Intraoperative measurement of parathyroid hormone in minimally invasive surgery for parathyroid adenoma.

INTRODUCTION: In the past bilateral neck exploration was the gold standard for successful surgical management of primary hyperparathyroidism. More restricted procedures have been introduced recently thanks to imaging techniques and intraoperative parathyroid hormone assay confirming eradication of hyperfunctioning tissue. METHODS: Thirty patients operated for parathyroid adenoma were submitted to intraoperative PTH determination with Quick Pack immunochemiluminescent assay (Nichols lab.) prior to excision and 5, 10 and 20 minutes after removal of the presumed hyperactive gland. Eleven patients were operated on by a minimally invasive procedure with videoassistance. RESULTS: Response to excision of the hyperfunctioning gland was evidenced by a significant decrease of PTH levels (50% of initial value) in 26 patients. Plasma PTH levels decreased by at least 80% of pre-excisional value after 20 minutes, 70% after 10 minutes and by 50% after 5 minutes. In 2 cases, significant decrease of PTH was obtained after 45 and 60 minutes respectively. In 2 other cases, the adenoma could not be found and there was no decrease of PTH even after extensive exploration of the neck. In the 11 patients who underwent minimal invasive surgery, 2 were converted to open neck surgery: in one case the adenoma was not accessible in the upper part of the neck, in the other case the hyperfunctioning gland remained undiscovered. CONCLUSION: intraoperative measurement of PTH should be considered a reliable and reproducible method for evaluation of the secreting activity of a parathyroid gland. The Quick Pack method has the advantage of confirming that the hyperactive gland has really been eradicated and consequently of considerably reducing operating time and avoiding extensive exploration of the neck.

Do multiple consecutive head and neck reconstructions improve the patients functional outcome?

BACKGROUND: The purpose of this study was to determined the functional outcome of surgically treated head and neck cancer patients who required more than "standard" microsurgical reconstruction. METHODS: Data concerning all patients with head and neck cancers, who underwent free-tissue transfers in our institution between January 1, 1994 and August 31, 1999 were reviewed. The cases of tumor recurrences and those with micro-surgical complications were excluded. Among 68 primary microsurgical reconstructions, we identified five cases where limitations in speech and/or swallowing required additional flap procedures. An objective assessment of speech and swallowing could be performed in four patients. RESULTS: In these five patients up to three consecutive additional procedured including three free-tissue transfers in one case, had to be performed mainly because of secondary contraction of the surrounding irradiated tissue. A total of 13 pedicled and free flaps were transferred to the head and neck. Three patients underwent two consecutive free tissue transfers. The additional reconstructions were requested to improved tongue mobility in three patients and to enlarge the upper digestive tract in two patients. The mean follow-up was 23 months (range : 9-53 months). Functional evaluation was rated average in three patients and poor in one patient. One patient died before functional evaluation could be performed because of disease. The four patients judged the final cosmetic result as satisfactory. CONCLUSION: We report five cases of head and neck microsurgical reconstructions where additional flap procedures were requested because of inadequately restored speech or nutrition capabilities. We show that, maybe because of extensive fibrosis, only limited improvement in the functional outcome can be expected despite the use of even sophisticated microsurgical reconstructions. This paper supports the idea that every effort should be put in the initial reconstruction, as further procedures are of poor functional prognosis.

Tracheoesophageal fistula: case report and review of literature.

The case of a 44 year old woman with progressive postoperative dysphagia and food inhalations complicated by recurrent pulmonary infections, due to a tracheoesophageal fistula (TEF) is reported. Some months earlier, this woman had been operated for a cerebral aneurysm with hemiplegia and aphasia. For several months, pulmonary and feeding difficulties had been attributed to neurological status. Wide TEF was diagnosed by bronchoscopy, confirmed with fistulography. Surgical closure was performed: the oesophagus was sutured, and covered with fascia and a segment of the cervical trachea was resected with end-to-end anastomosis. Acquired nonmalignant TEF is an uncommon disorder with a high degree of morbidity and mortality. The etiology of those TEF is still unclear: traumatic intubation, elevated endotracheal tube cuff pressure, nasogastric tube, inflammation, poor general conditions,.... A better knowledge of the predisposing factors and physiopathology could decrease the number of acquired TEF.

Bilateral chylothorax after left radical neck dissection.

Bilateral chylothorax, as a complication of neck dissection, is very rare as evidenced by the 11 cases reported in the literature up to date. We present an additional case of bilateral chylothorax following a left radical neck dissection and concomitant chylous neck fistula. This case was successfully treated by chest drainage and total parenteral nutrition. Early diagnosis of chylothorax is urged due to the consequences on metabolism and respiratory conditions. Management by aspiration drainage is usually sufficient to control pleural effusions.

An unusual case of squamous cell carcinoma of the nose.

A 49-year-old man presented with a tumoral lesion of the tip of the nose which had been manifest for 2 months. Within a few weeks, the tumour increased in size and became infiltrated. The biopsy showed a squamous cell carcinoma. Treatment consisted of a radical surgical excision.

Contribution of hook-guided breast biopsy to the pathological diagnosis of mammographic lesions.

This study was carried out to evaluate the reliability of a diagnostic approach with close cooperation between radiologists and surgeons for minimal breast disease. From 1993 to 1995, 152 evaluable patients with non palpable breast lesions were examined by mammography and their lesion was localized with a hook wire before being referred to the surgeon for biopsy. Comparison of mammography findings with pathological diagnosis indicated a good predictive value for benign lesions with only 8% non concordant diagnosis and a rather low predictive value in case of suspect mammograms with only 64% positive diagnosis. With hook-guided breast biopsy, a correct diagnosis was established in 93% of the cases. The remaining breast samples were either non contributory or necessitated a second biopsy. Several recommendations are proposed for improving accuracy of breast sampling such as securing the hook into the gland, orienting the limits of resection, sending specimen for X-ray study and inking the margins for the pathologist. This field experience revealed that some progress are to be made in diagnosis in particular by standardization of mammography and pathological criteria, more precise localization of the lesions with the hook and more refined surgical techniques for breast biopsy.

[Osteosarcoma of the jaws. Apropos of 12 cases]. / Les ostéosarcomes des maxillaires. A propos de 12 cas.

We report 12 cases of osteosarcoma (10 located in the mandible and 2 in the maxilla). There were 8 men and 4 women who were older than usually observed in osteosarcoma at other sites (8 of 121 patients were over 30 and the average age was 34 years). Clinical signs were variable. Bone tumefaction was the most frequent sign, with a diameter greater than 5 cm in most cases (10 out of 12). Surgery alone was used for 8 patients and radiosurgery for 3. Follow-up is available for 8 patients. All presented local recurrence with extensive tumors progression. All died within an interval of 3 to 30 months despite palliative surgery and/or radiotherapy or chemotherapy.

Parameningeal rhabdomyosarcoma. Report of 19 cases.

Parameningeal rhabdomyosarcomas are associated with a poor long term survival. This is due to the fact that they are aggressive tumours with early involvement of the skull base. The authors report a series of 19 cases between 1984 and 1995 with a relative proportion of children, male patients and tumours of embryonal type. Three patients were operated on and only one of them was found with tumour free margins. Systemic chemotherapy using the VAC-VAd protocol was administered in 18 patients and intrathecal chemotherapy was delivered in 5 patients with involvement of the skull base. Nine patients were irradiated with doses varying from 45 to 55 Gy. Twelve patients died from 20 days to 4 years after initial treatment; 6 were lost to follow up and only one patient is living without any evidence of disease after 11 years.

Chondroma of the trachea.

The case of a 76 year old man with a progressive upper respiratory distress due to a chondroma of the trachea is reported which necessitated a segmental tracheal resection with end-to-end anastomosis and restoration of the initial tracheal lumen. This case report is illustrative of a rare benign disease (10 cases described till today) originating from the cartilaginous rings of the trachea. The tumor usually appears as an upper airway obstructing syndrome and endoscopy is essential for establishing the diagnosis. Laser resection can be recommended for the treatment of limited lesions, whereas tracheal resection with end-to-end anastomosis is recommended for more advanced chondroma because it is prone to local recurrence and potentially exposed to malignant transformation into chondrosarcoma.

Quantitative glycohistochemistry defines new prognostic markers for cancers of the oral cavity.

BACKGROUND: Histopathologic grading and clinical staging cannot provide a precise prognosis of oral cavity cancer patients. The use of glycohistochemical markers may improve the level of prognostic accuracy of such conventional classification systems. METHODS: Computer-assisted microscopy was employed in a series of 40 oral cavity cancers to determine quantitatively the percentage of positive cells, the staining intensity, and the level of staining heterogeneity for 3 glycohistochemical markers, including peanut agglutinin (PNA), Thomsen-Friedenreich antigen (T antigen) as part of a neoglycoprotein, and sarcolectin. Data were evaluated by discriminant analysis. RESULTS: Although the level of differentiation (P < 0.01 to P < 0.001) and the T variable of the TNM staging system (P < 0.05 to P < 0.01) related mainly to the level of expression of the acceptor sites for PNA and the T antigen, the patient survival period (P < 0.05) was largely a fraction of the level of expression of the acceptor sites for the carrier-immobilized T antigen and for sarcolectin. CONCLUSIONS: In oral cavity cancer, determining the level of acceptor sites for PNA, T antigen, and sarcolectin provides useful information on histopathologic differentiation, clinical staging, and survival. Because these processes of determination were carried out quantitatively, a discriminant model was set up, which enabled the level of oral cavity cancer aggressiveness to be characterized precisely. The current methodology described in this article should therefore afford pathologists original and quantitative (and thus objective) prognostic markers for oral cavity cancers.

Undifferentiated carcinoma of the nasopharynx and leukemoid reaction: report of case with literature review.

A case of undifferentiated carcinoma of the nasopharynx presenting as a cervical mass associated with a paraneoplastic neutrophilic leukemoid reaction is reported. The diagnosis of undifferentiated nasopharyngeal carcinoma of the Regaud type was established by the presence of aggregates of epithelial neoplastic cells separated by areas of reactive lymphoid cells; the epithelial nature being confirmed by the positivity for epithelial markers (AE1/AE3, EMA). Serum IL-1a, GM-CSF and TNF alpha remained undetectable suggesting that these factors were not involved in the occurrence of the paraneoplastic leukemoid syndrome.

[Surgical treatment of iatrogenic injuries of the trachea]. / Traitement chirurgical des traumatismes iatrogènes de la trachée.

Surgical treatment of iatrogenic tracheal traumata. Eight cases of tracheal resection with immediate anastomosis in tracheal stenosis due to prolonged intubation are reported. Resection-anastomosis surgery is compared to recalibration technique.

Use of osteomuscular free flaps after extended maxillectomy and craniofacial resection. About two cases.

A composite free flap with the lower part of the scapula and the serratus muscle has been used in two clinical cases for reconstruction after extensive maxillectomy and craniofacial resection. The palatal defect was reconstructed with the lower part of the scapular bone and the bone and the serratus muscle was used to restore facial contour. This type of osteomuscular free flap based on the thoracodorsal artery and veins provides a one-stage reconstruction of complex facial defects, including bone and soft tissue. The main advantages of this flap are the configuration of its bony component that closely matches the hard palate and its versatility that allows other regional flaps such as the latissimus dorsi and/or the serratus to be raised on the same vascular pedicle.

Carcinomas of the thyroid with unusual presentation. About two cases.

Two cases of thyroid carcinoma with unusual presentation are reported. In the first case, a follicular carcinoma was associated with hyperthyroidism from a hot nodule located in the same lobe. This condition is not so infrequent as indicated by the literature and should warrant pathological examination at the time of excision of the hot nodule. In the second case, both anaplastic and follicular carcinomas were coexisting in the same tumour of a young adult. This occurrence is rather exceptional in the early period of life and is usually the fact of elderly people with long-standing goiters. The favourable outcome of this patient is also contrasting with the bad prognosis associated with anaplastic carcinoma of the thyroid. Another interesting feature is the existence of an anaplastic carcinoma of the thyroid in a family member of this second case.

[Differential diagnosis of nasopharyngeal masses in adolescents. Apropos of a case of antrochoanal polyps]. / Diagnostic différentiel des masses du cavum chez l'adolescent. A propos d'un cas de polype antrochoanal.

A case report of an antrochoanal polyp originating in the frontal sinus of a 14 year old boy is presented. This condition is very rare. The differential diagnosis is reviewed.

Randomised EORTC head and neck cooperative group trial of preoperative intra-arterial chemotherapy in oral cavity and oropharynx carcinoma.

Between February 1978 and January 1984, 222 eligible patients were randomised in a multicentre trial of preoperative intra-arterial chemotherapy in the treatment of oral cavity and oropharynx carcinoma. Patients were randomised between either surgery or preoperative chemotherapy. This latter group received vincristine and bleomycin for 12 days. Patients were stratified according to the primary site: floor of the mouth (FM) versus posterior oral cavity or oropharynx (POC) and institution. The FM group received postoperative radiotherapy depending upon quality of the margins and lymph-node pathological involvement, when it was systematically applied in the POC group. Tumour regression after chemotherapy either complete (CR) or partial (PR greater than 50%) was observed in 48% in the FM group and 41% in the POC group, and lymph-node regression (CR + PR) was respectively 15% and 23%. Some discrepancies appeared between clinical regression and pathological response, and the number of cases without histological response was clearly higher than the number of cases without clinical response. The overall survival showed a statistically significant difference (P = 0.048) between FM and POC groups. In the FM group, median survival in the chemotherapy arm was estimated at 7 years compared with 3 years in the surgery arm. In the POC group, median survival was estimated at 3 years in both treatment arms. Chemotherapy lowered the uncontrolled disease and local recurrence in the FM group. These differences do not exist in the POC group, which may be due to the systematically postoperative radiotherapy.

A randomized EORTC study on the effect of preoperative polychemotherapy in pyriform sinus carcinoma treated by pharyngolaryngectomy and irradiation. Results from 5 to 10 years.

226 patients with an operable epidermoid carcinoma of the pyriform sinus were entered in this clinical trial; 187 cases were considered evaluable, they were distributed as follows: 16 T2, 171 T3, 44 N0, 103 N1 and 40 N3 (UICC TNM Classification 1979). The 89 patients of the chemotherapy group received a 3 day course of Vincristine (1.5 mg/m2), Bleomycin (15 mg), Methotrexate (80 mg). Both the chemotherapy group and the 98 patients of the control group went through the surgical procedure of total laryngectomy with pharyngectomy and radical neck dissection. Radiotherapy was administered postoperatively according to tumor margins and nodal involvement. On examination of the surgical specimen, no evidence of tumor regression was observed in the chemotherapy group. The 3 and 5 year survivals are respectively 45% and 35% in both groups. Node metastasis was studied after N size, N status, capsular rupture (PR +) and revealed early and extensive nodal involvement with 25% capsular ruptures in N0 patients, up to 70% rate in N3. Capsular rupture is also associated with a significantly lower survival and a higher incidence of distant metastases.

[Value of echography and fine needle biopsy for diagnosis of thyroid nodules]. / Intérêt de l'échographie et de la ponction à l'aiguille fine dans la mise au point des nodules de la thyroïde.

Value of ultrasonography and fine needle biopsy for the diagnosis of thyroid nodules. From 1/1/1986 to 31/7/1987, thirty patients with a nodular disease of the thyroid (14 solitary nodules, 9 multiple nodules, 5 colloid cysts, 2 carcinomas) were included in a controlled prospective study using clinical examination, scintigraphy, sonography and fine needle biopsy of the gland. All the patients were operated on and the specimens were submitted to pathological examination. It is shown that palpation is not able to provide an accurate evaluation of the consistancy and number of nodules. The images derived from the scintiscans were not very helpful for discerning a possible malignancy. Sonography was revealed as a fiable method of investigation (21 nodules discovered on a total of 25) allowing to find discrete lesions of 0.5 cm diameter, and also fluid collections with a high resolution rate. Needle biopsy is very useful in diagnostic studies specially for screening of remote malignant lesions with an excellent accuracy approaching 95%. Although considerable progress has been made through these methods of study, a final diagnosis about a solitary solid nodule will always need a surgical exploration to be sure to exclude the risks of an occult carcinoma of the thyroid.

Ten-year results of randomized trial comparing radiotherapy and concomitant bleomycin to radiotherapy alone in epidermoid carcinomas of the oropharynx: experience of the European Organization for Research and Treatment of Cancer.

This trial of treatment for head and neck carcinoma was initiated in 1973 by the European Organization for Research and Treatment of Cancer. Its purpose was to investigate the value of single-agent chemotherapy with bleomycin (BLM) given during the course of a conventional treatment by external radiotherapy (RT) compared to treatment by external RT alone. In this randomized study, we compared treatment results in 2 groups of patients with squamous cell carcinoma of the oropharynx (T2, T3, and T4; International Union Against Cancer classification). One group of 92 patients was treated by RT at the prescribed dose of 70 Gy. The other group of 107 patients received radiation according to the same protocol and simultaneously received im injection of BLM at a dose of 15 mg twice a week, 2 hours prior to the session of RT, for a total dose of 150 mg in 5 weeks. The occurrence of local toxic effects (i.e., mucositis and epidermatitis) was significantly greater in the RT-BLM group (RT-BLM, 72%, vs. RT, 21%). Primary tumor response 6 weeks after completion of RT was the same in both arms of the study (RT, 68%, vs. RT-BLM, 67%). The 6-year survival rate was 24% (RT-BLM) versus 22% (RT). Long-term analysis (10 yr) is given.