[Free-flap head and neck reconstruction failures: predictive factors and management]. / Les échecs de la chirurgie reconstructrice cervicofaciale par lambeaux libres : facteurs favorisants et prise en charge.

BACKGROUND: Failure after head and neck reconstruction using free flap are rare but their management remains a challenging problem. The purpose of this study was to analyze the causes and the subsequent treatment of free-flap failure in head and neck reconstruction. PATIENTS AND METHODS: A retrospective review of patients who had undergone free flap transfer between 2000 and 2007 was performed in our center. Data were collected from computerized medical record to determine patient and tumor characteristics, as well as their treatment. Moreover, a univariate analysis was performed to determine factors associated with free flap failure. RESULTS: Three hundred and twelve patients had a free flap transfer after head and neck cancer resection. A total of 22 failures (7%) were encountered. Previous surgery for head and neck cancer (p=0.02), surgery after cancer recurrence (p=0.02) and reconstructions after circular pharyngolaryngectomy (p=0.008) were significantly associated with free-flap failure. A second free-flap was performed in 12 patients and the overall success rate of the repeated free flap was 92 percent (11 of 12 patients). CONCLUSION: After a free flap failure, surgeons should determine subsequent treatments after a reconsideration of the need of a second free flap, an analysis of the cause of the first flap failure and an evaluation of local and general conditions. In selected patients, second free flap has a high success rate.

[Total pharyngolaryngectomy in the 21st century: indications, oncologic and functional outcomes]. / Les pharyngo-laryngectomies totales au 21ème siècle : indications, résultats carcinologiques et fonctionnels.

INTRODUCTION: The development of laryngeal preservation protocols has considerably modified the indications for total (pharyngo-)laryngectomy (TPL). The objectives of our study are to analyze the current indications for TPL and to evaluate the oncologic and functional outcomes after TPL and their predictive factors. METHODS: All patients who underwent TPL for squamous cell carcinoma of the larynx or hypopharynx, at our institution, between 2000 and 2009, were included in this retrospective study. Predictive factors of oncologic and functional outcomes were assessed in univariate and multivariate analyzes. RESULTS: A total of 130 patients were enrolled in our study including 119 men and 11 women, with a mean age of 65.9 years. TPL was realized for salvage in 65 patients. Extra-laryngeal tumor extension (n = 42) was the main indication for TPL in the 65 remaining patients. Overall survival was 49 and 41% at 3 and 5 years respectively. In multivariate analysis, primary tumor site (hypopharynx in comparison to larynx; p = 0.04) has a significant pejorative impact on overall survival. Oral alimentation (no enteral nutrition) was recovered successfully by 94% of the patients. In multivariate analysis, primary tumor site (hypopharynx) has a significant pejorative impact on functional results (deglutition: p < 0.0001; phonation: p = 0.03). CONCLUSION: Primary tumor site is one of the main predictive factor of oncologic and functional outcomes after TPL.

[Transoral and cervical approach without mandibulotomy for oropharynx cancer with fasciocutaneous radial forearm free flap reconstruction]. / Voie d'abord transorale et cervicale sans mandibulotomie dans les cancers de l'oropharynx avec réparation par lambeau libre fasciocutané antébrachial.

OBJECTIVE: To evaluate the role of a combined transoral and cervical approach without mandibulotomy for surgery of oropharyngeal cancer with fasciocutaneous radial forearm free flap reconstruction. MATERIAL AND METHODS: All patients who underwent this type of surgery between 2003 and 2007 were included in this retrospective study. We analyzed postoperative outcomes, surgical margins (histological study) and the oncological and functional results. RESULTS: A total of 24 patients were included in this study. There was no free flap failure. Surgical margins were negative for 23 of the 24 patients. At 3 years, overall, cause-specific, and disease-free survival rates were 73, 76 and 68%, respectively. A good functional result (normal or slightly impaired function) was obtained for oral diet, speech, mouth opening and esthetic outcome in 78, 82, 92 and 86% of the patients, respectively. CONCLUSION: This double surgical approach without mandibulotomy in selective cases can replace the transmandibular approach in locally advanced oropharyngeal cancer surgery.

[Papillary thyroid microcarcinomas: review of 230 cases]. / Les microcarcinomes papillaires de la glande tyroïde: à propos de 230 cas.

OBJECTIVES: Papillary microcarcinoma (PMC) is one of the most frequent pathological forms of thyroid cancer Here, we describe the circumstances of diagnosis and the clinical and pathological characteristics of this tumour We also analyze the therapeutic management and compare it with the recent published guidelines. METHODS: Between 2000 and 2006, a total of 230 patients with a PMC of the thyroid gland were included in this retrospective study. We have investigated the correlations between some pathological parameters (plurifocality, lymph node invasion...) and several factors (age, gender, tumour size...). RESULTS: The diagnosis of PMC was suspected in the preoperative period in 15% of the patients, and was confirmed intraoperatively by the pathologist in 42% of the cases. Plurifocal or bilateral PMC were discovered in respectively 30 and 17% of the patients. The rate of lymph node invasion in the central neck (level VI) was 26%. An elevated tumor size was correlated with a higher rate of plurifocal or bilateral PMC and of lymph node metastasis (p < 0.05). The indications for postoperative radioiodine therapy were reduced by approxiately 50% in the second part of our study. There were no case of thyroid PMC-related death. CONCLUSIONS: Even for these small tumours, tumour size remains correlated with the tumour aggressiveness. The place of radioiodine therapy in the management of thyroid PMC was progressively reduced because of the good prognosis of this tumour.

[Ameloblastomas]. / Les améloblastomes.

OBJECTIVES: The aim of this work was to report on the clinical, radiological and histological characteristics of ameloblastomas concerning bone structures of the face, rare but not exceptional tumours, and to communicate our experience of their treatment. MATERIAL AND METHODS: The authors reexamined six recent cases of patients presenting with ameloblastoma at the centre Antoine Lacassagne in Nice. The diagnostic context, the treatment and the development of the disease are given in detail, emphasizing the frequency of local relapse of this histologically benign condition. RESULTS: The study of these cases confirmed the benefit of surgical treatment of ameloblastoma. The frequency of local relapse in the cases of close resection, leaving in place micro-foci, justifies enlarged intervention, which is often bone destructive. CONCLUSION: When the continuity of the bone is interrupted, in particular at the level of the mandible, and if the general condition of the patient permits, repair is preferable. In this situation, the procedure of choice is micro-anastomosis of the fibula.

[Mandibular reconstruction with osseous free flaps: functional results]. / La reconstruction mandibulaire par lambeaux libres osseux: résultats fonctionnels.

OBJECTIVES: The aim of this retrospective study is to evaluate functional results of oromandibular reconstruction with osseous free flaps. MATERIAL AND METHODS: A total of 67 patients who underwent oromandibular reconstruction with fibula (n=60) or scapular (n=7) free flap between 2000 and 2004 were included in this study. We analysed functional results (alimentation, elocution, mouth opening and cosmetic appearance) and researched the potentially predictive factors of these results (age, comorbidity, preoperative irradiation, type of defect...; Chi(2) test). RESULTS: The rate of free flap success was 89.6%. A functional result considered as normal or subnormal was obtained by more than 50% of patients. Oral alimentation (without tube feeding) and intelligible speech were recovered by 92.5% of patients. Through and through defects and free flap failures were determinant predictive factors of worse functional outcomes. CONCLUSION: Fibula free flap is considered as the flap of choice for oromandibular reconstruction and allows excellent functional results.

[Fibula free flap for reconstruction of extensive mandibular osteoradionecrosis]. / Lambeau libre de fibula pour la reconstruction des ostéoradionécroses mandibulaires évoluées.

OBJECTIVE: Treatment of mandibular osteoradionecrosis is always a therapeutic challenge. The aim of this article is to evaluate the interest of fibula free flap for mandible reconstruction after radical excision of osteoradionecrotic lesions. MATERIAL AND METHODS: Six consecutives cases of extensive osteoradionecrosis of the mandible were treated with fibula free flap reconstruction. We report a meticulous analysis of the cosmetic and functional results. RESULTS: All vascularized fibula osteocutaneous flaps transplanted were successful. Median hospital stay was 32 days. At 6 months, functional results (swallowing, mouth opening and speech) were good. All patients had sufficient oral intake and a comprehensible speech with just two patients requiring a soft diet and 1 patient retaining a moderate trismus. DISCUSSION: Extensive mandibular osteoradionecrosis requires a radical surgical treatment. Fibula free flap is the best solution for mandible reconstruction in this situation. This technique allows good functional results. CONCLUSION: Fibula free flap is the method of choice for mandible reconstruction after radical treatment of osteoradionecrosis.

Concomitant b.i.d. radiotherapy and chemotherapy with cisplatin and 5-fluorouracil in unresectable squamous-cell carcinoma of the pharynx: clinical and pharmacological data of a French multicenter phase II study.

PURPOSE: The aim of this phase II study conducted on unresectable squamous cell carcinoma (USCC) of the oro- and hypopharynx was to associate twice-a-day (b.i.d.) continuous nonaccelerated radiotherapy with concomitant cisplatin (CP)-5-fluorouracil (5-FU) chemotherapy, both given at full dose. Feasibility, efficacy, survival, and pharmacokinetic-pharmacodynamic relationships were analyzed. METHODS AND MATERIALS: Fifty-four consecutive patients with strictly USCC of oro- and/or hypopharynx received continuous b.i.d. radiotherapy (RT) (2 daily fractions of 1.2 Gy, 5 days a week, with a 6-h minimal interval between fractions). Total RT dose was 80.4 Gy on the oropharynx and 75.6 Gy on the hypopharynx. Three chemotherapy (CT) courses of CP-5-FU were given during RT at 21-day intervals (third not delivered after the end of RT). CP dose was 100 mg/m2 (day 1) and 5-FU was given as 5-day continuous infusion (day 2-day 6: 750 mg/m2/day cycle 1, 750 mg total dose/day cycle 2 and 3). Pharmacokinetics was performed for 5-FU (105 h follow-up) and CP (single sample at 16 h). Special attention was paid to supportive care. RESULTS: Good feasibility of RT was observed (85.2% of patients with total dose > 75 Gy). Five patients received 1 CT cycle, 34: 2 cycles, and 15: 3 cycles. The most frequent and severe acute toxicities were mucositis with grade 3-4 occurring in 28% at cycle 1 and 86% at cycle 2, as well as neutropenia (43% at cycle 2). Locoregional control at 6 months was observed in 66.7% of patients. No late toxicity above grade 2 RTOG was noticed. CP dose and 5-FU AUC(0-105h) were significantly linked to grade 3-4 neutropenia (cycle 2). Cumulative total platinum (Pt) concentration and Karnofsky index were the only independent predictors of locoregional control at 6 months. Finally, total RT dose and total Pt concentration were the only independent predictors of specific survival. CONCLUSION: This protocol showed good locoregional response with an acceptable toxicity profile. Pharmacokinetic survey is probably an effective approach to further reduce toxicity and improve efficacy. A multicentric randomized phase III study, now underway, should confirm these encouraging results.

The labelling index: a prognostic factor in head and neck carcinoma.

The thymidine labelling index (LI), representing the percentage of cells in the DNA-synthesis phase, was measured in vitro prior to therapy in 87 patients with squamous cell carcinoma of the head and neck, who were treated between 1977 and 1982. The LI was not related to patient age, site of the tumour, clinical stage or histological grade. Overall survival was 44.5%. Univariate analysis demonstrated that survival was affected by the following factors: (1) age: patients older than 55 had a better outcome (p = 0.03); (2) site of the tumour (p = 0.005): laryngeal tumours had the best survival; (3) clinical stage (p = 0.05). Histological grade did not influence the survival (p = 0.41). Patients having a tumour LI higher than 15.5% (mean + 1 S.D.) had a significantly lower survival than patients with lower tumour LI (p = 0.008). A multivariate analysis using the Cox model showed that clinical stage and LI kept their prognostic impact with regard to survival. Finally, survival after relapse was lower in patients with a high tumour LI. These results demonstrate that a high tumour proliferation rate is an additional factor influencing the disease outcome in head and neck carcinoma. Patients with bad prognosis defined by this parameter could be offered a more energetic treatment.

Clinical pharmacokinetic study of 5-FU in continuous 5-day infusions for head and neck cancer.

Twenty-nine previously untreated patients with head and neck carcinoma received a total of 63 cycles of an initial chemotherapy protocol combining cis-platinum (100 mg/m2 on day 1) and continuous 5-day infusion of 5-FU (1000 mg/m2/24 h) from day 2 to day 6. This protocol was repeated on day 16 and day 31. Two daily blood samples obtained from all patients every day during 5-FU administration were analyzed by HPLC to determine the 5-FU concentrations. In the majority of cases a constant elevation was observed in total 5-FU cycle exposure (C X T) from cycle to cycle. A close relationship was demonstrated between elevated 5-FU C X T values (over 30 000 ng h ml-1) and the frequency of cycles in which signs of toxicity (myelosuppression, mucositis, diarrhea) were observed. By contrast, no obvious association was noted between response to treatment and systemic 5-FU exposure.

Clinical experience with Gore-Tex for vocal fold medialization.

OBJECTIVES/HYPOTHESIS: Present clinical experience with vocal fold medialization under local anesthesia using a Gore-Tex implant. The procedure consists of placing the implant into a pocket formed by dissection of the inner perichondrium of the thyroid cartilage through a small window made in the thyroid ala. STUDY DESIGN: During 2 years, we used this technique preferentially in 13 of the 16 cases of vocal fold medialization (three patients underwent Teflon injection because of a contraindication to local anesthesia). Follow-up was longer than 3 months in 11 cases (mean, 13 mo). METHODS: Vocal result was analyzed by the means of perceptual analysis and by the measurement of jitter factor. Glottal leakage was evaluated perceptually using videolaryngoscopy, and oral airflow was measured during the production of a vowel. In cases with preoperative aspiration, videofluoroscopy was performed. RESULTS: Implantation was successful in all but one patient in whom extrusion of the implant material occurred. In the latter case, the implant was removed and the patient recuperated his preoperative voice without any other complication. In the 10 other cases, voice improvement assessed by perceptual and objective evaluation was satisfactory. CONCLUSIONS: Results compare favorably with those of endoscopic techniques using Teflon or collagen and laryngeal frame surgery techniques using silicone or cartilage. We conclude that Gore-Tex implantation is a simple, reproducible, and minimally invasive procedure for management of selected cases of vocal fold unilateral paralysis in the abductory position.

[Concomitant bifractionated radiotherapy and chemotherapy with cisplatin and 5-fluorouracil in locally progressive, non-resectable epidermoid carcinomas of the pharynx: ten years experience at the Antoine Lacassagne center]. / Radiothérapie bifractionnée et chimiothérapie par cisplatine et 5-fluoro-uracile concomitantes dans les carcinomes épidermoïdes localement évolués non résécables du pharynx: dix ans d'expérience au centre Antoine Lacassagne.

PURPOSE: Patients suffering from locally advanced unresectable squamous cell carcinoma of the oropharynx and hypopharynx treated with radiotherapy alone have a poor prognosis. More than 70% of patients die within 5 years mainly due to local recurrences. The aim of this study was to evaluate retrospectively the Antoine Lacassagne Cancer Center's experience in a treatment by concomitant bid radiotherapy and chemotherapy. Evaluation was based on analysis of the toxicity, the response rates, the survival, and the clinical prognostic factors. PATIENTS AND METHODS: From 1992 to 2000, 92 consecutive patients were treated in our single institution. All of them had stage IV, unresectable squamous cell carcinoma of the pharynx and they received continuous bid radiotherapy (two daily fractions of 1.2 Gy, 5 days a week, with a 6-h minimal interval between fractions). Total radiotherapy dose was 80.4 Gy on the oropharynx and 75.6 Gy on the hypopharynx. Two or three chemotherapy courses of cisplatin (CP)-5-fluorouracil (5FU) were given during radiotherapy at 21-day intervals (third not delivered after the end of the radiotherapy). CP dose was 100 mg/m2 (day 1) and 5-FU was given as 5-day continuous infusion (750 mg/m2/day at 1st course; 430 mg/m2/day at 2nd and 3rd courses). Special attention was paid to supportive care, particularly in terms of enteral nutrition and mucositis prevention by low-level laser energy. RESULTS: Acute toxicity was marked and included WHO grade III/IV mucositis (89%, 16% of them being grade IV), WHO grade III dermatitis (72%) and grade III/IV neutropenia (61%). This toxicity was significant but manageable with optimised supportive care, and never led to interruption of treatment for more than 1 week, although there were two toxic deaths. Complete global response rate at 6 months was 74%. Overall global survival at 1 and 2 years was 72% and 50% respectively, with a median follow-up of 17 months. Prognostic factors for overall survival were the Karnofsky index (71% survival at 3 years for patients with a Karnofsky index of 90-100% versus 30% for patients with a Karnofsky index of 80% versus 0% for patients with a Karnofsky index of 60-70%, p = 0.0001) and tumor location (55% at 3 years for oropharynx versus 37% for panpharynx versus 28% for hypopharynx, p = 0.009). CONCLUSION: These results confirm the efficacy of concomitant bid radiotherapy and chemotherapy in advanced unresectable tumor of the pharynx. The improvement in results will essentially depend on our capacity to restore in a good nutritional status the patients before beginning this heavy treatment.

[Ultrasonic findings of parotid tumours in 40 patients]. / Séméiologie échographique des tumerus de la parotide. A propos de 40 observations.

Ultrasonic findings of 40 parotid tumours are presented in this paper. After a technical description proceeding they show the ultrasonic pattern of the three main types of parotid tumours: mixed tumours, adenolymphomas and carcinomas. The differential diagnosis between malignancy and non malignancy is carried out in 87,5% of cases. This rate of success is, according to literature data, similar to that of sialography. Since it is non invasive, the authors recommend sonography in the assessment of parotid tumours, rather than sialography.

[High-definition real-time ultrasonic echography of tumors of the thyroid gland. Apropos of 379 surgically treated cases]. / Echographie ultrasonore en temps réel de haute définition des tumeurs du corps thyroïde. A propos de 379 cas opérés.

The authors present the results of a review of 379 cases of benign and malignant thyroid tumors examined by high frequency (7 MHz) ultrasound prior to surgery. Features of the 37 cases of cancer are described. Hyperechogenicity was almost always correlated with benign lesions (only 1 cancer out of 71 hyperechoic nodules). For 313 of the 342 cases of benign tumors a good correlation was found between sonograms and intraoperative examination of the two thyroid lobes. In the case of clinically evident polyadenomatous goiters, ultrasound is a highly accurate means of determining whether any zones of healthy tissue remain (sensitivity 104/110 cases, i. e. 93.7%). When a contralateral lobe is normal on sonograms, intraoperative examination only rarely reveals lesions (12/159 cases, including 2 false positives for surgical investigation). Due to the excellent concordance between ultrasound and intraoperative exploration, and the difficulties involved in anterior dissection, the results of sonograms can be used to decide on the surgical approach. Direct intraoperative surgical exploration of the lobe opposite a thyroid lesion appears unnecessary if the sonogram is normal (cases of non suspected occult thyroid cancer). Since intraoperative exploration can give false negatives, intraoperative ultrasound can be used in the rare cases where 1 or 2 deep micronodules have been detected by pre-surgery sonograms in the lobe contralateral to the main lesion.

[Latero-cervical septate cystic lesions in adults]. / Lésions kystiques cloisonnées latéro-cervicales de l'adulte.

Laterocervical septated lesions are infrequent in adults, and their etiological diagnosis is difficult. The authors report about four cases in which an exploration with imaging and an anatomical control were performed. Two etiologies are specially interesting, either because of their remarkable features with imaging (cystic lymphangioma) or because they require formal identification (metastatic adenopathy from thyroid or ovarian papillary carcinomas). While modern imaging can confirm the diagnosis, and sometimes define the treatment (cystic lymphangioma), the surgical exeresis of such lesions remains imperative in all cases of atypical appearances, in order to avoid leaving a prevailing lymph node metastasis unrecognized.

[Laryngeal cancer in a young adult]. / Carcinome du larynx chez un adulte jeune.

BACKGROUND: Carcinoma of the larynx is uncommon in young adults. Persistent dysphonia despite medical treatment is generally the primary manifestation. CASE REPORT: A 21-year-old woman with no known risk factors developed squamous cell carcinoma of the left vocal cord. Clinical cure was considered to be achieved 40 months after external radiotherapy. DISCUSSION: Clinicians should be aware of the possibility of carcinoma of the larnyx in young patients with no risk factors. Treatment should take into consideration not only the aggressive nature of these tumors but also the long-term side effects and the major functional and psychological sequelae.

[Repair after circular pharyngo-laryngectomy with deltopectoral flap (author's transl)]. / La réparation après pharyngo-laryngectomie totale circulaire par lambeau delto-pectoral. 11 cas.

Eleven patients with advanced tumors of eso-pharyngeal area were treated by circular eso-pharyngo-laryngectomy with repair of pharyngo-esophageal continuity by deltopectoral flap (V. Y. Bakamjian). Surgical procedures are described and results presented. Advantages and failures, compared with others techniques, have allowed us to recommend the use of deltopectoral flap, especially when the tumor remains located in hypopharyngeal region and doesn't exceed one cm below the eso-pharyngeal ring.

[Pectoralis major musculocutaneous flap after oncologic excision of the buccal cavity and oropharynx]. / Le lambeau musculo-cutané de grand pectoral après exérèse carcinologique de la cavité buccale et de l'oro-pharynx.

A musculocutaneous flap from pectoralis major was used for reconstruction after widespread excision for cancer of the oral cavity and oropharynx in 54 cases, the method of choice being transposition as islets. Necrosis in 6 cases (11%), was partial in 5 patients and was limited to the skin layer only. The advantages of the musculocutaneous flap from pectoralis major when compared with other reconstructive procedures, particularly deltopectoral and temporofrontal flaps, are discussed.

[Echography and parotid tumors]. / Echographie et tumeurs parotidiennes.

Morphological criteria obtained from ultrasonic exploration of 82 parotid tumors were compared with histological findings. Precise determination was possible of the size of the tumor, its cystic or solid nature, and the pre-operative evaluation of its benign or malignant nature. In spite of certain deficiencies, the safety, rapidity of execution, and reliability of ultrasonography make it a complementary investigation of choice for all isolated nodular lesions in the parotid region before surgical exploration, which remains indispensable.

[Intra-arterial chemotherapy of ORL tumors. 10 years' experience in the Antoine-Lacassagne Center]. / Chimothérapie intra-artérielle des tumeurs ORL. 10 ans d'expérience au Centre Antoine-Lacassagne.

One hundred and two patients with malpighian epithelioma of ORL origin were treated with intra-arterial chemotherapy (IAC) as initial therapy, followed by either surgery, radiotherapy or a combination of the two. Regression in tumor size of more than 50% was noted in 46% of cases, the introduction of cisplatin into the multiple system chemotherapy providing a response in 71% of the 42 patients treated in this way. A response to induction IAC is a factor of good prognosis as shown by the improvement in level of local and regional extensions and the probability rate of survival in responders. Technical and methodologic progress has made IAC a simple and effective procedure, and its place in the treatment of epitheliomas of head and neck should be established more precisely.