Geraldo Matos de Sá

Elective neck dissection versus observation in stage I squamous cell carcinomas of the tongue and floor of the mouth.

A retrospective study was undertaken of patients with T1N0M0 squamous cell carcinoma of the oral tongue and floor of the mouth who underwent surgical treatment between 1985 and 1995. Evaluation of two groups of patients (neck dissection versus observation) was made according to the management of the neck. Results were obtained regarding the presence of occult metastases, recurrence in the neck, treatment failure, results of salvage treatment, and disease-free survival. Forty-nine patients underwent surgical treatment: 25 resection of primary and 24 resection plus neck dissection. Overall incidence of regional metastases was 24.5%. Eight patients (16%) developed recurrence of the disease. Seven (14%) had regional recurrences (including 1 with distant metastases) and 1(2%) had local recurrence. Twenty-four percent of patients from the resection of primary group developed neck recurrences in comparison with 4% of the resection plus neck dissection group (P = 0.05). Overall salvage rate was 37.5%. Second primary tumors developed in 16% of patients. Patients who underwent elective neck dissection had a 23% higher disease-free survival rate compared with those who underwent resection of the tumor alone (P = 0.03). The findings of this study stress the importance of control of the neck in early oral cancer. Elective neck dissection significantly improved regional control of the disease.

Relevance of Skip Metastases for Squamous Cell Carcinoma of the Oral Tongue and the Floor of the Mouth

OBJECTIVE: To analyze the therapeutic implications of the distribution of neck metastases (NM) in patients with squamous cell carcinoma (SCC) of the tongue and the floor of the mouth (FOM). PATIENTS AND METHODS: From January 1987 through December 1997, 339 previously untreated patients with T1-2 N0 M0 SCC of the tongue and the FOM underwent primary surgical treatment in our institution. A retrospective review of the pathology reports and outcome of these patients was made to ascertain the prevalence and distribution of NM. Patients were grouped by clinical neck status at the time of neck dissection: elective neck dissection (END) in the NO neck and subsequent therapeutic dissection (STD) in the neck observed which converted clinically to N+ or regional recurrences after END. All patients were classified according to the American Joint Committee on Cancer (AJCC)/UICC 2002 TNM classification. RESULTS: All patients underwent surgical treatment of the primary cancer and had negative margins at frozen section. Overall incidence of NM was 41.3%. Twenty-seven point eight percent of T1 N0 M0 and 48.2% of T2 N0 M0 patients developed NM (P = .0004). Occult neck metastases occurred in 24.1% of patients. Clinically, N+ metastases occurred in 23.6% of patients. The overall incidence of NM in levels IV and V was 8.5%. Neck level IV nodes were involved in only 1.5% of patients in the END group versus 23.7% in the STD group (P < 0.001). Level V was always associated to nodal metastases in other neck levels. Only 2% of patients in our study presented “skip metastases” in the neck. CONCLUSIONS: Neck levels I and II were at great risk for the development of NM (46.9% and 75.3% respectively). Levels IV (6.5%) and V (2%) were rarely involved in our group of patients. The results found in this study support the indication of supraomohyoid neck dissection for N0 and a more comprehensive neck dissection (levels I-V) for N+ patients in Stage I-II SCC of the tongue and FOM. EBM rating: C-4

Elective neck dissection in the treatment of T3/T4 N0 squamous cell carcinoma of the larynx

BACKGROUND This study analyzed pathologic findings of clinically occult cervical lymph nodes of T3/T4 N0 squamous cell laryngeal carcinoma and their impact on locoregional failures and overall survival. PATIENTS AND METHODS A retrospective analysis of 76 patients with T3/T4 N0 laryngeal carcinoma was carried out between 1981 and 1989. Sixty-seven patients had transglottic tumor, 31 patients had extralaryngeal spread, 56 patients were T3 N0, and 20 patients were T4 N0. Seventy-five patients had total laryngectomy and 1 had near total laryngectomy. All patients had bilateral elective neck dissection. The chi-square test was applied to factors related to neck metastasis and locoregional failure. Survival was analyzed using the Kaplan-Meier actuarial method; differences were tested using the Wilcoxon signed-rank test. RESULTS Eighteen patients had positive surgical margins. Occult neck metastasis was observed in 30%. Univariate analysis showed that cancer stage and cartilage status were not significant to predict neck metastasis. Locoregional recurrence was observed in 28% of patients. Surgical margins, cervical metastasis, lesion extension, and cartilage invasion had significant impact on disease-free survival. The 5-year overall survival was 52%; disease-free survival was 57%. CONCLUSION The elective bilateral neck dissection performed in T3/T4 N0 patients yielded a 30% incidence of occult neck metastasis. Classification of transglottic carcinomas into endolaryngeal and exolaryngeal provides a better parameter for predicting neck metastasis than does T status. Disease-free and overall survival were significantly affected by neck metastasis, T stage, exolaryngeal tumor, cartilage infiltration, and surgical margins.

Supracricoid Laryngectomy with CHEP: Functional Results and Outcome:

OBJECTIVES: To assess whether supracricoid laryngectomy with cricohiodoepiglottopexy could successfully reach the cure and preserve the voice in glottic laryngeal cancer, we studied 27 patients with T2/T3 squamous cell carcinoma of the larynx treated in our institution with cricohiodoepiglottopexy. STUDY DESIGN: A retrospective analysis has been carried out between 1995 through 1997. We classified 11 patients as T2N0M0 and 16 patients as T3N0M0. Nineteen patients had bilateral selective lateral neck dissection, 3 patients had unilateral lateral neck dissection, and 5 patients had undissected neck. Survival was analyzed under the Kaplan-Meyer method. RESULTS: Five patients had postoperative complications, 2 were treated with a total laryngectomy. The remaining 25 patients kept the normal airway, swallowing, and speech. None of the patients in the neck dissection group had neck metastasis. Two patients had recurrences, 1 with local recurrence was treated with a total laryngectomy and is alive without disease; the other patient had neck recurrence, was treated with radical neck dissection plus radiotherapy, and is dead of the disease. One patient had a second tumor in oropharynx treated with palliative radiotherapy and is dead of the disease. Three years disease-free survival was 75% for T2 and 79% for T3. CONCLUSIONS: This technique is useful in the treatment of selected cases of T3/T2 glottic cancer regarding the extent of disease. The incidence of complications in need of a complete laryngectomy does not compromise the functionality of this technique. The survival is comparable to patients who submitted to total laryngectomy and near-total laryngectomy, regarding the extent of the lesion.

Neaivtotal laryngectomy for treatment of advanced laryngeal cancer

BACKGROUND In order to assess whether near-total laryngectomy (NTL) could successfully reach the cure and preserve the voice in advanced laryngeal cancer, we studied 28 patients with T3/T4 squamous cell carcinoma of the larynx treated with NTL in our institution. METHODS A retrospective analysis has been carried out from 1990 through 1994. We classified 24 patients as Stage III and 4 patients as Stage IV. All patients had lateral neck dissection. Survival was analyzed under the Kaplan-Meier method. RESULTS Twenty-six patients achieved voice preservation. Two patients in the bilateral neck dissection group had a metastatic lymph node on the opposite side. No patient had local recurrence. Three patients died of the disease, and 1 patient was salvaged with neck dissection. Three-year disease-free survival was 85%. CONCLUSION This technique is useful in the treatment of selected cases of advanced laryngeal cancer and achieves local control of the lesion in all cases. The survival is comparable with that of patients submitted to total laryngectomy, regarding the extent of lesion. Voice preservation can be achieved in most cases.

Metástase cervical de carcinoma epidermóide com tumor primário desconhecido

Revisamos nossa experiencia com carcinoma epidermoide metastatico (CEM) para o pescoco com tumor primario desconhecido com a intencao de evidenciar quando o tratamento radioterapico exclusivo ou o tratamento cirurgico seguido de radioterapia teriam impacto positivo sobre a sobrevida. Este e um estudo retrospectivo de 54 pacientes com CEM tratados na Secao de Cirurgia de Cabeca e Pescoco do Hospital do Câncer/INCa entre 1986 e 1992. Quarenta e oito pacientes (89%) eram do sexo masculino, a idade media foi de 54 anos. Quarenta pacientes tinham metastase para linfonodos cervicais da cadeia jugular interna alta (nivel 2). Utilizamos a classificacao TNM da UICC de 1992 para estagiar os pacientes, onde oito pacientes foram classificados como N1, vinte como N2, 22 como N3, sendo que quatro pacientes permaneceram nao classificados. Todos foram submetidos a endoscopia do trato aerodigestivo superior e raio X de torax. Trinta e cinco pacientes foram submetidos a biopsia de aspiracao com agulha fina. Trinta e oito pacientes tiveram tratamento com intencao curativa e 1.6 tiveram tratamento paliativo com radioterapia. Dos pacientes tratados com intencao curativa, dez foram submetidos a esvaziamento cervical e 28 tiveram tratamento exclusivo com radioterapia. Os 16 pacientes tratados com intencao paliativa foram excluidos dos calculos de sobrevida e analise das recidivas. As recidivas cervicais foram analisadas usando o metodo do qui-quadrado, e as curvas de sobrevida foram comparadas usando-se o teste de Wilcoxon. A biopsia aspirativa com agulha fina alcancou o diagnostico em 85% dos casos. Oito pacientes (15%) apresentaram metastase a distância. O tumor primario foi identificado subsequentemente em 9% dos pacientes. Dezoito pacientes (64%) tratados com radioterapia exclusiva tiveram recidivas no pescoco, e tres pacientes (33%) tratados com cirurgia + radioterapia tiveram recidivas no pescoco. (p=0,05) Os pacientes classificados como N2/N3 tratados com cirurgia + radioterapia tiveram melhores resultados do que os tratados com radioterapia exclusiva (respectivamente p=0,05 e p=0,09). Os pacientes Nl tiveram melhor sobrevida livre de doenca do que os pacientes N2/N3 (respectivamente p=0,007 e p=0,OO7). A sobrevida livre de doenca em cinco anos foi de 69% para os pacientes Nl, 11 % para os pacientes N2 e 15% para os pacientes N3. A sobrevida livre de doenca para todos os estagios foi de 28%. A biopsia aspirativa com agulha fina e um bom meio para diagnostico e deve ser usada rotineiramente.

Valor prognóstico da invasão de cartilagem no câncer de laringe

BACKGROUND: To evaluate the prognostic value of the cartilage invasion (thyroid, cricoid) in laryngeal cancer, in relation to disease free survival period. METHOD: Examination was made of the charts of 102 patients with cancer of the larynx treated at the INCA/MS-RJ Cancer Hospital between 1992 and 1994. These patients were divided into 4 groups: those having T3N0M0 stage III tumors (excluding patients with T3N1M0); those having T4N0M0 (with tumoral invasion of laryngeal cartilage without extralaryngeal spread); those having T4N0M0 (with neoplastic spread through the laryngeal compartment); and those having metastatic cervical lymphadenopathy (T3N2-3/T4N1-2-3). Survival rate curves were drawn for each group and the survival rate differences between the groups were compared using the Kaplan-Meier method. The value of statistical significance were calculated using the Wilcoxon-Gehan method. RESULTS: Those patients who presented with tumoral invasion of laryngeal cartilage without neoplastic spread, behaved like those with T3N0M0 tumors, with no statistical survival rate difference (p=0.36). Patients who had neoplastic invasion of the laryngeal cartilage (T4N0M0) had a better prognostic than those with extra laryngeal neoplastic spread (T4N0M0) (p=0.02). The presence of metastatic lymph nodes was the main adverse factor affecting prognosis (p=0.002). CONCLUSION: The findings of this study call into question the validity of the present TNM classification in the staging of T4N0M0 laryngeal tumors. New studies, based on a larger number of cases, are needed to corroborate our results.

Influence of clinical prognostic factors in neck metastasis from malignant parotid tumors

Abstract Objectives: Analyze the factors influencing lymph nodes metastasis in parotid malignant epithelial tumors. Methods: We retrospectively reviewed the files of 150 patients treated in our institution and by the authors, from 1974 to 1998. Twenty-three patients were excluded of this study because of nonsurgical treatment. The remaining 126 patients were treated with surgery and 75 patients had postoperative radiotherapy. Thirty-four patients were treated with parotidectomy plus neck dissection. The mean age was 49-years-old. According the UICC/1997 TNM Classification, we classified 49 patients as Stage I, 27 as Stage II, 22 as Stage III, and 28 as Stage IV. The influence of those factors on the presence of neck metastasis was analyzed using the chi-square method and multivariate analysis. Results: Forty patients had mucoepidermoid carcinoma, 18 patients had adenocarcinoma NOS, 18 patients had acinic cell carcinoma, 15 patients had adenoid cystic carcinoma, 11 patients had malignant mixed tumor, 11 patients had salivary duct carcinoma, 3 patients had basal cell adenocarcinoma, 3 patients had epithelial-myoepitelial carcinoma, 2 patients had malignant myoepithelioma, 2 patients had anaplastic carcinoma, 1 patient had primary squamous cell carcinoma, 1 patient had terminal duct adenocarcinoma, and 1 patient had papillary cystadenocarcinoma. Twenty-four patients had recurrences, 17 local recurrences, 4 patients had neck recurrences, and 3 locoregional recurrences. Seventeen patients had distant metastasis. The presence of neck metastasis was influenced by 4 factors in univariate analysis, age ( P 0.05), tumor classification ( P 0001), grade ( P 03), and histology ( P 003), and in multivariate analysis, Grade ( P 01) and tumor classification ( P 0001). Conclusions: The tumor classification and grade are an important factor to predict neck metastasis.

Carcinoma diferenciado da tireóide na infância

Os autores apresentam uma revisao de 12 casos de carcinoma da glândula tireoide em criancas, tratados na Secao de Cirurgia de Cabeca e Pescoco do Hospital do Câncer (INCa), no periodo entre 1986 e 1994. Trata-se de doenca pouco frequente, pois, neste levantamento, representou apenas 1,6% das 729 afeccoes cirurgicas da tireoide e 10% dos 126 casos de carcinoma papilifero da glândula tireoide atendidos no periodo referido. A avaliacao do sexo, forma de apresentacao da doenca, extensao do tumor inicial e resposta ao tratamento e evolucao demonstraram que estas neoplasias acometem mais frequentemente as meninas do que os meninos e, embora apresentem-se como forma de doenca avancada desde a matricula, geralmente respondem muito bem ao tratamento cirurgico agressivo, o que proporciona, na maioria dos casos, um prognostico bastante favoravel.