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1.
ANZ J Surg ; 88(11): 1193-1197, 2018 11.
Artículo en Inglés | MEDLINE | ID: mdl-29701284

RESUMEN

BACKGROUND: The prognostic significance of microscopic positive margins in papillary thyroid carcinoma (PTC) remains unclear. The aim of this study was to determine if microscopic positive margins are associated with increased risk of disease recurrence. METHODS: This is a retrospective analysis of 610 patients with PTC using multivariate Cox regression to evaluate the association between microscopic positive margins and disease-free survival. RESULTS: Microscopic positive margins were found in 67 (11%) patients and associated with extrathyroidal extension (P < 0.001), multifocality (P < 0.001), nodal metastases (P < 0.001), lymphovascular invasion (P < 0.001), age ≥55 years (P = 0.048), administration of radioactive iodine (RAI) therapy (P = 0.001) and a trend towards larger tumour size (18 versus 15 mm; P = 0.074). After a median follow-up of 3.4 years, there were 83 recurrences. Although involved margins were associated with increased risk of recurrence on univariate analysis (hazard ratio 2.6, 95% confidence interval 1.5-4.6; P = 0.001), there was no association after adjusting for age, nodal metastases, tumour size and extrathyroidal extension on multivariate analysis (hazard ratio 1.5, 95% confidence interval 0.8-2.9; P = 0.242). Similar results were obtained after adjusting for RAI and if margins were analysed as focal versus widely positive. In our study cohort, patients with involved margins generally had other indications for RAI. However, in the nine patients who did not receive RAI, there was no recurrence in the thyroid bed. CONCLUSION: Despite a strong association between microscopic positive margins and other adverse prognostic factors in PTC, there is no independent association with disease recurrence on multivariate analysis. Microscopic positive margins are rare (1.1%) in the absence of other indications for RAI.


Asunto(s)
Márgenes de Escisión , Recurrencia Local de Neoplasia/etiología , Cáncer Papilar Tiroideo/cirugía , Neoplasias de la Tiroides/cirugía , Tiroidectomía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Radioisótopos de Yodo/uso terapéutico , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/epidemiología , Modelos de Riesgos Proporcionales , Radiofármacos/uso terapéutico , Radioterapia Adyuvante , Estudios Retrospectivos , Factores de Riesgo , Cáncer Papilar Tiroideo/patología , Cáncer Papilar Tiroideo/radioterapia , Neoplasias de la Tiroides/patología , Neoplasias de la Tiroides/radioterapia , Resultado del Tratamiento , Adulto Joven
2.
JAMA Otolaryngol Head Neck Surg ; 140(12): 1138-48, 2014 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-25075712

RESUMEN

IMPORTANCE: The current American Joint Committee on Cancer (AJCC) staging system for oral cancer demonstrates wide prognostic variability within each primary tumor stage and provides suboptimal staging and prognostic information for some patients. OBJECTIVE: To determine if a modified staging system for oral cancer that integrates depth of invasion (DOI) into the T categories improves prognostic performance compared with the current AJCC T staging. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of 3149 patients with oral squamous cell carcinoma treated with curative intent at 11 comprehensive cancer centers worldwide between 1990 and 2011 with surgery ± adjuvant therapy, with a median follow-up of 40 months. MAIN OUTCOMES AND MEASURES: We assessed the impact of DOI on disease-specific and overall survival in multivariable Cox proportional hazard models and investigated for institutional heterogeneity using 2-stage random effects meta-analyses. Candidate staging systems were developed after identification of optimal DOI cutpoints within each AJCC T category using the Akaike information criterion (AIC) and likelihood ratio tests. Staging systems were evaluated using the Harrel concordance index (C-index), AIC, and visual inspection for stratification into distinct prognostic categories, with internal validation using bootstrapping techniques. RESULTS: The mean and median DOI were 12.9 mm and 10.0 mm, respectively. On multivariable analysis, DOI was a significantly associated with disease-specific survival (P < .001), demonstrated no institutional prognostic heterogeneity (I² = 6.3%; P = .38), and resulted in improved model fit compared with T category alone (lower AIC, P < .001). Optimal cutpoints of 5 mm in T1 and 10 mm in T2-4 category disease were used to develop a modified T staging system that was preferred to the AJCC system on the basis of lower AIC, visual inspection of Kaplan-Meier curves, and significant improvement in bootstrapped C-index. CONCLUSIONS AND RELEVANCE: We propose an improved oral cancer T staging system based on incorporation of DOI that should be considered in future versions of the AJCC staging system after external validation.


Asunto(s)
Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/patología , Neoplasias de la Boca/mortalidad , Neoplasias de la Boca/patología , Estadificación de Neoplasias/métodos , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/terapia , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/terapia , Invasividad Neoplásica , Valor Predictivo de las Pruebas , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Tasa de Supervivencia , Adulto Joven
3.
Ann Surg Oncol ; 21(9): 3049-55, 2014 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-24728823

RESUMEN

PURPOSE: There is evidence to suggest that a nodal yield <18 is an independent prognostic factor in patients with clinically node negative (cN0) oral squamous cell carcinoma (SCC) treated with elective neck dissection (END). We sought to evaluate this hypothesis with external validation and to investigate for heterogeneity between institutions. PATIENTS AND METHODS: We analyzed pooled individual data from 1,567 patients treated at nine comprehensive cancer centers worldwide between 1970 and 2011. Nodal yield was assessed with Cox proportional hazard models, stratified by study center, and adjusted for age, sex, pathological T and N stage, margin status, extracapsular nodal spread, time period of primary treatment, and adjuvant therapy. Two-stage random-effects meta-analyses were used to investigate for heterogeneity between institutions. RESULTS: In multivariable analyses of patients undergoing selective neck dissection, nodal yield <18 was associated with reduced overall survival [hazard ratio (HR) 1.69; 95 % confidence interval (CI) 1.22-2.34; p = 0.002] and disease-specific survival (HR 1.88; 95 % CI 1.21-2.91; p = 0.005), and increased risk of locoregional recurrence (HR 1.53; 95 % CI 1.04-2.26; p = 0.032). Despite significant differences between institutions in terms of patient clinicopathological factors, nodal yield, and outcomes, random-effects meta-analysis demonstrated no evidence of heterogeneity between centers in regards to the impact of nodal yield on disease-specific survival (p = 0.663; I (2) statistic = 0). CONCLUSION: Our data confirm that nodal yield is a robust independent prognostic factor in patients undergoing END for cN0 oral SCC, and may be applied irrespective of the underlying patient population and treating institution. A minimum adequate lymphadenectomy in this setting should include at least 18 nodes.


Asunto(s)
Carcinoma de Células Escamosas/cirugía , Escisión del Ganglio Linfático/normas , Neoplasias de la Boca/cirugía , Recurrencia Local de Neoplasia/cirugía , Nivel de Atención , Anciano , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/secundario , Femenino , Estudios de Seguimiento , Humanos , Agencias Internacionales , Metástasis Linfática , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/mortalidad , Neoplasias de la Boca/patología , Recurrencia Local de Neoplasia/mortalidad , Recurrencia Local de Neoplasia/patología , Estadificación de Neoplasias , Pronóstico , Tasa de Supervivencia
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