Sentinel lymph node biopsy for head and neck Merkel cell carcinoma: a preliminary study.

INTRODUCTION: A retrospective preliminary study assessed the feasibility of sentinel lymph node biopsy (SLNB) in the management of Merkel cell carcinoma (MCC) of the head and neck. PATIENTS AND METHODS: Twelve patients with stage I or II head and neck MCC underwent SLNB over a 4-year period. RESULTS: Only 1 of the 12 patients had a positive SLNB. The sentinel node was not identified in 3 patients. Two of the 8 patients with negative SLNB showed regional lymph node recurrence within 2years. One patient died during follow-up. CONCLUSION: Merkel cell carcinoma is an uncommon but highly aggressive pathology; management protocols have been based on small series. The role of SLNB in the management of MCC remains to be defined.

[Quality of life after primary parotidectomy for benign tumor]. / Parotidectomie conservatrice pour tumeur bénigne: résultats sur la qualité de vie à long terme.

INTRODUCTION: Parotidectomy is commonly performed for various indications, including benign tumors of the parotid region. Esthetic or functional sequels of various importance and lasting effects may occur, as after any surgical procedure. These disorders may impact the patient's quality of life. The authors retrospectively evaluated the long-term outcome of patients having undergone conservative primary parotidectomy for a benign tumor, with a minimum follow-up of 10 years. PATIENTS AND METHODS: A hundred and twenty-six superficial conservative primary or secondary parotidectomies were performed during 5 years, 94 (74.6%) of which for benign tumors. A flap of the sternocleidomastoid muscle (SCM) was inserted between the skin and facial nerve branches to prevent Frey's syndrome and alleviate surgical site depression according to some criteria. Questionnaires were completed at least 10 years after surgery. RESULTS: The data of 53 patients was analyzed. 88.7% of patients had undergone a superficial parotidectomy and 11.3% a total one. The average histological tumor size was 3.3 cm (2.6 to 6.3 cm). The tumors were distributed as follows: pleomorphic adenoma in 79.4% of patients, cystadenolymphoma in 15.1%, oncocytoma in 3.7%, and basal cell adenoma in 1.8%. Twenty-six SCM flaps (49.1%) were performed. No patient presented with facial paresis or facial paralysis at the end of the study. The average follow-up was 10.4 years (10-11 years). Overall, social, psychological, and professional implications were reported by 7.5% of patients, and in 1.8% of cases the impact was significant. The use of a SCM flap seemed to prevent Frey's syndrome (Fischer test P=0.00001) and improved cosmetic results (Fisher test P<0.00001). DISCUSSION: Conservative parotidectomy for primary benign tumors has a limited impact on the quality of life in the long run. This impact concerned 7.4% of patients. There was a significant impact in 2% of patients. We recommend filling the surgical site to improve functional and esthetic results and decrease long-term effects on the patient's quality of life.

Biangular fractures of the mandible.

INTRODUCTION: Bifocal fractures of the mandible often associate the angle and condyle or symphysis. Little data is available on biangular fractures. The authors had for aim to study their characteristics and to suggest an adapted management. MATERIAL AND METHODS: We retrospectively reviewed the records of patients operated on for a biangular fracture from January 2005 to December 2009. The impact of a third molar was evaluated using Pell and Gregory's and Shiller's classifications. RESULTS: Six hundred and forty patients underwent surgery for a mandibular fracture, seven of whom (1.1%) for biangular fractures. The patients' mean age was 27.6 years. Patients were predominantly men (85.7%). Assaults or brawls were the most frequent etiology (85.7%). The mechanism was direct impact in every case. The inferior alveolar nerve was injured in 57.1% of cases. There was an impacted third molar in 71.4% of cases. Most of the time, a single miniplate was sufficient for each angle. Two cases of postoperative infection were noted. The mean follow-up was 52.2months. The occlusion was restored in every case. Three patients presented with neurological sequels in the V3 area. DISCUSSION: Biangular fractures are rare and present a high risk of infection and neurological sequels. The presence of a mesioangular impacted third molar seems to be a predisposing factor. The risk of neurological sequels requires performing surgery rapidly.

Reconstruction of large mandibular and surrounding soft-tissue defects using distraction with bone transport.

Reconstruction of large bone and soft-tissue defects of the inferior third of the face is possible using various surgical techniques. Patients who require these procedures need to be in good general health, may have sequelae linked to donor sites, and require several interventions to achieve good aesthetic and functional results. The aim of this study was to report outcomes in patients with large mandibular and soft-tissue defects treated using osteogenic distraction with bone transport. Between 2001 and 2008, 14 patients had distraction with bone transport. Most patients were men (92.1%). The mean age was 43.1 years. The average mandibular bone reconstruction was 13.6 cm. The mean duration of distraction was 2.3 months. No infections occurred, and in all cases reconstruction of soft tissues was obtained. Two patients had non-union and underwent reconstruction using an iliac bone graft. Patients with sufficient bone height (57.1%) had dental implants. 44 implants were inserted, two of which were lost. 36 implants were activated. Six patients had satisfactory oral rehabilitation with implant-supported prostheses. Osteogenic distraction with bone transport allows total or partial restoration of oral function, provides an acceptable appearance, and enables patients to resume a reasonable quality of life.

[Tongue reconstruction with a bilateral infrahyoid flap innervated by Ansa Cervicalis after total glossectomy]. / Le lambeau infrahyoïdien bilatéral innervé par l'Ansa Cervicalis pour la reconstruction des glossectomies totales.

INTRODUCTION: Reconstruction after total glossectomy remains a functional challenge. It must provide a large volume to ensure adequate phonation and swallowing. We present the larynx sparing bilateral infrahyoid flap reconstruction procedure after total glossectomy. PATIENTS AND METHOD: Three patients managed for an epidermoid carcinoma of the tongue, classified T4N0, underwent total glossectomy. The tongue was reconstructed with a bilateral infrahyoid flap pedicled on two superior thyroid arteries and innervated by Ansa Cervicalis. RESULTS: Oral food intake was resumed after 8 to 20 days. No false route was observed. The muscular flap mobility was clinically satisfactory. It was assessed by EMG in one case. Esophageal transit confirmed the absence of stasis and false route for one patient. DISCUSSION: This short series proves the feasibility of bilateral innervated and pedicled infrahyoid flap procedure. It is an alternative to volumetric and functional reconstruction after total glossectomy. The indications are rare and restricted to patients without IIa nodal region invasion. Our results are still limited and need to be confirmed by a larger series and by a more systematic assessment.

Use of autologous platelet-rich clots for the prevention of local injury bleeding in patients with severe inherited mucocutaneous bleeding disorders.

Stopping or preventing local bleeding in patients with inherited bleeding disorders linked to abnormal platelet function is traditionally treated by transfusion of blood cell products or recombinant factor VIIa. We now report the use in such patients of autologous platelet-rich clots as an aid to preventing bleeding and to facilitating tissue regeneration at superficial sites. Two patients with von Willebrand's disease (VWD) type 2B and one patient with type I Glanzmann thrombasthenia were treated after tooth extraction and dental surgery. A fourth patient with platelet-type VWD underwent a skin biopsy. Whereas all four patients had a lifelong history of bleeding complications, the application of an autologous platelet-rich clot immediately after surgery combined with tranexamic acid intake to slow fibrinolysis prevented blood loss and resulted in rapid and normal healing. This new procedure is simple, safe and inexpensive; it provides extra security for patients with a bleeding risk undergoing dentistry or superficial surgery.

Effectiveness of modified radical neck dissection and postoperative radiotherapy.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the effectiveness of a modified radical neck dissection with preservation of non-lymphatic structures usually removed in advanced-stage head and neck epidermoid carcinoma associated with postoperative radiotherapy (PORT). METHODS: We analyzed retrospectively the files of 109 patients, presenting with epidermoid carcinoma of the upper digestive/respiratory tract staged N2 or N3, over a 6-year period. The rates of regional control, mortality, and recurrence were analyzed and linked to the kind of neck-dissection (usual radical neck dissection [RND], modified radical neck dissection [MRND], selective neck-dissection [SND]) performed. RESULTS: Forty-three neck dissections were RND, 92 were MRND, and 21 were SND. PORT was used in all cases. The mean follow-up was 57.3 months. The overall rate of regional control was 93.6% (97.7% for RND and 93.5% for MRND; p=0.35). Patients having undergone MRND had a better prognosis and less recurrence then patients having undergone RND (respectively p=0.007, and p=0.0004). DISCUSSION: MRND in association with PORT is an effective treatment in patients with advanced head and neck epidermoid carcinoma staged N2 and N3.

A multirecurrent ameloblastoma metastatic to the lung.

INTRODUCTION: The ameloblastoma is a rare tumor of odontogenic epithelial origin. It is a neoplasm in which ameloblastic features are revealed by the primary growth in jaws and by any metastatic growth. Recurrences are usually local and distant metastases are rare. We present a case of a multirecurrent ameloblastoma of the mandible metastatic to the lung. OBSERVATION: We present a case of a mandibular malignant ameloblastoma in a 42-year old man with widespread pulmonary metastases. Some of these lesions were treated surgically. DISCUSSION: Ameloblastoma metastasis often occurs in the lung. The curative treatment is surgical. The results of palliative chemotherapy and radiotherapy are not always efficient.

[Globulomaxillary cyst]. / Kyste globulomaxillaire.

Globulomaxillary cysts are located in the globular and maxillary process fusion area; they are not of odontogenic origin. Their etiology is similar to oral and facial clefts, which explains why they are classified as ontogenic fissural cysts. However, some clefts are not localized precisely on the premaxillary and maxillary process fusion area and their etiology as globulomaxillary cysts is questioned. In fact, those lesions could actually be of odontogenic origin.

[Hemophilic pseudotumors of the jaws]. / Pseudotumeurs hémophiliques maxillomandibulaires.

Hemophilic pseudotumors are observed in 1 to 2 % of severe hemophilia cases. They are very rare in the maxilla and mandible. Traumatic etiology is the most frequent. Osteolysis is the main radiological aspect. The treatment is usually enucleation, curettage, or intralesional fibrin glue injection.

[Aneurysmal bone cysts of the mandible]. / Kyste osseux anévrismal de la mandibule.

The aneurysmal bone cyst is a rare, expansive, osteolytic, pseudocystic lesion with an unknown etiology. It usually affects long bones and the spine. Two to 5 % of cases have mandibular localization (between 75 and 100 % present on the mandible) accounting for 1 % of all mandibular cysts. Less than 200 cases have been reported in English and French literature.

[Cancer of the cheek in a patient under etanercept]. / Carcinome jugal sous étanercept.

INTRODUCTION: Etanercept (Enbrel) is a TNF-alpha inhibitor effective in rheumatoid polyarthritis, psoriatic rheumatism, ankylosing spondyloarthritis, chronic plaque psoriasis, and juvenile idiopathic arthritis. Several cases of tumours have been described in patients under etanercept. However, no case of association with oral carcinoma had ever been described. The aim of this study was to report a case of carcinoma of the cheek mucosa in a patient treated with etanercept for rheumatoid polyarthritis. OBSERVATION: An 82-year-old female patient, non smoker, consulted for a tumour of the oral cavity. History revealed that this lesion had appeared soon after the initiation of etanercept treatment for severe and resistant rheumatoid polyarthritis. Clinical observation revealed a tumour of the right cheek mucosa 5 by 3 cm. The lesion was superficially infiltrative, budding in spots, and verrucous. The clinical observation was otherwise normal. The histological examination of the surgical piece revealed a micro-infiltrative and non-invasive orthoplastic epidermoid carcinoma. DISCUSSION: The possible development of an oral cavity carcinoma should be taken into account when following a patient under TNF-alpha inhibitor treatment. Anti-TNF treatment has improved the management of patients with severe chronic inflammatory diseases. They allow for a better quality of life. Nevertheless, their immunosuppressive effect should be taken into account when prescribed and during follow-up.

Mandibular reconstruction using induced membranes with autologous cancellous bone graft and HA-betaTCP: animal model study and preliminary results in patients.

Providing an acceptable quality of life for patients after reconstruction of mandibular segmental defects is challenging because the surgical techniques available have limitations. The authors evaluated two-stage mandibular reconstruction in rabbits and provide preliminary results in humans. 21 rabbits underwent bilateral segmental mandibulectomy and the defect was filled with methylmethacrylate. The methylmethacrylate was removed after 4 weeks and an iliac autograft performed on the right-hand side and an autogenous graft with hydroxyapatite and triphasic calcium phosphate (HA-betaTCP) on the left-hand side. Four patients with severe mandibular osteoradionecrosis underwent a two-stage reconstruction. No clinical or paraclinical complications were noted. Hematoxylin-eosin-saffron staining revealed an induced membrane lining the cavity of all samples with dense vascularity. Decalcified, undecalcified and histomorphometric analysis showed new bone formation in the biomaterial and the autograft. Calcium uptake was higher inside the new cortical bone, notably at sites with HA-betaTCP. CT scans at 6 months showed that two patients had a favorable outcome with cortico-cancellous bone. Microscopic and immunochemical analysis confirmed the experimental data. This study demonstrates the feasibility of mandibular reconstruction using the induced membranes technique. This technique is efficient, and the results would be better in non-irradiated patients with good general health.

[276 cases of horizontal infrahyoid myocutaneous flap]. / Le lambeau musculocutané infrahyoïdien à palette cutanée horizontale : à propos de 276 cas.

INTRODUCTION: The infrahyoid myocutaneous flap was described by Wang et al. in 1986. The horizontal design of the skin paddle is a modification of this technique allowing for a smaller scar. We have been systematically using this modified technique for 10 years. We had for aim to describe the interest of the horizontal infrahyoid myocutaneous flap for cervicofacial carcinology. PATIENTS AND METHODS: A horizontal infrahyoid myocutaneous flap procedure was performed in 276 cervicofacial carcinology patients for lesions of the mouth floor, the mandibular gum, the oropharynx and the tongue between March 1997 and March 2007. RESULTS: No complications were observed in 252 patients. No patient presented with total flap necrosis. DISCUSSION: Modifying the infrahyoid myocutaneous flap technique with a horizontal design of the skin paddle does not modify the reliability of the flap and prevents more extensive scars. The main indications of this technique are defects of the mouth floor, the tongue and the oropharynx.

[Psychological impact of alveolar mandibular distraction]. / Impact psychologique de la distraction alvéolaire mandibulaire.

INTRODUCTION: Implant supported dental prostheses are the most up-to-date solution for edentulous patients. This technique requires and adequate bone quantity and quality. Bone distraction may allow compensating for some bone deficit, especially mandibulary. Few studies have been dedicated to how patients adjusted to this therapy (Int J oral Maxillofac Surg 34 [2005] 238-42, Int J oral Maxillofac Surg 36 [2007] 896-9, Med Oral Pathol Oral Cir Bucal 12 [2007] E225-8). We evaluated the psychological impact of alveolar mandibular distraction. PATIENTS AND METHODS: Between 1999 and 2006, 31 patients aged 27 to 70 years underwent vertical alveolar mandibular distraction. Seventeen patients (54.8%) presented with complications. A questionnaire assessed the psychological impact by using notions used in healthcare psychology: perceived stress, perceived control, and social support. RESULTS: Twenty-three answers (74.2% of operated cases) were studied. In 87% of the cases, patients adjusted well the distraction procedure. Eighty-one percent felt no stress. Fifty-seven percent reported light to moderate pain, and 43% found the treatment painful. Confrontation to adverse events was mentioned only in 13% of the cases. In 17% of the cases, there was a slight alteration of sleep. Fifty-seven percent of the patients managed to forget the presence of the distractor. The most difficult stages were insertion of the distractor (48%) and the activation phase (17%). Seventy-one percent of the patients did not find the protocol restraining. The treatment length was not a problem for 65%. Two patients (9%) found it too long. Ninety-one percent of the patients activated the device on their own, for two (9% of the cases) the surgeon activated the device. Ninety-seven percent of the patients found supervision satisfactory. Medical information helped to adjust well to the procedure in 96% of the cases. Forty-three percent of the patients (10 cases) required specific help during the treatment: family support, attending physician, or surgical team. Among these, 70% considered the medical team's contribution as the most beneficial compared to family support, and 30% reported they were the same. For 96% of the patients, the medical team was the major actor of therapeutic success. Twenty-two percent of the patients considered they were partly responsible for treatment results (perceived internal control). Fifty-two percent of the cases reported they would be ready to undergo another distraction protocol if necessary. DISCUSSION: Alveolar mandibular distraction has only a weak psychological impact. It improves the patient's quality of life. It can be suggested that hope for improvement helped patients to better stand treatment. The information received contributed to better adjust to events. This unpredictable situation does not allow the patient to prepare himself and generates stress. Information in necessary before operating, to let the patient assess his own resources and prepare his own psychological adaptation mechanism. It is through this means that we can speak about true "informed consent or refusal".

[Prognostic value of infiltration of squamous cell carcinoma of the floor of the mouth]. / Valeur pronostique de l'infiltration des carcinomes épidermoïdes du plancher buccal.

OBJECTIVE: The aim of this preliminary retrospective study was to evaluate the prognostic value of tumor thickness in squamous cell carcinoma of the floor of the mouth. MATERIALS AND METHODS: A total of 61 patients with previously untreated T1N0, T2N0 or T3N0 squamous cell carcinoma of the floor of the mouth were included in this preliminary study. An optical micrometer was used to determine the maximum of tumor thickness. We studied the relation between the overall survival at two and five years and tumor thickness. RESULTS: The cohort comprised 52 male and nine female patients. The mean and the median thickness were 7.2 and 6mm, respectively. Overall survival was 79.5 and 36.7% at two and five years, respectively. There was no significant association between thickness and overall survival (p=0.71) and between thickness and disease-free survival (p=0.63). CONCLUSION: The prognostic value of tumor thickness was not demonstrated in this preliminary study. We are currently conducting a study involving a larger patient population in our unit and we believe that tumor thickness should be considered in the management plan for patients with oral carcinoma.

[Mouth floor and mobile tongue epidermoid carcinomas thickness: prognostic value]. / Epaisseur de l'infiltration tumorale des carcinomes épidermoïdes du plancher buccal et de la langue mobile : valeur pronostique.

INTRODUCTION: Most cancers of the oral cavity are epidermoid carcinomas. The prognosis is made on the patient's general health status and the tumoral stage. The UICC TNM staging classification system is one of the most important factors taken in consideration for the prognosis. But this classification in oral epidermoid carcinomas does not include the tumor thickness (except for T4 tumors). Several studies demonstrated that tumor thickness could influence the prognosis in epidermoid carcinoma and other types of cancers. The aim of our retrospective study was to assess the prognostic value of tumor thickness in oral epidermoid carcinoma. PATIENTS AND METHODS: The study included patients with mouth floor or mobile tongue epidermoid carcinoma classified T1N0, T2N0 and T3N0 between 1985 and 2005. All patients were treated with a curative intention. A pathologist analysed the tumor thickness and cervical lymph nodes. All the slides were examined to measure tumor thickness in millimetres. RESULTS: Three hundred and five patient files were reviewed and 124 patients were included, with 94 men (75.8%), and a mean age of 59.3 years (17-93). The mean and median tumor thickness were respectively 7.7 and 6.5 mm (0.4-30). The median tumor thickness was chosen for the study. There was a statistically significant link between the five-year probability of global survival and the initial tumor thickness and between neck node invasion and tumor thickness (p<0.05). DISCUSSION: This study suggests that tumor thickness should be taken in consideration in T1N0, T2N0 and T3N0 mouth floor and mobile tongue epidermoid carcinomas. In the future, the clinical evaluation of tumor thickness will help determine the therapeutic management.

[The horizontal infrahyoid myocutaneous flap: surgical technique]. / Le lambeau musculocutané infrahyoïdien à palette cutanée horizontale. Technique chirurgicale.

The infrahyoid myocutaneous flap technique was described by Wang in 1986, the skin pad being orientated vertically. Its blood supply comes from the superior thyroid artery. This flap consists of the sternohyoid muscle, the sternothyroid muscle, and the superior belly of the omohyoid muscle. The harvesting of a horizontal skin flap does not modify its reliability and avoids additional scars. The donor site anatomy and flap vascularization are briefly described as well as the flap features and harvesting technique.

[Head and neck reconstruction with antebrachial flap concerning 100 patients]. / La reconstruction par lambeau antébrachial au niveau de la sphère cervicofaciale : revue d'une série de 100 cas.

We studied the files of head and neck reconstruction with antebrachial flap used in 100 patients between May 1996 and March 2007 in the department of Maxillofacial Surgery of the CHU of Bordeaux. Flap harvesting and vascular anastomosis were performed by the same operator. Antebrachial flap was used to cover the defect after resection of head and neck cancer in 89 patients and after shotgun injuries of the face in 11 patients. This flap, by its smoothness and its plasticity, makes it possible to rebuild all the oral cavity localizations, even the most complex, by covering the defects without blocking deglutition and enunciation. It brings to the patient a better quality of life by decreasing the functional after-effects that can be seen with the traditional myocutaneous flaps. This flap is highly reliable, not requiring specific care after the operation as other micro-surgeries, which simplifies the postoperative quality of life of the aged and debilitated patients.