Metástases cervicais bilaterais no carcinoma epidermóide de cabeça e pescoço: tratamento cirúrgico em um ou dois tempos

Abstract

OBJETIVO: Avaliar os resultados do tratamento dos pacientes com metástases cervicais bilaterais de carcinoma epidermóide das vias aerodigestivas superiores. FORMA DE ESTUDO: Série de casos retrospectiva. CASUÍSTICA E MÉTODO: Revisão dos prontuários de 855 pacientes com carcinoma epidermóide de boca, orofaringe, hipofaringe e laringe submetidos à ressecção do tumor primário e esvaziamento cervical radical entre 1977 e 1996. Foram selecionados 96 pacientes com metástases bilaterais confirmadas histologicamente, dos quais 73 foram submetidos inicialmente ao esvaziamento cervical bilateral (ECB) e 23 pacientes que se submeteram ao esvaziamento unilateral e, posteriormente, desenvolveram recidiva cervical contralateral. A evolução dos pacientes foi avaliada por meio da sobrevida livre de doença e do controle cervical. RESULTADOS: Entre os 23 pacientes submetidos ao esvaziamento unilateral (pN+) que desenvolveram recidiva contralateral, foram resgatados 18 pacientes. O controle da doença no pescoço em 2 anos foi alcançado em 46% dos pacientes. Entre os 73 pacientes submetidos ao esvaziamento bilateral (pN2c) ocorreram 12 casos de recidivas cervicais, dos quais apenas 3 foram resgatados. O controle da doença no pescoço em dois anos foi alcançado em 77% dos pacientes. A sobrevida livre de doença foi semelhante entre os 2 grupos, apesar da diferença observada na taxa de controle cervical. CONCLUSÃO: O esvaziamento bilateral em tempo único apresentou melhor controle da doença no pescoço, mas não alterou a sobrevida livre de doença neste grupo de pacientes. A despeito do controle da doença cervical ser obtido na maioria dos pacientes, apenas um terço daqueles com metástases bilaterais apresentaram doença controlada após 2 anos.

Esvaziamento cervical no carcinoma epidermoide de laringe: indicação de esvaziamento eletivo contralateral

“…In supraglottis tumors, involvement of the central region established a high risk of contralateral metastases. In these cases, the incidence of contralateral metastases in lateralized lesions is higher than 20%, but are infrequent in the absence of ipsilateral metastases 3,4 . The ipsilateral pathological staging (pN) is even more reliable vis-à-vis the risk of contralateral metastases.…”

“…The possibility of postoperative radiotherapy, especially when the characteristics of the primary tumor and ipsilateral metastases would justify the adjuvant treatment, also deserves to be considered in relation to its use in the treatment of the contralateral neck. Although the efficacy of radiotherapy in the treatment of subclinical regional disease is an indirect evidence, the results are in favor of its use in this context 1 , 4 , 9 . Based on principles, the initial treatment must be sized in order to completely treat the disease, while the adjuvant treatment may be used for areas of a greater risk of recurrence, acknowledging that the advanced disease requires a combined treatment.…”

“…By the same token: comorbidities, the ease of patient follow up and the speed of rescue of a regional recurrence must also influence the decision to surgically treat the contralateral side. Some recurrences already present themselves as non-resectable disease and elective dissection provides the best regional control 4 , 6 , 11 , 12 , 13 . The results from the present study have shown that approximately 40% of the elective contralateral dissections, especially in NO supraglottic or glottic tumors, could be avoided without impairing the staging, since they proved to be pN0, but it is not possible to establish if the omission in neck dissection could affect the excellent result obtained in the regional disease control or even patient survival 4 , 13 .…”

“…Some recurrences already present themselves as non-resectable disease and elective dissection provides the best regional control 4 , 6 , 11 , 12 , 13 . The results from the present study have shown that approximately 40% of the elective contralateral dissections, especially in NO supraglottic or glottic tumors, could be avoided without impairing the staging, since they proved to be pN0, but it is not possible to establish if the omission in neck dissection could affect the excellent result obtained in the regional disease control or even patient survival 4 , 13 . We cannot disregard that in the routine pathology assessment there may be 8% false pN0, since one single cut in the lymph node fails to detect micrometastasis 14 .…”