A simple predictive model for postoperative mortality after head and neck cancer surgery with opening of mucosa.

The aim of this study was to determine the risk factors for the mortality during the first 30 days after a major head and neck cancer surgery. Two hundred and sixty one consecutive surgical procedure were prospectively studied at Oscar Lambret Cancer Centre within a 36-months period. Twenty variables were recorded for each patient. The significant risk factors for postoperative mortality were assessed by univariate and multivariate analysis. Overall 30-days mortality rate was 3.83% [95% CI 3.13-4.53]. In univariate analysis identified four risk factors: female gender (odd ratio 4.25 [95% CI 1.03-17.56]), age equal or superior than 70 (odd ratio 5.06 [95% CI 1.35-18.36]), current alcohol addiction (odd ratio 3.65 [1.02-13.06]) and laryngeal location (odd ratio 4.23 [CI 95% 1.18-3.38]). In multivariate analysis only female gender and laryngeal location remained significant. The incidence of postoperative mortality was 1.63% for patients without risk factor and was 6.41% for those with one or two risk factors. This model identifies easily high-risk patients for major head and neck cancer surgery. A multicenter validation is necessary.

Treatment of laryngeal cancer: the permanent challenge.

There are many options to treat larynx cancers. Throughout the 20th century, surgical research has provided many partial surgery techniques (either open surgery or endoscopic CO2 surgery). In parallel, the modification of radiotherapy schedules has notably improved the local control with definitive irradiation. The appearance of active chemotherapy regimens has also modified the concept of treatment for advanced disease, allowing a decrease in the total indications of laryngectomy, although this remains the treatment of choice in some cases. The selection of the most appropriate treatment is based on a multidisciplinary approach. Early diseases may be treated by open surgery, endoscopic laser CO2 surgery or irradiation. Some advanced diseases may be treated by partial surgery, but the majority are theoretically candidates for radical surgery when resectable. In many instances, but not in all, chemotherapy-based larynx-preserving protocols may avoid performing such mutilating surgery. When inoperable, larynx cancers are better treated by combined chemotherapy and irradiation when the performance status of the patient is compatible with such an intensive regimen.

Prognostic significance of wound infections following major head and neck cancer surgery: an open non-comparative prospective study.

OBJECTIVE: We evaluated the incidence, risk factors and consequences of wound infection (WI) following major head and neck cancer surgery in an open non-comparative study. PATIENTS AND METHODS: The study group, comprising 95 patients who underwent clean-contaminated procedures with opening of the upper aerodigestive tract for biopsy-proven squamous cell cancer, were studied over a 1-year period. Antibiotic prophylaxis was amoxicillin and clavulanic acid. More than 20 variables were prospectively recorded for each patient. The mean follow-up was 30 months. MAIN RESULTS: The overall WI rate was 50.5% (48/95). Most pathogens isolated from samples were gram-negative rods. In univariate analysis, we found three risk factors for WI: alcohol consumption (P = 0.07), a hypopharyngeal location (P = 0.02) and laryngectomy stoma (P = 0.01). WI were associated with postoperative fever (P = l.5 x 10(-11)), postoperative antibiotic therapy (P = 1.5 x 10(-5)) and postoperative death (P = 0.043). Patients without WI had a median postoperative hospital stay of 15 days compared with 29 days for those with WI (P < 0.001). Healing of WI was achieved after a median time of 48 days. WI delayed postoperative radiation therapy in 21 out of 33 evaluable patients. But overall survival, and local and metastatic failures were similar with and without WI. CONCLUSIONS: WI are associated with a heavy postoperative morbidity, but have no prognostic impact on cancer control.

Previous chemotherapy as a predictor of wound infections in nonmajor head and neck surgery: Results of a prospective study.

BACKGROUND: The goal of this prospective study was to determine the incidence of wound infections (WI) after clean uncontaminated head and neck cancer procedures and after emergency tracheotomies. METHODS: Two hundred twelve clean procedures without tracheotomy or opening of mucosa (neck dissections, large skin resections, thyroidectomies, parotid gland resections, and explorative cervicotomies) were studied at Oscar Lambret Cancer Center over a 24-month period. RESULTS: WI rate was 6.6% (14 of 212). In a univariate analysis, only one variable was significantly related to the likelihood of WI: previous anticancer chemotherapy. All but one patient who had had previous chemotherapy demonstrated WI (14 of 15). CONCLUSIONS: After previous chemotherapy, WI rate in clean uncontaminated head and neck surgery was as high as 90%. In this case, antibiotic prophylaxis should be evaluated.

[Induction chemotherapy and larynx preservation: is such practice useful?]. / Chimiothérapie d'induction et préservation laryngée qu'en est-il en pratique?

BACKGROUND: Surgery followed by irradiation is considered to be the standard treatment but require frequently a total laryngectomy. Chemotherapy followed by irradiation is available in larynx and hypopharynx squamous cell carcinoma (SCC) treatment. Are results obtained in daily induction chemotherapy usefulness identical to results obtained in larynx preservation studies? PATIENTS AND METHOD: We conducted a retrospective study on patients treated at centre Oscar-Lambret, Lille, from 1986 to 1995, by chemotherapy followed by definitive radiotherapy or by surgery and radiotherapy for laryngeal or hypopharyngeal cancer treatment. All patients were naive of previous head and neck SCC and a surgical treatment, requiring total laryngectomy, should be proposed with curative intent. Induction chemotherapy associated cisplatin (100 mg/m2) on day 1 and 5-fluorouracil (5FU)(1,000 mg/m2) on days 1-4 or 1-5. Irradiation was performed for responders (complete or partial > 50%). If case of non-responder, patients underwent surgical treatment followed by irradiation. We compared results obtained with patients enrolled in clinical trial and with patients whom benefited from this protocol out of trial. RESULTS: Hundred-eight patients were evaluable for purposes of this study. Fifty-two patients were included in clinical trial (group 1) while 56 patients (group 2) were not. There was no statistical difference as regard neither to sex nor to node (palpable or not palpable) and metastasis status between the groups. We found a higher frequency of laryngeal tumour in group 2 (31 vs 17; p =.03). We observed more stage III and less stage IV in group 1. For chemotherapy-related toxic reactions, the exclusive statistical difference observed was haematological toxicity grade III and IV after the second cycle (0 pt in group 1 vs 8 pts in group 2; p =.02). After initial treatment, complete response was achieved without statistical difference between the groups (88.2% vs 78%; p =.27). A surgical procedure was performed in 46 cases without difference according to the reference group and functional larynx preservation was 55.8% (29/52) in group 1 and 53.6% (30/56) in group 2. Whatever the group, causes of death were similarly distributed. Cancer was the first cause of death in both groups. The overall survival of the population (108 patients) was 81.5% at one year, 49.6% at 3 years and 35.3% at 5 years with a median survival of 3 years. There was no statistical difference between both groups. Some parameters influenced the overall survival like T (p =.04), response to chemotherapy (p=.006), extra capsular spread (p = 0.03) and response after completion treatment. CONCLUSION: Induction chemotherapy is available for larynx preservation but cannot be considered as a standard treatment. Nevertheless, results should be reproduced in daily practice with experimented teams as found with non included patient's results. The long-term side effects of such protocols should be evaluated. Recent publication, on increase postoperative infection after chemotherapy, should be evaluated in clinical trial. If confirmed, cost effectiveness of such complication must be integrated in larynx preservation protocols. Larynx preservation remains an interesting point of view for patients but stay an optional procedure and not a reference.