Two otorhinolaryngology surgical techniques, which have brought hope to cancer patients, are being used in a pioneering way at the Hospital de Clínicas (HC) at Unicamp. One is the endoscopic surgery technique for removing malignant tumors using nasal video endoscopy and the other is research into sentinel lymph nodes. Both were brought to Unicamp by professor at the Faculty of Medical Sciences (FCM) Carlos Chone, otorhinolaryngologist and head and neck surgeon. “What motivated us to look for these techniques was the improvement of our patients, as technologies change over time”, he highlighted.
The first surgery has a multidisciplinary approach, involving the areas of Oncology, Radiotherapy and Neurosurgery. It is considered minimally invasive, because it seeks to preserve the anatomy with minimal damage to the body. The removal of malignant tumors is done through the nose holes, without the need for external cuts and without pain. This procedure is routinely performed by very few institutions in the country and has recently begun to be adopted routinely by the HC. Twelve cases have already undergone this surgery, all with encouraging results.
Postoperative recovery has been shown to be faster than conventional procedures, even if the tumor is removed deeper and reaches the meninges (membranes that cover the central nervous system). The manipulation of brain tissue is much smaller, explains Chone. This technique has few publications and was originally used for pituitary tumors. It began to be described in the 1980s and was expanded to malignant tumors using video.
According to the worldwide case series, it has been the procedure of choice, compared to the traditional route, and – even in advanced cases – it has shown a cure rate of around 80%. Normally, when external cuts are made, the patient has to deal with probable bleeding. As a result, blood can impair visualization. “We see inside narrow cavities, like the sinuses, where there is little lighting,” she reveals. “In this case, the team’s decision is to make a larger opening in the region of interest to reach the tumor. There are often remnants of the tumor left over, which can be malignant.”
With the new technique, a camera is attached to an endoscope system which, in turn, has a lens system. These are long, thin pieces of equipment (4 mm thick) that are inserted into the holes in the nose, through which the surgeon works. “The visualization is excellent”, says the doctor. He comments that the human eye does not bend for viewing. With wide-angle lenses, it has been possible to see at different angles, beyond the curve. Special cautery and scalpel systems are attached to it to cut and coagulate the tumor, with a good oncological margin.
This technique has the same cure rate as the open (traditional) technique, but provides better postoperative and aesthetic recovery. Videoendoscopy recovery time, says Chone, is cut in half. When surgery is performed externally, it takes about ten days.
But the biggest advantage of the endoscopic route is that it eliminates the need to open the skull to remove extensive tumors. Therefore, it is less aggressive. Nowadays, open surgeries have little indication. Chone believes that, in the future, robotics will enter this market. The robotic arms are still large and do not go through the nose.
The recommended post-surgery care involves avoiding physical exertion for up to a month. In between, the nose is washed continuously with saline solution. Depending on the situation, the patient uses a tampon for three to five days after removing tumors that require further reconstruction.
Most nose tumors are diagnosed through symptoms such as nasal congestion that does not improve, pain above or below the eyes, blockage on one side of the nose, nasal drip in the back of the nose and throat, and bleeding. nasal.
guardians
Another technique used in HC is the search for sentinel lymph nodes in mouth cancer, successfully used in hundreds of cases. One difficulty in overcoming this type of cancer is metastasis to other organs, which occurs via the lymphatic route. Traditional, open treatment includes the removal of all nodes in the neck where metastasis may exist.
Using the new technique, instead of removing them all, a radioactive product is injected around the tumor. The investigation is carried out using a state-of-the-art ultrasensitive device, the gamma probe, capable of detecting radioactivity with great accuracy and sensitivity.
"Through it, the first lymph node (lymph node) is detected - the sentinel lymph node, which receives this name because it is precisely the guardian, in the neck. If it is contaminated with malignant cells, the chance of the others being malignant is greater. But This only occurs in 20% of cases”, informs the surgeon.
If he is disease-free, the chances of others being contaminated with malignant cells are negligible. The ganglion is removed and a thorough analysis is carried out using a biopsy, eliminating the need for additional treatments in the neck.
The benefit of this technique is that, instead of the surgeon moving the entire neck to remove the nodes, he only removes the sentinel. Treatment is shortened, the length of surgery is reduced and there is no need to dissect the nerves in the neck.
In the classic treatment, a large cut is made in the neck to remove these nodes. “Instead of removing 50 nodes from the neck and having to deal with nerves and veins, we removed just one using the sentinel lymph node technique”, says the surgeon. A small cut is made, maximum 5 cm.
Around 30% of patients who undergo traditional surgery may suffer shoulder pain and difficulty moving their arm, due to manipulation of the nerves. “The sentinel, when removed, solves the problem in 80% of cases, with less aggression, and the patient is discharged the next day”, guarantees Chone. “Previously, in addition to the surgery being extensive, it required the use of a drain and a longer hospital stay.”
Sentinel lymph node treatment is already a standard procedure in Europe to evaluate regional neck metastases. In Brazil, it is only practiced by Unicamp, the Cancer Institute of the State of São Paulo (Icesp) and the Cancer Hospital of Barretos, SP, in an institutionalized manner.
Mouth cancer, in the head and neck region, is the most common cancer in Brazil, where 17 thousand new cases are found per year. In the Campinas region, it is second only to prostate cancer. In other regions, it is in fourth or fifth place”, he emphasizes. The cure rate is related to early diagnosis, around 80% to 90% of initial cases.
Smoking and drinking are risk factors for this type of cancer. Today, the proportion is around two men for 1 woman affected by the disease. In the 1960s, this ratio reached seven men to one woman. But, as women are smoking more these days, cigarettes are a significant risk factor for this population as well.
This pathology can be noticed through injury, persistent changes or the feeling that the person has something bothering them inside their mouth when drinking or smoking. These changes appear more on the tongue and, if they do not disappear after 15 days, they should be studied by an otolaryngologist, head and neck surgeon or dentist.
