Frey syndrome. A proposal for evaluating severity

We aimed to establish the incidence of Frey's syndrome in patients that have been submitted to partial and total parotidectomy at a cancer-treating hospital in Mexico City and to propose a grading system to determine its severity. The incidence of Frey's syndrome in 77 patients (25 male and 52 female) under oncological follow-up due to parotid tumors was subjectively evaluated through clinical findings and objectively diagnosed through Minor's test. The positive hyperhydrotic areas were recorded and measured on transparent acetates. Numeric values were assigned according to clinical perception of symptomatology by the patients (0 for no perception and 1 for clinical recognition), extent of the affected area (1 if less than 2 cm; 2 if between 2.1 and 4 cm, and 3 if more than 4 cm), intensity and smell of sweat (3 if it was excessive or of unpleasant odor). Results were expressed as mild (if less than 4 points) or severe grades (if 4 or more points). Frey syndrome was objectively diagnosed in 28 patients (36%), although only 17 (22%) recognized to have clinical manifestations of this condition. There were 22 women (79%) and six men (21%). Of these, seventeen (61%) had been subjected to partial and eleven (39%) to total parotidectomy. Adjuvant radiotherapy had been employed in nine cases (32%). The cutaneous affected area in the whole group ranged from 0.7 to 29.8 cm(2) (mean 8.9 cm(2)), with a mean affected surface of 8.7+/-10.8 cm(2) for women and 9.0+/-8.8 cm(2) for men ( p > 0.05). Twelve cases were classified as mild and sixteen as severe. No significant differences were found between patients treated with partial vs. total parotidectomy or between patients treated with or without adjuvant radiotherapy. The incidence of Frey's syndrome in Mexican patients seems to be similar to those reported in other countries; however, the extent of hyperhydrosis is lower when compared to some European studies. Our proposal for evaluating this condition may be a helpful tool in assessing the incidence and severity among the diverse populations and it may be a useful tool to define more precisely the indications for treatment and to evaluate the available therapeutic methods according to the severity of the condition.

Effect of pilocarpine hydrochloride on salivary production in previously irradiated head and neck cancer patients

OBJECTIVE

To study the effects of pilocarpine hydrochloride on whole salivary gland production in Mexican patients affected by hyposalivation secondary to radiotherapy of the head and neck region.

STUDY DESIGN

With previous written informed consent, 20 patients affected by hyposalivation secondary to head and neck radiation therapy (>40 Gy) were evaluated through the whole saliva test (WST) before, during and after ten weeks of treatment with pilocarpine hydrochloride (5 mg t.i.d.). Hyposalivationrelated symptomatology was assessed before and at every week by means of a questionnaire with an ordinal scale ranging from 0-10. Salivary production values recorded at the end of the study and those obtained before treatment were compared by means of student's t test. A paired Wilcoxon test was used to compare the differences in the oral symptoms, such as oral dryness, soreness, ability for speaking and swallowing before and after treatment.

RESULTS

Initial WST had a mean salivary production of 0.8 cm (s.d. 0.7), with a range from 0 to 2.9 cm). After ten weeks of treatment salivary production increased to a mean of 2.24 cm (s.d. 0.7), with a range from 1.2 to 4.0 cm. There was a salivary flow increase of 64.5% (p<0.001). In addition, there were significant improvements in oral dryness, mouth comfort, ability to speak and ability to swallow (p<0.01). Adverse effects were usually minimal and they did not cause withdraw from the study in any case.

CONCLUSIONS

Administration of 5-mg pilocarpine hydrochloride tablets three times daily significantly improved salivary production and clinical symptomatology secondary to radiation-induced hyposalivation with minimal side-effects. In addition, this study showed that WST is a fast, technically simple and highly reliable method to study salivary production in prospective studies.

Clinical course of insular thyroid carcinoma

BACKGROUND

To present the clinical picture and outcome of poorly differentiated insular-type thyroid carcinoma (ITC) compared with papillary thyroid carcinoma (PTC) in a Mexican population in order to demonstrate their different biological behavior.

MATERIAL/METHODS

Retrospective, transversal study comparing ITC (G1) with PTC (G2). Assessed variables were: age, gender, size of tumor, previous history of thyroid disease, and outcome. The recurrence/death risk was established according to the MACIS, De GROOT, and AMES classifications. Statistical analysis was made by means of central tendency measures, the Kaplan-Meier method, Cox-Mantel's log-rank, Student's t, and chi-square tests.

RESULTS

Both groups were classified based on a high or low risk for thyroid neoplasms. G1 had 13 patients, tumor volume was 78 cm3, 7 cases presented metastases at the time of admittance, five had antecedents of goiter. Average follow-up time was 23 months. G2 had seventy-one patients, tumor volume was 42 cm3, and follow-up time of 44 months. Kaplan-Meier revealed a lower survival in Group 1 than Group 2, statistically significant by the Cox-Mantel log-rank test. A significant statistical difference existed regarding survival and the presence of metastases: G1 (61%) and G2 (53.8%). No statistical difference was found between tumor size.

CONCLUSIONS

ITC is more aggressive than PTC. It occurs in the 6th decade of life, with antecedents of long-standing goiter, and has a high recurrence, metastasis and mortality frequency.

Phase II trial of gemcitabine concurrent with radiation for locally advanced squamous cell carcinoma of the head and neck

BACKGROUND

Concurrent chemoradiation is the current standard of treatment for patients with advanced unresectable head and neck squamous cell carcinoma (HNSCC). Due to the potent radiosensitizing properties of gemcitabine, we decided to assess its efficacy and toxicity with concurrent radiation in patients with advanced HNSCC.

PATIENTS AND METHODS

From January 1997 to December 2001, 27 patients with locally advanced HNSCC (stage III, 37%; stage IV, 63%) were enrolled. All received a course of radiotherapy (70 Gy over 7 weeks) concurrent with weekly infusions of gemcitabine at 100 mg/m2 or 50 mg/m2.

RESULTS

All patients were assessable for toxicity and 26 for response. Severe mucositis (grade 3-4) was observed in 74% of patients (grade 4, 41%). Severe hematological toxicity was uncommon. Mild and moderate xerostomy was the most common late toxicity in 23 patients (85%). The median radiation dose delivered was 70 Gy (40-80 Gy), 25 patients (93%) received > or = 80% of the intended dose. Gemcitabine dose intensity was > or = 80% in only 13 (48%) patients. The rate of complete and partial responses were 61% and 27%, respectively, for an overall response rate of 88%. At a median follow-up of 13 months (range 6-62), the actuarial 3-year progression-free survival (PFS) and overall survival (OS) were 37% and 33%, respectively. The only variable associated with prolonged survival (P = 0.0001) was the degree of response. No difference was observed in response or toxicity with either gemcitabine 50 or 100 mg/m2.

CONCLUSIONS

The concurrent use of radiotherapy and gemcitabine is effective but produces manageable severe mucositis in a high percentage of patients.

[Appendicitis following esophagogastroduodenal study: report of a case]

Retention of barium within appendix following a gastrointestinal tract study may predispose in rare instances to narrowing of appendiceal lumen, thus contributing to development of acute appendicitis. We present the case of a 42-year-old woman in whom this sequence of events was recognized who presented with clinical signs of acute appendicitis 9 days after barium swallow test was performed. Patients must be informed increased chance for development of appendicitis in these cases and be instructed to recognize early symptoms. Surgical treatment is reserved for symptomatic patients and prophylactic appendectomy is not reccommended.

[Critical points for success in supracricoid partial laryngectomy with cricohyoidepiglottoepexy]

Cancer of the larynx is a relatively rare neoplasia in Mexico as well as in the rest of the world; however, evolution of treatment in recent years showed important results in terms of survival and local control. Supracricoid partial laryngectomy with cricohyoidoepiglottopexy is a surgical technique that permits similar oncologic results to other conservatives techniques for glottic carcinoma, with excellent functional results. The objective of the present work was to show the critical points of the technique based on the description of Laccourreye, emphasizing the anatomical aspect of resection and reconstruction to avoid complications and achieve best results.

Primary lymphoma of bone

Primary lymphoma of bone (PLB) is a rare clinical-pathological entity representing less than 1% of all lymphomas. This work was aimed to review the presentation characteristics of PLB at the Instituto Nacional de Cancerología including its management and evolution.

MATERIAL AND METHODS

Thirty cases of lymphoma of bone were diagnosed between 1972 and 1999 from a database including 577 patients with lymphoma. Among them, only 8 patients (1.36% of the total lymphomas) met the criteria set out to be diagnosed as primary lymphoma of bone, stage IE. In all patients, diagnosis was histopathologically made through open biopsy, and they were classified in accordance with the former criteria of the Working Formulation (WF). This review applied the current criteria of the World Health Organization (WHO).

RESULTS

Three women and five men with a mean age of 40 years (range 20-65) were identified. Mean physical performance (Karnofsky) was 80%. Six patients presented clinically evident disease of the affected region. The most frequent symptom was pain at the site of the lesion in 3 patients, being the cardinal symptom in 1 patient. Histological diagnosis was diffuse large cell lymphoma, and B immunophenotype was confirmed in 5 patients. Five patients received sequential chemotherapy and radiotherapy; 1 patient received chemotherapy; and 2 patients received exclusive radiotherapy. The chemotherapy regimes were based on anthracyclines. Five patients presented complete response and 3 patients showed progressive disease. One patient showing complete response relapse 16 years after the treatment. The mean follow-up in this series was 60 months (range 3-190 months). Tumor localization and functional condition of the patient were the best prognostic factors. Surgery was not therapeutic in any case.

CONCLUSIONS

PLB still remains a rare clinical-pathological entity, and represented 1.3% of total lymphomas in this series. Sequential anthracycline-based chemotherapy and radiotherapy are the most important therapeutic choices. Functional condition of patients at diagnosis and tumor localization were the most accurate prognostic factors.

Is there an indication for palliative surgical procedure of shoulder and upper limb malignancies?

AIMS

Major amputation is not a frequent procedure at present, however, there is a group of patients still considered for these treatments. Our objective was to evaluate the results of this surgical intervention as well as to evaluate morbidity, local control, free disease, and palliation.

METHODS

The study included 57 patients on whom interscapulothoracic disarticulation (STDI) was carried out at the Instituto Nacional de Cancerología were (Mexico City) from 1974 to 1993. Patients with oncologic pathology were operated with a palliative aims. Twenty eight male and twenty nine female patients were found with average age of 44 years (range: 13 to 79 years). Clinical situation was characterized by tumor (100%), pain (46%), functional incapacity (39%), ulceration (32%), and bleeding (9%), Karnofsky 80% (range, 50 to 100). Time of evolution was 25 months (range: 1-121 months) and size was > 10 cm in 86% of cases.

RESULTS

Postoperative complications were present in ten, followed by patients follow infection in five cases, hematoma in the upper lung lobe in two and femoral thrombosis, skin wound necrosis, and bleeding in one case each. Palliation was evaluated to eliminate tumoral load, ulceration, bleeding, functional incapacity, and pre- and postoperative pain. Global survival was 12 months (range, 1-139 months).

CONCLUSIONS

Interscapulothoracic disarticulation is an infrequently performed surgery with low morbidity and mortality, low recurrence, no effect on survival, and excellent palliative results.

[Supracricoid laryngectomy with cricohyoidoepiglotopexy (CHEP). Preliminary report of the National Institute of Cancer]

OBJECTIVE

To present the preliminary results in our institute with supracricoid laryngectomy with cricohyoidoepiglotopexy (CHEP), as well as to evaluate possible short-term complications.

METHODS

This study included eight patients with diagnosis of squamous cell carcinoma of the larynx glottic region (three patients were in stage I, two in II and three in III). Histologic grade was well differentiated in three patients, moderately differentiated in four and poorly differentiated in one.

RESULTS

Supracricoid laryngectomy with cricohyoidoepiglotopexy were performed in all cases, and bilateral elective functional neck dissection was done in 6 patients. Both cricoarytenoid units were preserved in 6 patients and only one in the other two cases. Mean time of hospitalization was 11 days. Mean time of decanulation was 12 days for the whole group; however, in those patients that preserved both cricoarytenoid units, the mean time of decanulation was 6 days, and in those that preserved one cricoarytenoid unit it was 31 days. Physiologic phonation was achieved in all patients at the moment of decanulation. Mean time for remotion of nasogastric sonde was 25 days, and it was 17 days for those who preserved both cricoarytenoid units and for patients with one cricoarytenoid unit it was 46 days.

CONCLUSIONS

Supracricoid laryngectomy with cricohyoidoepiglotopexy allows to preserve the basic functions of the larynx (respiration, degluttion and phonation), as well as the reintegration of affected patients to social life. All patients must be evaluated carefully in order avoid changing the stage or the surgical plan due to substadification of the tumor.

Supracricoid partial laryngectomy for non-squamous cell carcinoma of the larynx

The objective of this paper was to evaluate the potential utility of supracricoid partial laryngectomies (SCPLS) for non-squamous cell carcinoma of the larynx. To illustrate our management of such tumours we present a case series based on six patients. Local control was achieved in five patients, with the sixth being salvaged by total laryngectomy and post-operative radiation therapy. Three of the six patients died of distant metastases. We concluded that supracricoid partial laryngectomies should become part of the armamentarium of the otolaryngologist - head and neck surgeon for non-squamous cell carcinoma of the larynx.