuss controversial subjects such as the role of lymphatic mapping, pre-therapeutic studies and appropriate treatment schedule. Fortunately, the prevalence of breast cancer during pregnancy is low. It is generally considered, however, that this prevalence will slowly increase because of two factors: 1) breast cancer is showing an increasing prevalence and 2) in Western societies the age when a woman becomes pregnant for the first time has increased, which is also associated with the age when breast cancer frequency rises. As in the general population, breast cancer is the most frequent neoplasm in pregnant women. When diagnostic questions arise that sometimes do not have an answer based on scientific evidence, therapeutic decisions are often made based on knowledge acquired in breast cancer treatment of nonpregnant women. To routinely apply new diagnostic/therapeutic technologies with the safety of protecting the pregnancy is a difficult decision to make. In the end, the main objective of treatment of a pregnant woman with breast cancer is to maintain the standard of the desired oncological results while preserving the integrity of the fetus.

Abordaje diagnóstico-terapéutico del cáncer de mama asociado con embarazo: actualización 2010 / Diagnostic-therapeutic approach to breast cancer associated with pregnancy: update 2010

Definido como la presencia de cáncer de la glándula mamaria durante el periodo de gestación y hasta un año después de la resolución del embarazo, el cáncer de mama asociado con el embarazo representa dilemas, controversias y contradicciones éticas en su abordaje diagnósticoterapéutico; son temas de controversia el pronóstico, el método diagnóstico y la interrupción del embarazo. El objetivo de esta comunicación es mostrar las recomendaciones en el diagnóstico-tratamiento en estas pacientes, con base en evidencia, y discutir temas controvertidos como el papel del mapeo linfático, estudios preterapéuticos y momentos ideales del tratamiento. Aunque poco frecuente, se considera que su prevalencia se incrementará lentamente, no solo porque la neoplasia en sí misma tiene una frecuencia cada día mayor sino porque en las sociedades occidentales las mujeres se embarazan por primera vez a edades mayores, cuando el cáncer mamario es más frecuente. Al igual que en la población general, el cáncer de mama es la neoplasia más frecuente en mujeres embarazadas y cuando se diagnostica surgen interrogantes que en ocasiones no tienen respuesta basada en evidencia científica; en numerosas ocasiones, las decisiones terapéuticas se toman con base en el conocimiento obtenido en el tratamiento del cáncer mamario en la mujer no embarazada. Aplicar rutinariamente la nueva tecnología diagnóstico-terapéutica teniendo la seguridad de no afectar al binomio madre-hijo es una decisión difícil de tomar. El principal objetivo del tratamiento de una mujer embarazada con cáncer de mama es obtener el estándar del resultado oncológico y preservar la integridad del producto.

Breast cancer associated with pregnancy (defined as the presence of breast cancer during gestation extending until a year after the resolution of the pregnancy) represents controversial ethical dilemmas and contradictions in its diagnostic and therapeutic approach. Diagnostic methods and the role of pregnancy interruption are controversial subjects for prognosis. Our objective was to discuss the recommendations for diagnosis and treatment for these patients using evidence-based medicine and to discuss controversial subjects such as the role of lymphatic mapping, pre-therapeutic studies and appropriate treatment schedule. Fortunately, the prevalence of breast cancer during pregnancy is low. It is generally considered, however, that this prevalence will slowly increase because of two factors: 1) breast cancer is showing an increasing prevalence and 2) in Western societies the age when a woman becomes pregnant for the first time has increased, which is also associated with the age when breast cancer frequency rises. As in the general population, breast cancer is the most frequent neoplasm in pregnant women. When diagnostic questions arise that sometimes do not have an answer based on scientific evidence, therapeutic decisions are often made based on knowledge acquired in breast cancer treatment of nonpregnant women. To routinely apply new diagnostic/therapeutic technologies with the safety of protecting the pregnancy is a difficult decision to make. In the end, the main objective of treatment of a pregnant woman with breast cancer is to maintain the standard of the desired oncological results while preserving the integrity of the fetus.