Carlos Neutzling Lehn

Perioperative frozen section examination in parotid gland tumors

CONTEXT The minimal recommended surgical approach to parotid tumors is partial parotidectomy with resection of the superficial lobe of the gland. Histologic diagnosis prior to surgery is not possible, as incisional biopsies are contraindicated due to the possibility of facial nerve injury or incomplete tumor resection. Thus, the biopsies tend to be perioperative. OBJECTIVE To compare the results of frozen section examination with the definitive pathological diagnosis. DESIGN Accuracy study by retrospective analysis. SETTING Head and Neck Surgery Service of Heliópolis Hospital, São Paulo, Brazil. SAMPLE 153 cases of parotid gland tumors treated between 1977 and 1994. DIAGNOSTIC TEST Frozen section and pathological diagnosis. MAIN MEASUREMENTS Sensibility and specificity of the frozen section examination. RESULTS Frozen section study diagnosed 19 (12.4%) malignant and 127 (83.7%) benign tumors. Sensitivity of the frozen sections for malignancy was 61.5% (95% CI 54 to 69%) and specificity was 98% (95% CI 94 to 100%), and this result is comparable to the literature. CONCLUSIONS We consider that frozen section examination for salivary gland tumors is not sufficient on its own for deciding on the best management. Their interpretation must be correlated with clinical and intraoperative findings, in association with the surgeons experience.

Smad2 and Smad6 as predictors of overall survival in oral squamous cell carcinoma patients

BackgroundTo test if the expression of Smad1-8 mRNAs were predictive of survival in patients with oral squamous cell carcinoma (SCC).Patients and MethodsWe analyzed, prospectively, the expression of Smad1-8, by means of Ribonuclease Protection Assay in 48 primary, operable, oral SCC. In addition, 21 larynx, 10 oropharynx and 4 hypopharynx SCC and 65 matched adjacent mucosa, available for study, were also included. For survival analysis, patients were categorized as positive or negative for each Smad, according to median mRNA expression. We also performed real-time quantitative PCR (QRTPCR) to asses the pattern of TGFβ1, TGFβ2, TGFβ3 in oral SCC.ResultsOur results showed that Smad2 and Smad6 mRNA expression were both associated with survival in Oral SCC patients. Cox Multivariate analysis revealed that Smad6 positivity and Smad2 negativity were both predictive of good prognosis for oral SCC patients, independent of lymph nodal status (P = 0.003 and P = 0.029, respectively). In addition, simultaneously Smad2- and Smad6+ oral SCC group of patients did not reach median overall survival (mOS) whereas the mOS of Smad2+/Smad6- subgroup was 11.6 months (P = 0.004, univariate analysis). Regarding to TGFβ isoforms, we found that Smad2 mRNA and TGFβ1 mRNA were inversely correlated (p = 0.05, R = -0.33), and that seven of the eight TGFβ1+ patients were Smad2-. In larynx SCC, Smad7- patients did not reach mOS whereas mOS of Smad7+ patients were only 7.0 months (P = 0.04). No other correlations were found among Smad expression, clinico-pathological characteristics and survival in oral, larynx, hypopharynx, oropharynx or the entire head and neck SCC population.ConclusionSmad6 together with Smad2 may be prognostic factors, independent of nodal status in oral SCC after curative resection. The underlying mechanism which involves aberrant TGFβ signaling should be better clarified in the future.

Swallowing and quality of life after total laryngectomy and pharyngolaryngectomy

UNLABELLED Dysphagia can be a consequence of total laryngectomy even in the absence of symptoms and it could indeed directly or indirectly compromise quality of life. AIM To evaluate the characteristics of swallowing after total laryngectomy and pharyngolaryngectomy with pharyngeal T closure, correlating them with the Quality of Life in Swallowing Disorders questionnaire. METHODS A prospective evaluation was performed in 28 patients; fifteen undergoing total laryngectomy and thirteen undergoing total pharyngolaryngectomy. Swallowing was evaluated through videofluoroscopy regarding the preparatory, oral and pharyngeal phases of swallowing, and the quality of life related to swallowing questionnaire was employed to measure quality of life. RESULTS Anatomical and functional changes were observed under videofluoroscopic evaluation. Dysphagia was diagnosed in 18 patients (64.3%), being mild in 66.6% and moderate/severe in 33.3%. The questionnaire indicated good quality of life in almost all scales. Complaints of dysphagia were associated to the burden (p=0.036) and mental health scale (p=0.031). The questionnaire indicated impact on the mental health scale for patients with severe dysphagia (p=0.012). CONCLUSIONS High incidence of dysphagia was observed in some quality of life assessments, especially of mild degree.

Head and neck squamous cell carcinoma in childhood

BACKGROUND Squamous cell carcinoma (SCC) of the head and neck region is rare in young patients and even less frequent in children 15 years or younger children. The patients reported in the literature are isolated cases and their management is always difficult because there is no large experience or a convincing theory to support treatment decisions for every child. PROCEDURES AND RESULTS Four patients aged 15 years or younger were treated for SCC of head and neck between 1977 and 1995 at the Head and Neck Service of Heliópolis Hospital, São Paulo, Brazil, and with this paper we are reporting our experience with their treatment, including a genetic investigation in two cases (immunohistochemical analysis using monoclonal antibodies against p53 and c-erbB-2 oncogenes). These patients had no history of tobacco or ethanol abuse and no history of cancer in their families. Many authors attribute an unusual aggressiveness to SCC in childhood, with propensity to locoregional recurrence and high death rates and therefore, propose aggressive multidisciplinary therapy. Our cases, with the exception of one, had an early diagnosis and were treated using the same method we use for adults; the results were very good. CONCLUSIONS We recommend for these cases the same protocol as for older patients. In these cases, however, the primary lesion is resected with a safety margin which is usually 2 to 3 mm larger than usual safety margins and selective neck dissection is routinely indicated. This management is adopted in an attempt to avoid postoperative irradiation which may prove to be dangerous in the future for young patients. On the other hand, we recognize that due to a small number de patients, definitive treatment recommendations cannot be made at this time.

Qualidade de vida e prognóstico nos carcinomas epidermóides de cabeça e pescoço

Aim: a quality life questionnaire (QLQ) assessment and its relationship with prognostic of patients with head and neck cancer. Study design: prospective clinical. Material and method: a study of 31 patients with squamous cell carcinoma of upper aerodigestive tract submitted to therapy in Head and Neck Surgery and Otorhinolaryngology Department of Heliopolis Hospital, Hosphel between August,1999 and November, 2000. For evaluation of quality of life it was used the questionnaire QLQ-C30 and the module QLQ-H&N35, both supplied by EORTC, accomplished previously to the treatment. The differences of scores among patients with controlled disease and those with recurrence in the first 12 months after treatment was evaluated. Results: a significant difference was observed in scores between assimptomatic patients and those with recurrence, when related to the fadiga, problems of eating in public and global quality of life (p £ 0,05). The scores in this group were similar to those observed in other populations. Conclusion: the pre-treatment quality of life can be a prognostic indicator for patients with head and neck cancer.

Spinal accessory nerve neuropathy following neck dissection

UNLABELLED The most common complication of neck dissection is shoulder dysfunction due to manipulation of spinal accessory nerve, resulting in trapezius muscle atrophy mainly in procedures involving the posterior neck triangle. AIM This study used electromyography to evaluate the injury to the spinal accessory nerve following neck dissection. MATERIALS AND METHODS Prospective case series of 51 patients submitted to 60 neck dissections followed by physical therapy evaluation of shoulder dysfunction. Nerve integrity was evaluated before and after the surgery by means of surface EMG registering the electric activity of the trapezius muscle during voluntary contraction. The patients were grouped according to the type of neck dissection, presence of shoulder pain, impairment during abduction movement and hypotrophy/atrophy of the trapezius muscle. RESULTS Action potential had median values of 54.3 microV before surgery and 11.6 microV after it (p<0.001). There was a mean decrease of 70% comparing to preoperative values. The median was 12.5 microV after dissection including level IIb, and 8.9 microV after dissection including levels IIb and V (p<0.002). CONCLUSION Surface EMG is a sensitive and painless method for spinal accessory nerve dysfunction evaluation. The results suggest the usefulness of the trapezius muscle electromyography to confirm diagnosis and early physical therapy intervention in neuropathies of the spinal accessory nerve.

Deglutição e qualidade de vida após laringectomia e faringolaringectomia total

Dysphagia can be a consequence of total laryngectomy even in the absence of symptoms and it could indeed directly or indirectly compromise quality of life. A...

TOTAL THYROIDECTOMY WITH ULTRASONIC SCALPEL: A MULTICENTER, RANDOMIZED CONTROLLED TRIAL

The ultrasonic scalpel is a recently introduced device in head and neck surgery. Total thyroidectomy is the most common endocrine procedure performed by surgeons.

Four-gene expression model predictive of lymph node metastases in oral squamous cell carcinoma

Abstract Background. Previous knowledge of cervical lymph node compromise may be crucial to choose the best treatment strategy in oral squamous cell carcinoma (OSCC). Here we propose a set four genes, whose mRNA expression in the primary tumor predicts nodal status in OSCC, excluding tongue. Material and methods. We identified differentially expressed genes in OSCC with and without compromised lymph nodes using Differential Display RT-PCR. Known genes were chosen to be validated by means of Northern blotting or real time RT-PCR (qRT-PCR). Thereafter we constructed a Nodal Index (NI) using discriminant analysis in a learning set of 35 patients, which was further validated in a second independent group of 20 patients. Results. Of the 63 differentially expressed known genes identified comparing three lymph node positive (pN +) and three negative (pN0) primary tumors, 23 were analyzed by Northern analysis or RT-PCR in 49 primary tumors. Six genes confirmed as differentially expressed were used to construct a NI, as the best set predictive of lymph nodal status, with the final result including four genes. The NI was able to correctly classify 32 of 35 patients comprising the learning group (88.6%; p = 0.009). Casein kinase 1alpha1 and scavenger receptor class B, member 2 were found to be up regulated in pN + group in contrast to small proline-rich protein 2B and Ras-GTPase activating protein SH3 domain-binding protein 2 which were upregulated in the pN0 group. We validated further our NI in an independent set of 20 primary tumors, 11 of them pN0 and nine pN + with an accuracy of 80.0% (p = 0.012). Conclusions. The NI was an independent predictor of compromised lymph nodes, taking into the consideration tumor size and histological grade. The genes identified here that integrate our “Nodal Index” model are predictive of lymph node metastasis in OSCC.

Efeito da clorexidina na mucosite induzida por radioterapia em câncer de cabeça e pescoço

A radioterapia em pacientes com neoplasias de Cabeca e Pescoco causa alteracoes na mucosa oral comprometendo a execucao terapeutica e o resultado final. OBJETIVO: Avaliar o efeito protetor do gluconato de clorexidina, sobre a mucosa oral, durante o tratamento actinico fracionado e o seu reflexo na qualidade de vida referida pelos pacientes. FORMA DE ESTUDO: Clinico prospectivo. MATERIAL E METODO: Foram selecionados 21 portadores de câncer de Cabeca e Pescoco alocados em dois grupos: grupo Placebo (n=11, 9H e 2M, idade media 58 anos) agua destilada - dois bochechos diarios e grupo Medicacao (n=10, 7H e 2M, idade media 52 anos) gluconato de clorexidina a 0,12% - dois bochechos diarios. Os pacientes foram avaliados semanalmente com exame local para deteccao das alteracoes de mucosa (classificacao de acordo com a WHO e Grupo de Terapia por Radiacao em Oncologia - graus 0 a IV) e preenchimento de questionario de qualidade de vida ressaltando os aspectos de dor, apetite, paladar e habitos alimentares. A analise estatistica realizada pelo teste exato de Fisher. RESULTADOS: A graduacao da mucosite foi mais intensa no grupo Placebo em 6 das 10 semanas de avaliacao. A frequencia e intensidade das dores foram piores no grupo Placebo na 4a semana de radioterapia e a modificacao de paladar foi mais intensa nos individuos que nao usavam o medicamento apenas na 7a semana. Nao foram encontradas diferencas nos outros parâmetros de qualidade de vida. CONCLUSAO: Podemos concluir que o gluconato de clorexidina nao eliminou as lesoes de mucosa mas diminuiu, significativamente, os seus efeitos deleterios e intensidade sem apresentar um reflexo persistente na qualidade de vida dos pacientes.