Thiago Celestino Chulam

Long-term Results of Observation vs Prophylactic Selective Level VI Neck Dissection for Papillary Thyroid Carcinoma at a Cancer Center

IMPORTANCE The indication for prophylactic central neck dissection in papillary thyroid cancer (PTC) is controversial. OBJECTIVE To compare long-term results of observation vs prophylactic selective level VI neck dissection for PTC. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study of 812 patients with PTC who were treated from January 1, 1996, through January 1, 2007, at the Department of Head and Neck Surgery and Otorhinolaryngology of A. C. Camargo Cancer Center. A group of 580 consecutive patients with previously untreated PTCs and without lymph node metastasis were eligible for the study. We collected and analyzed retrospective data from February 1, 2012, through August 31, 2013. INTERVENTIONS One hundred two patients (group A) underwent total thyroidectomy with elective central neck dissection; 478 patients (group B) underwent total thyroidectomy alone. MAIN OUTCOMES AND MEASURES Absence of difference in rates of locoregional control and rates of major complications in group A. RESULTS In group A, the rate of occult metastatic disease was 67.2%. Patients in group A exhibited higher rates of temporary hypocalcemia (46.1% vs 32.2%; P = .004) and permanent hypoparathyroidism (11.8% vs 2.3%; P < .001). We also found a significantly higher incidence of temporary (11.8% vs 6.1%; P = .04) and permanent (5.9% vs 1.5%; P = .02) recurrent laryngeal nerve dysfunction in group A. The overall recurrence rate at level VI was 1.9%. CONCLUSIONS AND RELEVANCE Although the risk for occult lymph node metastasis reached 67.2% in a selected group of patients, elective central neck dissection for patients with PTC increased the risk for complications and did not contribute to a decrease in local recurrence rates.

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.

Late Surgical Outcomes of Carotid Resection and Saphenous Vein Graft Revascularization in Patients with Advanced Head and Neck Squamous Cell Carcinoma

BACKGROUND In head and neck squamous cell carcinoma, invasion of the carotid artery is a severe mortality predictor. We report an updated experience of 19 patients who underwent head and neck resection for squamous cell carcinoma with concomitant carotid reconstruction. This study aims to analyze overall survival rates, primary patency of the reconstructions, vascular and nonvascular complications, radiotherapy dosing as well as late follow-up and outcomes. METHODS From September 1997 to 2011, 19 patients with advanced squamous cell carcinoma with carotid artery invasion were submitted to resection and concomitant vascular reconstruction in a single referred oncological institution. Patient follow-up was done by means of periodic outpatient returns, where clinical and duplex scan evaluations were performed to study graft patency. RESULTS The average length of follow-up was 23.3 (± 34.4) months. Nonvascular complications occurred in 6 patients (31.6%). Only 1 (5.3%) vascular complication was observed, resulting from the immediate occlusion of the carotid graft. All patients were submitted to preoperative, adjuvant, or curative intent radiotherapy during the course of the oncologic treatment, with varying doses. Overall disease-free survival, primary patency, and survival with patent graft rates in 5 years are respectively 12.9%, 93.1%, and 13.0%. Three patients (15.9%) are still alive, all without tumor recurrence, and present a disease-free long-term follow-up with patent grafts 21 months, 68 months, and 151 months after surgery. CONCLUSIONS Aggressive surgical approach for patients with advanced squamous cell head and neck carcinoma with carotid invasion can lead to cure in a select group of patients. Saphenous vein grafts demonstrated favorable outcomes with low infection and high patency rates, suggesting a valid alternative for arterial reconstruction in these cases.

Retroauricular Endoscope-Assisted Approach to the Neck: Early Experience in Latin America

Introduction There has been a significant increase in concern towards improving aesthetic and functional outcomes without compromising the oncologic effectiveness in head and neck surgery. In this subset, endoscope-assisted and robotic procedures allowed the development of new approaches to the neck, including the retroauricular access, which is now routinely used, especially in Korea. Objectives This study aims to provide a descriptive analysis of our initial experience with retroauricular endoscope-assisted approach assessing feasibility, safety, and aesthetic results. Methods Prospective analysis of the first 11 eligible patients submitted to retroauricular endoscope-assisted approach for neck procedures in the Head and Neck Surgery Department at AC Camargo Cancer Center. Results A total of 18 patients were included in this study, comprising 7 supraomohyoid neck dissections, 8 submandibular gland excisions, 3 thyroid lobectomies, and one paraganglioma excision. There was no significant local complications, surgical accident, or need for conversion into conventional open procedure in this series. Conclusion Our initial experience has shown us that this approach is feasible, safe, oncologically efficient, and applicable to selected cases, with a clear cosmetic benefit.

Prognostic Factors in Patients with Well-Differentiated Thyroid Carcinoma withLocoregional Recurrence Submitted for Salvage Treatment

Background: Well-differentiated thyroid carcinoma is characterized by an excellent prognosis; however, recurrence rates range from 5% to 23%, and mortality after salvage treatment ranges from 38% to 69%. Objectives: To identify prognostic factors in patients who have undergone salvage therapy for well-differentiated thyroid carcinoma. Patients and methods: This is a retrospective cohort series including 102 patients with respectable locoregional recurrences who underwent salvage treatment. One hundred twenty loco-regional recurrences were observed amongst 102 patients. Univariate survival analysis was performed using the Kaplan-Meier method. Results: Five-year overall survival rates were significantly associated with age over 45 years (67.6%) (p <0.0001), site of recurrence (local or regional recurrence and distant metastasis (65.8%), only local recurrence (88.8%), only regional recurrence (92.2%) (p=0.0267), and histology (papillary carcinoma (90.3%) and follicular carcinoma, (72.2%) (P=0.0156). Conclusion: Age over 45 years, follicular carcinoma and location of recurrence were significant prognostic factors in patients with well-differentiated thyroid carcinoma who underwent salvage treatment.

Retroauricular endoscopic and robotic versus conventional neck dissection for oral cancer

There has been a significant increase in concern towards improving aesthetic and functional outcomes without compromising the oncologic effectiveness in head and neck surgery. The aim of the current study is to assess the feasibility and oncological outcome of the retroauricular approach for endoscopic and robot-assisted selective neck dissection (SND) for oral cancer in comparison with the conventional SND. A retrospective single institute cohort study was designed. Patients undergoing an SND for oral cavity carcinoma were included and allocated into two groups: (1) retroauricular approach group for endoscopic-assisted or robot-assisted SND or (2) transcervical approach group for the conventional SND. Primary endpoint was the perioperative and postoperative treatment outcomes. Secondary endpoint was the early oncologic outcome. Sixty patients were included (17 retroauricular; 43 conventional). For the primary outcome, only a significant longer operative time in the retroauricular group was identified. No unintentional injury or conversion to the conventional surgery was recorded. There was no significant difference identified in the early oncologic outcome, including number of retrieved lymph nodes and disease-free survival. Postoperative aesthetic results were considered superior when subjectively compared to the conventional approaches. Endoscopic and robot-assisted SND via a retroauricular approach is feasible, safe, and oncologically efficient when compared with the conventional surgery in a short follow-up scenario. It can be used for selected cases with a clear cosmetic benefit. However, further research with longer follow-up and patient satisfaction analysis is mandatory.

Clinicopathologic analysis of 14 cases of odontogenic myxoma and review of the literature

Background Odontogenic myxoma is a rare benign neoplasm that originates from odontogenic ectomesenchyme. There is no standard of care and recurrences are frequent after conservative surgical procedures. Material and Methods A retrospective study conducted at a single cancer center, with analysis of medical records of all patients diagnosed with odontogenic myxoma from 1980 to 2010, along with a literature review. Results There were 14 patients with diagnosis of odontogenic myxoma (OM). Most patients were female (78.6%) and Caucasian (100%), with ages ranging from 7 to 51 years (21.6 ± 11.6 years). The time period between the first symptom and first consultation ranged from 0 to 60 months (19.4 ± 19.97 months). The most frequent complaints were increased local volume or failure to tooth eruption. The most common tumor site was the mandible (11 cases, 78.5%). About radiological findings, most lesions were multilocular (9 cases, 64.3%) and with imprecise limits (12 cases, 85.7%). Surgery was performed in all cases and curettage was the most applied technique (10 cases, 71.4%). Three patients underwent mandibulectomy and complex reconstructions including iliac crest microvascular flap. Three patients had postoperative complications and 4 had local recurrences of the tumor. The follow up time ranged from 12 to 216 months (112 ± 70.8 months). All patients are without clinical and radiographic evidence of disease. Conclusions OM is a locally aggressive and rare tumor. There is no gold standard surgical management and the therapeutic decision should be individualized taking into account the characteristics and extension of the tumor. Key words:Mandible, myxoma, odontogenic, odontogenic tumor.

Variations and results of retroauricular robotic thyroid surgery associated or not with neck dissection

Background Technological advances in the last decades allowed significant evolution in head and neck surgery toward less invasive procedures, with better esthetic and functional outcomes, without compromising oncologic soundness. Although robotic thyroid surgery has been performed for some years now and several published series reported its safety and feasibility, it remains the center of significant controversy. This study shows the results of a case series of robotic thyroid surgery, combined or not with robotic neck dissection. Methods A retrospective cohort including 48 cases of robotic thyroid surgery with or without neck dissection, using retroauricular or combined approaches, performed in a tertiary cancer center, comprised the study. Results Between 2015 and 2017, we performed 2,769 thyroid surgical procedures, of which 48 (1.7%) were robot-assisted, in 46 patients [26 hemithyroidectomies, 7 total thyroidectomies, and 12 total thyroidectomies (or totalization) with selective neck dissection (SND) II-VI; and 3 neck dissections for thyroid carcinoma]. There were 43 (89.6%) women, and the median age was 35 years. The mean hospital stay was 1.9 days. In 3 (6.2%) cases, drains were not placed (hemithyroidectomies), whereas the other 45 (93.8%) cases had a mean drain stay of 4.4 days (range, 1-9 days). The console time (robotic thyroid resection and neck dissection) ranged from 11 to 200 min (mean 66.1 min; median 40 min), and the total operating room time ranged from 80 to 440 min (mean 227.9 min; median 170 min). Three (6.2%) patients had transient vocal cord paresis. Transient hypocalcemia was reported in three cases (6.2%). There were 30 carcinomas (62.5%), and the mean number of retrieved lymph nodes (LNs) (considering only cases that included robotic neck dissection) was 27.2 (range, 17-40). The mean follow-up time was 17.4 months (range, 1.4-31.9 months), and no recurrence was diagnosed. Conclusions The quality outcomes and complication rates are comparable to the conventional approaches. Therefore, robotic thyroidectomy can be an option for selected patients that are motivated to avoid a visible neck scar, treated in high-volume centers. For the patients who require lateral neck dissection, the retroauricular robotic approach could be even more attractive, especially for young patients.

Safe implementation of retroauricular robotic and endoscopic neck surgery in South America

In the last three decades, otolaryngology and head and neck oncological surgery have shown remarkable progress with the development of several modalities of endoscopic-assisted minimally invasive surgeries. More recently, the Da Vinci robotic surgery system has promoted the development of several surgical approaches with less morbidity and better cosmetic results, including the transaxillary and retroauricular approaches for thyroid surgery and neck dissections. In South America, there are several shortcomings regarding financial resources as well as the lack of support for innovation leading to a significant delay in adoption of numerous technological advances in medical practice. Despite these obstacles, we obtained training in transoral robotic surgery and neck procedures, and then decided to implement neck endoscopic and robotic surgery at our institution. We developed a collaborative training program with Yonsei University that, together with several local measures, allowed for a safe implementation. From June 2014 to December 2016, we have performed a total of 121 retroauricular neck surgeries, of which 65 were robotic-assisted and 56 were endoscopic assisted procedures, with a complication rate that seems to be comparable to conventional procedures in our experience and a smooth learning curve. Safety compliance has been continuously assessed. Aiming to develop and disseminate these techniques, we have ongoing collaborative work with Yonsei University faculty, to continue increasing our clinical experience, and we are now preparing the group and infrastructure to establish a local training program for South American surgeons. We have been presenting our results at national and international medical meetings and started to publish the preliminary results in peer reviewed medical journals. The emphasis is that a retroauricular approach is a therapeutic option to be considered, especially for young patients. Media exposure has been avoided so far. As expected, resistance by our peers is still present and much more work is needed to overcome it, including the generation of data on the outcomes and a critical analysis of the advantages and disadvantages of endoscopic and robotic neck surgery.

Abordagem cervical por via retroauricular modificada com uso da técnica robótica: Experiência inicial na América Latina

Objective: to evaluate the thickness of the gastric wall at the time of intra gastric balloon (IGB) placement, at the time of its withdrawal and one month after withdrawal. Methods: fifteen morbidly obese patients underwent the introduction of IGB under general anesthesia. In all patients, there was infusion of 500ml of distilled water in the balloon for the test. Measurements of the thickness of the gastric wall were made in the antrum, body and proximal body, using a radial echoendoscope with a frequency of 12MHz and maximum zoom, and its own balloon inflated with 5ml of distilled water. Results: the presence of IGB led to increased wall thickness of the gastric body by expanding the muscle layer. These changes were apparently transient, since 30 days after the balloon withdrawal there was a tendency to return of the wall thickness values ​​observed before the balloon insertion. Conclusion: the use of intragastric balloon for the treatment of obesity determines transient increase in the wall thickness of the gastric body caused by expanded muscle layer.OBJECTIVE to evaluate the thickness of the gastric wall at the time of intra gastric balloon (IGB) placement, at the time of its withdrawal and one month after withdrawal. METHODS fifteen morbidly obese patients underwent the introduction of IGB under general anesthesia. In all patients, there was infusion of 500ml of distilled water in the balloon for the test. Measurements of the thickness of the gastric wall were made in the antrum, body and proximal body, using a radial echoendoscope with a frequency of 12MHz and maximum zoom, and its own balloon inflated with 5ml of distilled water. RESULTS the presence of IGB led to increased wall thickness of the gastric body by expanding the muscle layer. These changes were apparently transient, since 30 days after the balloon withdrawal there was a tendency to return of the wall thickness values ​​observed before the balloon insertion. CONCLUSION the use of intragastric balloon for the treatment of obesity determines transient increase in the wall thickness of the gastric body caused by expanded muscle layer. RESUMO A preocupação com a melhoria dos resultados estéticos e funcionais sem comprometimento dos resultados oncológicos na cirurgia de cabeça e pescoço tem aumentado significativamente. Os procedimentos minimamente invasivos e principalmente aqueles que utilizam a tecnologia robótica permitiram o desenvolvimento de novas abordagens, incluindo o acesso retroauricular, que agora é usado rotineiramente, especialmente na Coréia do Sul. A presente nota irá ilustrar a técnica e a experiência inicial na América Latina, demonstrando que esta abordagem é viável, segura e eficaz oncologicamente, podendo ser utilizada em casos selecionados com um benefício estético evidente.