João Gonçalves Filho

Surgical complications after thyroid surgery performed in a cancer hospital

OBJECTIVE: This study evaluates the incidence and risk factors of complications in patients submitted to thyroidectomy in a cancer hospital with residency training. STUDY DESIGN: A retrospective chart and complications review of 1020 patients (1990–2000) underwent to thyroidectomy. RESULTS: At our cancer hospital, 1020 patients underwent thyroidectomy. The main postoperative complications consisted of transient hypocalcemia in 134 (13.1%) patients, permanent hypocalcemia in 26 (2.5%) patients, transient vocal cord palsy in 14 (1.4%) patients, and permanent vocal cord palsy in 4 (0.4%) patients. The type of thyroidectomy, neck dissection, and paratracheal lymph node dissection were significantly associated with transitory and permanent hypocalcemia. CONCLUSION: Thyroid surgery can be performed safely in a surgical residency training program under direct supervision of an experienced surgeon with little morbidity to the patients. Hypocalcemia is the most significant complication. Neck and para-tracheal lymph node dissections were the most significant predictors of hypocalcemia in patients who underwent total thyroidectomy.

Biological markers and prognosis in recurrent oral cancer after salvage surgery.

OBJECTIVE To analyze the prognostic effect of epidermal growth factor receptor (EGFR), matrix metalloproteinases 2 and 9, and vascular endothelial growth factor expression in patients with locally recurrent oral carcinoma after salvage surgery. DESIGN Retrospective cohort study. Settings Tertiary center cancer hospital. PATIENTS The charts of 111 patients with local recurrence of oral carcinomas were retrospectively analyzed. The previous treatment consisted of surgery in 33 patients (30.0%), radiotherapy with or without chemotherapy in 46 patients (41.0%), and surgery with adjuvant radiotherapy in 32 patients (29.0%). The expression of EGFR, matrix metalloproteinases 2 and 9, and vascular endothelial growth factor was analyzed with a tissue microarray immunohistochemical technique. MAIN OUTCOME MEASURES Overall survival and cancer-specific survival (CSS). RESULTS The recurrences were diagnosed in less than 1 year in 69 patients (62.2%) and in more than 1 year in 42 patients (37.8%). The prognosis was worse in the group with the disease-free interval of less than 1 year (P = .01). Patients with more advanced disease (clinical stage of recurrence, III/IV) had worse rates of CSS (P = .04). Cases that were positive for EGFR had a 3-year CSS of 27.2%, while EGFR-negative cases had a 3-year CSS of 64.3% (P = .001). The expression of matrix metalloproteinases 2 (P = .83) and 9 (P = .15) and vascular endothelial growth factor (P = .86) was not significant in this group. In multivariate analysis, only the disease-free interval and the overexpression of EGFR were associated with a higher risk of cancer death. CONCLUSIONS Local recurrence in oral carcinomas carries a poor prognosis. A disease-free interval of more than 1 year and a EGFR-negative expression are the main prognostic factors related to better CSS in patients treated with salvage surgery.

Diagnosis and treatment of recurrent laryngeal cancer following initial nonsurgical therapy.

Surgery is the preferred modality for curative treatment of recurrent laryngeal cancer after failure of nonsurgical treatments. Patients with initial early‐stage cancer experiencing recurrence following radiotherapy often have more advanced‐stage tumors by the time the recurrence is recognized. About one third of such recurrent cancers are suitable for conservation surgery. Endoscopic resection with the CO2 laser or open partial laryngectomy (partial vertical, supracricoid, or supraglottic laryngectomies) have been used. The outcomes of conservation surgery appear better than those after total laryngectomy, because of selection bias. Transoral laser surgery is currently used more frequently than open partial laryngectomy for treatment of early‐stage recurrence, with outcomes equivalent to open surgery but with less associated morbidity. Laser surgery has also been employed for selective cases of advanced recurrent disease, but patient selection and expertise are required for application of this modality to rT3 tumors. In general, conservation laryngeal surgery is a safe and effective treatment for localized recurrences after radiotherapy for early‐stage glottic cancer. Recurrent advanced‐stage cancers should generally be treated by total laryngectomy.

Second salvage surgery for re-recurrent oral cavity and oropharynx carcinoma

Salvage surgery is considered the best treatment approach for patients with recurrent oral carcinoma. Unfortunately, 50% to 60% of the patients who undergo salvage surgery will develop further locoregional recurrence, and they are not usually considered for further treatment. Our aim in this study was to report our experience with a second salvage surgery for selected patients with re‐recurrent oral cavity and oropharyngeal squamous cell carcinoma (SCC).

Vocal Handicap and Quality of Life After Treatment of Advanced Squamous Carcinoma of the Larynx and/or Hypopharynx

OBJECTIVE/HYPOTHESIS To evaluate and correlate voice-specific quality of life (QOL) and health-related QOL (HR-QOL) after treatment for advanced cancer of the larynx and/or hypopharynx. STUDY DESIGN Cross-sectional study. METHODS Patients submitted to partial laryngectomy (PL), salvage PL (sPL), concomitant radiotherapy and chemotherapy (RT+Chemo), total laryngectomy (TL), salvage TL (sTL), total pharyngolaryngectomy (TP) and salvage total pharyngolaryngectomy (sTP). The following questionnaires were used: (1) Voice Handicap Index (VHI) and (2) University of Washington Quality of Life Questionnaire (UW-QOL; version 4). RESULTS Eighty-four patients participated in the study. All the patients PL (10), sPL (1), and RT+Chemo (24) communicated by laryngeal voice. Of the 49 patients submitted to total removal of the larynx, 30 communicated with alaryngeal phonation, the major part being tracheoesophageal prosthesis (17). The worst subscale of VHI for the total patient group was functional (mean=13.15), and the value of the total score was 31. Patients submitted to PL, RT+Chemo, and TL presented slight handicap (medians of 27, 14, and 21.5, respectively). Patients treated with sTL, TP, and sTP presented moderate handicap (medians of 45, 37.5, and 31.5, respectively). HR-QOL was considered between good and excellent for 78.6% of the patients, and poor for 21.4%. The correlation between voice-specific QOL and HR-QOL was significant (P=0.0001). CONCLUSION Patients treated for advanced cancer of the larynx/hypopharynx present slight to moderate voice handicap and good/excellent HR-QOL. Stricter analysis of both the VHI and UW-QOL data suggests that more attention be given to the vocal handicap of the individual patient.

Analysis of surgical margins in oral cancer using in situ fluorescence spectroscopy

UNLABELLED Oral cancer is a public health problem with high prevalence in the population. Local tumor control is best achieved by complete surgical resection with adequate margins. A disease-free surgical margin correlates with a lower rate of local recurrence and a higher rate of disease-free survival. Fluorescence spectroscopy is a noninvasive diagnostic tool that can aid in real-time cancer detection. The technique, which evaluates the biochemical composition and structure of tissue fluorescence, is relatively simple, fast and, accurate. OBJECTIVES This study aimed to compare oral squamous cell carcinoma lesions to surgical margins and the mucosa of healthy volunteers by fluorescence spectroscopy. MATERIALS AND METHODS The sample consisted of 56 individuals, 28 with oral squamous cell carcinoma and 28 healthy volunteers with normal oral mucosa. Thirty six cases (64.3%) were male and the mean age was 60.9 years old. The spectra were classified and compared to histopathology to determine fluorescence efficiency for diagnostic discrimination of tumors. RESULTS In the analysis of the other cases we observed discrimination between normal mucosa, injury and margins. At two-year follow up, three individuals had local recurrence, and in two cases investigation fluorescence in the corresponding area showed qualitative differences in spectra between the recurrence area and the area without recurrence at the same anatomical site in the same patient. CONCLUSION In situ analysis of oral mucosa showed the potential of fluorescence spectroscopy as a diagnostic tool that can aid in discrimination of altered mucosa and normal mucosa.

Complicações pós-operatórias em tireoidectomias com ou sem dreno

BACKGROUND: This study analyzes the occurrence of local postoperative complications (hematoma, seroma and wound infection) and length of hospital stay in patients submitted to thyroidectomy with or without drains. METHODS: Four hundred and ninety eight patients who underwent thyroidectomy were classified into three groups: group not drained; group with Penrose drain; and group with suction drain (Hemovac). Each group was composed by 166 patients. RESULTS: The overall postoperative complication rate was of 7.4% (37/498). The time of hospitalization varied from 1 to 5 days (median, 1 day), with 85.6% of the patients in the group not drained staying one day. The same occured in 51.8% of the patients of the group drained with Hemovac and in only 26.9% of the patients of the group drained with Penrose. The hospital stay was significantly shorter in the nondrained group compared with the other groups (p=0.0001). Postoperative hematoma was found in 7 patients (1.4%). Other local complications as seroma and wound infection occurred in 4.4% and 1.8% of the patients, respectively. No significant correlations were observed between these complications and the use or not of drains. CONCLUSION: The routine use of drains seems to be unnecessary in patients submitted to thyroidectomy. However, the use of meticulous dissection and transoperative hemostasis are important measures to reduce the risk of postoperative complications as hematoma and seroma.

Evolution in the profile of thyroid cancer cases treated in an oncology reference service: what changed in the last 20 years.

OBJECTIVE To evaluate the characteristics of thyroid carcinoma cases treated at a reference hospital for cancer between 2008 and 2010. METHODS we studied 807 cases and analyzed the following clinicopathologic variables: symptoms, risk factors, diagnostic tests, staging, histological type, treatment performed and complications. RESULTS Females were more affected, with 660 cases (82%). The average age at diagnosis was 44.5 years. Prior exposure to ionizing radiation was reported by 22 (3%) patients, a family history of thyroid cancer by 89 (11%), and 289 (36%) individuals reported other types of cancer in the family. The fine needle aspiration biopsy was the main parameter for surgical indication and was suggestive of carcinoma in 463 patients (57%). Papillary carcinoma was the most common histological type, with 780 cases (96.6%). There were 728 (90%) total thyroidectomies, 43 (5.3%) reoperations or partial thyroidectomies followed by totalization, 23 (2.8%) extended thyroidectomies and only 13 (1.6%) partial thyroidectomies (lobectomy with isthmectomy). Neck dissection associated with thyroidectomy was done in 158 patients (19.5%). We observed a predominance of tumors classified as T1 in 602 (74.6%) patients. Transient hypocalcemia was the most frequent complication. CONCLUSION The results show that the worldwide increase in the incidence of thyroid cancer has changed the profile of patients seen at a referral service. In addition, there were changes in the type of surgical treatment used, with increased use of total thyroidectomy in relation to partial and subtotal ones, and decreased use of elective neck dissections.

Preservation of the Internal Jugular Vein in the Radical Treatment of Node-Positive Neck—Is It Safe?

BackgroundThe aim of this study was to evaluate risk factors of neck recurrence in patients with pN+ necks submitted to a modified or a classic radical neck dissection and the safety of preserving the internal jugular vein in the treatment of a subgroup of these patients.MethodsThe medical records of 311 untreated patients with squamous cell carcinoma of the oral cavity (106 cases), oropharynx (95 cases), larynx (49 cases), and hypopharynx (61 cases) were reviewed. Their clinical stages (CS) were CS II in 1%, CS III in 19.9%, CS IVA in 76.2%, and CS IVB in 19.6% of the cases. All patients were pN+.ResultsIpsilateral neck recurrence occurred in 18 cases (5.8%), 14 cases (4.5%) where the internal jugular vein was resected, and 4 cases (1.3%) where the internal jugular vein was preserved. Neck recurrence did not have significant correlation with tumor site (P = .852), T stage (P = .369), N stage (P = .963), adjuvant radiotherapy (P = .701), number of positive lymph nodes (P = .886), jugular vein preservation (P = .240), and extracapsular spread (P = .670). There was significant correlation between neck recurrence and the lymph node size (.040).ConclusionsModified radical neck dissection with internal jugular vein preservation can be performed in selected patients with lymph node metastases, with no significant increase in the risk of neck recurrence.

Reconstrução total de faringe: análise de 69 casos

Os autores analisaram retrospectivamente as reconstrucoes apos faringolaringectomias totais e faringolaringo-esofagectomias totais realizadas num periodo de 18 anos, com o objetivo de comparar os resultados imediatos e tardios das diversas tecnicas empregadas. Foram revistos 69 casos submetidos a reconstrucoes totais de faringe realizadas no Hospital A.C.Camargo, de 1980 a 1997. Hipofaringe e laringe eram os locais da neoplasia em 57 pacientes (82,6%), o esofago cervical, em sete (10,1 %), e outras localizacoes em cinco (7,2%). Em 62,4% dos casos, o tumor encontrava-se em estadio avancado, e em 18,8% os pacientes apresentavam recidivas de tumores previamente tratados. As cirurgias consistiram em faringolaringoesofagectomia total e transposicao de tubo gastrico (gastric pull-up) em 14 pacientes (20,3%), e com interposicao de colon em cinco (7,3%); e de faringolaringectomia total com reconstrucao a partir da rotacao de retalho do musculo peitoral maior tubulizado em 16 pacientes (23,2%), com retalho do musculo peitoral maior suturado a fascia pre-vertebralis em 29 (42,0%) e com outras reconstrucoes em cinco (7,2%). Das tecnicas de reconstrucao em faringolaringoesofagectomia, o gastric pull-up apresentou indices menores de complicacoes e mortalidade pos-operatoria. Quando comparamos as reconstrucoes em faringolaringectomia total, os casos reconstruidos com retalho miocutâneo suturado a fascia pre-vertebralis apresentaram indices menores de fistula e estenose. No entanto, essas diferencas nao foram estatisticamente significativas. Diante destes resultados, nossa conduta em faringolaringectomias totais, quando nao e possivel a reconstrucao da faringe com sutura primaria, e realizar a rotacao do retalho do musculo peitoral maior suturado a fascia pre-vertebralis. Quando e necessaria a faringolaringoesofagectomia, realizamos reconstrucao com gastric pull-up.