M a r c o s B r a s ilin o d e C a r v a lh o , A b r a o R a p o p o r t , A n t o n io S e r g io F a v a , J o s e F r a n c is c o d e G 6 is F ilh o , J o s e F r a n c is c o S a lle s C h a g a s , J o s s i L e d o K a n d a , J o s ia s d e A n d r a d e S o b r in h o , L u iz P a u lo K o w a ls k i
The value of therapeutic planning and the degree of
experience of the surgical team on the results of cancer
treatment of the larynx and hypopharynx
Head and Neck Surgery Service of the Heliopolis Hospital Complex, Sao Paulo.
Locus- Advanced
Center - Head and Neck - Sao Paulo, Brazil
T h is is a p ro s p e c tiv e s tu d y s u p p o rte d b y 1 7 0 c a s e s o f e p id e rm o id c a rc in o m a o f th e la ry n x o r h y p o p h a ry n x , tre a te d d u rin g th e p e rio d fro m J a n u a ry o f 1 9 8 1 to J a n u a ry o f 1 9 8 8 , a t th e H e a d a n d N e c k S u rg e ry S e rv ic e o f th e H e li6 p o lis H o s p ita l C o m p le x , S a o P a u lo . T h e o b je c tiv e o f th is p ro je c t w a s to e v a lu a te th e im p o rta n c e o f s u rg e o n e x p e rie n c e w ith re g a rd to th e ra te s o f p o s t-o p e ra tiv e c o m p lic a tio n s a n d th e ra te s o f re la p s e a n d s u rv iv a l. T h e re s u lts o f th e 8 s u rg ic a l s p e c ia lis ts w h o in te g ra te th e p e rm a n e n t s ta ff a t th e in s titu te a n d w h o d iffe re n t v a ry in g d e g re e s o f e x p e rie n c e w ith re g a rd to tim e s p e n t e x e rc is in g th e ir s p e c ia ltie s w e re c o m p a re d . T h e re s u lts o b -ta in e d d id n o t s h o w a s ig n ific a n t d iffe re n c e a m o n g th e v a rio u s s u rg e o n s , a n d th is u n ifo rm ity is e x p la in e d b y th e fa c t th a t a ll th e th e ra p e u tic p la n n in g w a s e la b o ra te d th ro u g h c o n s e n s u s o f th e w h o le g ro u p , a n d th is c o u ld h a v e m in im iz e d th e e ffe c t o f e x p e rie n c e o f a s u rg e o n re s p o n s ib le fo r th e o p e ra tio n . T h e a u th o rs e m p h a s iz e th e im p o rta n c e o f p re -o p e ra tiv e e v a lu a tio n fo r g o o d re s u lts a n d p ro p o s e th a t it is in th e d ire c tio n o f c o m p le te m a s te ry o f p re lim in a ry w o rk in th e a re a th a t p ro g ra m s fo r th e fo rm a tio n o f n e w s p e c ia lis ts s h o u ld b e d ire c te d .
U N IT E R M S : L a ry n x a n d h y p o p h a ry n x n e o p la s ia . L a ry n g e c to m y . C o m p lic a tio n s . S u rv iv a l. H e a d a n d n e c k s u rg e ry . T ra in in g a n d fo rm a tio n o f s p e c ia lis ts .
IN T R O D U C T IO N
C
ancer in the upper aero-digestive
tract has been,
more and more, a territory reserved for the work
of a specialist
in head and neck surgery.
This
argument
gains
weight
when we restrict
ourselves
to
A d d r e s s f o r c o r r e s p o n d e n c e : M a r c o s B r a s ilin o d e C a r v a lh o
P r a c a A m a d e u A m a r a l, 4 7 , C o n ju n t o 8 2 S a o P a u lo / S P - B r a s il- C E P 0 1 3 2 7 - 0 1 0
tumors of the larynx and hypopharynx.
Clinical evaluation
of these neoplasias is difficult as there are various degrees
of malignancy,
based
on macro
and
microscopic
characteristics.
The natural history
of the tumors
varies
according
to their
exact
location.
Once
the clinical
diagnosis is made and the staging of the lesion determined,
histological
confirmation
leads to the therapeutic
choise.
The objective of this study is evaluating
whether or
not, after the definition of treatment,
the experience
of the
specialist
doing the surgery
has a significant
impact on
the results.
C L I N I C A L D A T A A N D M E T H O D S
T h is p ap er is b ased o n th e p ro sp ectiv e an aly sis o f
1 7 0 cases o f ep id erm o id carcin o m a o f th e lary n x o r
h y p o p h ary n x , treated fro m Jan u ary o f 1 9 8 1 to Jan u ary o f
1 9 8 8 , at th e H ead an d N eck S u rg ery S erv ice o f th e
H eli6 p o lis H o sp ital C o m p lex , S ao P au lo .
B efo re th e treatm en t p ro p o sal w as d efin ed , th e
p atien t w as p resen ted to th e w h o le team o f su rg eo n s an d
th e fo llo w in g item s w ere d eb ated : h o w lo n g th e p atien t
h ad h ad th e p ro b lem , th e g en eral co n d itio n , th e lo catio n
o f th e n eo p lastic lesio n , its ex ten sio n , its stag e an d
h isto lo g ical ty p e. A d ecisio n as to th e ad eq u ate treatm en t
w as tak en th ro u g h co n sen su s o f th e w h o le g ro u p .
A ll th e p atien ts w ere su b m itted to resectio n o f th e
p rim ary lesio n (lary n g ecto m y o r p h ary n g o lary n g ecto m y )
in one block
w ith co m p reh en siv e n eck d issectio n . T h ese su rg eries w ere led b y eig h tsu rg eo n s th at b elo n g to th ep erm an en t staff o f th e in stitu te. O f th ese, h alf (su b g ro u p
x ), rep resen ted th e b asic fo u n d in g g ro u p o f th e S u rg ery
S erv ice, an d w h o p articip ated activ ely in th e fo rm atio n
an d train in g o f th e o th ers (su b g ro u p y ), w h o w ere y o u n g er
b u t reco g n ized as fu lly cap ab le o f p erfo rm in g su rg ery
acco rd in g to th e co rrect o n co lo g ic p aram eters. T h e
p articip atio n o f th e v ario u s su rg eo n s in th ese cases w as
n o t at ran d o m an d w as d eterm in ed b y th e o p eratio n al
ro u tin e d em an d o f th e in stitu tio n . S u b g ro u p x p erfo rm ed
7 8 su rg eries (4 5 .9 % ) an d su b g ro u p y ,9 2 (5 4 .1 % ).
D u rin g th e an aly sis o f th e resu lts th e eig h t su rg eo n s
w ere d esig n ated b y n u m eric co d e fro m 1 to 8 , an d
id en tificatio n w as n o t k n o w n u n til th e en d o f th e an aly sis
o f th e d ata. A n attem p t w as m ad e to o b serv e a co rrelatio n
b etw een th e ex p erien ce o f th e su rg eo n an d th e rates o f
co m p licatio n s, recu rren ce an d su rv iv al. In th e an aly sis o f
th e rates o f relap se an d su rv iv al o n ly 1 1 5 p atien ts w ere
co n sid ered , ex clu d in g th e 5 5 rem ain in g w h ich sh o w ed
m etastatic ly m p h n o d es w ith tran scap su lar sp read .
T h e calcu latio n s fo r g lo b al su rv iv al (O S ) an d su rv iv al
free o f d isease (S F D ) w as d o n e u sin g th e K A P L A N &
M E IE R tech n iq u e(3 ). T h e co m p u ter p ro g ram K M S U R y (l)
w as u sed fo r th e statistical an aly sis. R eg ressio n tech n iq u es
o f C O X (2 ) w ere em p lo y ed w ith th e aim o f p red ictin g ,
sep arately , th e risk s o f relap se an d o f d eath , w h en
co m p arin g th e d ata o f th e co o rd in atin g au th o r in th is w o rk
(M B C ) w ith th o se o b tain ed b y th e o th er m em b ers o f th e
S u rg ery S erv ice.
R E S U L T S
T ab le I sh o w s th e co m p licatio n s b y su rg eo n an d T ab le
II sh o w s th e d istri b u rio n o f th e p o st-o p erati v e
co m p licatio n s b etw een th e tw o su b g ro u p s o f su rg eo n s an d
th e d ifferen ces o b serv ed w ere n o t statistically sig n ifican t.
T h ere w ere n o p o st-o p erativ e co m p licatio n s in 6 9 (4 0 ,6 % )
o f th e p atien ts.
F ig u res I an d II sh o w , resp ectiv ely , th e actu arial
cu rv es o f su rv iv al free o f d isease an d th e g lo b al su rv iv al
T a b le I
D is t r ib u t io n o f t h e p o s t - o p e r a t iv e c o m p lic a t io n s b y s u r g e o n
t y p e s u r g e o n
2 3 4 5 6 7 8
f is t u la 1 1 1 0 1 2 3 5 1 8 4
3 6 .7 3 5 .7 4 0 .0 2 6 .7 2 9 .4 2 0 .0 2 2 .9 4 0 .0
n e c r o s is a n d d e h is c e n c e 9 5 1 1 3 6 1 1 0 6
3 0 .0 1 7 .9 3 6 .7 2 0 .0 3 5 .3 2 0 .0 2 8 .6 6 0 .0
in f e c t io n 2 4 2 2 2 6
6 .7 1 4 .3 1 3 .3 1 1 .8 4 0 .0 1 7 .1
d e a t h 2 1 2 2 4
7 .1 3 .4 1 3 .4 1 1 .8 1 1 .4
n o c o m p lic a t io n 1 3 1 2 1 1 8 5 1 1 5 4
4 3 .4 4 2 .9 3 6 .7 5 3 .3 2 9 .4 2 0 .0 4 2 .9 4 0 .0
985
Table II
Distribution of the post-operative com plications by subgroup
type sub-group x (% ) sub-group y (% ) total
fistula 25 29 54
30.1 21.5 31.8
necrosis and 18 33 51
dehiscence 23.1 . 35.9 30.0
infection 10 8 18
12.8 8.7 10.6
death 4 7 11
5.1 7.6 6.5
no com plications 34 35 69
43.6 38.0 40.6
com paring the results obtained by the author w ith those
of the others of the m em bers of the team . T he differences
observed w ere not statistically significant (p. 0.8060 and
0.9188).
T able III show s the risks relative to recurrence and
death and again there w as no significant difference
com pared to the other surgeons of the D epartm ent of
Surgery.
---& - O THER STUDIES
ref. 0.55 - 1.92 1.00
1.03
RR of death
Ie
95% IC95%ref. 0.59 - 1.95 1.00
1.07
Table III
Relative risks of recurrence and death
RR of recurrence
. T he efficiency of surgical treatm ent is linked
fundam entally to the criteria of indication, the severity of
the disease and the technical expertise of the surgeon. T he
severity of consequences that can follow inappropriate or
untim ely treatm ent is observed daily in the out patient clinic
of H ead and N eck Surgery D epartm ent. C ancer of the
larynx and of the hypopharynx are diseases of usually
unfavorable prognosis and w ith fairly com plex indications
for treatm ent.
T his com plexity com es from the m ultiplicity of
variables that need to be considered w hen choosing the
best treatm ent. O n the other hand, the operation itself, even
though it dem ands from the surgeon perfect know ledge
of anatom y and of the principles of oncological surgery,
has been standardized for years as to tim ing and sequence
and is easily m astered by the specialists in this area. Its
im portant to rem em ber that the cases in w hich m acroscopic
capsular rupture w as detected w ere excluded from the
analysis on global survival and survival free
of disease, since for these cases the prognosis
is invariably very unfavorable and this could
distort the results.
T he results of this study show that, by
guaranteeing the criteria of an adequate
indication, the treatm ent w ill be effective
regardless of the experience of the surgeon,
provided that an adequate level of training
suitable for the realization of an oncological
and technical surgery has been assured. In
such a w ay, the training of new specialists of
head and neck surgery should be centered
around assuring and solid theoretical
know ledge of the natural history of diseases
120 that affect this region, these being essential
for a satisfactory outcom e.
(M O NTHS)
DISCUSSIO N
author others
100
80
60 40
20
--e - AUTHO RS
o
20
o
60 100
80
40
Figure 1. Actuarial curve of survival free of disease
986
~~~":"~t~~=*"~:miW M :W ~-% .¥M W 4*.:~.?m:::=wt_$:m::m~~~t.~t.{-::'.:m::f$~:m;~~:~g~:W :::i.:~:[!:~~tl:*;m~:m=::'W ..~t~W :m--n~~~,~-m:~@ ~1:mW -:m:*ft'4
1 0 0
C O N C L U S I O N
80
In the surgical treatment of cancer of the larynx and of the hypopharynx, when 60
correctly indicated and conducted by
efficient, recognized specialists, the
incidence of complication and the rates of 40
recurrence and survival are independent of
the experience of the surgeon. All the efforts 20
of the attending team should be concentrated
on the pre-surgical evaluation of the cases,
so as to assure an adequate therapeutic plan. 0
o 20 40 60 80 1 0 0 120
-e--A U T H O R S - - + - O T H E R S T U D I E S ( M O N T H S )
A C K N O W L E D G M E N T S F ig u r e 2 . A c t u a r ia l c u r v e o f g lo b a l s u r v iv a l
The authors thank Dr. Luiz Paulo Kowalski for the statistical analysis of these cases.
RESUM O
O b je t iv o : a v a lia r a im p o r t a n c ia d a e x p e r iim c ia d o c ir u r g ia o n o s I n d ic e s d e c o m p lic a y a o p 6 s - o p e r a t 6 r ia e n a s t a x a s d e r e c id iv a e d e s o b r e v id a . M a t e r ia l e M e t o d o s : f o r a m c o m p a r a d o s o s r e s u lt a d o s o b t id o s p e lo s 8 c ir u r g i6 e s e s p e c ia lis t a s in t e g r a n t e s d o q u a d r o p e r m a n e n t e d o S e r v iy o e q u e p o s s u ia m g r a u s v a r ia d o s d e e x p e r iim c ia c o n s id e r a n d o 0 t e m p o d e e x e r c f c io d a e s p e c ia lid a d e . R e s u lt a d o s : o s r e s u lt a d o s o b s e r v a d o s n a o a p r e s e n t a r a m d if e r e n y a s ig n if ic a n t e e n t r e o s v a r io s c ir u r g i6 e s e e s t a u n if o r m id a d e
e
e x p lic a d a p e lo f a t o d e q u e t o d o 0p la n e ja m e n t o t e r a p e u t ic o f o i e la b o r a d o p o r c o n s e n s o d e t o d o 0 g r u p o e is t o p o d e t e r m in im iz a d o u m a m e n o r e x p e r ie n c ia d o c ir u g ia o r e s p o n s a v e l p e la c o n d u y a o d o a t o o p e r a t 6 r io . C o n c lu s o e s : o s a u t o r e s e n f a t iz a m a im p o r t a n c ia d a a v a lia y a o p r e - o p e r a t 6 r ia c o m o u m a c o n d iy a o p a r a q u e b o n s r e s u lt a d o s s e ja m e s p e r a d o s e p r o p 5 e m q u e e n a d ir e y a o d o c o m p le t o d o m ln io d a p r o p e d e u t ic a d a r e g ia o q u e d e v e m s e r d ir ig id o s o s p r o g r a m a s d e f o r m a y a o d e n o v o s e s p e c ia lis t a s .R E F E R E N C E S
I . CAM POS FILHO, N.& FRANCO, E.L. - M icrocomputer ~ assisted univariate survival data analysis using Kaplan-M eier life table estimators. Computer M ethods Programs Biomed 27: 223-28, 1988.
2. COX, D.R. - Regression models and life-tables.
J
R Static Soc Br 34: 187-220, 1972.3. KAPLAN, E.L. & M EIER, P. - Nonparametric estimation from incomplete observations. J Am Static Assoc 53: 457-81, 1958.
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