Comparison of [¹¹¹In]pentetreotide-SPECT and [¹8F]FDOPA-PET in the localization of extra-adrenal paragangliomas: the case for a patient-tailored use of nuclear imaging modalities.

AIMS AND METHODS: The aim of this prospective study was to compare the diagnostic value of [¹8F]FDOPA-PET and [¹¹¹In]pentetreotide-SPECT somatostatin receptor scintigraphy (SRS) in patients with nonmetastatic extra-adrenal paragangliomas (PGLs). Twenty-five consecutive unrelated patients who were known or suspected of having nonmetastatic extra-adrenal PGLs were prospectively evaluated with SRS and [¹8F]FDOPA-PET. ¹³¹I-MIBG and [¹8F]FDG-PET were added to the work-up in patients with a personal or familial history of PGL, predisposing mutations, abdominal PGLs, metanephrine hypersecretion and abdominal foci on SRS and/or [¹8F]FDOPA-PET. RESULTS: SRS correctly detected 23/45 lesions of which 20 were head or neck lesions (H&N) and 3 were abdominal lesions. [¹8F]FDOPA-PET detected significantly more lesions than SRS (39/45, P < 0·001). Both SRS and ¹8F-DOPA-PET detected significantly more H&N than abdominal lesions (66·7% vs 20%, P = 0·003 and 96·7% vs 67%, P = 0·012, respectively). In two patients with the succinate dehydrogenase D (SDHD) mutation, [¹8F]FDOPA-PET missed five abdominal PGLs which were detected by the combination of SRS, [¹³¹I]MIBG and [¹8F]FDG-PET. A lesion-based analysis using a forward stepwise logistic regression model demonstrates that size ≤ 10 mm (P = 0·002) and abdominal lesions (P = 0·031) were independently associated with "[¹8F]FDOPA-PET diagnosis only". In turn, a previous history of surgery and/or the presence of germline mutation was associated with lower lesion size (P = 0·001). CONCLUSIONS: The sensitivity of SRS for localizing parasympathetic PGLs is lower than originally reported, and [¹8F]FDOPA-PET is better than SRS for localizing small lesions. SRS should be replaced by [¹8F]FDOPA-PET as the first-line imaging procedure in H&N PGL, especially in patients at risk of multifocal disease (predisposing mutations and or previous history of surgery).

A schwannoma of the hypoglossal nerve presenting as a malignant tumour of the oral floor.

OBJECTIVES: We describe a case of an unusual schwannoma of the hypoglossal nerve presenting clinically as a malignant tumour of the floor of the oral cavity. CASE REPORT: A 77-year-old woman presented with a bulky tumour located between the left anterior floor of mouth and the ventricular portion of the tongue. The tumour was ulcerated, painful and presented with a necrotic aspect. Neurological examination revealed a mild left hemiparesis of the tongue. MRI and CT showed a circumscribed tumour with a broad necrotic centre. The patient underwent a transoral excision of the tumour under general anaesthesia. CONCLUSION: Schwannomas are generally managed by complete surgical excision but they can mimic primary or metastatic cancer in the head and neck, preoperative diagnosis is therefore necessary to avoid a wide excision.

Management of cervical lymph node recurrence of melanoma of the head and neck.

OBJECTIVES: To compare the diagnostic accuracy between Positron emission tomography using 2-[fluorine-18] fluoro-2-deoxy-D-glucose (FDG-PET scan) and conventional work-up such as ultrasound (US) and/or Computed tomography (CT) in the detection of cervical lymph node recurrences of melanoma of the head and neck after initial cervical lymph node surgery. METHODS: A retrospective review was performed on patients who presented with clinical and/or radiological suspicion of isolated cervical lymph node recurrence after lymph node surgery from April 2004 to January 2007. All patients underwent CT and/or US of the neck, and FDG-PET scan before salvage neck dissection. None of included patients had clinical or radiological detectable distant metastases at the time of the lymph node dissection. Performances of conventional imaging and FDG-PET scan in detection of lymph node recurrence were calculated and compared by using the histopathological results of lymphadenectomy as gold standard with Fischer's exact test. RESULTS: Of the twelve cases in included in the study (9 patients, 3 of them had 2 consecutive lymph node redissection for a second lymph node recurrence), melanoma recurrence was found in 10 cases (83%). Sensitivity, specificity, positive predictive value and negative predictive values were 78.6%, 40%, 78.6%, and 40% respectively for conventional imaging and 85.7%, 40%, 80% and 50% for FDG-PET scan. No statistically significant difference was found between the 2 methods. CONCLUSION: This is the first study that compares the diagnostic accuracy between FDG-PET scan and conventional imaging in the detection of cervical lymph node recurrence of melanoma of the head and neck. Our results showed that FDG-PET scan is actually not better than conventional imaging to detect these cervical lymphatic recurrences.

[Role of diffusion weighted MR in the diagnosis of parotid tumours]. / Apport des séquences d'IRM de diffusion au diagnostic des tumeurs parotidiennes.

OBJECTIVE: To evaluate the contribution of sequences of diffusion for the diagnosis of nature of the tumours of the parotid. METHODS: Retrospective study based on 29 patients all operated of a parotid tumour They had a MRI in conventional acquisition (T1, T1 Gadolinium, T2) and in sequences of diffusion. An ADC cartography (apparent coefficient of diffusion) and an ADC ratio between the tumoral area and the healthy controlateral parotid were successively analyzed by two experienced radiologists. We calculated the effectiveness of these MRI sequences, focusing more particularly on the diagnosis of the malignant tumours. We also determined the sensitivity and the specificity of the sequences of diffusion, with their positive and negative predictive values. RESULTS: On the 7 malignant tumours, 3 had been classified wrongly like benign thanks to the only cartography of diffusion. We obtained a sensitivity of this examination for the diagnosis of malignity of 57%. Out of the 22 benign tumours, 1 only was classified wrongly like malignant. The specificity of the diffusion for the diagnosis of malignity thus rose with 95%, its positive predictive value with 80% and its negative predictive value to 87%. It should be noted that all the malignant tumours had an ADC ratio lower or equal to 1.8. CONCLUSIONS: The histological characteristics of the malignant tumours of the parotid are very variable. Generally, they have large nuclei associated with a hypercellularity involving a decrease of the ADC. The results of this MRI sequence are encouraging even if they remain not very reliable in front of cystic or necrotic tumours.

[The frontal pneumosinus dilatans: surgical management by modelling osteoplasty]. / Le pneumosinus dilatans frontal: à propos d'un cas d'ostéoplastie modelante.

UNLABELLED: Pneumosinus dilatans is a rare disease that most commonly occurs in young men. It is characterized by an hyperpneumatization of sinus cavities. Its etiopathogenis remains unclear. The bony and mucosal structures are normal and there is no sinus disorders associated with. Most of patients with pneumosinus dilatans present with a cosmetic complaint. CASE REPORT: We report a new surgical technique performed in a young male with bilateral frontal pneumosinus dilatans. A Bi-coronal incision makes it possible to largely expose the anterior wall of the frontal sinus. This wall is then weakened by drilling which should not be transfixiant. A soft impaction of the weakened wall of the sinus, by avoiding any effraction of the sinusal mucous membrane allows a reduction in volume of the frontal sinus with disappearance of the sus-orbital tumefaction. Cosmetic and functional outcomes, 18 months after surgery are good and stable. CONCLUSION: This technique of impaction, without sinusal bone window nor osteosynthesis or bone grafting, preserves the integrity of the sinusal mucous membrane while guaranteeing a good cosmetic result.

[Role of [18]-FDG PET/CT in the initial staging of head and neck cancers]. / Apport de la [18F]-FDG TEP/TDM dans la stadification initiale des cancers de la tête et du cou.

OBJECTIVE: To evaluate the impact of fusion of positron emission tomography with computed tomography (FDG-PET/CT) in the initial staging of head and neck carcinomas. METHODS: This retrospective study included 44 patients with squamous cell carcinoma of the upper aerodigestive tract. Patients underwent a standard workup and a PET/CT image fusion during the initial staging. The standard workup included CT scan of the head, neck and chest, panendoscopy under general anaesthesia, oesophageal endoscopy and abdominal echography. Potential additional diagnostic value of PET/CT was evaluated. RESULTS: Findings between PET/CT and standard workup were concordant in 41/44 cases for primary tumour in 79/88 cases for lymph node staging, in 36/44 cases for distant metastases (or distant second primary) and in 41/44 cases for synchronous second primaries of the upper aero-digestive tract. PET/CT leads to a change of treatment for 6.8% of patients (1 for lymph node staging and 2 for distant metastases). 17.2% of pathological FDG uptake foci found by PET/CT were false-positives results. CONCLUSION: PET/CT enables to realise a whole body check-up in a single time. However, it cannot be used alone, due to its lack of spatial resolution: It must be used in complement of the standard workup. This high rate of false-positive findings, asking for further expensive diagnostic procedures, limits its usefulness.

[Remodeling of the nasal lobule using cartilaginous grafts on tip projection]. / La restructuration du lobule du nez par greffons cartilagineux.

OBJECTIVES: Nasal tip projetion and definition are essential parameters which should be considered in the preoperative rhinoplasty plan. Jonhson and Toriumi have defined a technique of rhinoplasty to restructure the lobule using columellar strut and tip grafts. The aim of this study was to define the influence of this procedure on nasal tip projection, using the Goode method (objective measurement of the tip projection). METHODS: Forty patients underwent primary rhinoplasty, by open approach, with remodeling of the lobule using cartilagenous grafts, according to Jonhson and Torium technique. Goode ratio was calculated to assess tip projection preoperatively and postoperatively, based on photographic analysis. Moreover, postoperatively, all patients were clinically evaluated at 2, 4 and 6 months, and based on photographs of face at 2 and 6 months. RESULTS: Five hypoprojected preoperative nasal tips (Goode ratio (GR): 0,45 to 0,51) had a normal nasal tip projection postoperatively (GR: 0,55 to 0,59). Among the eight normal projected preoperative nasal tips (GR: 0,56 to 0,60), six had a normal postoperative nasal tip projection while two showed a hyperprojection (GR: 0,62 and 0,63). Among the 27 hyperprojected preoperative nasal tips (GR: 0,62 to 0,75), 17 showed a normal projection of the nasal tip postoperatively while 10 remained hyperprojected despite a decreased Goode ratio. CONCLUSION: Restructuration of the lobule, using cartilagenous grafts, is a reliable and reproducible technique allowing satisfying aesthetic results and objective measurements of the changes in nasal tip projection using the Goode method.

[Contribution of 18-F-FDG PET for detection of head and neck carcinomas with an unknown primary tumor]. / Apport du TEP scanner au [18F]-FDG dans les adénopathies cervicales primitives.

OBJECTIVES: To evaluate the usefulness of fusioning positron emission tomography with computed tomography (PET/CT) for the detection of head and neck carcinomas of unknown primary. METHODS: This prospective study included 20 patients with cervical lymph node of squamous cell carcinoma of unknown primary after standard initial workup (nasofibroscopy and CT scan of the chest and head and neck). Patients underwent PET/CT and panendoscopy of the upper airways and upper digestive tract with PET/CT directed biopsies. The follow-up was 6 months minimum in all patients. RESULTS: A potential primary tumor was found in 10 of the 20 cases and confirmed by histology in 7 cases (3 bases of tongue, 1 tonsillar pillar, 1 vallecula, 1 tonsillar fossa, 1 piriform sinus). Four of these seven patients presented a normal endoscopy (diagnosis was made with submucosal PET/CT directed biopsies). PET/CT was normal in 10 of 20 cases with 3 false negatives. The sensitivity of PET/CT was 70%, the specificity was 70% and the accuracy was 70%. CONCLUSION: PET/CT seems to be of interest in the detection of head and neck carcinoma of unknown primary. PET/CT detected 15% of unknown primary tumors with treatment-related implications.

[Contribution of 18FDG PET/CT post treatment surveillance of head and neck squamous cell carcinoma]. / Intérêt de la TEP au 18FDG couplée à la TDM dans la surveillance post-thérapeutique des carcinomes épidermoïdes des voies aérodigestives supérieures.

OBJECTIVE: To evaluate the contribution of 18FDG positron emission tomography for the post treatment surveillance of head and neck carcinomas. METHODS: : This prospective study included 61 patients with advanced squamous cell carcinoma of the upper airways and/or digestive tract and who underwent curative treatment. Patients underwent a standard workup (physical examination, CT scan and panendoscopy) and a PET/CT image fusion 3 months after the end of treatment. The follow-up was 6 months minimum in all patients after this workup. PET/CT was evaluated in terms of: primary tumor, cervical lymph nodes, metastases and overall patient assessment. RESULTS: : For diagnosis of the primary tumor, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of PET/CT were respectively 86.7%, 82.6%, 62%, 95% and 83.6%. Values for cervical lymph nodes were: 100%, 98.2%, 80%, 100% and 98.3%. Values for metastases were: 100%, 92.2%, 66.7%, 100% and 93.2%. Values for overall patient assessment were: 88.8%, 78.1%, 64%, 94.1% and 81.4%. Performances of PET/CT were better than standard workup in 22% of patients. CONCLUSION: PET/CT contributes useful information in this indication, particularly an excellent negative predictive value.

[Papillary thyroid carcinoma metastasis to parapharyngeal lymph nodes: interest of the PET scan]. / Métastase ganglionnaire parapharyngée d'un carcinome papillaire thyroïdien. Intérêt du TEP scan.

UNLABELLED: Thyroid cancer rarely metastasizes to the parapharyngeal space. A inconsistent lymphatic drainage pathway is involved, as described by Rouvière. OBJECTIVES: To demonstrate the interest of [18 F]-FDG PET in early diagnosis of metastasis and in the follow up of the patient. MATERIAL AND METHOD: 40 y.o. male with papillary carcinoma who had a secondary parapharyngeal metastasis. The diagnosis of recurrence was difficult, as the plasmatic thyglobulin was low, and the iodine scan was not informative. In this case, [18 F]-FDG PET-CT was informative (clear parapharyngeal fixation) and led to the diagnosis of recurrence. CONCLUSION: It appears that 18F FDG PET has a good diagnostic value and that its sensitivity is better than CT scan and MRI. Some authors recommend the use of [18 F]-FDG PET and scintigraphy with Iodine 131 to screen patients with thyroid cancer recurrences.

Microvascular radial forearm fasciocutaneous free flap in hard palate reconstruction.

THE AIM OF THIS STUDY: To report the reconstruction of palatal defects by microvascular radial forearm fasciocutaneous free flap (RFFF) and to report patient's quality of life outcomes after this procedure. MATERIAL AND METHODS: During the period 1990-2002, 30 cases of palatal defects were reconstructed using RFFF in our institution. RFFF allowed restoration of a vestibular sulcus to maintain dental prostheses. Outcome measurements included post-operative assessment of speech, swallowing and diet evaluation 6 months, 1 year and 2 years after reconstruction. Quality of life outcomes were measured 1 and 2 years post-reconstruction. RESULTS: RFFF surgery was successful in 28 cases. Six months after resection 28 patients reported satisfactory speech and swallowing. Two years after surgery, 92% (n=26) of patients resumed a normal diet. All patients underwent dental evaluation and 68% (n=19) of patients required dental rehabilitation over a post-operative period of 3-18 months. Patients self assessed their quality of life on a scale of 0-2. First year post-operatively, 21 patients reported a good quality of life (score=2). After the second year, 26 patients reported a good quality of life and the remaining two patients reported an intermediate quality of life (score=1) because they did not resume a normal diet. CONCLUSION: RFFF for palatal reconstruction is a reliable technique and provides a definitive separation between oral and sinusonasal cavities. Furthermore, it improves quality of life by improving speech, swallowing and chewing. It should be considered an integral component of head and neck cancer therapy and rehabilitation.

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.

Partial frontolateral laryngectomy with epiglottic reconstruction for management of early-stage glottic carcinoma.

OBJECTIVES: The aim of this study was to demonstrate that partial frontolateral laryngectomy with epiglottic reconstruction (PFLER) is an effective therapeutic option for treatment of T1 and T2 glottic carcinoma. STUDY DESIGN: Retrospective study. METHODS: Between 1982 and 1997, we treated 127 cases of early glottic carcinoma with PFLER. Early glottic carcinoma was staged using the Union Internationale Contre le Cancer TNM classification as either T1N0M0 (62 cases) or T2N0M0 (65 cases). Selection criteria, depending on the limits of exeresis, must remain glottic carcinoma with less than 0.5 cm of anterior subglottic involvement, with no involvement of the supraglottic space or laryngeal side of the epiglottis, with involvement of only one arytenoid, and with good mobility of both arytenoids even if vocal cord mobility is decreased. RESULTS: Postoperative recovery was uneventful in all cases, and all patients but one were able to breath and eat normally. The failure involved a patient with a permanent gastrostomy. As with other partial laryngectomy techniques, the main drawback of PFLER was deterioration of voice quality. All patients presented hoarseness and weakness of the voice. Five-year survival rates calculated according to the Kaplan-Meier method were 91% (standard error, 5%) in the T1N0M0 group and 86% (standard error, 5%) in the T2N0M0 group. No recurrence was observed in the T1N0M0 group. Local control was successful in 92% in the T2N0M0 group after a median follow-up of 5 years. CONCLUSION: These findings show that PFLER is an effective therapeutic option in selected cases of early T1N0M0 or T2N0M0 glottic carcinoma.

Major complications of sinus surgery: a review of 1192 procedures.

Based on this review of 1192 intranasal sinus procedures under endoscopic control with video assistance, the risk of major complications was estimated to be about 1.3 per cent. Ethmoidectomy was the most hazardous procedure. Operation by a right-handed surgeon standing on the right side of the patient was an added risk factor. We stress ways of achieving prevention, peroperative recognition of cerebrospinal fluid leaks and proper management of complications.

Difference in the height of the right and left ethmoidal roofs: a possible risk factor for ethmoidal surgery. Prospective study of 150 CT scans.

A prospective study of 150 CT scans showed that the right ethmoidal roof was lower than the left in 8.6 per cent of cases. The reverse situation, i.e. the right higher than the left, was observed in only 1.2 per cent of cases. This finding could account for the higher reported incidence of endocranial complications associated with right ethmoidectomy. Coronal CT scans allowing comparison of the right and left ethmoidal roofs should always be made before undertaking intranasal ethmoidectomy.

Role of magnetic resonance imaging in predicting late facial motor function after removal of vestibular schwannomas by the translabyrinthine approach.

Facial motor function was assessed in 61 patients 18 months after surgical resection, by the translabyrinthine approach, of vestibular schwannoma involving both the cerebellopontine angle (CPA) and the auditory canal. Pre-operative magnetic resonance imaging (MRI) was performed to measure the maximum extracanalicular diameter of the tumour between the porus and the farthest extension in the CPA on transverse slices and to calculate extracanalicular tumour volume. Post-operative facial motor function was graded according to the House and Brackmann system. There was a statistically significant relationship between late facial motor function and extracanalicular diameter. The best cut-off point for good and poor results was 20mm. There was no relationship between the tumour volume and the late post-operative facial motor function grade. In this study the best pre-operative radiological predictor of the late facial motor function in patients operated on by the translabyrinthine approach was the maximum diameter measured by MRI.

Nonlinear behavior of vocal fold vibration: the role of coupling between the vocal folds.

Coupling between the vocal folds is one of the nonlinear mechanisms allowing regulation and synchronization of mucosal vibration. The purpose of this study was to establish that modulations such as diplophonia and abnormalities observed in vocal signals that may be observed in some cases of laryngeal pathology can be considered as nonlinear behavior due to the persistence of some physical interaction (coupling). An experimental model using excised porcine larynx was designed to create tension asymmetry between the vocal folds and to obtain vocal signals with modulations. Signals were analyzed by spectral analysis and the phase portrait method. Results were compared with computer-generated synthetic signals corresponding to nonlinear combinations of sinusoid signals. Under these conditions, evidence of nonlinear behavior was detected in 85% of experimental signals. These findings were interpreted as a demonstration of vocal fold interaction. Based on these findings, the authors conclude that (1) coupling must be taken into account in physical models of laryngeal physiology, and that (2) methods of nonlinear dynamics may be used for objective voice analysis.

[Chondrosarcoma in nasal fossae and Maffucci's syndrome]. / Chondrosarcome des fosses nasales et syndrome de Maffucci-Kast.

INTRODUCTION: Maffucci's syndrome is a congenital non-hereditary disease very similar to Ollier's disease and associates multiple cutaneous hemangiomas, dyschondroplasia and often enchondromas. EXEGESIS: We report a unique case involving synchronous localization of chondrosarcoma in nasal fossae and anterior chest wall, disclosing Maffucci's syndrome. CONCLUSION: Atypical chondrosarcoma localization must lead to further investigation of potential multiple enchondromatosis.

[Radiologic diagnosis of acoustic neurinoma. Apropos of 130 patients]. / Le diagnostic radiologique du neurinome de l'acoustique. A propos de 130 patients.

Diagnostic value of radiologic examinations was assessed in a homogeneous series of 130 cases of neurinoma of acoustic nerve seen over the last 10 years. Radiologic exploration is conceived and used at the present time for two purposes. Firstly, it enables selection of patients with suspected acoustic nerve neurinoma. Radiotomography appears to be currently an accessory examination because of the discriminative performance of early auditory evoked potentials tests on the brain stem. Secondly, radiology is necessary for confirmation of diagnosis. Visualization of the tumoral syndrome can be obtained only by a scan or possibly opaque or gas meatocisternography.

[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.