Recalcitrant hypocalcemia after total thyroidectomy and bariatric surgery.

PROBLEM: Patients with Roux en Y gastric bypass (RYGBP) who undergo total thyroidectomy may be at increased risk for recalcitrant symptomatic hypocalcemia. METHODS: All patients who underwent total thyroidectomy with a history of preceding RYGBP from 2007 to 2012 were identified retrospectively. Cases were matched 2:1 for age, gender, and BMI to a control group undergoing total thyroidectomy without previous RYGBP during the same study period. RESULTS: Age and body mass index were equivalent between cases (n = 14) and controls (n = 23). A comparison between groups demonstrated that cases had a significantly higher incidence of symptomatic hypocalcemia resulting in paresthesia and tetany (38% vs. 0%; P <0 .01), received intravenous calcium more often (18% vs. 0%; P < 0.01), and had longer hospital stays (2.2 vs. 1.2 days, P = 0.02) than controls. CONCLUSIONS: Physicians and surgeons need to be aware of this complication and take measures to identify and prevent it, and patients should be informed. In this patient population, calcium levels should be closely monitored and early calcium and vitamin D spplementation should be initiated preemptively.

Chemoradiation for advanced oral and (pharyngo) laryngeal carcinoma: single institution outcome analysis.

AIM: Chemoradiation ( CRT) is a valuable treatment option for(pharyngo)laryngeal squamous cell cancer and a palliative cure in advanced oral cancers. However, toxicity is scarcely reported. Therefore, efficacy, acute and toxic effects of chemoradiation for advanced head and neck squamous cell carcinomas were evaluated, using retrospective study. METHODS: Previously untreated patients with stage III-IV head and neck squamous cell carcinomas were included. Radiotherapy consisted of 70 Gy/7 weeks/35 fractions. All patients received concurrent Cisplatin 40 mg/m2 weekly. RESULTS: The most common acute toxic effects were dysphagia and mucositis. Dysphagia and xerostomia remained problematic during follow-up. Loco regional disease control was respectively 91% and 98% after 6 months. The median overall survival (calculating starting form the end of the treatment) was 33 months (range 0-111months). The 5-year disease specific survival was 41%. CONCLUSION: The results indicated that concurrent chemoradiotherapy for advanced head and neck squamous cell carcinoma is associated with high locoregional control and disease-specific survival. However, significant acute and long-term toxic effects occur, and organ preservation appears not necessarily equivalent to preservation of function in pharyngolaryngeal cancers.

The effect of hyperbaric oxygen therapy on treatment of wound complications after oral, pharyngeal and laryngeal salvage surgery.

INTRODUCTION: Radiation therapy alone, or combined with chemotherapy, are both used for cancer in the head and neck. This can lead to damage of tissue cells and vasculature. Surgery in such compromised tissues has increased complication rates, because wound healing with angiogenesis and fibroplasias requires normal cell growth conditions. Hyperbaric oxygen therapy raises oxygen levels in hypoxic tissue, stimulates angiogenesis and fibroplasia. In this report, we review the clinical value of hyperbaric oxygen therapy for major wounds that had shown no signs of healing as well as fistulas after salvage surgery in patients treated with (chemo)radiation of the head and neck regions. METHODS: In this retrospective study, 16 patients with soft-tissue wounds without signs of healing after salvage surgery, after radiation, and most after chemotherapy were treated in the head and neck regions with hyperbaric oxygen therapy. The patients were treated by HBO2, 2.5 bars 90 minutes daily, usually 20 treatments. RESULTS: The healing processes seemed to be initiated and accelerated by HBO2. Fourteen of the 16 patients healed completely. There were no life-threatening complications. CONCLUSION: Radiotherapy and combined chemoradiation therapy leads to damage of tissue cells and vasculature. Salvage surgery in such tissues has an increased complications rate, because wound healing requires angiogenesis and fibroplasias, all of which are jeopardized. Hyperbaric oxygen therapy raises oxygen levels in hypoxic tissue, stimulates angiogenesis and fibroplasias and is an effective and powerful treatment for postoperative wounds in oral, pharyngeal and laryngeal carcinomas surgery.

[Quality of life after radical surgery and radiotherapy for advanced or recurrent laryngeal and hypopharyngeal cancers]. / Evaluation de la qualité de vie après chirurgie radicale et radiothérapie dans le traitement de tumeurs avancées ou récidivantes du pharyngolarynx.

AIM: To determine the functional disabilities and overall quality of life of patients operated for advanced (Stages III-IV) or recurrent squamous cell carcinomas (SCCA) after radiation therapy of the (pharyngo)larynx. METHODS: From 1984 to 1997, 135 patients were consecutively treated for SCCA of the (pharyngo)larynx. There were 118 men and 17 women with a mean age of 60 years. The University of Washington QOL questionnaire (UW-QOL) (Deleyiannis et al) was administered to 19 long term survivors. Self-administered scale consisting of nine domains affected by treatment for head and neck cancer: pain, physical appareance, global activity, entertainement, employment, chewing, swallowing, speech and shoulder function. For each patient, a total score and weighted score were determined. Descriptive statistics were used. RESULTS: 9/19 patients reported that compared with one year prior to the diagnosis of cancer their general health was the same. Pain resolved in 78%; the physical appearance was juged not modified in 52% of the cases. Chewing and swallowing functions were respected in 94% of the cases. These functions were considered as very important in 53% and 68% respectively. Five patients are still at work; 11 patients retired. Work was considered as very important for 9/19 patients. Speech rehabilitation permitted a modified but well understandable communication in 63% of the cases. This function was considered by 88% of the patients as very important. Finally, 73% of the patients (14/19) reported having a good to excellent overall QOL. CONCLUSION: Though disabling, pharyngolaryngectomies do not necessarily translate into worse overall QOL; ultimate disabilities are widely variable. Many factors such family, friends, personal leisure, activities, employement, cultural habits were important and depending on each patient in enjoyement of life's estimation.

[Cervical necrotizing fasciitis arising from dental abscess: a rare clinical observation]. / Fasciite nécrosante cervicale compliquant un abcès dentaire: observation clinique rare.

Necrotizing fasciitis of the head and neck is a rare polymicrobial infection, rapidly progressing with a potentially fatal outcome, without early recognition and treatment. Odontogenic infection spreading to the lower neck or anterior chest is an important clinical feature. CT-scan and MRI can be useful in case of doubt. As the relative mild external clinical signs can mask the severe underlying necrosis, the difference in outcome is due to the rapidity of diagnosis and surgical intervention. Surgery consists of complete debridement of all necrotic tissues, repeated as needed and associated with an early tracheotomy. Antibiotherapy is based on the organisms most frequently involved. Hyperbaric oxygen therapy and vacuum-assisted closure could have a role after initiation of intravenous antibiotics and surgical debridement. We report a case of a 23-year old man with a necrotizing fasciitis from a dental origin, necessitating an extensive and repeated surgery, a tracheotomy and antibiotherapy; he developed severe complications such as multisystem organ failure, pericardial effusion and cardiorespiratory arrest.

Combined ipsilateral treatment of cervical lymph nodes metastases from an unknown primary.

INTRODUCTION: The management of squamous cell carcinoma in undetermined primary tumours in the head and neck region (approximately 5.5% of patients) is controversial. MATERIAL AND METHODS: The present report examines the outcomes for 14 patients after an initial treatment strategy directed principally at the side of the neck that is clinically involved. The distribution of nodal status was as follows: 1 N1, 8 N2A, 4 N2B, and 1 N3. RESULTS: Initial treatment included a modified neck dissection in 12 cases and radical neck dissection in 2 cases, plus postoperative radiation in 10 cases. Radiotherapy was directed at the ipsilateral side of the neck alone. Concomitant radiochemotherapy was given in 2 cases. The rate of disease control on the ipsilateral side was 12/14. Two patients were treated by chemotherapy but died of their disease. The failure rate on the contralateral side was 2/14. These two patients were successfully salvaged. During follow-up, a primary tumour was detected in one case. At the end of the follow-up, 10 patients were alive. CONCLUSIONS: Modified radical neck dissection combined with postoperative radiation with or without chemotherapy could be considered in N1-N3 lymph node status. Despite generally advanced disease at presentation, patients presenting with cervical metastasis from an unknown primary carcinoma have a reasonable survival expectation and aggressive treatment is warranted. Careful follow-up is required for effective salvage treatment.

[Incidental metastases of well-differentiated thyroid carcinoma in lymph nodes of patient with squamous cell head and neck cancer: case report with review of the literature]. / Métastase cervicale fortuite d'un cancer différencié de la thyroïde concomitant a un cancer des voies aéro-digestives supérieures: cas clinique et revue de la littérature.

We report the case of a patient treated by neck dissection for a cervical recurrence from a head and neck cancer. The histopathologic study of the lymph nodes evidenced the presence of a occult metastases of differentiated thyroid carcinoma. We discuss the treatment of these patient, with review of the literature. Management of thyroid carcinoma found incidentally during treatment of squamous cell carcinoma of the head and neck is still debatable, and all patients must be evaluated individually with regard to its benefit.

[Primary lymphoma of the thyroid gland]. / Lymphome primitif de la thyroïde: à propos de 5 cas.

Malignant primary lymphoma of the thyroid gland is a rare disease. The principal clinical sign is a rapidly growing goiter, leading to signs of compression, raising the question of differential diagnosis with anaplastic cancer. Multimodality therapy with surgery, radiotherapy, and chemotherapy appears to be of value. We retrospectively reviewed the management and outcomes of five consecutives patients with thyroid lymphoma.

Acrylamide, an in vivo thyroid carcinogenic agent, induces DNA damage in rat thyroid cell lines and primary cultures.

Chronic treatment of rats with acrylamide induces various tumors among which thyroid tumors are the most frequent. The aim of the present study was to develop an in vitro model of acrylamide action on thyroid cells to allow the investigation of the mechanism of this tumorigenic action. The first part of the study considered as targets, characteristics of thyroid metabolism, which could explain the thyroid specificity of acrylamide action: the cAMP mitogenic effect and the important H2O2 generation by thyroid cells. However, acrylamide did not modulate H2O2 or cAMP generation in the thyroid cell models studied. No effect on thyroid cell proliferation was observed in the rat thyroid cell line FRTL5. On the other hand, as shown by the comet assay, acrylamide induced DNA damage, as the positive control H2O2 in the PC Cl3 and FRTL5 rat thyroid cell lines, as well as in thyroid cell primary cultures. The absence of effect of acrylamide on H2AX histone phosphorylation suggests that this effect does not reflect the induction of DNA double strand breaks. DNA damage leads to the generation of mutations. It is proposed that such mutations could play a role in the carcinogenic effect of acrylamide. The mechanism of this effect can now be studied in this in vitro model.

Sentinel lymph node evaluation in squamous cell carcinoma of the head and neck cancer: preliminary results.

INTRODUCTION: Sentinel lymph node biopsy is a new technique in staging the clinically NO neck. Tumour spread to the neck is the most important prognostic factor in head and neck squamous cell carcinoma (HNSCC). MATERIAL AND METHODS: Patients with histologically confirmed HNSCC, with no clinical and no radiological (CT or MRI) evidence of cervical lymph node involvement were eligible for this prospective study. The lymph node mapping was performed by preoperative lymphoscintigraphy and intraoperative use of hand-held gamma probe. Four injections (with Tc 99m-labeled nanocolloids) were performed around the primary tumour. The SLN, as indicated by dynamic scintigraphy and the neck dissection specimen, were sent separately for histological analysis. The presence of occult metastasis in the SLN and in the neck dissection specimen were compared. RESULTS: Ten consecutive patients (8 males ; 2 females) with a mean age of 61 years (range 47 to 74 years) were prospectively entered into the study. The primary tumour was located on the oral tongue in 4 cases, in the floor of the mouth in 5 cases and in the oropharynx in 1 case. Primary tumours were staged T2 in nine cases, one tumour was staged T1 according to UICC 1997. All the tumours were clinically staged cN0 by palpation and computed tomography (or MRI). Lymphoscintigraphy was performed and revealed a SLN in all cases. The sentinel node biopsy technique permitted an upstaging of the clinically cN0 neck in 3/10 cases. The SLN technique was false negative in one patient with a skip metastasis. CONCLUSION: SLN evaluation in HNSCC is feasible and provides a highly accurate staging of NO necks in oral and oropharyngeal carcinomas.

Survival improvement in resectable non-small cell lung cancer with (neo)adjuvant chemotherapy: results of a meta-analysis of the literature.

The recent publication of many randomised trials about (neo)adjuvant chemotherapy in resectable non-small cell lung cancer (NSCLC) has prompted our group to update a prior meta-analysis of the literature. Randomised studies published in French and English between 1965 and June 2004 were included in this analysis. A qualitative assessment of each trial was first performed using the European lung cancer working party (ELCWP) and the Chalmers' scales. In absence of statistically significant quality difference between positive and negative trials, a quantitative aggregation (meta-analysis) of the individual results was performed. Two trials for which data were available on ASCO virtual meeting website were also included in the meta-analysis. Twenty-five studies eligible for this analysis assessed chemotherapy as induction (n = 6) or adjuvant to surgery (n = 19). No quality difference was detected between positive and negative trials according to the two scores, whatever all trials were combined or only adjuvant chemotherapy studies were considered. The overall meta-analysis showed that the hazard ratio (HR) of the combined results was 0.66 (95% CI 0.48-0.93) in favour of the addition of induction chemotherapy to a standard surgical procedure and 0.84 (95% CI 0.78-0.89) in favour of adjuvant chemotherapy. The effect was significant for adjuvant chemotherapy in stages I and II with a HR of 0.88 (95% CI 0.83-0.94). It was not statistically significant in stage III although the trend was in favour of chemotherapy whatever adjuvant (HR = 0.85; 95% CI 0.69-1.04) or (neo)adjuvant (HR = 0.65; 95% CI 0.41-1.04) chemotherapy was tested. In conclusion, our meta-analysis shows the efficacy of adjuvant chemotherapy in stages I and II resected NSCLC. More data are needed to confirm such a role for induction chemotherapy. Further trials should separate stage III disease from earlier stages.

Skin metastases from a head and neck carcinoma: a prognostic factor?

BACKGROUND: Distant metastases in head and neck cancer are often to the lung, and rarely to the skin sites. METHOD: To ascertain that a skin metastasis indicates a poor prognosis, a review was conducted of patients with head and neck cancer. RESULTS: Three out of seven patients had evidence of local recurrence at the time of development of the skin metastases, and three out of seven had evidence of distant metastases. The average survival time was 1 month after the development of skin metastases. CONCLUSION: Skin metastases may represent the first clinical evidence of impending recurrence or distant metastasis. The development of skin metastasis is associated with a poor prognosis. Current treatment options are limited in their efficacity.

Prognostic value of FDG PET/CT in head and neck squamous cell carcinomas.

INTRODUCTION: The purpose of this study was to evaluate the use of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) to identify the presence of cervical lymph nodes metastases and extracapsular spread with histologic correlations in head and neck squamous cell carcinoma. METHODS: The medical records of 54 patients who underwent (18)F-FDG PET/CT for head and neck squamous cell carcinoma before surgery were reviewed. Receiver operating characteristic (ROC) analysis was performed to differentiate patients with cervical lymph node metastasis from those without lymph node metastasis. The same statistical analysis was done to differentiate cervical lymph nodes with extracapsular spread from those without extracapsular spread. RESULTS: Metastatic disease was diagnosed histologically in 49% (26 of 54) of the patients. Extracapsular spread was present in ten of the 54 patients (19%). When ROC curve analysis and maximum standardized uptake (SUVmax) values were used to detect cervical lymph node metastasis, the area under the ROC curve was 0.96 and the optimal cutoff value for SUVmax was 4.05 based on ROC curve analysis. The sensitivity and specificity of SUVmax for the detection of cervical lymph node metastasis using this cutoff point were 92% and 88%, respectively. When ROC curve analysis and SUVmax values were used in order to detect extracapsular spread, the area under the ROC curve was 0.86, and the optimal cutoff value for SUVmax was 4.15 based on ROC curve analysis. Using this cutoff value, the sensitivity and specificity of SUVmax for the detection of extracapsular spread were 83% and 88%, respectively. CONCLUSION: In our study, a median (18)F-FDG PET/CT SUVmax cutoff value of 4.15 was found to be related with cervical lymph node metastasis and extracapsular spread in patients with head and neck cancer.

Contribution of cervical ultrasound and ultrasound fine-needle aspiration biopsy to the staging of thoracic oesophageal carcinoma.

This study was performed to evaluate the use of cervical ultrasonography and ultrasound-guided fine-needle aspiration for pretherapeutic staging of oesophageal cancer. 50 patients with a thoracic-oesophageal cancer (upper third = 8, middle = 36, lower = 6), previously untreated, underwent cervical ultrasonography to detect supraclavicular lymph node metastases (LN). An ultrasound fine-needle aspiration biopsy was attempted in 12 cases of suspected LN. 26 patients were operated on, of which 13 had surgical exploration of the neck. All patients were followed after treatment with special attention to the supraclavicular area. 14 patients (28%) were ultrasonography positive, 5 of 8 in the upper third, 9 of 42 in the two other thirds. Of the 12 patients where a fine-needle biopsy was attempted, 9 showed neoplastic cells (75%). 5 patients had cervical metastatic LN at surgery, and 5 other patients demonstrated supraclavicular LN metastases during the follow-up. There was one false positive and six false negatives from cervical ultrasonography and two false negatives of UGFAB (ultrasound-guided fine-needle aspiration biopsy). The sensitivity and the specificity of the cervical ultrasonography were 68 and 97%, respectively. The pretherapeutic staging was modified: 7 patients initially stage II-III were regraded to stage IV. Cervical ultrasonography is a reliable method of assessment of supraclavicular LN in thoracic oesophageal carcinoma.

Survival is better predicted with a new classification of stage III unresectable non-small cell lung carcinoma treated by chemotherapy and radiotherapy.

UNLABELLED: The 1997 International staging system (ISS) classification separated stage III non-small cell lung cancer (NSCLC) into stages IIIA and IIIB. In a previous study including unresectable NSCLC initially treated with chemotherapy, we analysed survival according to tumour (T) and node (N) stages and derived a classification into stages IIIbeta (T3-4N3) and IIIalpha (other TN stage III) that had a better discrimination on survival distribution. The aim of this study was to validate these results in a further set of patients. Patients with unresectable stage III NSCLC included in a phase III trial assessing the role of increased dose chemotherapy (SuperMIP: mitomycin 6 mg/m2, ifosfamide 4.5 g/m2, cisplatin 60 mg/m2, carboplatin 200 mg/m2) in comparison to standard chemotherapy MIP (mitomycin 6 mg/m2, ifosfamide 3 g/m2, cisplatin 50 mg/m2), before thoracic irradiation (60 Gy in 30 fractions over 6 weeks) were the subject of this study. Survival distributions were assessed by the method of Kaplan-Meier. Survival comparisons were made by the log-rank test. Multivariate analyses using Cox regression models, included all potential prognostic factors for survival with a P-value <0.2 in univariate analysis. According to the 1997 International staging system classification, 328 eligible patients were included in the study. There was no imbalance between the two arms. Five parameters were significantly associated (P < or = 0.05) with survival in univariate analysis: European lung cancer working party (ELCWP) staging (IIIalpha[n = 294 pts] versus IIIbeta [n = 46]), Karnofsky index, weight loss, platelet count and haemoglobin level. These variables as well as the 1997 ISS staging, white blood cell (WBC) count, LDH and sodium levels were included in a multivariate analysis. Two models were constructed, including either the ELCWP or the 1997 ISS. In model 1 (ISS included), Karnofsky index (HR 0.69; 95% confidence interval (CI) 0.47-1.00; P = 0.05) and haemoglobin (HR 1.49; 95% CI 1.11-1.99; P = 0.007) were found significant. In model 2, including ELCWP staging, two variables were associated with survival: ELCWP staging (HR 1.68; 95% CI 1.20-2.35; P = 0.002) and haemoglobin (HR 1.54; 95% CI 1.15-2.07; P = 0.01). CONCLUSION: In initially unresectable stage III NSCLC treated by chemotherapy and radiotherapy, we validated the results of our previous study. The classification into stages IIIbeta (T3-4N3M0) and IIIalpha (other TN stage III) better discriminates the patients in term of survival than the 1997 ISS classification.

Subcutaneous lymphoid hyperplasia arising at site of ethnic scarifications and mimicking subcutaneous panniculitis-like T-cell lymphoma.

The case of a 40-year-old black man, who developed a very unusual tumour-like lymphoid hyperplasia involving primarily the subcutaneous tissue, is reported. The lesion, which arose at a site of tribal scarifications, displayed a deceptive morphology that closely resembled subcutaneous panniculitis-like T-cell lymphoma (SPTCL). An accurate diagnosis could only be made following detailed immunohistochemical and molecular studies. Although SPTCL has been thought to represent a very specific clinicopathologic entity, the present case illustrates that its histological appearance can, however, be closely mimicked by reactive and benign conditions.

Human medullary thyroid carcinoma: cell cultures and xenotransplants in nude mice. Immunocytochemistry and calcitonin secretion.

Occult primary and recurrent medullary thyroid carcinomas (MTC) detected only by elevated calcitonin levels in the peripheral blood, generally after pentagastrin-test stimulation, are difficult to localize. Some new imaging procedures with radionuclide tracers or radiolabelled monoclonal antibodies against carcinoembryonic antigen seem to bring some potentially therapeutic benefits. We report our results with cell cultures and xenotransplants of human MTC with the intention of establishing reproducible models in vitro and in vivo. Cell cultures secrete calcitonin at up to 1200 pg/ml for periods ranging from 3 to 13 weeks. Immunocytochemistry detects cytoplasmic granules positive for calcitonin in polygonal epithelioid cells with dendritic processes. Xenotransplants in nude mice fare better in the subcutaneous axilla than in the subrenal capsule assay. In the former location the tumor-take is good and calcitonin is detected in the blood of the tumor-bearing animals, at levels ranging from 286 to more than 20,000 pg/ml. These models would be potentially usable as targets for radionuclide tracers and/or radiolabelled monoclonal antibodies.

Thyroid carcinoma metastasis to the sternum: resection and reconstruction.

Metastases of thyroid carcinoma to the sternum are not so frequent and ablative surgery enables the patients to live longer with a better quality of life. After such a resection, the surgical defect has to be covered either by autogenous or artificial substitutes. We present a 62 years old patient with an asymptomatic sternal metastasis of a poorly differentiated follicular thyroid carcinoma. After radical excision, including the sternum, both clavicular heads and an upper mediastinal dissection, the defect was reconstructed in two layers, combining a Marlex mesh and a pedicled pectoralis major muscle flap. Postoperative course was uneventful and respiratory function was not disturbed.

[Surgical resection for gastrointestinal metastatic melanoma]. / Traitement chirurgical des métastases digestives de mélanome.

AIM: Metastases of melanoma are frequent. On the gastro-intestinal tract, commonest localizations are small bowel, stomach and colon. Surgical treatment of digestive metastases from melanoma is not well known and its value is still debated. PATIENTS AND METHODS: Medical records of 10 patients (six female and four male) operated for metastatic melanoma to gastro-intestinal tract were reviewed to determine results of surgery. RESULTS: Gastro-intestinal metastases were symptomatic in eight patients (abdominal pain in three, bowel obstruction in three, abdominal mass and obstructive jaundice in one each). Two patients had anemia. Diagnosis has been suggested by imaging in seven patients and endoscopy in three. All patients were operated on by laparotomy for resection of metastases located on small bowel in four patients, gallbladder in two, stomach in two and colon in two. Complete resection suppressed symptoms in nine cases. In one patient, resection was incomplete but provided satisfying symptomatic relief. One patient died at day 3; in other patients, median survival was 18 months (range: 3-120). CONCLUSION: In a patient with previous history of melanoma, digestive symptoms indicate morphological explorations due to suspicion of metastases to gastro-intestinal tract. Surgical treatment of these metastases is usually palliative but, in some cases, allows long-term survival.

[Isolated pelvic metastasis of thyroid cancer]. / Métastase pelvienne isolée d'un cancer de la thyroïde.

Thyroid cancer rarely metastasizes to the pelvis. We report a case where the metastasis was found two years before the thyroid cancer. Treatment included initial surgery with resection of the metastatic tumor and reconstruction of the acetabulum with bone cement, and secondly total thyroidectomy, node dissection and I131. Surgical treatment of locoregional recurrence had no influence on the clinical course leading to the patient's death. Early diagnosis of unique metastasis of a thyroid cancer is important in terms of prognosis and quality of life. This case is exceptional due to the unique bone metastasis and treatment options for acetabular metastases. Therapeutic options should be adapted according to algorithms reported in the literature.