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Introduction Laryngeal squamous cell carcinoma is the second most prevalent malignancy among head and neck tumors, and the treatment of patients with stage I or II disease can be performed with surgery or radiation therapy. National population studies describing therapeutic results comparing these modalities are unusual, but they can be very important to direct treatment guidelines. Objective To evaluate the survival results of patients with laryngeal squamous cell carcinoma at clinical stages I or II, according to the main therapeutic modalities used. Methods Cross-sectional, population-based study using the database of Fundação Oncocentro de São Paulo from January 2000 to March 2019. Inclusion criteria were patients with laryngeal squamous cell carcinoma in clinical stages cT1-2N0. To compensate for the non-random allocation of patients and the imbalance between confounding variables between groups, we used the propensity score methodology. Results A total of 3786 patients met the inclusion criteria. Regarding the cT stage, there were 2171 patients (57.3%) with cT1 tumors. Patients in the public health system had a longer time between diagnosis and treatment (p< 0.001). The analysis by propensity score showed that patients treated with surgery had a tendency towards better disease-specific survival (p = 0.012). Comparing radiotherapy alone versus its combination with radiochemotherapy, radiotherapy alone showed a tendency towards a better survival rate (p< 0.001). Conclusion Analysis by propensity score identified better results for disease-specific survival in patients with laryngeal squamous cell carcinoma at clinical stages I and II treated by surgery when compared to radiotherapy. Resumo Introdução O carcinoma epidermoide de laringe é o segundo mais prevalente entre os tumores de cabeça e pescoço e o tratamento dos pacientes com doença em estádio I ou II pode ser feito com cirurgia ou radioterapia. Estudos populacionais nacionais que descrevem os resultados terapêuticos e compararam essas modalidades são poucos frequentes, mas podem ser muito importantes para orientar diretrizes de tratamento. Objetivo Avaliar os resultados de sobrevida dos pacientes com carcinoma epidermoide de laringe em estádios clínicos I ou II de acordo com as principais modalidades terapêuticas usadas. Método Estudo transversal de base populacional com a base de dados da Fundação Oncocentro de São Paulo de janeiro de 2000 a março de 2019. Os critérios de inclusão foram pacientes com carcinoma epidermoide de laringe em estádios clínicos cT1-2N0. Para compensar pela alocação não randômica dos pacientes e pelo desequilíbrio entre variáveis confundidoras entre os grupos, usamos a metodologia do escore de propensão. Resultados Preencheram os critérios de inclusão 3.786 pacientes. Em relação ao estádio cT, houve 2.171 pacientes (57,3%) com tumores cT1. Os pacientes do sistema único de saúde (SUS) apresentaram um maior tempo entre o diagnóstico e o tratamento (p < 0,001). A análise por escore de propensão mostrou que os pacientes submetidos a cirurgia apresentaram uma tendência de melhor sobrevida doença específica (p = 0,012). Comparando-se radioterapia isolada versus combinação com radioquimioterapia, o tratamento isolado demonstrou tendência a melhor taxa de sobrevida (p< 0,001). Conclusão A análise por escore de propensão identificou melhores resultados de sobrevida doença específica em pacientes com carcinoma epidermoide de laringe estádios clínicos I e II tratados por cirurgia quando comparados a radioterapia.

Most cases of thyroid carcinoma are classified as low risk. These lesions have been treated with open surgery, remote access thyroidectomy, active surveillance, and percutaneous ablation. However, there is lack of consensus and clear indications for a specific treatment selection. The objective of this study is to review the literature regarding the indications for management selection for low-risk carcinomas. Systematic review exploring inclusion and exclusion criteria used to select patients with low-risk carcinomas for treatment approaches. The search found 69 studies. The inclusion criteria most reported were nodule diameter and histopathological confirmation of the tumor type. The most common exclusions were lymph node metastasis and extra-thyroidal extension. There was significant heterogeneity among inclusion and exclusion criteria according to the analyzed therapeutic approach. Alternative therapeutic approaches in low-risk carcinomas can be cautiously considered. Open thyroidectomy remains the standard treatment against which all other approaches must be compared.

The rates of laryngeal preservation according to therapeutic modality in patients with initial laryngeal squamous cell carcinoma (LSCC) are still controversial. This study evaluated the rates of laryngeal preservation in patients who underwent treatment with surgery or radiotherapy.This retrospective cohort study evaluated 151 patients with stage I or II LSCC. Ninety-six patients were matched using a propensity-score and outcomes were compared within this group.Regarding overall, cancer-specific survival and larynx preservation, no differences were observed according to the therapeutic modalities, but patients who underwent radiotherapy had a higher rate of local recurrence than those who underwent surgery. Patients classified as ASA 3 or 4 and treated with radiotherapy showed a tendency of higher risk of larynx loss.Patients with stage I or II laryngeal tumours can be submitted to surgery or radiotherapy with similar rates of laryngeal preservation.Preservazione d’organo ed esiti oncologici nel carcinoma laringeo in stadio iniziale: uno studio basato sul punteggio di propensione.Le percentuali di conservazione della laringe nei diversi trattamenti dei pazienti affetti da carcinoma a cellule squamose della laringe iniziale (LSCC) sono ancora controversi. Questo studio ha valutato i tassi di preservazione laringea nei pazienti sottoposti a trattamento chirurgico o radioterapia.Questo studio di coorte retrospettivo ha valutato 151 pazienti con LSCC, stadio I o II. Novantasei pazienti sono stati abbinati utilizzando un punteggio di propensione e i risultati sono stati confrontati all’interno di questo gruppo.Per quanto riguarda la sopravvivenza globale, cancro-specifica e la conservazione della laringe, non sono state osservate differenze in base alle modalità terapeutiche, ma i pazienti sottoposti a radioterapia avevano un tasso di recidiva locale più elevato rispetto a quelli sottoposti a intervento chirurgico. Inoltre, i pazienti classificati come ASA 3 o 4 e trattati con radioterapia hanno mostrato una tendenza a un rischio maggiore di perdita della laringe.I pazienti con tumori laringei in stadio I o II possono essere sottoposti a chirurgia o radioterapia con tassi di conservazione laringea simili.

Background: The aim of this study was to address the first cases of TOETVA done in Brazil, by TOETVA-Bra study group, regarding safety and complications. Materials and Methods: Series of the first 93 TOETVAs cases in Brazil. All authors except LPK, AJG JOR and RPT received TOETVA training including cadaveric hands-on in Thailand or United States (Johns Hopkins Medicine) during 2017. After they came back to Brazil and started doing their first TOETVA cases in the cities of Rio de Janeiro, Sao Paulo and Chapecó they agreed to collaborate and gather data using an online spreadsheet. All patients were submitted to the technique described by Anuwong. Results: A total of 93 patients underwent TOETVA. Most patients (58.1%) were submitted to total thyroidectomy and 59.1% had benign disease. Two patients (2.2%) needed conversion to open surgery. Five patients (9.3%) developed transient hypoparathyroidism and there were 3 (2.0%) temporary recurrent laryngeal nerve palsy. There was one (0.7%) permanent unilateral palsy. Twenty patients had some sort of complication, 16.1% were minor and 5.4% were major. A total of 73 patients (78.5%) had an uneventful recovery. Conclusion: The technique is reproducible with a low complication rate. While further studies are needed to confirm equivalency, early efforts suggest that TOETVA is not inferior to traditional open thyroidectomy in appropriately selected patients.

In the attempt to improve the cosmetic and functional outcomes in head and neck surgeries, robotic or video-assisted neck dissection using remote access has gained ground in recent years. Retroauricular approach emerged as the most versatile option, allowing proper dissection at all neck levels. In this technique, after retroauricular incision, a skin flap is elevated and a self-retaining retractor is placed, creating working space for the robotic, or endoscopic neck dissection. Numerous published series have shown the safety and favorable outcomes of retroauricular robotic neck dissections, without any major complications or surgery-related deaths. The only consistently reported disadvantage is a longer operative time. Our group has an experience of 190 retroauricular neck dissections performed over the last 5 years, without any major setbacks. The oncologic and safety outcomes have been comparable to the conventional technique, with clearly superior aesthetic results. In the process of expansion of Robotic Surgery in Brazil, our center is currently providing training and proctoring to capacitate other head and neck surgeons, and enable other centers to offer this surgical modality.

Purpose of review The progressive growth of endoscopic and robotic-assisted procedures provided the tools for development of remote approaches to the neck, which could avoid a visible large neck scar usually necessary for neck dissections. This review explores the current experience with robotic neck dissection, looking for pros and cons in surgical, oncologic and aesthetic outcomes. Recent findings Robotic neck dissection was shown to be feasible and well tolerated, with adequate oncological outcomes in different tumours. Although difficult to objectively analyse, cosmetic satisfaction seems to be significatively higher in patients submitted to this procedure when compared with those submitted to conventional neck dissection. The only consistently reported disadvantage was longer operative time. Other potential advantages beyond cosmesis such as improvements on oedema, fibrosis, neck movement, sensory loss and social interactions were not well explored so far. Summary Surgical treatment of neck metastasis had several evolutions in the last decades. Robotic neck dissection emerged as an option to avoid extensive visible neck scars, improving cosmesis and probably other functional outcomes, although securing oncologic effectiveness. Technological innovation is increasingly dynamic, promising progressive evolution in robotic surgery. Together, the lack of objective data on functional outcomes warrants the need for further investigation on robotic neck dissection.

BACKGROUND Well-established conventional thyroidectomy has satisfactory outcomes; however, robotic and endoscopic thyroid surgery can avoid visible anterior neck scars. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is the most recent of these techniques. METHODS This was a retrospective review of 412 patients who underwent TOETVA from 2017 to 2020 in 13 Brazilian centers. RESULTS The study included 359 (87.1%) females and 53 (12.9%) males, with a mean age of 40 years. There were 231 (56.1%) total thyroidectomies. The conversion rate was 0.7%. The transient vocal cord palsy rate was 7.6% (30 patients). Temporary and persistent hypocalcemia rates were 4.0% and 0.8%, respectively. There were two cases of infection (0.5%). DISCUSSION This is a large multi-institute TOETVA study, with one of the largest cohorts published to date that; despite its retrospective nature and selection bias, reached outcomes comparable to previously reported series, this study reinforced safeness, feasibility, and nationwide reproducibility for this technique.

International audience; Background: Insufficient exposure may require termination of procedure in transoral robotic surgery (TORS). The aim of study was to develop a "Pharyngoscore" to quantify the risk of difficult oropharyngeal exposure (DOE) before TORS.Methods: Three-hundred six patients undergoing any surgical procedure at one Academic Hospital were prospectively enrolled. Oropharynx was exposed with Feyh-Kastenbauer retractor. Exposure was evaluated by direct and endoscopic visualization of the four oropharyngeal subsites. Preoperative clinical/anthropometric parameters were studied in good oropharyngeal exposure and DOE groups. Logistic regression was performed to explore association between clinical/anthropometric parameters and DOE. Statistically significant parameters at multivariate analysis were incorporated into a nomogram.Results: Sixty-five (21.2%) subjects were characterized by DOE. Variables associated with DOE at univariate analysis were male (p = 0.031), modified Mallampati Class (MMC) ≥ III (p < 0.001), smaller interincisor gap (p < 0.001), and larger neck circumference (p = 0.006). MMC, interincisor gap, and neck circumference were significant at multivariate analysis and were presented with a nomogram for creating the Pharyngoscore.Conclusions: The Pharyngoscore is a promising tool for calculating DOE probability before TORS.

The transient acute hypocalcemia (HypoCa) is the most prevalent complication after total thyroidectomy, detected primarily by subnormal intact parathyroid hormone (iPTH) and calcium levels. However, the need for calcium supplementation is ambiguous in patients who exhibit low iPTH with normal calcium levels. The aim of this study was to evaluate complementary predictors of HypoCa in this scenario.A retrospective cohort study with of 1597 consecutive patients undergoing total thyroidectomy, with or without neck dissection, from January 2014 to December 2018 at a single institution. Patients with an iPTH12 pg/mL and a total calcium level ≥8 mg/dL in the first 8 h after surgery were included.1597 patients identified with low postoperative iPTH without overt calcium deficiency was diagnosed. The transient HypoCa in that specific subgroup was 509 (31.9%). Multivariate analysis indicated that HYPOCA was associated with bilateral level VI neck dissection and pre- to postoperative calcium reduction38 pg/mL. To better illustrate the model, we plotted a nomogram with the variables selected for the final model.Total thyroidectomy patients who exhibit low postoperative iPTH levels without overt calcium deficiency should be considered for calcium replacement therapy when they a marked drop in iPTH postoperatively and underwent bilateral level VI neck dissection.

To explore the advances in robotic head and neck surgery (HNS) beyond TORS. Although limited, the current literature corroborates the safety of robotic neck surgery, revealing similar surgical/oncologic outcomes, except longer operative time and superior cosmesis. In most of the remote thyroid approaches, use of robotic-assisted surgery is essential. However, for the recently popularized transoral approach, endoscopic technique has been preferred by most surgeons, due to longer operative time in robotic-assisted technique. On the other hand, retroauricular approach has been considered the standard for comprehensive/selective robotic neck dissections. Robotic technology has an increasing role in HNS. Robotic neck dissection has shown encouraging results, being routinely used in some centers around the globe. Robotic thyroid surgery, although safe when well applied, has lost ground to endoscopic transoral thyroidectomy. In the future, more evolved robotic systems could improve multiple areas of HNS.

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.

BACKGROUND: The relationship between preoperative vitamin D deficiency and postoperative hypocalcemia in cases of total thyroidectomy (TT) is a matter of controversy and may vary according to geographical scenarios and populations. OBJECTIVE: The objective here was to evaluate whether preoperative vitamin D deficiency was associated with postoperative symptomatic hypocalcemia in a population in South America. DESIGN AND SETTING: Retrospective cohort study on data from all patients undergoing total thyroidectomy, with or without central compartment lymph node dissection, from January 2014 to December 2017, at the A. C. Camargo Cancer Center. METHODS: Patients with benign thyroid disease (Graves’ disease, multinodular goiter or hyperthyroidism) or thyroid cancer who underwent primary total thyroidectomy with or without central compartment lymph node dissection were included. The exclusion criteria were simultaneous parathyroidectomy and conditions that could affect serum calcium levels. The data collected included patient demographics, thyroid pathology, extent of the surgical procedure and complications. Information on preoperative and postoperative calcium, parathyroid hormone (PTH) and vitamin D levels were retrieved from the medical records. RESULTS: 1,347 patients were assessed and postoperative hypocalcemia was diagnosed in 284 patients (21%). The vitamin D levels were considered deficient in 243 patients (18%). Postoperative hypocalcemia was diagnosed in 357 patients (31.5%). Multivariate analysis showed that central compartment dissection and preoperative total calcium and deficient vitamin D levels were significant risk factors for postoperative hypocalcemia. CONCLUSION: Deficient preoperative vitamin D levels were a significant risk factor for postoperative hypocalcemia. Preoperative oral supplementation should be considered, to minimize this risk.

Surgical scars are a significant cosmetic problem, especially when in exposed areas such as the anterior neck. To avoid or reduce visible scarring, diverse innovative surgical approaches to the neck have been introduced. The purpose of this study was to evaluate the feasibility and safety of the endoscopic resection using the retroauricular approach for submandibular gland excision. The present study enrolled 48 patients who underwent conventional transcervical submandibular gland excision and 23 patients who underwent endoscope-assisted retroauricular approach submandibular gland excision, from February 2014 through February 2018 at the Department of Head and Neck Surgery and Otorhinolaryngology of the AC Camargo Cancer Center, in Sao Paulo, Brazil. The surgical outcomes were retrospectively reviewed. In the conventional group, 26 (54%) patients were male. The mean age was 49.3 years (range 22–81). Twenty-two patients (46%) had sialoadenitis; twenty-one (44%) had benign and five (10%) had malignant tumors. The mean total surgical time was 86.4 min (range 40–180), and the mean total length of hospital stay was 1.3 days. Twenty-seven (56%) patients suffered from local postoperative complications in the neck. In the retroauricular group, 14 (61%) patients were male. The mean age was 44.1 years (range 24–71 years). Seven patients (31%) had sialoadenitis, twelve (53%) had benign tumors and four (16%) had malignant tumors. The mean total surgical time was 86.4 min (range 75–300 min), and the mean total length of hospital stay was 1.2 days. Twelve (53%) patients suffered from local postoperative complications in the neck. No surgical site infections or systemic complications were described. The retroauricular endoscopic-assisted submandibular gland resection is feasible, with excellent cosmetic results and no significant complication rate increase, and can be a safe potential surgical alternative for patients who are motivated to avoid a visible neck scar.

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.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.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.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.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.

In this note we describe the standard technical maneuver used in our department to protect the skin during thyroidectomy in order to get the best aesthetic result. We use surgical gloves to protect the skin during these operations to reduce the negative impact of thermal trauma and mechanical retractors and energy delivery devices at the edges of the skin incised. This practice is effective, inexpensive, rapid, reproducible and showed no complication in our experience of over 2,500 thyroidectomies.

Quality assessment is a major tool for evaluation of health care delivery. In head and neck surgery, the University of Texas MD Anderson Cancer Center (MD Anderson) has defined quality standards by publishing benchmarks.We conducted an analysis of 360 head and neck surgeries performed at the AC Camargo Cancer Center (AC Camargo). The procedures were stratified into low-acuity procedures (LAPs) or high-acuity procedures (HAPs) and outcome indicators where compared to MD Anderson benchmarks.In the 360 cases, there were 332 LAPs (92.2%) and 28 HAPs (7.8%). Patients with any comorbid condition had a higher incidence of negative outcome indicators (p = .005). In the LAPs, we achieved the MD Anderson benchmarks in all outcome indicators. In HAPs, the rate of surgical site infection and length of hospital stay were higher than what is established by the benchmarks.Quality assessment of head and neck surgery is possible and should be disseminated, improving effectiveness in health care delivery. © 2015 Wiley Periodicals, Inc. Head Neck 38: 1002-1007, 2016.

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. Objetivo: avaliar características casos de carcinoma de tireoide atendidos em um hospital de referência em câncer entre 2008 e 2010.Métodos: foram analisadas variáveis clínico-patológicas de 807 casos tratados em três anos: sintomas, fatores de risco, exames de diagnóstico, estadiamento, tipo histológico, tratamento realizado e complicações.Resultados: o sexo feminino foi o mais acometido com 660 casos (82%). A média de idade ao diagnóstico foi 44,5 anos. A exposição prévia à radiação ionizante foi referida por 22 (3%) pacientes, a história familiar de câncer de tireoide por 89 (11%) pacientes e 289 (36%) pacientes relataram outros tipos de câncer na família. A punção aspirativa por agulha fina foi o principal parâmetro para indicação operatória e foi sugestiva de carcinoma em 463 pacientes (57%). O carcinoma papilífero foi o tipo histológico mais incidente, com 780 casos (96,6%). Foram realizadas 728 (90%) tireoidectomias totais, 43 (5,3%) reoperações ou tireoidectomias parciais seguidas de totalização, 23 (2,8%) tireoidectomias ampliadas e apenas 13 (1,6%) tireoidectomias parciais (lobectomia com istmectomia). O esvaziamento cervical, associado à tireoidectomia, foi feito em 158 pacientes (19,5%). Observamos predomínio dos tumores classificados como T1 em 602 (74,6%) dos pacientes. A hipocalcemia transitória foi a complicação mais frequente.Conclusão: os resultados mostram que o aumento mundial da incidência do câncer de tireoide alterou o perfil dos pacientes atendidos em serviço de referência. Além disso, ocorreram mudanças no tipo de tratamento cirúrgico empregado, com aumento no uso da tireoidectomia total em relação às parciais e subtotais e diminuição do uso de esvaziamento cervical eletivo para estas neoplasias.