Syftet med studien var att belysa hur patienter som strålats mot huvud- och halscancer upplevde sin orala hälsa efter avslutad strålbehandling. Studien är kvalitativ och består av intervjuer med åtta informanter. Intervjuerna har utförts med hjälp av en intervjuguide. Intervjuerna spelades in på bandspelare och varade i ca 10-20 minuter. Intervjumaterialet har analyserats med en kvalitativ innehållsanalys. Resultatet av studien visade att majoriteten av informanterna upplevde sin orala hälsa negativt efter avslutad strålbehandling, dessa benämns i fysisk effekt och psykisk begräsning. Informanterna upplevde smärta samt muntorrhet efter avslutad strålbehandling. Resultatet visade även att nutritionsbegränsingar uppstod och att de var tvungna till att göra kostförändringar, även sväljning och tuggning försvårades. Informanterna upplevde generellt att det var jobbigt att äta i stora sammanhang då rädslan för att sätta maten i halsen förekom. Strålbehandlingen påverkade även informanterna psykiskt genom att de ofta var låga i humöret. Slutsatsen av studien visar att dessa patienter upplever smärta, har problem med att äta och påverkas psykiskt samt att de hämmas socialt. / The purpose of this study was to illustrate how patients radiated against head and neck cancer, experience their oral health after ending radiotherapy. The study is qualitative and considers interviews with eight informants. The interviews were conducted using an interview guide. The interviews were recorded on a tape recorder and lasted about 10-20 minutes. The interview data were then analysed using a qualitative content analysis. The results of this study show that a majority of the respondents experience their oral health negatively after ending radiotherapy; these are mentioned in physical effect and mental limitation. The informants experienced pain and dry mouth after completing radiotherapy. The results also showed that they had trouble eating, including swallowing and chewing difficult and that they were forced to make dietary changes. The informants experienced generally it was hard to eat at large surroundings because the fear of choking occurred. Radiotherapy had also affected the informants psychologically, as they often was in low mood. The conclusion of the study shows that these patients experience pain, have trouble eating and that they are affected psychologically as well as inhibited socially.

Der Hedgehog Signaltransduktionsweg (HhP) ist in der Embryologie und für die Tumor-entstehung bedeutsam und kann durch den spezifischen Antagonisten Cyclopamin (Cyc) inhibiert werden. Simvastatin (Sim) kann die für den HhP essentielle Cholesterolsynthese blockieren. Die therapeutische Unterdrückung des HhP in Kopf-Hals-Plattenepithel-karzinomen (HNSCC) zu untersuchen erschien nach verschiedenen Literaturhinweisen lohnend. In den Experimenten, deren Ergebnisse bereits in Artikeln publiziert wurden, konnten antineoplastische Effekte von Cyc bzw. Sim allein und in Kombination mit den Leitlinientherapeutika Cisplatin (Cis) oder Docetaxel (DTX) an der epithelialen Zelllinie KB, den Kopf-Hals-Zelllinien FaDu und HN-5, sowie an primären HNSCC ex vivo nachgewiesen werden. Biopsien von 49 HNSCC wurden im FLAVINO-Assay mit Cyc bzw. Sim in steigenden Konzentrationen allein und kombiniert mit Cis oder DTX untersucht. In die Auswertung konnten gemäß den Einschlusskriterien (histopathologisch bestätigtes HNSCC und suffiziente Koloniebildung im FLAVINO-Assay) 18 HNSCC einbezogen werden. Bei den Voruntersuchungen führten sowohl Cyc als auch Sim zu einer signifikanten Zeit- und Dosis-abhängigen Reduktion der Lebensfähigkeit von KB, FaDu und HN-5. Ebenso unterdrückten sowohl Cyc als auch Sim die Koloniebildung epithelialer Zellen im FLAVINO-Assay hochsignifikant. Auch tolerierbare Cis- und DTX-Konzentrationen zeigten eine signifikante Wachstumshemmung. In der Analyse des Interaktionsmodus wurde in den untersuchten Kombinationen (Sim+Cis, Sim+DTX, Cyc+Cis und Cyc+DTX) in allen Fällen Additivität als prädominanter Interaktionstyp ermittelt. Die Ergebnisse dieser Arbeit weisen den HhP als potentielles Target in HNSCC aus. Potentere und human besser verträgliche HhP-Blocker sollten unsere Ergebnisse bestätigen und in klinischen Studien getestet werden. Auch die Wirksamkeit von Sim auf HNSCC sollte in prospektiven klinischen Studien weiter analysiert und bestätigt werden. Möglicherweise vermag Sim bzw. die HhP-Blockade zukünftig einen Beitrag zur Therapie von HNSCC im Rahmen multimodaler Therapiekonzepte zu leisten.

Made available in DSpace on 2014-08-13T14:50:43Z (GMT). No. of bitstreams: 0 Previous issue date: 2013-05-08Bitstream added on 2014-08-13T18:00:55Z : No. of bitstreams: 1 000750710.pdf: 832145 bytes, checksum: 2b135f4526d2bc2da676628715a1e741 (MD5) / O presente estudo identificou características sociodemográficas, da saúde física e mental, percepções e expectativas ao atendimento e diagnóstico de pacientes com suspeita de câncer de cabeça e pescoço. Avaliou-se 49 pacientes de dois centros de diagnóstico oral. O delineamento constou de dois Momentos: pré-biópsia (M1) e pósdiagnóstico (M2). No M1, investigaram-se dados sociodemográficos, apoio social e estilo de vida (questionário), sintomas ansiosos (Inventário de Ansiedade Traço- Estado, IDATE), depressivos (Inventário de Depressão de Beck, BDI) e uso de álcool (Alcohol Use Disorders Identification Test, AUDIT); motivo da consulta, sentimentos, percepção do problema e expectativas sobre diagnóstico e atendimento (entrevista). No M2, reavaliaram-se sintomas ansiosos (IDATE-Estado) e depressivos (BDI), percepções e sentimentos ao diagnóstico, enfrentamento, expectativas e a satisfação com o atendimento (entrevista) dos 29 pacientes com diagnóstico de câncer. As respostas às entrevistas foram categorizadas. Utilizou-se de análises descritivas e bivariadas (chi-quadrado ou exato de Fisher, Goodman e Wilcoxon – p<0.05). Resultados: na amostra total, predominaram: homens (73,4%), idade de 59 anos, 4,5 anos de estudo, ocupação remunerada (40,8%), rendimento de R$ 670,65, viver com companheiro 61,2% e com parentes 87,8%, relatar sentimento de apoio social 83,7%, ter religião 93,9%, tabagismo e etilismo 44,9%, ter problemas de saúde 45,0% e autoavaliação da “saúde boa” 69,4%. O tempo médio de observação da lesão foi de seis meses, sendo a maioria intraoral (83,7%) e encaminhados por dentistas 51,0%. No M1, 53,9% das mulheres foram consideradas caso para ansiedade-Traço, 61,5% para Estado e 46,2% para sintomas depressivos; e 36,1% dos homens apresentaram risco para de uso de álcool. Observou-se que 61,2% dos pacientes relataram percepções realistas sobre sua saúde, satisfação com atendimento ... / This study aimed to describe the sociodemographic characteristics, lifestyle, and physical and mental health status of patients with head and neck cancer, as well as identify their perceptions and expectations regarding care and diagnosis. 49 patients were evaluated before and after diagnosis communication as they were submitted to biopsies in two diagnostic oral centers. Before the diagnosis (moment 1), the sociodemographic and lifestyle variables were evaluated using a questionnaire and validated instruments to assess anxiety (State - Trait Anxiety Inventory, STAI), depression (Beck Depression Inventory, BDI) and alcohol abuse (Alcohol Use Disorders Identification Test, AUDIT); reason for examination, feelings, perception of the problem, and expectations were investigated through a structured interview. After cancer diagnosis (moment 2), 29 patients had some aspects reassessed: anxiety, depression levels, perceptions, feelings about the disease, and expectations towards medical and dental care. Were also investigated coping and satisfaction with the service received from dentists. Data collected during the interviews were categorized and a descriptive and bivariate analysis (Qui-square, fisher, Goodman and Wilcoson – p<0,05) to other variables. The initial sample consisted mostly of males (73.4%) (mean age of 59 years), with four and a half years of study, employed (40.8%), low income (53,0%), having a partner (61.2%), living with relatives (87.8%), having feelings of social support (83.7%) and a religion (93.9%), smoking (44.9%) and (45.0%) drinking habits, and classified their health as “good” (69.4%). The mean time between observation of symptoms and seeking for help was six months, which were mostly intraoral lesions (83.7%), referred by dentists (51.1%). Before diagnosis (Moment 1), women had a high prevalence for anxiety-trait (53.9%), state (61.5%) and depressive symptoms (46.2%). Men had a higher frequency of risky use of ...

Made available in DSpace on 2014-08-13T14:50:43Z (GMT). No. of bitstreams: 0 Previous issue date: 2013-07-17Bitstream added on 2014-08-13T18:00:53Z : No. of bitstreams: 1 000750768.pdf: 1405991 bytes, checksum: 68568a010dcdca88df8b22b4614eb667 (MD5) / O carcinoma espinocelular (CEC) é tumor maligno das células espinhosas da epiderme caracterizado por evolução mais rápida, maior poder invasivo e metastático em relação ao carcinoma basocelular (CBC). A área mais profunda e infiltrativa do CEC, conhecida como fronte de invasão, revela células neoplásicas malignas com menor grau de diferenciação comparadas à totalidade da lesão. Estudos recentes demonstram a influência do padrão do fronte de invasão tumoral no prognóstico de CEC de laringe e colo uterino. Contudo, não há estudos sobre o mesmo em relação a CEC cutâneos de cabeça e pescoço. Estudar as características clínicas, histopatológicas e perfil imuno-histoquímico do CEC de cabeça e pescoço e fronte de invasão tumoral, correlacionando-o com comportamento biológico. O estudo foi do tipo coorte retrospectivo, sendo selecionados os pacientes que tiveram diagnóstico de CEC de cabeça e pescoço confirmados pelo exame anatomopatológico no período de 1999 a 2009. A avaliação do fronte de invasão tumoral foi realizada empregando-se imuno-histoquímica para E-caderina, ki-67 e p53. Resultados: O tipo de fronte de invasão, bem como as expressões de E-caderina e ki-67, seja em sítio superficial ou profundo, não apresentaram associação com os critérios prognósticos histopatológicos. Os achados mostraram que a E-caderina, o p53 e o ki-67 foram mais expressos em tumores com tamanho ˃ 2cm. Em relação a espessura do tumor, observamos que o p53 foi mais expresso na profundidade nas lesões mais espessas (índice de Breslow maior que 2mm), e que foi acompanhada também pela expressão maior do Ki-67.A expressão de p53 em sítio superficial teve associação inversa com o critério de espessura (p<0,049) e, em sítio profundo, teve associação direta com a intensidade do processo inflamatório local (p<0,046). O tipo de fronte de invasão, bem como as expressões de E-caderina, ki-67 e p53, em sítios ... / The Squamous Cell Carcinoma (SCC) is a malignant epidermal tumor of squamous epithelial cells, characterized for greater aggressiveness much higher incidence of metastasis than Basal Cell Carcinoma (BCC). The deepest invading tumor area, known as invasive tumor front usually disclose less differentiated malignant cells, compared with the whole lesion. Recent studies demonstrate the influence of the invasive tumor front pattern on the prognosis of larynx and uterine cervix SCC. However, there is no studies about that on cutaneuos SCC of the head and neck. To study the clinical, histopathological and immunohistochemical profile of the SCC from head and neck and its invasive tumor front, correlating it with its biological behavior. The study was a retrospective type coorte, where the patients with histopathological diagnosis of head and neck cutaneous SCC among 1999 to 2009 were selected. The evaluation of invasive tumor front was immunohistochemistry for E-cadherin, ki-67 and p53. The pattern of invasive tumor front, as well as E-cadherin and ki-67 expressions, at superficial and deep sites, did not present association with histopathological prognostic criteria. The findings showed that E-cadherin, p53 and Ki-67 were more highly expressed in tumors with size ˃ 2cm. Regarding the thickness of the tumor, we observed that p53 was expressed in depth in thicker lesions (Breslow thickness greater than 2 mm), which was also accompanied by higher expression of Ki-67. p53 expression, at superficial site, had inverse association with thickness criteria (p<0,049) and, at deep site, had direct association with local inflammatory process intensity (p<0,046). The invasive tumor front, as well as E-cadherin, ki-67 and p53 expressions, at superficial and deep sites, did not demonstrate impact on free disease survival. The characteristics of invasive tumor front did not correlate with prognosis in cutaneuos SCC of the head and neck regarding to the ...

Orientador: Ana Maria Teresa de Abreu Ramos Cerqueira / Coorientador: Antonio Bento Alves de Moraes / Banca: Gimol Benzaquen Perosa / Banca: Márcio Ajudante Lopes / Resumo: O presente estudo identificou características sociodemográficas, da saúde física e mental, percepções e expectativas ao atendimento e diagnóstico de pacientes com suspeita de câncer de cabeça e pescoço. Avaliou-se 49 pacientes de dois centros de diagnóstico oral. O delineamento constou de dois Momentos: pré-biópsia (M1) e pósdiagnóstico (M2). No M1, investigaram-se dados sociodemográficos, apoio social e estilo de vida (questionário), sintomas ansiosos (Inventário de Ansiedade Traço- Estado, IDATE), depressivos (Inventário de Depressão de Beck, BDI) e uso de álcool (Alcohol Use Disorders Identification Test, AUDIT); motivo da consulta, sentimentos, percepção do problema e expectativas sobre diagnóstico e atendimento (entrevista). No M2, reavaliaram-se sintomas ansiosos (IDATE-Estado) e depressivos (BDI), percepções e sentimentos ao diagnóstico, enfrentamento, expectativas e a satisfação com o atendimento (entrevista) dos 29 pacientes com diagnóstico de câncer. As respostas às entrevistas foram categorizadas. Utilizou-se de análises descritivas e bivariadas (chi-quadrado ou exato de Fisher, Goodman e Wilcoxon - p<0.05). Resultados: na amostra total, predominaram: homens (73,4%), idade de 59 anos, 4,5 anos de estudo, ocupação remunerada (40,8%), rendimento de R$ 670,65, viver com companheiro 61,2% e com parentes 87,8%, relatar sentimento de apoio social 83,7%, ter religião 93,9%, tabagismo e etilismo 44,9%, ter problemas de saúde 45,0% e autoavaliação da "saúde boa" 69,4%. O tempo médio de observação da lesão foi de seis meses, sendo a maioria intraoral (83,7%) e encaminhados por dentistas 51,0%. No M1, 53,9% das mulheres foram consideradas caso para ansiedade-Traço, 61,5% para Estado e 46,2% para sintomas depressivos; e 36,1% dos homens apresentaram risco para de uso de álcool. Observou-se que 61,2% dos pacientes relataram percepções realistas sobre sua saúde, satisfação com atendimento ... / Abstract: This study aimed to describe the sociodemographic characteristics, lifestyle, and physical and mental health status of patients with head and neck cancer, as well as identify their perceptions and expectations regarding care and diagnosis. 49 patients were evaluated before and after diagnosis communication as they were submitted to biopsies in two diagnostic oral centers. Before the diagnosis (moment 1), the sociodemographic and lifestyle variables were evaluated using a questionnaire and validated instruments to assess anxiety (State - Trait Anxiety Inventory, STAI), depression (Beck Depression Inventory, BDI) and alcohol abuse (Alcohol Use Disorders Identification Test, AUDIT); reason for examination, feelings, perception of the problem, and expectations were investigated through a structured interview. After cancer diagnosis (moment 2), 29 patients had some aspects reassessed: anxiety, depression levels, perceptions, feelings about the disease, and expectations towards medical and dental care. Were also investigated coping and satisfaction with the service received from dentists. Data collected during the interviews were categorized and a descriptive and bivariate analysis (Qui-square, fisher, Goodman and Wilcoson - p<0,05) to other variables. The initial sample consisted mostly of males (73.4%) (mean age of 59 years), with four and a half years of study, employed (40.8%), low income (53,0%), having a partner (61.2%), living with relatives (87.8%), having feelings of social support (83.7%) and a religion (93.9%), smoking (44.9%) and (45.0%) drinking habits, and classified their health as "good" (69.4%). The mean time between observation of symptoms and seeking for help was six months, which were mostly intraoral lesions (83.7%), referred by dentists (51.1%). Before diagnosis (Moment 1), women had a high prevalence for anxiety-trait (53.9%), state (61.5%) and depressive symptoms (46.2%). Men had a higher frequency of risky use of ... / Mestre

O objetivo deste estudo foi avaliar a efetividade de uma formulação farmacêutica experimental (solução com 1,54% de pilocarpina em spray) sobre o fluxo salivar (FS), experiência de boca seca e qualidade de vida (QV), comparado com placebo, em pacientes tratados com radioterapia (RTx) para câncer de cabeça e pescoço (CCP). Este ensaio clínico randomizado, controlado, duplo-cego e crossover foi realizado em pacientes com xerostomia (n=28). O FS foi medido pela sialometria estimulada (técnica do hálito fresco), a experiência de boca seca pelo Xerostomia Inventory (XI) e a QV pelo Oral Health Impact Profile (OHIP-14). As avaliações foram feitas antes do início da terapêutica - baseline (T0), um (T1), dois (T2) e três (T3) meses após iniciar o uso do spray, além da mensuração do FS uma hora após o baseline (T0+), seguido de período washout de 01 mês e após crossover, os mesmos períodos foram avaliados. O FS apresentou maior após uma hora (p=0,003 - teste de Wilcoxon) e dois meses (p=0,002 - teste de Friedman) de uso do spray com pilocarpina; melhoria na experiência de xerostomia, verificado pela diminuição significante (p<0,05 - teste de Friedman) dos escores em cinco itens do XI; melhoria na QV, verificado pela diminuição significante (p<0,05 - teste de Friedman) dos escores em três itens do OHIP-14, com o passar de alguns dos períodos de avaliação. A aplicação tópica da formulação de pilocarpina em spray melhoraram significantemente o FS, experiência de xerostomia e QV para os pacientes tratados com RTx para CCP. / The aim of this study was to evaluate the effectiveness of an experimental pharmaceutical formulation (1.54% pilocarpine spray solution) on salivary flow (SF), dry mouth experience and quality of life (QoL), compared to placebo, in patients treated with radiotherapy (RTx) for head and neck cancer (HNC). This randomized, controlled, double-blind, crossover clinical trial was performed in patients with xerostomia (n = 28). SF was measured by stimulated sialometry (fresh breath technique), dry mouth experience by Xerostomia Inventory (XI) and QoL by the Oral Health Impact Profile (OHIP-14). The evaluations were done before - baseline (T0), one (T1), two (T2) and three (T3) months after starting the spray, besides the measurement of FS one hour after the baseline (T0+), followed by a washout period of 1 month and after crossover, the same periods were evaluated. The SF presented higher after one hour (p=0.003 - Wilcoxon test) and two months (p=0.002 - Friedman test) of the use of the pilocarpine spray; improvement in the xerostomia experience, verified by the significant decrease (p<0.05 - Friedman test) of the scores in five items of XI; improvement in the QoL, verified by the significant decrease (p<0.05 - Friedman\'s test) of the scores on three items of the OHIP-14, with the passing of the evaluation of some periods. Topical application of the pilocarpine spray formulation significantly improved SF, xerostomia experience and QoL for patients treated with RTx for HNC.

Orientador: Paula Rahal / Banca: Ana Elizabete Silva / Banca: Erika Cristina Pavarino Bertelli / Banca: Erico Tosoni Costa / Banca: Raphael Bessa Parmigiani / Resumo: O carcinoma de células escamosas de cabeça e pescoço (HNSCC) é uma doença heterogênea que afeta o epitélio da cavidade oral, laringe e faringe. A maioria dos pacientes é diagnosticada em estágios avançados da doença e ainda não existe nenhum marcador sensível e específico para o comportamento agressivo deste tumor. Portanto, uma detecção precoce e biomarcadores de prognóstico são altamente necessárias para uma administração mais racional da doença. A hipermetilação de ilhas CpGs é um dos mecanismos epigenéticos mais importantes que levam a um silenciamento gênico em tumores e tem sido extensivamente utilizados para a identificação de biomarcadores. Neste estudo foram combinados as análises de Rapid Substractive Hybridization (RaSH) e microarray de uma maneira hierárquica para selecionar genes que, supostamente, são reativados pelo agente desmetilante 5'Aza'2'deoxicitidina (5Aza'dC) em linhagens celulares derivados de carcinoma de cabeça e pescoço (FaDu, UM' SCC'14A, UM'SCC'17A e UM'SCC'38). Esta análise combinada identificou 78 genes dos quais 35 foram reativados em, pelo menos, 2 linhagens celulares e apresentavam ilha CpG nas suas regiões 5'. A reativação de três destes 35 genes (CRABP2, MX1 e SLC15A3) foi confirmada por PCR em tempo real (Fold change ≥ 3). O seqüenciamento de bissulfito de sódio das suas ilhas CpGs revelou que eles estão, de fato, diferencialmente metilados em linhagens celulares derivadas de carcinoma de cabeça e pescoço. Foram detectadas uma maior freqüência de hipermetilação dos genes CRABP2 (58.1% para a região 1) e MX1 (46.3%) em amostras primárias de câncer de cabeça e pescoço quando comparados a linfócitos de indivíduos saudáveis utilizando o PCR de metilação específica (MSP). Finalmente a ausência da proteína CRABP2 foi associada com... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Head and neck squamous cell carcinoma (HNSCC) is a heterogeneous disease affecting the epithelium of the oral cavity, pharynx and larynx. Most patients are diagnosed at late stages of the disease and no sensitive and specific predictors of aggressive behavior have been identified yet. Therefore, early detection and prognostic biomarkers are highly desirable for a more rational management of the disease. Hypermethylation of CpG islands is one of the most important epigenetic mechanisms that leads to gene silencing in tumors and has been extensively used for the identification of biomarkers. In this study, we combined Rapid Subtractive Hybridization (RaSH) and microarray analysis in a hierarchical manner to select genes that are putatively reactivated by the demethylating agent 5'aza'2'deoxycytidine (5Aza'dC) in HNSCC cell lines (FaDu, UM'SCC'14A, UMSCC'17A, UM'SCC'38A). This combined analysis identified 78 genes of which 35 were reactivated in at least 2 cell lines and harbored a CpG island at their 5' region. Reactivation of three out of these 35 genes (CRABP2, MX1 and SLC15A3) was confirmed by qRT'PCR (fold change ≥ 3). Bisulfite sequencing of their CpG islands revealed that they are indeed differentially methylated in the HNSCC cell lines. Using Methylation Specific PCR (MSP), we detected a higher frequency of CRABP2 (58.1% for region 1) and MX1 (46.3%) hypermethylation in primary HNSCC, when compared to lymphocytes from healthy individuals. Finally, absence of the CRABP2 protein was associated with decreased disease'free survival rates, supporting a potential use of CRABP2 expression as a prognostic biomarker for HNSCC patients / Doutor

O câncer de cabeça e pescoço (CCP) abrange cerca de 10% dos tumores malignos, sendo uma doença cujo tratamento é agressivo em suas diferentes abordagens. Tanto a doença quanto os tratamentos podem gerar impactos na qualidade de vida (QV) dos pacientes de forma temporária ou definitiva. O objetivo deste estudo foi verificar mudanças na percepção de QV e nas condições de saúde bucal de um grupo de pacientes de CCP tratados em um hospital de Porto Alegre, em relação ao período pré-tratamento após 30 meses decorridos de seu tratamento oncológico. Outro objetivo foi identificar diferenças entre os participantes sobreviventes e falecidos quanto às medidas registradas na linha de base. Na linha de base, foram entrevistados e examinados 46 pacientes com tumores primários em regiões de cabeça e pescoço e que ainda não haviam iniciado o tratamento oncológico. No acompanhamento, foram constatados 23 óbitos e 04 perdas entre os integrantes do grupo inicial, conseguindo-se entrevistar e examinar 19 sobreviventes. Foram utilizados os questionários de QV geral abreviado da Organização Mundial de Saúde (WHO Quality of Life Bref – WHOQOL Bref) e o de QV relacionado à saúde específico para pacientes de CCP da European Organisation for Research and Treatment of Cancer (EORTC Quality of Life Questionnaire Head &Neck 35 – EORTC H&N 35), e os índices de dentes cariados, perdidos e obturados (CPO-D), e de Uso e Necessidade de Prótese. Ainda, foram registradas informações de autopercepção de saúde bucal, acesso e satisfação dos sobreviventes em relação ao atendimento odontológico. Para a análise estatística, as medidas iniciais e finais foram comparadas utilizando-se os testes qui-quadrado, Exato de Fisher, T de Student e Mann-Whitney. Na linha de base, foram encontradas diferenças significativas entre os pacientes sobreviventes e falecidos em relação ao estadiamento tumoral, tipo de tratamento, disfagia, domínio físico do questionário de QV WHOQOL Bref, escore geral do questionário de qualidade de vida relacionado à saúde EORTC H&N35 e seus itens dor, deglutição e comer em público. De forma geral, após uma média de 32 meses de acompanhamento, os sobreviventes apontaram impactos físicos relacionados ao câncer e seu tratamento, contudo, sua percepção de QV não sofreu alteração significativa no acompanhamento de longo prazo. Em relação às condições de saúde bucal, houve elevação do escore médio do CPO-D e do uso de próteses dentárias. Os pacientes sentiram necessidades de atendimento odontológico em razão de dor e reabilitação protética no período pós-tratamento oncológico e, com exceção de quatro casos, não receberam acompanhamento odontológico sistematicamente organizado com relação ao CCP. Os achados deste estudo acompanham as recomendações da literatura para incluir, rotineiramente, a avaliação de QV pelos serviços oncológicos, como uma ferramenta que potencializa a qualificação deste cuidado posto que permite aprofundar a compreensão dos pacientes e de suas necessidades. / Head and neck cancers, which represent approximately 10% of all malignancies, usually have an aggressive treatment, irrespective of the therapeutic approach. Both the disease and its treatment may impact temporarily or definitively on quality of life. The objective of this study was to verify changes in the perception of quality of life and in the oral health of patients with head and neck cancer in a hospital of the city of Porto Alegre, immediately before and at least 30 months after the cancer treatment. Additional objective was to evaluate the differences between survivors and deaths in respect to baseline measures. Baseline evaluation comprised interviews carried out with 46 patients diagnosed with primary head and neck tumors before the start of the oncologic treatment. The follow up study was carried out with 19 survivors, while 23 participants died during the follow up and the 4 remaining were not located. Quality of life was assessed using WHOQOL Bref and EORTC H&N 35 questionnaires, while oral health examinations included DMFT and dental prostheses assessments following the WHO criteria. Information in respect to self-perceived oral health, access to and satisfaction with oral health services were also collected. Baseline and follow up measures were compared using Chi-square, Fisher’s exact, Student’s t and Mann-Whitney tests. Baseline results revealed significant differences between survivors and deaths in respect to tumor stage, type of treatment, dysphagia, physical domain WHOQOL Bref scores, EORTC H&N 35 full scores and pain, swallowing and eating in public items. Overall, survivors reported physical impacts related to the disease and its treatment. However, the perception of quality of life was not significantly changed during follow up. In respect to oral health, there was an increase in the mean DMFT and in the use of dental prostheses between the baseline and the follow up after 30 months. Participants of the follow up reported the need of dental treatment due to pain and dental prosthetic rehabilitation after the completion of the cancer treatment. With the exception of four participants, cancer patients who took part of the study did not receive systematic oral care. The findings of this study are in accordance with the previous recommendations of the inclusion of quality of life evaluations routinely by oncologic services in order to provide a tool to potentiate the quality of care and to improve the understanding of the cancer patients and their needs.

O câncer representa um importante problema de saúde pública no mundo, devido ao aumento da sua prevalência, além do grande impacto individual, institucional e social. Assim, merece uma abordagem ampliada, integral e interdisciplinar, a fim de minimizar as seqüelas decorrentes da doença ou do seu tratamento, visando à cura com manutenção da qualidade de vida (QV). Dessa forma, este trabalho teve como objetivos descrever o perfil sócio-demográfico e de saúde bucal de pacientes com câncer de cabeça e pescoço assistidos no HNSC, Porto Alegre – RS e, verificar o impacto na QV destes de um protocolo de cuidados odontológicos sistemático, antes, durante e depois da terapia oncológica. O estudo, delineado como um Ensaio Clínico Randomizado, teve a participação de 46 sujeitos com diagnóstico de neoplasia primária de cabeça e pescoço, captados por conveniência, consecutivamente e distribuídos aleatoriamente em dois grupos. No grupo controle, os pacientes foram examinados e orientados sobre os possíveis efeitos do tratamento oncológico e encaminhados aos serviços de atenção básica de referência para atendimento odontológico. No grupo intervenção, os pacientes foram examinados e orientados, sobre os possíveis efeitos do tratamento oncológico. Os sujeitos incluídos neste grupo receberam um protocolo de cuidados odontológicos na instituição, com acompanhamento profissional sistemático antes, durante e depois da terapia oncológica. Também foram fornecidas, aos cuidadores e pacientes, em ambos os grupos, orientações sobre os possíveis efeitos secundários da terapia oncológica e de ações para minimizar estes problemas. Os dados coletados referem-se a condições sócio-demográficas e de saúde bucal e também de avaliação da QV através de dois questionários - EORTC (específico para pacientes com câncer de cabeça e pescoço) e WHOQOL (avaliação geral da QV), aplicados em dois momentos distintos: antes e quinze dias depois da terapia oncológica concluída. Os resultados mostraram uma maior prevalência do câncer de cabeça e pescoço em homens, de baixo nível educacional e sócio-econômico, com pobre condição oral e média de idade de 54,2 anos. O diagnóstico histopatológico mais freqüente foi o carcinoma epidermóide, sendo as localizações preferenciais a língua e orofaringe. Mais de 60% dos diagnósticos foram realizados nas fases avançadas (III e IV – TMN) e os principais tratamentos realizados a cirurgia e a radioterapia. Apesar das características basais serem desfavoráveis, o grupo intervenção apresentou melhora na avaliação geral de QV e manutenção da específica após o tratamento oncológico, enquanto que o grupo controle mostrou piora em ambos, porém não houve diferença significativa entre os grupos. Entretanto, a variação das medidas (delta) no grupo intervenção, quando comparadas as características basais e finais, mostra uma projeção que tendencia uma melhoria significativa ao longo do tempo. Verifica-se também uma redução de candidíase (p<0,05) e mucosite no grupo intervenção. Conclui-se que os pacientes assistidos no Serviço de Oncologia do HNSC apresentaram o perfil típico dos tumores de localização de cabeça e pescoço no país, com maior prevalência de homens, tabagistas, de baixo nível sócio-econômico e educacional e pobre saúde oral. O protocolo de cuidados odontológicos desenvolvido foi capaz de reduzir danos decorrentes da terapia oncológica, além de poder contribuir para uma melhoria da QV ao longo do tempo aos pacientes com câncer de cabeça e pescoço. / Cancer represents a major public health problem all over the world due to the increase in its prevalence, besides its great individual institutional, and social impact. Thus, it deserves a wide, integral, and interdisciplinary approach in order to minimize the sequelae resulting from the disease or its treatment, and aiming to the healing with maintenance of the quality of life (QoL). This way, this study aimed to describe the social-demographic and oral health profile of head and neck cancer patients treated in Hospital Nossa Senhora da Conceição (HNSC), Porto Alegre, Brazil, and to check the impact of a systematic dental care guideline on the QoL before, during, and after the oncological therapy. The study, designed as a Randomized Clinical Trial, had the participation of 46 subjects with diagnosis of head and neck primary neoplasy, captured by convenience, consecutively, and randomly distributed in two groups. In the control group, patients were examined and advised about the possible effects of the oncological treatment and referred to the basic health care services for dental care. In the test group, patients were examined and advised about the possible effects of oncological treatment. The subjects included in this group received a dental care guideline in the institution, with a systematic professional follow-up before, during, and after the oncological therapy. Also, both caretakers and patients from each group received guidance about the possible secondary effects of the oncological therapy and the actions to minimize these problems. Collected data refer to the social-demographic and oral health status, as well as the evaluation of QoL by means of two questionnaires - EORTC (specific for head and neck cancer patients), and WHOQOL (general evaluation of QoL). These were administered in two distinct moments: before the onset and fifteen days after the conclusion of the oncological therapy. Results showed a higher prevalence of head and neck cancer in men, with low educational and social-economic level, with a poor oral condition, and an average age of 54.2 years. The most frequent histopathological diagnosis was epidermoidis carcinoma, being the preferential sites the tongue and the oropharynx. More than 60% of the diagnosis was done in the advanced phases (III e IV – TMN), and the main treatments performed were surgery and radiotherapy. In spite of the unfavorable baseline characteristics, the test group showed an improvement in the general evaluation of QoL, and maintenance of the specific QoL after the oncological treatment. The control group showed a worsening in both of them, although there was no significant difference between the groups. However, the range of the measures (delta) in the test group, when compared to the baseline and final characteristics, shows a projection tending to a significant improvement along time. A decrease in candidiasis (p<0,05) and muccositis was also shown in the test group. It is concluded that the patients treated in the Oncology Service of HNSC have shown a profile that is typical of the head and neck tumors in the country, with higher prevalence in men, smokers, low social-economic and educational level, and poor oral health. The dental care guideline that was developed was able to decrease harm resulting from the oncological therapy, as well as to contribute for an improvement of QoL along the time for the patients with head and neck cancer.

Anatomic changes occur throughout head and neck radiotherapy, and a new treatment plan is often required to mitigate the resulting changes in delivered dose to key structures. This process is known as adaptive radiotherapy (ART), and can be labour-intensive. The aim of this thesis is to optimise ART, addressing some of the technical and clinical challenges facing its routine clinical implementation. Optimising the frequency and timing of adaptive replanning is important, and it has been shown here that intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) are equally robust to weight loss during head and neck radiotherapy. Plan adaptation strategies that have previously been developed for IMRT are therefore applicable to VMAT.Contour propagation is an important component of ART, and it is essential to ensure that propagated contours are accurate. A method for assessing the suitability of a metric for measuring automatic segmentation accuracy has been developed and applied to the head and neck. For the parotids and larynx, metrics based on surface agreement were better than the commonly used Dice similarity coefficient. By establishing a consensus on which metrics should be used to assess segmentation accuracy, comparison of different algorithms is more objective and should lead to more accurate automatic segmentation. A novel method of assessing contour propagation accuracy on a patient-specific basis has also been developed. This was demonstrated on a cohort of head and neck patients and shows potential as a tool for identifying propagated contours that are subject to a high degree of uncertainty. This is a novel tool that will increase the efficiency of automatic segmentation and, therefore, ART.Optimum ART requires consideration of different radiotherapy-related toxicities, and image-based data mining is a powerful technique for spatially localising dose-response relationships. Correction for multiple comparisons through permutation testing is essential, but has so far only been applied to categorical data. A novel method has been developed for performing permutation testing and image-based data mining with a continuously variable clinical endpoint. Application to trismus for head and neck radiotherapy identified a region with a dose-response relationship in the ipsilateral masseter. Sparing this structure during radiotherapy should reduce the severity of radiation-induced trismus. ART mitigates the dosimetric effects of anatomic changes, and this thesis has addressed technical and clinical challenges that have so far limited its clinical implementation. Detailed knowledge of dose-response relationships will enable selection of patients for ART based on potential clinical benefit, and accurate contour propagation will make ART more efficient, facilitating its routine implementation.