[Value of (99m)Tc tetrofosmin scan in well-differentiated thyroid cancer].

BACKGROUND: Patients with cold thyroid nodules without ultrasound malignant suspicion and with benign/undetermined cytology may be subjected to follow-up surveillance. 99mTc-tetrofosmin scan (99mTc-TS) may identify patients where this observation can be performed with more certainty. Absence of uptake never occurs in carcinoma patients. Our objective was to determine the 99mTc-TS negative predictive value (NPV) in patients with cold thyroid nodules. METHODS: An evaluation with 99mTc-TS was conducted prior to surgery in patients with thyroid gland tumor who were candidates for surgery. All patients underwent thyroidectomy according to histology; NPV and test sensitivity were evaluated when compared with the histopathological result. Then, 296-370 MBq (8-10 mCi) of 99mTc-tetrofosmin was administered, and scan images were evaluated after 120 min. Scan result was reported as a) with increased metabolic activity (IMA) or b) without increased metabolic activity (WIMA). RESULTS: Included in the study were 86 consecutive patients. In 60 patients the scan showed IMA, 20/60 (33%) with carcinoma, 67% with benign nodule. In 26 (30.2%) the scan was WIMA. In this group, 3/26 (11.5%) had carcinoma and (88.4%) had a benign neoplasia. Sensitivity = 91.43 (95% CI = 80.73-100), specificity = 45.10 (95% CI = 30.46-59.73), positive predictive value = 53.33 (95% CI = 39.8-66.79) and NPV = 88.46 (95% CI 74.26-100). Negative probability ratio = 0.19. CONCLUSIONS: IMA-99mTc-TS is less specific in thyroid cancer; nevertheless, in WIMA patients the possibility of carcinoma is 13%. Most patients (70%) showed IMA, 33% with carcinoma. WIMA-NPV = 30%. 99mTc-TS may be useful in the therapeutic decision of patients with thyroid nodule with concerns about surgery. Its usefulness lies in the NPV.

Valor de la gammagrafía con Tc-99m-tetrofosmín en el diagnóstico del cáncer bien diferenciado de tiroides / Value of (99m)Tc tetrofosmin scan in well-differentiated thyroid cancer

Introducción: Los pacientes con nódulos tiroideos hipocaptantes sin sospecha ultrasonográfica y con citología benigna o indeterminada pueden ser vigilados. El gammagrama con Tc- 99m-tetrofosmín (Tc-99m-TS) identifica pacientes en los que la vigilancia es más segura. La ausencia de captación nunca ocurre en pacientes con carcinoma. El objetivo de este estudio fue conocer el valor predictivo negativo del Tc-99m-TS en pacientes con nódulo tiroideo. Material y métodos: Evaluación preoperatoria con Tc-99m-TS de pacientes con nódulo tiroideo candidatos a cirugía. Tiroidectomía de acuerdo con el diagnóstico en todos. Evaluación de valor predictivo negativo y sensibilidad al comparar con el resultado histopatológico. Se administraron 296-370 MBq (8-10 mCi) de Tc-99m-TS; evaluación de imágenes a los 120 minutos. Resultado reportado con actividad metabólica aumentada (AMA) o sin actividad metabólica aumentada (SAMA). Resultados: Se incluyeron 86 pacientes consecutivos. Sesenta (69.7 %) tuvieron AMA, 20/60 con carcinoma (33 %), en 67 % el diagnóstico fue de nódulo benigno. En 26 (30.2 %) SAMA, 11.5 % tuvo carcinoma y 88.4 % neoplasia benigna. Sensibilidad de 91.43 % (IC 95 % = 80.73-100 %), especificidad de 45.10 % (IC 95 % = 30.46-59.73), valor predictivo positivo de 53.33 % (IC 95 % = 39.8-66.79), valor predictivo negativo de 88.46 % (IC 95 % = 74.26-100). Razón de verosimilitud negativa = 0.19. Conclusiones: Tc-99m-TS con AMA es poco específico en cáncer tiroideo; en pacientes SAMA 13 % tiene carcinoma. La mayoría de los pacientes (70 %) mostró AMA, 33 % con carcinoma. Valor predictivo negativo en grupo SAMA = 88 %. Tc-99m-TS podría ser útil en la decisión terapéutica de pacientes con nódulo tiroideo en los que existe duda de cirugía; su utilidad radica en el valor predictivo negativo.

BACKGROUND: Patients with cold thyroid nodules without ultrasound malignant suspicion and with benign/undetermined cytology may be subjected to follow-up surveillance. 99mTc-tetrofosmin scan (99mTc-TS) may identify patients where this observation can be performed with more certainty. Absence of uptake never occurs in carcinoma patients. Our objective was to determine the 99mTc-TS negative predictive value (NPV) in patients with cold thyroid nodules. METHODS: An evaluation with 99mTc-TS was conducted prior to surgery in patients with thyroid gland tumor who were candidates for surgery. All patients underwent thyroidectomy according to histology; NPV and test sensitivity were evaluated when compared with the histopathological result. Then, 296-370 MBq (8-10 mCi) of 99mTc-tetrofosmin was administered, and scan images were evaluated after 120 min. Scan result was reported as a) with increased metabolic activity (IMA) or b) without increased metabolic activity (WIMA). RESULTS: Included in the study were 86 consecutive patients. In 60 patients the scan showed IMA, 20/60 (33%) with carcinoma, 67% with benign nodule. In 26 (30.2%) the scan was WIMA. In this group, 3/26 (11.5%) had carcinoma and (88.4%) had a benign neoplasia. Sensitivity = 91.43 (95% CI = 80.73-100), specificity = 45.10 (95% CI = 30.46-59.73), positive predictive value = 53.33 (95% CI = 39.8-66.79) and NPV = 88.46 (95% CI 74.26-100). Negative probability ratio = 0.19. CONCLUSIONS: IMA-99mTc-TS is less specific in thyroid cancer; nevertheless, in WIMA patients the possibility of carcinoma is 13%. Most patients (70%) showed IMA, 33% with carcinoma. WIMA-NPV = 30%. 99mTc-TS may be useful in the therapeutic decision of patients with thyroid nodule with concerns about surgery. Its usefulness lies in the NPV.

[Partial pharyngolaryngectomies for treatment of pharyngolaryngeal cancer]. / Faringo-laringectomías parciales para el tratamiento del cáncer faringolaríngeo.

BACKGROUND: We undertook this study to evaluate the results obtained with conservation therapy of the larynx in patients with laryngopharyngeal epidermoid carcinoma. METHODS: Patients with stages I and II epidermoid cancer of the larynx and pharynx were included. All patients were evaluated endoscopically, functionally, and with cervical tomography. Results of the procedures were evaluated on the basis of oncological control and laryngeal function (voice, swallowing and ventilation). RESULTS: There were 41 male patients with a median age of 55 years. In 32 patients, surgery was the initial treatment and in nine patients as rescue treatment after radiotherapy. In 58.5% the location was glottic, in 22% supraglottic, in 12% glotto-supraglottic and in 7% vallecular and hypopharynx. Subtotal laryngectomy was performed with cricohyoidepiglottopexy in 18 patients, frontolateral in 11, supraglottic in 5, subglottic-epiglottectomy in 3, hemipharyngolaryngectomy in 3, and in one hemiglottectomy. The time until decannulation and removal of nasogastric catheter depended on the type of surgery. One patient (2%) had to be subjected to a rescue laryngectomy due to constant aspiration. This patient demonstrated residual tumor in the sample. Nine patients had some type of complication, the most frequent being wound infection (7.3%). One patient died postoperatively due to sepsis (2.4%), and another patient died due to systemic causes 4 months after the intervention. Median follow-up time is 25 months and no patient has presented tumor recurrence. CONCLUSIONS: Voice conservation surgery is an alternative to mutilation of the larynx in patients with locally advanced neoplasms of the larynx with a high risk of recurrence if treated with radiotherapy.

Faringo-laringectomías parciales para el tratamiento del cáncer faringolaríngeo / Partial pharyngolaryngectomies for treatment of pharyngolaryngeal cancer

BACKGROUND: We undertook this study to evaluate the results obtained with conservation therapy of the larynx in patients with laryngopharyngeal epidermoid carcinoma. METHODS: Patients with stages I and II epidermoid cancer of the larynx and pharynx were included. All patients were evaluated endoscopically, functionally, and with cervical tomography. Results of the procedures were evaluated on the basis of oncological control and laryngeal function (voice, swallowing and ventilation). RESULTS: There were 41 male patients with a median age of 55 years. In 32 patients, surgery was the initial treatment and in nine patients as rescue treatment after radiotherapy. In 58.5% the location was glottic, in 22% supraglottic, in 12% glotto-supraglottic and in 7% vallecular and hypopharynx. Subtotal laryngectomy was performed with cricohyoidepiglottopexy in 18 patients, frontolateral in 11, supraglottic in 5, subglottic-epiglottectomy in 3, hemipharyngolaryngectomy in 3, and in one hemiglottectomy. The time until decannulation and removal of nasogastric catheter depended on the type of surgery. One patient (2%) had to be subjected to a rescue laryngectomy due to constant aspiration. This patient demonstrated residual tumor in the sample. Nine patients had some type of complication, the most frequent being wound infection (7.3%). One patient died postoperatively due to sepsis (2.4%), and another patient died due to systemic causes 4 months after the intervention. Median follow-up time is 25 months and no patient has presented tumor recurrence. CONCLUSIONS: Voice conservation surgery is an alternative to mutilation of the larynx in patients with locally advanced neoplasms of the larynx with a high risk of recurrence if treated with radiotherapy.

[Human papillomavirus: association with head and neck cancer]. / Virus del papiloma humano asociado a cáncer de cabeza y cuello.

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) is the 6th most common cancer worldwide. In 2005, 400,000 cases of HNSCC were diagnosed worldwide. The most frequently affected site is the oral cavity. Alcohol/tobacco consumption is the most important risk factor for this neoplasia; nevertheless, since 1983 it has been suggested that human papilloma viruses (HPV) have a role in HNSCC, mainly in the oropharynx (level 1 evidence). We undertook this study to determine HPV prevalence and types in patients with HNSCC. METHODS: Presence of HPV was determined by polymerase chain reaction and staged by in situ hybridization. We analyzed stage, tumor site of origin, sexual practices, and alcohol/tobacco consumption. Fisher's exact test and Student's t-test were used for statistical analysis. We performed a multiple regression analysis for adjustment of variables. RESULTS: There were 118 patients were HPV positive and oropharyngeal and laryngeal cancer patients were the most frequently affected (55% and 50%, respectively). HPV-16 was most frequently isolated (70%). Laryngeal cancer patients suffered the highest ratio of HPV-16 infection (68.7%). Factors associated with HPV (univariate analysis) were age >50 years, tobacco/alcohol consumption and male gender. In multivariate analysis, none of the variables showed importance (p >0.5); HPV infection was more frequent in patients with history of alcohol/tobacco consumption (p = 0.6). CONCLUSIONS: There was HPV presence in 42% of HNSCC patients, HPV-16 in 70%, with the oropharynx and larynx being the most affected sites. No variables are associated with the virus presence. HPV is a co-factor in HNSCC etiology.

The number of sentinel nodes identified as prognostic factor in oral epidermoid cancer.

In patients with oral cavity epidermoid cancer without palpable nodes, the standard cervical treatment is supraomohyoid dissection; nevertheless, lymphatic mapping with sentinel node (SN) biopsy has been useful and allows the identification of a group of patients where neck dissection may be prevented. The objective of this study was to examine which factors diagnose the possibility of metastasis in SN. A non-randomized prospective study was performed during a two year period and included patients with T1-2, N0 oral cavity cancer >4 mm thick, SN was identified by blue dye and Rhenium colloid. All patients underwent pre-operatory lymphogammagraphy and elective-selective neck dissection. Age, gender, tumor site, T, tumor thickness and number of sentinel nodes found were evaluated. In 48 patients, at least one sentinel node was found, 2 per patient on average. 10.4% showed drainage outside the supraomohyoid region, 13/48 had nodular metastasis, 4 with negative SN(8.3%). T, location, thickness and number of SN are related to non-SN metastasis. Identification of 3SN or more was related to the possibility of SN metastasis p=0 (RR 10.1, I. C. 95% 1.1 91.2). The combined technique (dye-colloid) offers a high index of success in the identification of SN in patients with oral cavity cancer, while lymphogammagraphy identifies patients with anatomically unexpected drainage. Patients with T1 less than 2cm, not located on the tongue with thickness <5 mm and more than 2 SN were less likely to have metastasis in non-sentinel nodes. The identification of at least 3 sentinel nodes decreases the possibility of identifying patients with hidden metastasis (p=0.04).

[Thyroidectomy associated with laryngectomy in laryngeal cancer treatment. Is it routinely necessary?]. / Tiroidectomía asociada a laringectomía en el tratamiento del cáncer laríngeo, ¿es necesario efectuaria rutinariamente?

INTRODUCTION: In patients with laryngeal invasive epidermoid carcinoma who are candidates for total laryngectomy, it is recommended to resect en bloc at least half of the thyroid gland on the same side as the laryngeal tumor with the objective of decreasing local recurrence associated with thyroid infiltration. Nevertheless, in the histopathologic analysis of the specimen, a minority of thyroid glands show tumor infiltration. The fact that in these patients even partial thyroid resection is associated with hypothyroidism increased by postoperative radiotherapy is well known. The study was undertaken to determine the frequency of thyroid gland invasion in patients who have undergone total laryngectomy due to laryngeal cancer and its associated factors. MATERIAL AND METHODS: We evaluated the histological results of glands resected en bloc with laryngectomy in patients who underwent total laryngectomy due to laryngeal cancer; the clinical stage was compared to the laryngeal subsite tumor origin. The glandular histological condition was compared to the local recurrence presence (peristomal). RESULTS: Ninety two patients were included, 11 (12%) showed glandular infiltration due to epidermoid carcinoma, all with tumors clinically typified as T3 and T4, 8/11 were transglottic and only 3 (27%) showed subglottic invasion. During follow-up (5-year mean) 17/92 showed peristomal recurrence (18%), only 3 (3%) showed thyroid invasion. Among patients with glandular invasion the peristoma recurrence rate was 27% (3/11). DISCUSSION: The best laryngeal cancer thyroid tumor invasion predictor is the evidence of extralaryngeal extension. Thyroid resection en bloc should not be routinely advised due to the low frequency of glandular infiltration.

[Transverse glossectomy for tongue cancer treatment]. / Glosectomía transversa para el tratamiento del cáncer de lengua.

INTRODUCTION: Standard care of patients with oral tongue-invasive squamous cell carcinoma in early stages is local resection and neck dissection. Traditionally, tumor resection was performed with hemiglossectomy (tongue resection in lingual long axis), which implied morbidity for deglutition and speech. Although surgical margins are sufficient, they are usually larger than necessary. OBJECTIVE: To know functional results and surgical margins in patients with T1-T2 oral tongue cancer submitted to transverse glossectomy (TG). MATERIAL AND METHODS: We analyzed charts of patients with T1-T2 oral tongue squamous cell carcinoma treated by TG during a 2-year period. We studied surgical margins, deglutition, speech intangibility, performance status and patient satisfaction. RESULTS: We included 20 patients: 12 women and eight men, with mean age of 45 years. Tumor-thickness mean was 8 mm; 19 patients showed free tumor margins in definitive histology study with mean of 1.8 cm three-dimensionally. In one patient, frozen sections were free-of-tumor, but definitive study showed a microscopic area of squamous cell carcinoma in surgical margin. All patients preserved > 50% of oral tongue and all showed lingual tip deviation and short tongue. None required nasogastric tube for feeding and speech was intelligible in all patients. CONCLUSIONS: TG provided sufficient surgical margin in all patients in this series without important morbidity and with good functional result; thus, TG is an alternative to classic vertical hemiglossectomy for patients in early stages of tongue mobile cancer.