Fábio Roberto Pinto

Tobacco and alcohol use after head and neck cancer treatment: influence of the type of oncological treatment employed

OBJECTIVE To assess the cigarette smoking and alcohol intake maintenance rate in patients treated for head and neck squamous cell carcinoma and to compare the observed outcome with the type of oncological treatment employed. METHODS One hundred and ten patients treated for high aero-digestive tract squamous cell carcinoma were included and divided into a surgical group, treated with a surgery, and a medical group, treated with chemotherapy and/or radiation. The patients were interviewed to determine whether or not they had persisted with the smoking and drinking behavior after treatment. The habit maintenance rate was compared with the treatment modality employed. The relationship between the oncological status of the patients and the cigarette smoking and alcohol intake rates found was also tested. RESULTS Among smokers, 35% maintained the habit after treatment. The medical group had a significantly higher percentage of patients maintaining smoking compared with the surgical group (58.3% vs 25.0%; p = 0.004). Among alcohol users, 16.6% kept drinking alcoholic beverages, with a percentage also shown higher for the medical group (23.8% vs 13,3%), but with no statistically significant difference. The oncological status of patients was not related to the maintenance of the habits studied. CONCLUSION Smoking and alcoholism maintenance rates are high after head and neck squamous cell carcinoma is treated, especially if we consider smoking in patients treated with chemotherapy and/or radiation. A more effective multidisciplinary approach is required in order to obtain better rates of tobacco and alcohol quitting, especially in patients undergoing non-surgical treatments.

Enhanced Morbidity of Pectoralis Major Myocutaneous Flap Used for Salvage after Previously Failed Oncological Treatment and Unsuccessful Reconstructive Head and Neck Surgery

Introduction. The reconstruction of complex cervicofacial defects arising from surgical treatment for cancer is a real challenge for head and neck surgeons, especially in salvage reconstruction surgery and/or failed previous reconstruction. The pectoralis major myocutaneous flap (PMMF) has been widely used in these specific situations due to its reliability and low rate of failure or complications. Objectives. Identify factors that determine complications and influence the final outcome of the reconstructions with PMMF in salvage cancer surgery or in salvage reconstruction. Methods. A cross-sectional study design was used to evaluate a sample including 17 surgical patients treated over a period of ten years that met the inclusion criteria. Results. Reconstruction was successful in 13 cases (76.5%), with two cases of partial flap loss and no case of total loss. Complications occurred in 13 cases (76.5%) and were specifically related to the flap in nine instances (52.9%). An association was identified between the development of major complications and reconstruction of the hypopharynx (P = 0.013) as well as in patients submitted to surgery in association with radiation therapy as a previous cancer treatment (P = 0.002). The former condition is also associated with major reconstruction failure (P = 0.018). An even lower incidence of major complications was noted in patients under the age of 53 (P = 0.044). Conclusion. Older patients, with hypopharyngeal defects and submitted to previous surgery plus radiation therapy, presented a higher risk of complications and reconstruction failure with PMMF.

Os espaços cervicais profundos e seu interesse nas infecções da região

BACKGROUND. Although rare, deep neck space infections are associated with high morbidity and mortality rates. The surgical approach is necessary in the majority of the cases, and the surgeon must know the complex anatomy of the cervical fasciae and deep neck spaces. PURPOSE. The anatomy of the cervical fasciae and deep neck spaces is reviewed. As an illustration, a series of deep neck space infections is presented. MATERIAL AND METHOD. Four clinical cases are reported: 1) a case of Ludwigs angina with several complications (mediastinitis, pericarditis, pneumonia, pleural effusion and empyema, esophageal fistula and septic shock), 2) a case of cervical abscess that appeared without apparent cause, in a young diabetic patient, 3) a case of abscess of the submandibular triangle, and 4) a case of parapharyngeal abscess that came forth after a dental treatment. Data from history taking, physical examination, X-rays, echography, CT scan and treatment and the follow-up are presented. The image tests were valuable and, in two of the cases, they demonstrated that more than one deep neck space were affected. CONCLUSIONS. The literature reinforces the high mortality and morbidity rates, the diversified etiology (dental infection, intravenous drug abuse, infections of the upper aerodigestive tract and others), and the tracheostomy indication made in about half of the cases. It stresses also the need for combined therapy (antibiotics and surgery). Evaluation with CT scan and other radiologic methods is indispensable to determine the site and extent of the process and to plan properly the treatment.BACKGROUND Although rare, deep neck space infections are associated with high morbidity and mortality rates. The surgical approach is necessary in the majority of the cases, and the surgeon must know the complex anatomy of the cervical fasciae and deep neck spaces. PURPOSE The anatomy of the cervical fasciae and deep neck spaces in reviewed. As an illustration, a series of deep neck space infections is presented. MATERIAL AND METHOD Four clinical cases are reported: 1) a case of Ludwigs angina with several complications (mediastinitis, pericarditis, pneumonia, pleural effusion and empyema, esophageal fistula and septic shock), 2) a case of cervical abscess that appeared without apparent cause, in a young diabetic patient, 3) a case of abscess of the submandibular triangle, and 4) a case of parapharyngeal abscess that came forth after a dental treatment. Data from history taking, physical examination, X-rays, echography, CT scan and treatment and the follow-up are presented. The image tests were valuable and, in two of the cases, they demonstrated that more than one deep neck space were affected. CONCLUSIONS The literature reinforces the high mortality and morbidity rates, the diversified etiology (dental infection, intravenous drug abuse, infections of the upper aerodigestive tract and others), and the tracheostomy indication made in about half of the cases. It stresses also the need for combined therapy (antibiotics and surgery). Evaluation with CT scan and other radiologic methods is indispensable to determine the site and extent of the process and to plan properly the treatment.

Manutenção do tabagismo e etilismo em pacientes tratados por câncer de cabeça e pescoço: influência do tipo de tratamento oncológico empregado

OBJECTIVE: To assess the cigarette smoking and alcohol intake maintenance rate in patients treated for head and neck squamous cell carcinoma and to compare the observed outcome with the type of oncological treatment employed. METHODS: One hundred and ten patients treated for high aero-digestive tract squamous cell carcinoma were included and divided into a surgical group, treated with a surgery, and a medical group, treated with chemotherapy and/or radiation. The patients were interviewed to determine whether or not they had persisted with the smoking and drinking behavior after treatment. The habit maintenance rate was compared with the treatment modality employed. The relationship between the oncological status of the patients and the cigarette smoking and alcohol intake rates found was also tested. RESULTS: Among smokers, 35% maintained the habit after treatment. The medical group had a significantly higher percentage of patients maintaining smoking compared with the surgical group (58.3% vs 25.0%; p = 0.004). Among alcohol users, 16.6% kept drinking alcoholic beverages, with a percentage also shown higher for the medical group (23.8% vs 13,3%), but with no statistically significant difference. The oncological status of patients was not related to the maintenance of the habits studied. CONCLUSION: Smoking and alcoholism maintenance rates are high after head and neck squamous cell carcinoma is treated, especially if we consider smoking in patients treated with chemotherapy and/or radiation. A more effective multidisciplinary approach is required in order to obtain better rates of tobacco and alcohol quitting, especially in patients undergoing non-surgical treatments.

The subclavicular versus the supraclavicular route for pectoralis major myocutaneous flap: a cadaveric anatomic study

The aim of this paper was to determine if the subclavicular route of rotation improved the pectoralis major myocutaneous flap’s ability to reach head and neck sites in comparison to the traditional supraclavicular rotation. We dissected 50 flaps in 25 fresh adult male cadavers. The length of the pedicle and the flap’s ability to reach five anatomical head and neck sites (laryngeal prominence of thyroid cartilage, mentum, angle of the mandible, external auditory canal, and orbit) were tested by supraclavicular and subclavicular rotation. Although the average length of the flap’s pedicle was higher when the subclavicular rotation was employed, there was no statistical difference between the two techniques concerning the flap’s ability to reach the studied sites. Our results suggest that the subclavicular route apparently adds little to the reconstruction of head and neck defects using the pectoralis major myocutaneous flap. We believe that the indication of this technique should be evaluated on a case-by-case basis before it is recommended to keep from unnecessarily increasing the potential morbidity of the reparative procedure.

Delayed histological changes in cutaneous portion of pectoralis major flaps employed in upper aero-digestive tract reconstruction

Our aim was to determine whether histological changes occur in the cutaneous portion of pectoralis major flaps employed for upper aero-digestive tract reconstruction and, if present, to characterize these changes and try to infer their cause. Seven patients submitted to repair of aero-digestive tract defects secondary to cancer resection with pectoralis major myocutaneous flap were included in this study. All patients received adjuvant radiotherapy. Biopsies were taken from: the cutaneous portion of the flap; buccal mucosa; irradiated neck skin and chest skin opposite the donor site. Histological changes toward a “mucosalization” occur in the cutaneous portion of the pectoralis major flaps, characterized by disappearance of the horny layer or a reduction of its thickness and a decrease of the amount of cutaneous appendages. These changes are probably a result of continuous exposure to the intraoral environment in association with radiotherapy effects and may represent an advantageous adaptation for the patient.

Unusual location of a cervical paraganglioma between the thyroid gland and the common carotid artery: case report.

Paragangliomas are rare tumors derived from the extra-adrenal paraganglionic system, which is composed of cells from the neural crest that are associated with the autonomous nervous system.1,2 They have been observed at many sites in the head and neck area, including the carotid body, the jugular-tympanic region, and the vagus nerve.2,3 Unlike pheochromocytomas, head and neck paragangliomas are usually non-functioning tumors; in other words, they do not secrete catecholamines, and the primary symptom is a slow growing mass in the neck.2,4 Paragangliomas arising within the thyroid gland or the neighboring area are extremely rare, and are believed to derive from the inferior laryngeal paraganglia.5–9 The laryngeal paraganglia was first described in 1963 by Watzka,10 who showed the presence of this particular tissue in the upper and anterior third of ventricular folds. One year later, Kleinsasser11 reported the presence of paraganglia in the subglottic larynx and named it the inferior laryngeal glomus; this author also labeled Watzka’s discovery as the superior laryngeal glomus. In anatomical studies of the human larynges, Zak12 and Lawson13 demonstrated that the position of the inferior laryngeal paraganglia can vary from patient to patient. They found paraganglionic tissue to lie between the inferior horn of the thyroid cartilage and the cricoid cartilage, to lie between the cricoid and the first tracheal ring, or to be in intimate contact with the medial aspect of the capsule of the thyroid gland. Aberrant positions, such as in front of the cricoid cartilage and over the cricothyroid membrane, have also been described.11–13 The association between the inferior laryngeal paraganglia and the inferior laryngeal nerve and its branches has been well document.11–14 The objective of this paper is to report the diagnosis and treatment of a paraganglioma located in the anterior visceral cervical space, between the thyroid gland and the common carotid artery, which during surgery showed no relationship with the recurrent laryngeal nerve and was easily dissected from the thyroid capsule. The origin of the reported tumor, which cannot be explained by the previous anatomical descriptions of the inferior laryngeal paraganglia, is discussed.

Oral cavity squamous cell carcinoma: factors related to occult lymph node metastasis.

INTRODUCTION Elective neck dissection is recommended in cases of oral cavity squamous cell carcinoma without lymph node metastasis because of the risk of occult metastasis. OBJECTIVE The present study aimed to evaluate predictive factors for occult lymph node metastasis in patients with oral cavity squamous cell carcinoma treated with elective neck dissection and their impact on overall and disease-free survival. METHODS Forty surgically treated patients were retrospectively included. RESULTS Ten cases (25%) had lymphatic metastasis. Of the studied variables, perineural and angiolymphatic invasion in addition to tumor thickness were statistically associated with lymph node metastasis. Only angiolymphatic invasion was identified as an independent risk factor for occult metastasis in the logistic regression (OR=39.3; p=0.002). There was no association between overall and disease-free survival with the presence of occult lymph node metastasis. CONCLUSION Metastatic disease rate was similar to that found in the literature. Perineural and angiolymphatic invasion and tumor thickness were associated with occult metastasis, but only angiolymphatic invasion showed to be an independent risk factor.Introduction Elective neck dissection is recommended in cases of oral cavity squamous cell carcinoma without lymph node metastasis because of the risk of occult metastasis.

Original articleOral cavity squamous cell carcinoma: factors related to occult lymph node metastasisCarcinoma espinocelular da cavidade oral: fatores relacionados à presença de metástases linfonodais ocultas☆☆☆

INTRODUCTION Elective neck dissection is recommended in cases of oral cavity squamous cell carcinoma without lymph node metastasis because of the risk of occult metastasis. OBJECTIVE The present study aimed to evaluate predictive factors for occult lymph node metastasis in patients with oral cavity squamous cell carcinoma treated with elective neck dissection and their impact on overall and disease-free survival. METHODS Forty surgically treated patients were retrospectively included. RESULTS Ten cases (25%) had lymphatic metastasis. Of the studied variables, perineural and angiolymphatic invasion in addition to tumor thickness were statistically associated with lymph node metastasis. Only angiolymphatic invasion was identified as an independent risk factor for occult metastasis in the logistic regression (OR=39.3; p=0.002). There was no association between overall and disease-free survival with the presence of occult lymph node metastasis. CONCLUSION Metastatic disease rate was similar to that found in the literature. Perineural and angiolymphatic invasion and tumor thickness were associated with occult metastasis, but only angiolymphatic invasion showed to be an independent risk factor.Introduction Elective neck dissection is recommended in cases of oral cavity squamous cell carcinoma without lymph node metastasis because of the risk of occult metastasis.

Tumor volume as an independent predictive factor of worse survival in patients with oral cavity squamous cell carcinoma

The purpose of the present study was to investigate the role of tumor volume in the prognosis of patients with oral cavity squamous cell carcinoma (SCC).