Latin American Consensus on the Treatment of Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.

Impact of lymph node ratio and number of lymph node metastases on survival and recurrence in laryngeal squamous cell carcinoma

INTRODUCTION

The aim of this study is to assess the impact of lymph node ratio (LNR) and number of positive lymph nodes (NPLN) on mortality and recurrence rates in patients with laryngeal squamous cell carcinoma.

MATERIALS AND METHODS

We conducted a retrospective multicenter international study involving 24 Otorhinolaryngology-Head and Neck Surgery divisions. Disease-specific survival (DSS) and disease-free survival (DFS) were evaluated as the main outcomes. The curves for DSS and DFS according to NPLN and LNR were analyzed to identify significant variations and establish specific cut-off values.

RESULTS

2507 patients met the inclusion criteria. DSS and DFS were significantly different in the groups of patients stratified according to LNR and NPLN. The 5-year DSS and DFS based on LNR and NPLN demonstrated an improved ability to stratify patients when compared to pN staging.

CONCLUSION

Our data demonstrate the potential prognostic value of NPLN and LNR in laryngeal squamous cell carcinoma.

Management of Stage III Oral Cavity Squamous Cell Carcinoma in Light of the New Staging System: a Critical Review

PURPOSE OF REVIEW

Oral squamous cell carcinoma (OSCC) patients have a poor prognosis, especially in advanced stages. AJCC/UICC staging system 8th edition (TNM8) included depth of invasion (DOI) as part of T staging and stage III has become a heterogeneous group of lesions, composed of patients with larger DOI and/or width. Additionally, stage III includes N1, regardless of the primary tumor width or DOI. The real prognostic value of each of these characteristics and the need for adjuvant treatment for stage III patients is not well established.

RECENT FINDINGS

TNM8 stratified OSCC into prognostic groups based on overall survival. Extranodal extension, positive or close margins, pT3 or pT4 tumors, pN2 or pN3 nodal disease, nodal disease in levels IV or V, perineural invasion, vascular invasion, and lymphatic invasion are the main adverse features for OSCC, and adjuvant treatment is largely recommended for these patients. Stage III patients should be addressed with caution. So far, there is no significant evidence for recommending or excluding adjuvant treatment for stage III OSCC without adverse features. The authors largely recommend adjuvant radiotherapy for these cases, especially because pT3 without adverse features is rare. Further studies on this topic are necessary.

Survival in differentiated thyroid carcinoma: Comparison between the 7th and 8th editions of the AJCC/UICC TNM staging system and the ATA initial risk stratification system

BACKGROUND

The AJCC/UICC TNM staging system evaluates the risk of death from cancer. Its 8th edition aimed to increase its accuracy. In turn, the American Thyroid Association proposed an initial risk stratification system (IRSS) focusing on the risk of recurrence in differentiated thyroid carcinoma. The present study intended to analyze their prediction abilities.

METHODS

Six hundred and eighty-five consecutive surgical patients (mean follow-up 71.6 months) were staged. Correlations with disease-free survival (DFS) and overall survival (OS) were carried out.

RESULTS

IRSS was discriminative for DFS but not for OS. Applying TNM 8th, 36.9% of the cohort was downstaged. Their DFS was shorter, compared with other patients in the same stage, but with no impact on OS. However, all those who died of the disease had been downstaged.

CONCLUSIONS

IRSS was more effective to predict DFS, but not OS. TNM 8th was more appropriate for OS analysis than TNM 7th and IRSS.

Oral Squamous Cell Carcinoma Bone Invasion: Possible Roles of E-Cadherin in Osteoclastogenesis and Bone Infiltration

INTRODUCTION

Squamous cell carcinoma is the most common cancer of the oral cavity. When the tumor invades the bone tissue, the prognostic and survival rates decrease a lot, and the treatment becomes more aggressive, with several damages to the patient and health system. Many of the molecular mechanisms of bone invasion process are not understood yet, but it is already known that one of central processes of tumor evolution - adjacent tissues invasion and metastasis - is a large spectrum of phenotypic changes in epithelial cells to mesenchymal, in a process named as epithelial-mesenchymal transition (EMT). Loss of E-cadherin, an important epithelial cell adhesion protein, is a hallmark of this phenomenon. The objective of this retrospective study is to evaluate the expression of E-cadherin protein, comparing its distribution with clinical characteristics of the patients and possibly relation to EMT.

METHODS

Sixty-two cases with respective clinical data were analyzed by comparing immunohistochemical, H and E staining, and clinical data, observing the tumor-bone interface (TBI) and the surrounding tumor that had no direct contact with the bone surface (ST).

RESULTS

Forty cases were positive for E-cadherin (64%) with a heterogeneous pattern. Statistical analysis showed a significant difference between the presence of E-cadherin expression and tobacco smokers. Also, the equal or weaker protein expression in the ST than TBI is related to a worse overall survival. No statistically significant difference in other prognostic factors was observed.

CONCLUSION

Our results suggest that the tumor cells that interact with the bone tissue could gain molecular changes, like partial EMT and osteoclastogenesis induction, which facilitate their migration and increase the bone resorption, resulting in a worse patient's prognosis.

MicroRNA-mediated extracellular matrix remodeling in squamous cell carcinoma of the oral cavity

BACKGROUND

We evaluated microRNAs and extracellular matrix component profiles in squamous cell carcinoma of the oral cavity (OSCC) in comparison to healthy mucosa.

METHODS

Retrospective study investigating 64 microRNAs related to oncogenic process and to constituents of the extracellular matrix. We also performed immunohistochemical assays for molecules involved in the same biological processes.

RESULTS

High expression of miR-21-5p (p < 0.001) and miR-106-5p (p < 0.001) and low expression of miR-320a (p = 0.001) and miR-222-3p (p = 0.001) were predictors of malignancy. Individually, miR-21-5p exhibited the best statistical performance (area under the curve = 0.972; 95% confidence interval: 0.911-1.000) in the differentiation between tumor tissue and healthy mucosa. Moreover, tumor sample showed increased expression of MMP-2, MMP-9, α-laminin, and β-laminin in tumor-related fibroblasts and lower continuity of type IV collagen in the basement membrane.

CONCLUSION

The present study demonstrates the biological effects of microRNAs on the carcinogenesis of OSCC as well as the intense modification of the tumor microenvironment.

The impact of sentinel lymph node biopsy on the quality of life in patients with oral cavity squamous cell carcinoma

INTRODUCTION

Sentinel lymph node biopsy is a proven method for staging the neck in patients with early oral cavity squamous cell carcinoma because it results in less comorbidity than the traditional method of selective neck dissection, with the same oncological results. However, the real effect of that method on the quality of life of such patients remains unknown.

OBJECTIVE

The present study aimed to evaluate the quality of life of patients with oral cavity squamous cell carcinoma T1/T2N0 submitted to sentinel lymph node biopsy compared to those that received selective neck dissection.

METHODS

Cross-sectional study including 24 patients, after a 36 month follow-up, 15 of them submitted to the sentinel lymph node biopsy and 9 to selective neck dissection. All patients answered the University of Washington quality of life questionnaire.

RESULTS

The evaluation of the questionnaires showed a late worsening of the domains appearance (p=0.035) and chewing (p=0.041), as well as a decrease of about 10% of general quality of life (p=0.025) in patients undergoing selective neck dissection ​​in comparison to those undergoing sentinel lymph node biopsy.

CONCLUSION

Patients with early-stage oral cavity squamous cell carcinoma undergoing sentinel lymph node biopsy presented better late results of general quality of life, mainly regarding appearance and chewing, when compared to patients submitted to selective neck dissection.

Cancer-associated fibroblast regulation by microRNAs promotes invasion of oral squamous cell carcinoma

The objective of the present study was to evaluate the role of microRNA-mediated remodeling of the extracellular matrix in the process of tumor invasion of oral squamous cell carcinoma and to evaluate its relationship with the prognosis of these patients. This was a retrospective study on material from the paraffin blocks of patients operated on for oral squamous cell carcinoma, in addition to a group of healthy oral mucosa samples of paired patients. miR-1-3p, miR-133-3p, and miR-21-5p were differentially expressed between the superficial and deep tumor groups. miR-21-5p was the one with the greatest accuracy in the differentiation between superficial and deep tumors. By immunohistochemistry, the group of deep tumors showed greater immunoreactivity to matrix metalloproteinases 2 and 9 and laminin α in tumor-associated fibroblasts, with consequent degradation of the basal membrane, measured by greater loss of continuity of type IV collagen. This process was also associated with lower and higher expression of miR-1-3p and miR-21-5p, respectively. There was also a trend toward better overall and disease-free survival rates in patients with higher miR-133a-3p. The present study showed the interaction between microRNAs and extracellular matrix remodeling in oral squamous cell carcinoma.

Neutrophil-to-lymphocyte ratio as a prognostic factor for pharyngocutaneous fistula after total laryngectomy

SUMMARY

The role of systemic inflammatory response as a prognostic factor has been proposed in a variety of cancers. The purpose of this study was to investigate the prognostic value of the pretreatment neutrophil-to-lymphocyte ratio (NLR) in the incidence of pharyngocutaneous fistula (PCF) in patients who underwent total laryngectomy. We conducted a retrospective cohort analysis of 141 patients with squamous cell carcinoma of larynx who underwent total laryngectomy from 2009 to 2015. The incidence of PCF was 49.6%. A higher risk of 23% was observed among patients with NLR > 2.5 for the occurrence of PCF (p = 0.007). Patients with laryngeal squamous cell carcinoma who present elevated values in the ration > LR> (> 2.5) presented a higher risk of developing pharyngocutaneous fistula in the postoperative setting of total laryngectomy.

Assessment of quality of life in patients with advanced oral cancer who underwent mandibulectomy with or without bone reconstruction

INTRODUCTION

Malignant neoplasms of the head and neck, due to its anatomical location, can cause significant alterations in vital functions related to feeding, communication and social interaction of the affected patients.

OBJECTIVE

To analyze the quality of life of patients with advanced malignant neoplasms of the oral cavity and submitted to radical operations with curative intent.

MATERIAL AND METHODS

47 patients with oral cavity squamous cell carcinoma (SCC), in stages III and IV, underwent surgical treatment with segmental mandibulectomy and complementary radiotherapy. The patients were submitted to the quality of life questionnaires after a minimum time of six months after the surgical treatment.

RESULTS

Of the 183 patients, only 47 (25.7%) were able to answer the questionnaire and were included as the sample of the study. The majority of patients selected were male (39; 82.9%). The mean age was 64.4 years. The majority of the patients presented clinical stage IV (83%) and were submitted to adjuvant radiotherapy (95.4%). The mean score obtained after the questionnaires were applied was 64.6. The worst scores were found in swallowing and chewing.

CONCLUSION

There were no statistically significant differences in the domains of quality of life between the two groups studied (with bone reconstruction versus no bone reconstruction). Patients interviewed 2 years or more after treatment presented higher scores (p = 0.02).

Superficial cervical plexus blockade improves pain control after thyroidectomy: A randomized controlled trial

OJECTIVES

The aim was to evaluate the ability of bilateral superficial cervical plexus blockade to control pain and to reduce the side effects of general anesthesia in patients submitted to thyroidectomy.

METHODS

In this randomized controlled trial, we prospectively studied 100 consecutive patients who underwent total thyroidectomy. The simple random patient sample was divided into two groups: 50 patients received general anesthesia alone (group 1 [G1]), and 50 patients received general anesthesia with bilateral superficial cervical plexus blockade (group 2 [G2]). Statistical analyses were performed, and a 5% significance level was adopted.

RESULTS

The mean arterial blood pressure and heart rate were 12% lower in G2 patients than in G1 patients 60 minutes after surgery (101 mmHg for G1 vs. 92.3 mmHg for G2; p<0.001). G2 patients reported less pain than G1 patients, and opioid consumption was lower in G2 patients than in G1 patients, not upon postanesthesia care unit arrival, but at 30 minutes (2% vs. 34%; p<0.001, respectively), 45 minutes (0% vs. 16%; p=0.006, respectively), and 4 hours postoperatively (6% vs. 20%; p=0.037, respectively). The incidence of nausea and vomiting was lower in G2 patients than in G1 patients from 45 minutes (0% vs. 16%; p=0.006, respectively) to 8 hours postoperatively (0% vs. 14%; p=0.012, respectively).

CONCLUSIONS

The present study demonstrated that the combination of bilateral superficial cervical plexus blockade with general anesthesia for thyroidectomy is feasible, safe, and effective for achieving pain control and improving patient outcomes.

Morphological Evaluation of Thyroid Cartilage Invasion in Early Glottic Tumors Involving the Anterior Commissure

INTRODUCTION

The anterior commissure is an area of glottic cancer infiltration, even in early stages.

OBJECTIVE

To evaluate the invasion by tumors into the anterior commissure cartilage in surgical specimens of frontolateral laryngectomy.

METHODS

Forty-eight patients who had undergone frontolateral laryngectomy for T1b/T2 squamous cell carcinoma were included. Epidemiological and clinical aspects as well as morphological histopathological analysis were evaluated.

RESULTS

Of the 48 patients, 42 (87.5%) had T1b lesions and 6 (12.5%) had T2. Thirty-four cases (70.8%) showed healthy tissue between the tumor and the thyroid cartilage, 10 cases (20.8%) had a tumor in close proximity to the cartilage, and in 4 cases (8.3%) there was cartilage invasion. There was no major risk of adverse outcome in the groups with infiltration or tumor adjacent to the cartilage. Level of differentiation, mitotic index, nuclear irregularity, and the presence of nucleolus and tumor necrosis were not related to cartilage invasion.

CONCLUSION

The infiltration of thyroid cartilage occurred in 8.3% of tumors and did not change the outcome in patients submitted to frontolateral laryngectomy. The morphological characteristics did not present any statistical significance.

The role of E-cadherin and β-catenin in laryngeal cancer

Epithelial cadherins with catenins form the E-cadherin-catenin complex that acts on cell-to-cell adhesion. The loss of these complex lead to the reduction or absence of epithelial cadherin expression in the cell membrane, cytoplasmic accumulation of β-catenin and its translocation to the nucleus, contributing to carcinogenic events. The objective of this study was to evaluate the expression of epithelial cadherin and β-catenin in patients with laryngeal tumor. A retrospective study of 52 patients with glottic or supraglottic squamous cell carcinoma was conducted and evaluated according to the tumor site, histological differentiation, TNM stage, survival analysis and compared with the immunohistochemical expression of epithelial cadherin and β-catenin. We observed statistically significant association between the epithelial cadherin expression reduction and supraglottic localization of the lesion, the presence of cervical metastasis, poorly differentiated tumors and locally advanced tumors when in glottic topography. Related to the expression of β-catenin, statistical significance was also found to the presence of cervical metastasis and tumor of low differentiation with the decreased expression of this marker. Regarding survival analysis, the low expression of β-catenin is related to worse overall survival and the reduction of expression of both markers to worse disease-free survival. We concluded that the reduction in expression of the markers studied leads to a prognostic impact as they are related to tumors with greater local aggressiveness and presence of cervical metastasis.

Oral Cancer Treatment: Still an Indication for Elective Neck Dissection?

INTRODUCTION

Oral squamous cell carcinoma has a high incidence and, although elective neck dissection is recommended, the removed nodes frequently present without metastasis. This surgical approach causes disabilities and increases possible surgical complications.

OBJECTIVE

To evaluate the possibility of a watchful waiting approach in oral cancer.

METHODS

We compared 78 patients with clinical and pathological node metastases and their counterparts with pathological node metastases but without evident clinical neck disease. Therefore, we provided a theoretical comparison between the patients who had an elective neck dissection and those who waited until a clinically positive node was evident.

RESULTS

The prognostic factor rates were similar between the groups. Their regional recurrence and mortality rates had no statistical differences.

CONCLUSION

A watchful waiting policy could be applied to selected oral cancer patients who can undergo a very close follow-up. This option would be more cost-effective and less harmful than elective neck dissection.

Accuracy of sentinel lymph node mapping in detecting occult neck metastasis in papillary thyroid carcinoma

OBJECTIVES

The objectives of this study were to evaluate the following: 1) the accuracy of sentinel lymph node mapping (SLNM) in detecting metastasis in papillary thyroid carcinoma (PTC), and 2) if SLNM could modify the American Joint Committee on Cancer (AJCC) staging of previous cN0 PTC patients.

SUBJECTS AND METHODS

Forty SLNM were performed prospectively in 38 consecutive cN0 PTC patients, with total thyroidectomy and elective compartment neck dissection (CND). The results of SLNM were compared with CND pathological findings to verify the accuracy of sentinel SLNM.

RESULTS

The mean patients' follow-up was 36 months. A total of 133 SLN were found at levels VI, II, III and IV. The SLN was identified in 95% of the patients with one false negative, 95% sensitivity, a 94% negative predictive value and 97% accuracy. The SLNM upstaging from cN0 to pN+ was 49%, and to stages III and IVa, it was 21%.

CONCLUSIONS

For this series of cN0 PTC patients: 1) SLNM accuracy was 97%, and 2) SLNM upstaging from cN0 to pN+ was 49%, whereas to stages III and IVa, it was 21%.

Analysis of KIT gene mutations in patients with melanoma of the head and neck mucosa: a retrospective clinical report

Unlike their cutaneous counterparts, head and neck mucosal malignant melanomas (HNMM) are more aggressive, and their prognostic markers have not been fully elucidated. This study, comprising 28 patients with HNMM, aimed to establish the relationship between different mutations and outcome, define the incidence of KIT mutations in HNMM, and identify the correlation among therapeutic options, histopathological findings, demographic data, and clinical response. Clinical analysis included patient characteristics, staging, primary and palliative treatments, and disease-free survival and overall survival (OS). Progression-free survival and OS were analyzed. Paraffin blocks were selected following histologic analyses, enabling DNA extraction. PCR amplification of exons 9, 11, 13, and 17, with different DNA concentrations, was performed. Patients were predominantly females (57%) and aged 27–85 years. All patients underwent surgery; 17 received adjuvant radiotherapy, and recurrences occurred in 82% patients. Oncologic mutations in KIT were found in 7 of 7 tumors, 3 in exon 9, 3 in exon 11, and 1 in exon 13. Predictive factors for recurrence were mitotic rate, vascular invasion, and perineural spread. There were no significant differences in DFS and OS according to KIT mutation. Our study results suggest that some patients might benefit from appropriate targeted therapy with kinase inhibitors.

Speech-language therapy program for mouth opening in patients with oral and oropharyngeal cancer undergoing adjuvant radiotherapy: a pilot study

Purpose Assess the effectiveness of an orofacial myofunctional therapeutic program in patients with oral or oropharyngeal cancer submitted to adjuvant radiotherapy through pre- and post-program comparison of maximum mandibular opening. Methods Prospective study involving five adult patients and five elderly patients postoperatively to oral cavity/oropharynx surgery who were awaiting the beginning of radiotherapy or had undergone fewer than five treatment sessions. The study participants had their maximum jaw opening measured using a sliding caliper at the beginning and end of the program. Two mobility exercises and three mandibular traction exercises were selected and weekly monitored presentially for 10 weeks. Descriptive data and pre- and post-therapy comparative measures were statistically analyzed using the Wilcoxon test. Results Ten patients (two women and eight men) with mean age of 58.4 years, median of 57.0 years, completed the therapeutic program. They presented mean maximum mandibular opening of 31.6 ± 11.7 and 36.4 ± 8.0 mm pre- and post-therapy, respectively (p =0.021). Conclusion The proposed orofacial myofunctional therapeutic program increased the maximum jaw opening of patients referred to adjuvant radiotherapy for oral cavity or oropharynx cancer treatment.

Risk Factors for Distant Metastasis in Patients with Oral Cavity Squamous Cell Carcinoma Undergoing Surgical Treatment

OBJECTIVE

The aim of this study is to investigate the clinical and pathological factors related to distant metastasis in patients with oral cavity squamous cell carcinoma (OCSCC) undergoing surgery.

STUDY DESIGN

A retrospective data review was conducted on patients who underwent primary surgery for OCSCC at the Instituto do Cancer do Estado de São Paulo (ICESP) between 2009 and 2015. Distant metastasis rates were calculated and predictive factors were determined by the Cox proportional-hazards model.

RESULTS

There was a total of 274 patients, including 210 (76.6%) men and 64 (23.4%) women, with a mean age of 59.9 ± 10.9 years. The incidence of distant metastasis was 9.6%, with the lung being the most common site. The mean time interval between surgical treatment and the diagnosis of distant metastasis was 12 months (range 2-40 months). In the multivariate analysis, angiolymphatic invasion (HR = 2,87; p = 0.023), contralateral cervical metastasis (HR = 3.3; p = 0,007), tumor thickness >25 mm (HR = 3.50; p = 0.009), and locoregional recurrence (HR = 6.59; p < 0.0001) were the only independent risk factors for distant metastasis.

CONCLUSION

Patients with OCSCC who have contralateral lymph node metastasis, tumors with a thickness >25 mm, angiolymphatic invasion, or locoregional recurrence after surgical treatment have a greater risk of developing distant metastasis.

Malignancy Rates in Thyroid Nodules Classified as Bethesda Categories III and IV: Retrospective Data from a Tertiary Center

BACKGROUND

Thyroid fine needle aspiration (FNA) has a well-established role in the diagnosis of thyroid nodules, and the "Bethesda system for reporting thyroid cytopathology" is used to interpret FNA results. Bethesda categories III and IV encompass varying risks of malignancy. In addition, there is some debate in the literature about how to select among many acceptable treatment approaches.

OBJECTIVES

To establish an association between these 2 cytological categories and malignancy rates in patients treated in a referral tertiary cancer center, where surgical treatment is recommended for all these patients.

METHODS

A total of 615 thyroid nodules (582 patients) were included in this retrospective study. There were 478 nodules that were classified as Bethesda category III and 137 nodules as Bethesda category IV. Electronic records were reviewed to establish a correlation between the FNA cytological results and the final histopathological analyses. Incidentally detected carcinomas were considered separately.

RESULTS

Among the bethesda category III group, 75 malignant nodules (15.7%) were coincident with the target nodule (74 patients, 16.2%). Incidental carcinomas were found in 13.8% of these patients. The remaining 403 (84.3%) target nodules were benign. Among the bethesda category IV nodules, 23 malignant nodules (16.8%) were coincident with the target nodule. Incidental carcinomas were found in 25 patients (19.7%). The other 114 target nodules were benign. A total of 46 patients (52.3%) had carcinomas in the thyroid lobe contralateral to the one containing the target nodule, and 40 patients (45.5%) had carcinomas exclusively in the contralateral lobe.

CONCLUSIONS

We observed a 16% rate of malignancy in nodules classified as bethesda category III and 17% among bethesda category IV. When incidental carcinomas were included, the rates of malignancy doubled.

Malignancy rates for Bethesda III subcategories in thyroid fine needle aspiration biopsy (FNAB)

OBJECTIVES

Most thyroid diseases are nodular and have been investigated using ultrasound-guided fine needle aspiration biopsy (FNAB), the reports of which are standardized by the Bethesda System. Bethesda category III represents a heterogeneous group in terms of lesion characteristics and the malignancy rates reported in the literature. The objective of the present study was to evaluate the differences in the malignancy rates among Bethesda III subcategories.

METHODS

Data from 1,479 patients who had thyroid surgery were reviewed. In total, 1,093 patients (89.6% female, mean age 52.7 (13-89) years) were included, and 386 patients were excluded. FNAB results (based on Bethesda Class) and histopathological results (benign or malignant) for coincident areas were collected. Bethesda III patients were subcategorized according to cytopathological characteristics (FLUS: follicular lesion of undetermined significance, Bethesda IIIA; AUS: atypia of undetermined significance, Bethesda IIIB). Data were correlated to obtain the malignancy rates for each Bethesda category and the newly defined subcategory.

RESULTS

FNAB results for these patients were as follows: Bethesda I: 3.1%; Bethesda II: 18.6%; Bethesda III: 35.0%; Bethesda IV: 22.1%; Bethesda V: 4.1%; and Bethesda VI: 17.1%. The malignancy rates for Bethesda Class IIIB were significantly higher than those for Bethesda Class IIIA (p<0.001) and Bethesda Class IV (p<0.001). Bethesda Class IIIA showed significantly lower malignancy rates than Bethesda Class III overall (p<0.001) CONCLUSIONS: Improvements of the Bethesda System should consider this subcategorization to better reflect different malignancy rates, which may have a significant impact on the decision-making process.

Oncological results of surgical treatment versus organ-function preservation in larynx and hypopharynx câncer

Summary Introduction: Since the beginning of the 1990s, non-surgical radiochemotherapy treatment has become popular with the prospect of maintaining oncological results and preserving the organ in patients with advanced squamous cell carcinoma of the larynx and hypopharynx. However, subsequent studies demonstrated increased recurrence and mortality after the non-surgical treatment became popular. Objective: To compare the oncological results of surgical and non-surgical treatments of patients with larynx and hypopharynx cancer and to evaluate the variables associated with disease recurrence. Method: This is a retrospective cohort study of 134 patients undergoing surgical (total or partial laryngectomy) or non-surgical (isolated radiotherapy, chemotherapy or induction chemotherapy followed by radiotherapy and chemotherapy) treatment, with 62 patients in the surgical group and 72 in the non-surgical group. Results: Disease-free survival rates were higher in the surgical group (81.7% vs. 62.2%; p=0.028), especially in III/IV stages (p=0.018), locally advanced tumors T3 and T4a (p=0.021) and N0/N1 cases (p=0.005). The presence of cervical lymph nodes, especially N2/N3, was considered a risk factor for disease recurrence in both groups (HR=11.82; 95CI 3.42-40.88; p<0.0001). Patients not undergoing surgical treatment were 3.8 times more likely to develop recurrence (HR=3.76; 95CI 1.27-11.14; p=0.039). Conclusion: Patients with larynx or hypopharynx cancer non-surgically treated had a poorer disease-free survival, especially in cases with locally advanced tumors (T3 and T4a) and in which the neck was only slightly affected (N0/N1).

Combined Vocal Exercises for Rehabilitation After Supracricoid Laryngectomy: Evaluation of Different Execution Times

INTRODUCTION

The supracricoid partial laryngectomy allows the preservation of laryngeal functions with good local cancer control.

OBJECTIVE

To assess laryngeal configuration and voice analysis data following the performance of a combination of two vocal exercises: the prolonged /b/vocal exercise combined with the vowel /e/ using chest and arm pushing with different durations among individuals who have undergone supracricoid laryngectomy.

METHODS

Eleven patients undergoing partial laryngectomy supracricoid with cricohyoidoepiglottopexy (CHEP) were evaluated using voice recording. Four judges performed separately a perceptive-vocal analysis of hearing voices, with random samples. For the analysis of intrajudge reliability, repetitions of 70% of the voices were done. Intraclass correlation coefficient was used to analyze the reliability of the judges. For an analysis of each judge to the comparison between zero time (time point 0), after the first series of exercises (time point 1), after the second series (time point 2), after the third series (time point 3), after the fourth series (time point 4), and after the fifth and final series (time point 5), the Friedman test was used with a significance level of 5%. The data relative to the configuration of the larynx were subjected to a descriptive analysis.

RESULTS

In the evaluation, were considered the judge results 1 which have greater reliability. There was an improvement in the general level of vocal, roughness, and breathiness deviations from time point 4 [T4].

CONCLUSION

The prolonged /b/vocal exercise, combined with the vowel /e/ using chest- and arm-pushing exercises, was associated with an improvement in the overall grade of vocal deviation, roughness, and breathiness starting at minute 4 among patients who had undergone supracricoid laryngectomy with CHEP reconstruction.

Risk factors for salvage surgery failure in oral cavity squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

Locoregional recurrences of oral cavity squamous cell carcinoma (SCC) may be diagnosed during follow-up of surgically treated patients. Nevertheless, few studies have investigated factors that impact salvage surgery failure and the mortality rates of these patients. The objectives were to identify predictive factors of salvage surgery failure and mortality in patients who undergo surgical treatment for recurrent oral cavity SCC and to compare the overall survival rates of these patients with those of patients who undergo only one surgical treatment.

STUDY DESIGN

Retrospective cohort study.

METHODS

Forty-six patients submitted to salvage surgery for local or locoregional recurrence.

RESULTS

The presence of lymph node metastasis and positive surgical margins at the salvage surgery time were the only independent factors associated with both recurrence rates (hazard ratio [HR]: 5.04 and 2.82, respectively) and mortality (HR: 3.51 and 3.24, respectively). When the overall survival rates of the 199 patients who only underwent one surgical treatment were compared to those of the 46 patients subjected to salvage surgery, a similarity was evident when patients who underwent salvage surgery did not have a new disease recurrence (70.7% vs. 54.7%, respectively; P = .158). Likewise, patients with new recurrences after salvage surgery and patients who received palliative treatment for relapsed disease had similar overall survival rates (0.6% vs. 0.0%, respectively; P = .475).

CONCLUSIONS

The presence of lymph node metastasis at the time of recurrence and positive surgical margins after the salvage surgery were associated with a worse overall survival rate in patients with oral cavity SCC relapse.

LEVEL OF EVIDENCE

2b. Laryngoscope, 128:1113-1119, 2018.

Substernal goiter and laryngopharyngeal reflux

OBJECTIVE

This study aims to compare the prevalence of laryngopharyngeal reflux signs between two groups of patients undergoing thyroidectomy for voluminous goiter: substernal goiters and voluminous cervical goiter without thoracic extension.

SUBJECTS AND METHODS

A retrospective case-control study was performed with data retrieved of the charts of the patients submitted to thyroidectomies occurred at a tertiary care center (Head and Neck Surgery Department, University of São Paulo Medical School) between 2010 and 2014. The selected thyroidectomies were allocated in two groups for study: patients with substernal goiters and patients with voluminous cervical goiter without thoracic extension. Cervical goiters were selected by ultrasonography mensuration. Clinical criterion was used to define substernal goiter.

RESULTS

The average thyroid volume in patients with substernal goiter was significantly greater than the average volume in patients with only cervical goiter (p < 0.001). The prevalence of signs of reflux laryngitis at laryngoscopy was significantly greater in substernal goiter patients (p = 0.036). Moreover, substernal goiter was considered as the unique independent variable for high reflux laryngitis signs at laryngoscopy (OR = 2.75; CI95%: 1.05-7.20; p = 0.039) when compared to only cervical goiter patients.

CONCLUSION

This study shows a significant association between substernal goiters and signs of laryngopharyngeal reflux at preoperative laryngoscopy. Therefore, when compared with voluminous cervical goiters, the substernal goiters increase the chance of reflux laryngitis signs in patients.

Deaths related to differentiated thyroid cancer: a rare but real event

Objective

The present study describes the clinical and tumor characteristics of patients that died from differentiated thyroid cancer and reports on the cause and circumstances of death in these cases.

Subjects and methods

Retrospective analysis of all the differentiated thyroid cancer (DTC) related deaths at a single institution over a 5-year period, with a total of 33 patients.

Results

Most of the patients were female (63.6%), with a mean age at diagnosis of 58.2 years. The most common histologic type was papillary (66.7%) and 30.3% were follicular. The distribution according to the TNM classification was: 15.4% of T1; 7.7% T2; 38.4% T3; 19.2% of T4a and 19.2% of T4b. Forty-four percent of cases were N0; 20% N1a and 36.6% of N1b. Twelve patients were considered non-responsive to radioiodine. Only one of the patients did not have distant metastases. The most common metastatic site was the lung in 69.7%. The majority of deaths were due to pulmonary complications related to lung metastases (17 patients, 51.5%), followed by post-operative complications in 5 cases, neurological disease progression in 3 cases, local invasion and airway obstruction in one patient. Median survival between diagnosis and death was reached in 49 months while between disease progression and death it was at 22 months.

Conclusion

Mortality from DTC is extremely rare but persists, and the main causes of death derive from distant metastasis, especially respiratory failure due to lung metastasis. Once disease progression is established, median survival was only 22 months.

Quantitative analysis of lymph nodes in neck dissection specimens. Morphologic study

PURPOSE

To quantify the amount of lymph nodes harvested in modified radical neck dissection.

METHODS

Cross-sectional anatomical study conducted in 28 non-preserved cadavers.

RESULTS

The mean number of lymph nodes found in each nodal level of the 56 modified radical neck dissections performed were: level IA - 1.5 (95% CI: 1.1 - 1.8), level IB - 2.5 (95% CI: 2.1 - 2.9), level IIA - 7.2 (95% CI: 6.0 - 8.5), IIB level - 6.5 (95% CI: 5.5 - 7.4), level III - 6.6 (95% CI: 5.7 - 7.4), level IV - 8.6 (95% CI: 7.1 - 10.1), level V - 11 (95% CI: 9.2 - 12.7), totalizing 43.8 lymph nodes (95% CI: 40.3 - 47.4).

CONCLUSION

The results defined a parameter in relation to the minimum recommended nodal yield in a modified radical neck dissection, as well as the number of lymph nodes in each level of this dissection, performed in clinical practice.

Vocal fold mobility alteration reversed after thyroidectomy

The involvement of the inferior or recurrent laryngeal nerve (RLN) in mobility derangement of the vocal folds occurs more frequently due to thyroid malignancy invasion. Although uncommon, the same derangement, which is caused by benign thyroid entities, is also described and reverts to normality after a thyroidectomy in up to 89% of cases. In these cases, the pathogenesis of the vocal cord mobility disturbance is attributed to the direct compression of the RLN by massive thyroid enlargement. The authors describe three cases of patients presenting unilateral vocal cord palsy, which, before surgery, was diagnosed by laryngoscopy concomitantly with large and compressive goiter. Vocal fold mobility became normal after the thyroidectomy in all three cases. Therefore, it is noteworthy that these alterations may present reversibility after appropriate surgical treatment. An early surgical approach is recommended to reduce the nerve injury as much as possible; to preserve the integrity of both RLNs since the nerve function will be restored in some patients.

DEATH RELATED TO PULMONARY METASTASIS IN PATIENTS WITH DIFFERENTIATED THYROID CANCER

OBJECTIVE

The purpose of the present study was to investigate the predictive factors for shorter disease-specific survival in patients with pulmonary disease secondary to differentiated thyroid cancer (DTC).

METHODS

This was a retrospective cohort study conducted over a 5-year period that included 54 patients with pulmonary disease secondary to DTC during the follow-up. Among these patients, 13 (24.1%) died from the disease. Dedifferentiation characteristics were identified at pathological examination of the metastatic disease (lymph node or distant metastases) and was defined as the abrupt transformation of a well-differentiated tumor into high-grade morphology lacking the original distinct histologic characteristics.

RESULTS

Tumor dedifferentiation marked by cellular aberrations and radioiodine (RAI) therapy resistance occurred in 5 (9.3%) patients. Four of them died due to pulmonary progression (80.0%), and the median survival of this group was 30 months compared to 279 months in the patients without dedifferentiation. The cumulative disease-specific survival was 20.0% in the patients with dedifferentiation during the follow-up versus 46.1% among the cases without this condition (P = .003, log-rank test). Moreover, dedifferentiation was independently associated with shorter disease-specific survival (hazard ratio [HR] = 31.607; 95% confidence interval [CI]: 4.815-207.478; P<.0001, Cox regression model) as were age over 45 years (HR = 10.904; 95% CI: 1.145-103.853; P = .038) and male sex (HR = 4.210; 95% CI: 1.056-16.783; P = .042).

CONCLUSION

DTC patients with pulmonary disease exhibited shorter disease-specific survival, particularly those who developed tumor dedifferentiation, and these patients require special attention during follow-up.

ABBREVIATIONS

CI = confidence interval DTC = differentiated thyroid cancer FTC = follicular thyroid carcinoma HR = hazard ratio IQR = interquartile range LN = lymph node LR = likelihood ratio PTC = papillary thyroid carcinoma RAI = radioiodine pTNM = pathologic tumor-node-metastasis stage system.

25-Hydroxyvitamin D and TSH as Risk Factors or Prognostic Markers in Thyroid Carcinoma

Objective

The increasing incidence of thyroid nodules demands identification of risk factors for malignant disease. Several studies suggested the association of higher TSH levels with cancer, but influence of 25-hydroxyvitamin D (25OHD) is controversial. This study aimed to identify the relationship of thyroid cancer with higher TSH levels and hypovitaminosis D and to evaluate their influence on prognostic characteristics of papillary thyroid carcinomas (PTC).

Methods

We retrospectively evaluated 433 patients submitted to thyroidectomy for thyroid nodules. Patients were categorized according to quartiles of TSH and 25OHD levels. Clinicopathological features were analyzed.

Results

Subjects with thyroid carcinomas were more frequently male and younger compared to those with benign disease. Their median TSH levels were higher and adjusted odds-ratio (OR) for cancer in the highest-quartile of TSH (> 2.4 mUI/mL) was 2.36 (1.36–4.09). Although vitamin D deficiency/insufficiency was prevalent in our cohort (84%), no significant differences in 25OHD levels or quartile distribution were observed between benign and malignant cases. Among 187 patients with PTC, analyses of prognostic features revealed increased risk of lymph nodes metastases for subjects with highest-quartile TSH levels (OR = 3.7, p = 0.029). Decreased 25OHD levels were not overtly associated with poor prognosis in PTC.

Conclusions

In this cross-sectional cohort, higher TSH levels increased the risk of cancer in thyroid nodules and influenced its prognosis, particularly favoring lymph nodes metastases. On the other hand, no association was found between 25OHD levels and thyroid carcinoma risk or prognosis, suggesting that serum 25OHD determination may not contribute to risk assessment workup of thyroid nodules.

Parotidectomy for Primary Nonparotid Diseases

OBJECTIVE: To analyze the indications and results of parotid gland resections for patients with primary nonparotid diseases.

STUDY DESIGN AND SETTING: Retrospective analysis of 442 consecutive parotidectomies (76 for primary nonparotid disease) in a referral head and neck surgery service, tertiary care university hospital.

RESULTS: Skin cancer (mainly squamous cell and basal cell carcinomas) was the most common indication for parotidectomy. Superficial parotidectomy with preservation of the facial nerve was the most commonly performed operation (61.8%), with some form of nerve sacrifice necessary in 31.6%. Parotid gland parenchyma and/or lymph nodes were pathologically positive in 46 cases. Neck dissections were carried out in conjunction with parotidectomy in 42 patients (1 patient had had previous neck dissection), of which 16 turned out to be pN+.

CONCLUSION: Parotidectomy should be considered as part of the surgical treatment of tumors whenever oncologically necessary for appropriate margins, lymph node dissection, and for proper identification and preservation of the facial nerve.

Validation of methodology for assessment of pulmonary function in patients who undergo total laryngectomy

BACKGROUND

In patients submitted to laryngectomy, pulmonary complications may lead to death. A simple method with a standardized extratracheal device for the pulmonary assessment of laryngectomized patients would be very useful. The purpose of this study was to validate the methodology for pulmonary assessment in these patients through the application of an adhesive extratracheal device.

METHODS

This transversal study included 50 patients who had been submitted to total laryngectomy. Pulmonary tests were used to characterize the presence of respiratory functional limitation. Aiming at evaluating the reproducibility of the performed tests, parameters were used for the acceptance of the tests. A comparison of these parameters was made with 50 tests performed in nonlaryngectomized patients.

RESULTS

The total of rejected tests was greater in the control group when compared to the laryngectomized group.

CONCLUSION

The methodology for the assessment of the pulmonary function by using the extratracheal proposed device is reliable, accurate, and reproducible. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2030-E2034, 2016.

Prevalence of oral and oropharyngeal human papillomavirus infection in Brazilian population studies: a systematic review

Introduction

Human papillomavirus has been associated with head and neck squamous cell carcinoma. However, there is no conclusive evidence on the prevalence of oral or pharyngeal infection by human papillomavirus in the Brazilian population.

Objective

To determine the rate of human papillomavirus infection in the Brazilian population.

Methods

Systematic review of published articles. Medline, The Cochrane Library, Embase, Lilacs (Latin American and Caribbean Health Sciences) and Scielo electronic databases were searched. The search included published articles up to December 2014 in Portuguese, Spanish and English. A wide search strategy was employed in order to avoid publication biases and to assess studies dealing only with oral and/or oropharyngeal human papillomavirus infections in the Brazilian population.

Results

The 42 selected articles enrolled 4066 patients. It was observed that oral or oropharyngeal human papillomavirus infections were identified in 738 patients (18.2%; IC 95 17.6–18.8), varying between 0.0% and 91.9%. The prevalences of oral or oropharyngeal human papillomavirus infections were respectively 6.2%, 44.6%, 44.4%, 27.4%, 38.5% and 11.9% for healthy people, those with benign oral lesions, pre-malignant lesions, oral or oropharyngeal squamous cell carcinoma, risk groups (patients with genital human papillomavirus lesions or infected partners) and immunocompromised patients. The risk of human papillomavirus infection was estimated for each subgroup and it was evident that, when compared to the healthy population, the risk of human papillomavirus infection was approximately 1.5–9.0 times higher, especially in patients with an immunodeficiency, oral lesions and squamous cell carcinoma. The rates of the most well-known oncogenic types (human papillomavirus 16 and/or 18) also show this increased risk.

Conclusions

Globally, the Brazilian healthy population has a very low oral human papillomavirus infection rate. Other groups, such as at-risk patients or their partners, immunocompromised patients, people with oral lesions and patients with oral cavity or oropharyngeal squamous cell carcinoma have a high risk of human papillomavirus infection.

Prognostic Performance of Current Stage III Oral Cancer Patients After Curative Intent Resection: Evidence to Support a Revision of the American Joint Committee on Cancer Staging System

BACKGROUND

The American Joint Committee on Cancer (AJCC) stage III classification of oral cavity squamous cell carcinoma (OCSCC) represents a heterogeneous group of patients with early local disease with regional metastases (T1N1 and T2N1) and advanced local disease with or without regional metastasis (T3N0 and T3N1).

OBJECTIVE

The aim of this study was to evaluate prognostic heterogeneity in the stage III category.

METHODS AND PATIENTS

An international retrospective multicenter study of 1815 patients who were treated for OCSCC from 2003 to 2011.

RESULTS

Kaplan-Meier survival analysis and multivariate models of stage III patients revealed better overall survival (OS; HR 2.12, 95 % CI 1.03-4.15; p = 0.01) and disease-specific survival (DSS; HR 1.7, 95 % CI 1.16-4.12; p = 0.04) rates for patients with T1-2N1/T3N0 disease than for patients with T3N1 disease. The outcomes of patients with T3N1 and stage IVa disease were similar (p = 0.89 and p = 0.78 for OS and DSS, respectively). Modifying stage classification by transferring the T3N1 category to the stage VIa group resulted in a better prognostic performance [Harrell's concordance index, C index 0.76; Akaike's Information Criterion (AIC) 4131.6] compared with the AJCC 7th edition staging system (C index 0.65; AIC 4144.9) for OS. When DSS was assessed, the suggested staging system remained the best performing model (C index 0.71; AIC 1061.3) compared with the current AJCC 7th edition staging (C index 0.64; AIC 1066.2).

CONCLUSIONS

The prognosis of T3N1 and stage IVa disease are similar in OCSCC, suggesting that these categories could be combined in future revisions of the nodal staging system to enhance prognostic accuracy.

Pharyngocutaneous fistula after total laryngectomy: systematic review of risk factors

BACKGROUND

Pharyngocutaneous fistula (PCF) is the most common surgical complication after total laryngectomy. Controversy still remains regarding the multiple risk factors implicated. The purpose of this study was to evaluate the potential risk factors for PCF.

METHODS

The strategy for our literature survey included research in MEDLINE up to December 2013. The risk factors analyzed were age, sex, smoking habit, alcohol use, comorbidity, preoperative hemoglobin level, blood transfusion, preoperative tracheotomy, previous radiotherapy and chemoradiotherapy, primary tumor site, T classification, cartilage invasion, tumor grade, surgical margins, suture material, second layer of suture, reconstruction, tracheoesophageal prosthesis, and neck dissection.

RESULTS

The electronic search resulted in 311 studies from which 63 met the inclusion criteria.

CONCLUSION

Chronic obstructive pulmonary disease (COPD), previous hemoglobin <12.5g/dL, blood transfusion, previous radiotherapy or chemoradiotherapy, advanced primary tumors, supraglottic subsite, hypopharyngeal tumor site, positive surgical margins, and the performance of neck dissection were risk factors for PCF.

Malignant solitary fibrous tumor of the thyroid: a case-report and review of the literature

Solitary fibrous tumor (SFT) is an uncommon spindle-cell neoplasm that most often involves the pleura, rarely occurring in extra-thoracic locations. Twenty-six cases of SFT arising in the thyroid gland have been described. We report a case of a 60-year-old woman presenting an 8-month history of enlargement of the neck associated with dysphagia. The patient underwent a right hemithyroidectomy and SFT of the thyroid was diagnosed. Immunohistochemistry showed positivity for CD34 marker, and the high number of mitoses and the presence of cellular atypia suggested that the tumor was malignant. To our knowledge, this is the second case of malignant SFT of the thyroid gland ever reported. Due to the rarity of these tumors, the indication of adjuvant therapy and prognosis are uncertain. Long-term follow-up after surgical resection seems to be advisable.

Delayed postoperative radiation therapy in local control of squamous cell carcinoma of the tongue and floor of the mouth

Objective

To evaluate the effect of time between surgery and postoperative radiation therapy on local recurrence of squamous cell carcinoma of the tongue and floor of the mouth.

Methods

A total of 154 patients treated between 1996 and 2007 were selected considering local recurrence rate and time of the adjuvant radiotherapy.

Results

Local recurrence was diagnosed in 54 (35%) patients. Radiation therapy reduced the rate of local recurrences, although with no statistical significance. The time between surgery and initiation of postoperative radiotherapy did not significantly influence the risk of local recurrence in patients referred to adjuvant treatment (p=0.49).

Conclusion

In the presence of risk factors for local recurrence, a short delay in starting the adjuvant radiation therapy does not contraindicate its performance.