Pharyngeal diverticulum: Iatrogenic complication of anterior cervical spine surgery.

INTRODUCTION: Dysphagia is a common presenting complaint and can often be due to pharyngoesophageal diverticulum, including Zenker's diverticulum. Iatrogenic pharyngeal diverticulum, occurring after anterior cervical spine surgery, is a rare cause of dysphagia. CASE REPORT: We report the case of a 51-year-old man, with a history of anterior cervical fusion about ten years previously, who complained of chronic dysphagia and disabling episodes of aspiration. Anterolateral pharyngeal diverticulum in contact with the cervical screw plates was diagnosed on barium swallow and upper gastrointestinal endoscopy. DISCUSSION: Pharyngeal diverticulum differs from Zenker's diverticulum in terms of its position and its origin. It may occur early or late after anterior cervical spine surgery. Treatment consists of endoscopic or open surgery via a neck incision. In our case, appropriate treatment allowed complete resolution of the patient's symptoms with no complications following rigorous postoperative surveillance.

Role of supracricoid partial laryngectomy with cricohyoidoepiglottopexy in glottic carcinoma with anterior commissure involvement.

OBJECTIVES: To analyze oncologic and functional outcomes after supracricoid laryngectomy with cricohyoidoepiglottopexy (SCL-CHEP) in glottic carcinoma with anterior commissure (AC) involvement, to determine predictive factors, and to compare results with those reported for other therapeutic strategies. MATERIAL AND METHODS: A retrospective analysis included all patients who underwent SCL-CHEP for glottic squamous cell carcinoma with anterior commissure involvement in our institution, between 2000 and 2014. Swallowing function was evaluated on the DOSS (Dysphagia Outcomes and Severity Scale). RESULTS: Fifty-three patients were included. Three-year overall, cause-specific and recurrence-free survival rates were 86, 95 and 80%, respectively. There were 5 cases of local recurrence (9%), all treated by total laryngectomy. Smoking was the only predictive factor of recurrence-free survival (P=0.02). Mean DOSS score was 5.5±0.9. DOSS scores≥6 (normal oral feeding) were recovered by 59% of patients. T-stage≥2 was the only predictive factor for DOSS score (P=0.04). CONCLUSION: In glottic carcinoma with anterior commissure involvement, SCL with CHEP provided a local control rate of more than 90%, which is higher than reported with endoscopic surgery or external radiotherapy. However, contrary to LSC, salvage of local recurrence can often be obtained by conservative treatments after endoscopic surgery. Therefore, total-laryngectomy-free survival rates after SCL-CHEP and endoscopic surgery are finally comparable.

Dental occlusal-surface-supported titanium guide to assist cutting and drilling in mandibular bilateral sagittal split osteotomy.

INTRODUCTION: Cutting and drilling guides manufactured using computer-aided design/computer-aided manufacturing (CAD/CAM) technologies have attracted increasing interest in orthognathic surgery, particularly in complex cases. The development of these guides requires virtual surgery planning and three-dimensional modelling before they can be printed in titanium, polyamide or resin. We report the use of a personalized titanium device to assist bilateral sagittal split osteotomy (BSSO) with or without genioplasty combined with individual implants for repositioning and fixation. This one-piece guide for both sides of the BSSO allows the initiation of cutting and drilling with less invasive drill placement and greater accuracy. PROCEDURE: The titanium guide was manufactured using CAD/CAM technologies after conventional digital planning of BSSO. Intraoperatively, the guide was fitted on each side of the mandibular occlusal surface and screwed to predesigned drill holes. The guide facilitates the predrilling of screw holes and the initiation of cutting for buccal, lingual and external oblique ridge corticotomy using a piezosurgery device. CONCLUSION: Based on our experience, we think that this guide is a promising new tool to assist BSSO. It helped limit the extent of tissue detachment required and provided the strength necessary for accurate bone cutting and drilling. It also allowed the accurate fixation of preformed plates to obtain occlusion as per virtual planning.

[Reirradiation of head and neck cancers]. / Réirradiation des cancers des voies aérodigestives supérieures.

Locoregional relapse in previously irradiated region for head and neck tumours is associated with a bad locoregional and distant prognosis. Reirradiation might be exclusive, or feasible in addition with surgery and/or chemotherapy, according to histopronostic factors. Data show that reirradiation is feasible with some severe toxicity due to the bad prognosis of this situation. Hyperfractionnated regimen with split course or normofractionnated regimen without split course are possible with similar efficacy. If tumour size is small, stereotactic ablative radiotherapy may be considered, and if the treatment centre has proton therapy, it could be proposed because of better organs at risk sparing. There is no standard regarding reirradiation schedules and several trials have to be done in order to determine the best technique. Nevertheless, it is agreed that a total dose of 60Gy (2Gy per fraction) is needed. Other trials testing the association with new systemic agents have to be performed, among them agents targeting the PD1/PD-L1 axis.

Candidate apoptotic and DNA repair gene approach confirms involvement of ERCC1, ERCC5, TP53 and MDM2 in radiation-induced toxicity in head and neck cancer.

INTRODUCTION: Single nucleotide polymorphisms (SNPs) of DNA repair and apoptosis genes have been associated with outcome in head and neck squamous cell carcinoma (HNSCC) patients receiving radiotherapy (RT). Our goal was to conduct a candidate gene study in HNSCC patients receiving RT or chemoRT. METHODS: 122 non-resectable HNSCC patients undergoing RT (N=38) or chemoRT (N=84) between 1992 and 2006 were retrospectively analyzed. ERCC1 Lys259Thr (rs735482), ERCC2 Lys751Gln (rs13181), ERCC5 His46His C>T (rs1047768), XRCC1 Arg399Gln (rs25487), TP53 Arg72Pro (rs1042522) and MDM2 309T>G (rs2279744) were analyzed on tumor DNA. SNP profile was considered to assess RT-related toxicity. RESULTS: All 120 evaluable patients experienced RT-related toxicity at any time. Among them, 83% had G3-4 acute side-effects during RT, mainly dysphagia, mucositis, epithelitis and/or xerostomia (DMEX). 28/105 patients (27%) had early G3-4 toxicity up to 3months after the end of RT. 29/96 patients (30%) had G3-4 late toxicity thereafter. The presence of G allele of MDM2 or Thr allele of ERCC1 was associated with a significantly higher risk of acute and/or early DMEX toxicity. The MDM2 309GG genotype was linked to a higher risk of acute G3-4 dermatitis. The ERCC5 TT genotype was associated with more frequent G3-4 late cervical skin fibrosis or xerostomia. Pro allele of TP53 72 was associated with a higher risk of G3-4 osteoradionecrosis. CONCLUSION: Relevant SNPs in DNA repair (ERCC1 and ERCC5) and apoptosis (MDM2 and TP53) genes might influence the severity of radiation-related side-effects in HNSCC patients. Prospective clinical SNP-based validation studies are needed on these bases.

Ambulatory surgery for primary hyperparathyroidism: A 67-case series.

INTRODUCTION: Surgery for primary hyperparathyroidism, targeted by ultrasound and scintigraphy, satisfies the theoretical criteria allowing ambulatory surgery. The purpose of this study was to validate this strategy on a homogeneous case series assessed by this imaging strategy. MATERIAL AND METHODS: All patients operated for primary hyperparathyroidism by ambulatory surgery from 01/01/13 to 30/04/15 were included in this retrospective study. The usual endpoints of ambulatory surgery were evaluated. RESULTS: A total of 144 patients were operated for primary hyperparathyroidism during the study period. Ambulatory surgery was possible in 67 patients, who all had a preoperative diagnosis of parathyroid adenoma. All patients were assessed by ultrasound and 66 patients were assessed by sestamibi scintigraphy, resulting in targeted unilateral neck surgery in 98.5% of cases. Two patients had to be hospitalised overnight due to minor complications. CONCLUSION: Surgery for primary hyperparathyroidism can be performed with short operating times in carefully selected patients with a low complication rate, thereby allowing ambulatory surgery.

Transoral-transcervical oropharyngectomy without mandibulotomy, associated to fasciocutaneous radial forearm free-flap reconstruction, for oropharyngeal cancer: Postoperative course, oncologic and functional results, and prognostic factors.

OBJECTIVE: To analyze postoperative course, oncologic and functional results and prognostic factors of transoral-transcervical oropharyngeal cancer surgery without mandibulotomy, associated to radial forearm free-flap reconstruction. MATERIAL AND METHODS: Retrospective analysis of computerized medical records of all patients who underwent this type of surgery in our institution between 2004 and 2014. Predictive factors of oncologic and functional results were investigated on univariate and multivariate analyses. RESULTS: Forty-four patients (37 male, 7 female; mean age, 62.3±9.3years) were included. Three-year overall, disease-specific and recurrence-free survival was 90%, 92% and 79%, respectively. Functional scores were satisfactory (normal or slight impairment) for feeding, speech and oral opening functions in 86%, 93% and 100% of cases, respectively. ASA score≥III had significantly negative impact on overall survival (P=0.005) and on feeding (P=0.01) and speech (P=0.01). CONCLUSION: Transoral-transcervical oropharyngeal cancer surgery without mandibulotomy provided excellent oncologic and functional outcomes; it is an advantageous alternative to the conventional conservative transmandibular oropharyngectomy.

Primary total laryngectomy and pharyngolaryngectomy in T4 pharyngolaryngeal cancers: Oncologic and functional results and prognostic factors.

OBJECTIVES: The aims of this study were to assess oncologic and functional outcome in primary total laryngectomy or pharyngolaryngectomy (TL/TL/TPL) for laryngeal or hypopharyngeal cancer with extra-laryngeal extension (T4) and to determine the predictive factors of these results. MATERIAL AND METHODS: A retrospective analysis was performed on the computerized medical records of all patients undergoing primary TL/TPL for T4 larynx or hypopharynx squamous cell carcinoma between 2000 and 2014 at our institution. Predictive factors of oncologic and functional outcome were investigated on univariate and multivariate analysis. RESULTS: Sixty-three patients (58 men, 5 women; mean age, 68.8±9.7 years) were included. Overall and disease-specific survivals were 69% and 80% at 3 years, and 56% and 69% at 5 years, respectively. On multivariate analysis, gender (female, P<0.001), ASA score (ASA≥3; P=0.006) and vascular embolism (P=0.006) had significant pejorative impact on overall survival. Six months after end of treatment, 90% of patients had recovered independent oral feeding and 83% of those with tracheoesophageal voice prostheses had recovered an intelligible voice. CONCLUSION: Primary TL/TPL remains the gold standard treatment for T4 larynx or hypopharynx cancer. It provides satisfactory oncologic and functional outcomes.

Virtual planning and guided surgery in fibular free-flap mandibular reconstruction: A 29-case series.

INTRODUCTION: Virtual planning and guided surgery (VPGS) has been recently developed for mandibular reconstruction, but benefit remains to be assessed. The aim of this study was to analyze the impact of VPGS on operative time and postoperative course. MATERIAL AND METHODS: All patients who underwent fibula free-flap mandibular reconstruction between 2013 and 2014 in our institution were included in a retrospective study. Operative times and postoperative course were compared between patients who underwent conventional surgery in 2013 and those who underwent VPGS in 2014. RESULTS: A total of 29 patients were included: 11 in 2013 and 18 in 2014. Taking all types of mandibular defect together, ischemia time was significantly decreased by VPGS (75min, vs 150min for conventional surgery; P<0.001), whereas overall operative time was not significantly reduced (481 and 516min, respectively; P=0.4). VPGS had no impact on postoperative course: local or general complications, time to decannulation and nasogastric tube removal, or length of stay. CONCLUSION: VPGS significantly reduced fibula free-flap ischemia time. Long-term functional and esthetic benefit remains to be evaluated.

Spontaneous intra-parotid pseudoaneurysm of the external carotid artery.

INTRODUCTION: The authors report a case of spontaneous intra-parotid pseudoaneurysm of the external carotid artery, never previously described in the literature. CASE REPORT: A 59-year-old woman presented with a palpable, non-pulsatile, 2 cm retromandibular left parotid mass with no triggering factors. This mass was considered to be a mixed tumour, although it did not present the typical features on MRI. At surgery, the lesion in the lower pole of the parotid gland was found to be pulsatile, in favour of pseudoaneurysm of the external carotid artery. The external carotid artery was ligated to remove the lesion. Definitive histological examination confirmed the diagnosis of pseudoaneurysm. DISCUSSION: Pseudoaneurysms of extracranial arteries are rare, most commonly involve the internal carotid artery and are essentially secondary to trauma. Review of MRI images demonstrated hyperintense arterial blood flow within the hypointense mass on T2-weighted sequences. The presence of this sign must therefore be investigated in the context of atypical images of a parotid mass. Although rare, and despite the absence of trauma, the diagnosis of pseudoaneurysm of the external carotid artery or one of its branches should therefore be considered in the presence of an atypical parotid mass.

[Ectopic thyroid basi-lingual: A case report].

Introduction: The thyroid ectopic gland is a rare anomaly, especially when it's a lingual thyroid. It is characterized by aspecific clinical presentation, causing a diagnostic problem. The diagnosis is based on a combination of imaging techniques as well as histological examination. Case presentation: We are presenting a case of a patient with thyroid basi-lingual treated surgically. Discussion: The low incidence of ectopic lingual thyroid , and their clinical variability requires radiological and isotopic investigations. Conclusion: The diagnosis of this disease is primarily histological. The management of these ectopic thyroid is surgical.

[Cervical lymph nodes: surgeon's point of view]. / Ganglions cervicaux : point de vue du chirurgien.

Squamous cell carcinomas of the upper aerodigestive tract or head and neck cancers, are localized in a complex anatomical region with a major lymphohilic locoregional cervical extension. Cervical lymph node surgery is systematized and drainage areas are sectorized with an increasingly conservative attitude. Improving imaging techniques allow the realization of selective neck dissection; sentinel node techniques are being evaluated. The traditional dissection is reserved to the lymph in capsular rupture or cervical interstitial mass.

[Free flap reconstruction after oral and oropharyngeal advanced stage carcinoma surgery]. / Reconstruction par lambeau libre après chirurgie des cancers de la cavité buccale et de l'oropharynx de stade avancé.

INTRODUCTION: The aim of the study was to evaluate the survival and locoregional recurrence in patients with advanced oral and oropharyngeal squamous cell carcinoma treated by surgery with free flap reconstruction followed or not by radiochemotherapy. POPULATION AND METHODS: A retrospective study was performed on 188 patients treated by surgery with microvascular reconstruction with or without postoperative radiochemotherapy for an advanced stage squamous carcinoma of the oral cavity and/or of the oropharynx. All patients underwent free flap reconstruction. The study parameters were survival and recurrence rates. RESULTS: The 5-year overall survival, disease specific survival, and disease free survival rates were 54%, 65%, and 61% respectively. A high level of comorbidity was the only factor that influenced the survival rate. The overall recurrence rate was 34%. Only 9% of patients having recurred were treated successfully. The survival rate after locoregional recurrence and metastasis was 6% at 2 years. DISCUSSION: Surgery and postoperative radiochemotherapy allows for an acceptable survival rate for patients with advanced oral and oropharyngeal squamous cell carcinoma.

Impact of preoperative radiotherapy on head and neck free flap reconstruction: a report on 429 cases.

BACKGROUND: The primary objective of this study was to evaluate the impact of preoperative radiotherapy on the outcomes of head and neck microvascular reconstruction. The secondary objective was to assess the specific effects of irradiation doses (IDs) ≥60 Gy on the outcomes of head and neck microvascular reconstruction. METHODS: All patients who underwent head and neck free-flap reconstruction in our institution between 2000 and 2010 were included in this retrospective study. A total of 429 patients were enrolled including 136 patients previously irradiated on the head and neck. The impact of preoperative radiotherapy on free-flap success, local and general complications, postoperative mortality, time of decannulation, duration of enteral nutrition and length of stay was assessed in univariate and multivariate analyses. RESULTS: In multivariate analysis, preoperative radiotherapy (irrespective of ID) was a significant risk factor for fistula formation (p = 0.003) and wound infection (p = 0.005). Previous neck irradiation at doses ≥60 Gy was associated with an increased risk of free-flap failure (p = 0.04), overall local complications (p = 0.05), haematoma (p = 0.04) and longer duration of enteral nutrition (p = 0.006) and hospital stay (p = 0.004). CONCLUSIONS: Preoperative radiotherapy, particularly for ID ≥ 60 Gy, is one of the main determinants of the outcomes of head and neck microvascular reconstruction.

Osteosarcomas of the mandible: multidisciplinary management of a rare tumor of the young adult a cooperative study of the GSF-GETO, Rare Cancer Network, GETTEC/REFCOR and SFCE.

BACKGROUND: Mandibular osteosarcomas (MOS) mostly affect young adults. Their treatment is extrapolated from that of extragnathic osteosarcomas. MATERIAL AND METHODS: A retrospective multicooperative group study was conducted to determine the impact of chemotherapy, adjuvant radiation therapy and surgery on outcomes and to identify prognostic factors. This ethical committee-approved study included a centralized review of histology slides and operative reports. RESULTS: Of 111 patients, 58.6% were male, median age 35 years (13%, ≤18 years). Histology was osteoblastic, chondroblastic, fibroblastic, conventional not otherwise specified and others in 39.6%, 30.6%, 8.1%, 12.6% and 8.0%, respectively. Pathological World Health Organisation grades were low, intermediate and high grade in 6.4%, 11.8% and 81.8%, respectively. Surgery was carried out for 94.5% of patients. Neoadjuvant chemotherapy (mixed protocols) was carried out in 93.1% of patients. Postoperative chemotherapy and radiotherapy were carried out in 54.7% and 23.8%, respectively. Median follow-up was 59.6 months (range). Five-year local control, metastasis-free, disease-free and overall survival rates were 64.6%, 68.9%, 53.2% and 69.2%, respectively. Survival was significantly associated with age, tumor size and surgery. Wide surgery with clear margins and free flap reconstruction was the strongest prognostic factor. Neoadjuvant chemotherapy improved disease-free and metastatic-free survival and increased clear margins rates from 50% to 68%. Intermediate grades behaved like high grades in terms of metastatic-free and disease-free survival. CONCLUSION: This homogeneous series is the largest to date and emphasizes the major impact of clear margins and multidisciplinary management. Neoadjuvant chemotherapy improves disease-free survival and should be recommended for both high and intermediate grade MOS.

Clinical and histological prognostic factors in locally advanced oral cavity cancers treated with primary surgery.

OBJECTIVE: The primary objective of this study was to determine the clinical and pathological prognostic factors in locally advanced oral cavity cancers treated by primary surgery. METHODS: All patients treated by primary surgery with free-flap reconstruction for locally advanced oral cavity squamous cell carcinoma in our institution between 2000 and 2010 were included in this retrospective study. Overall, cause-specific and locoregional disease-free survivals were determined by Kaplan-Meier analyses. Clinical and histological prognostic factors were assessed by univariate (Log Rank tests) and multivariate (Cox models) analyses. RESULTS: A total of 149 patients (102 men and 47 women; mean age=61.3±12.1 years) were included in the study. Five-year overall, cause-specific and locoregional disease-free survivals were 55%, 68% and 71%, respectively. Age, comorbidity and tumour size (histological evaluation) were significantly correlated with overall survival (P<0.05). Age, tumour size, bone invasion and surgical margins were significantly correlated with locoregional disease-free survival (P<0.05). CONCLUSION: The main prognostic factors identified in this study were clinical (age and comorbidity) and histological (pathological tumour size, bone invasion and surgical margins).

Prognostic impact of tumour multifocality in thyroid papillary microcarcinoma based on a series of 160 cases.

OBJECTIVE: The objective of this study was to evaluate the prognostic impact of tumour multifocality in papillary thyroid microcarcinoma (PTMC). METHODS: All patients who underwent total thyroidectomy and central neck dissection for PTMC in our institution between 1990 and 2007 were included in this retrospective study. Statistical correlations between tumour multifocality and various clinical or pathological prognostic parameters were assessed by univariate and multivariate analyses. RESULTS: A total of 160 patients (133 women and 27 men; mean age: 47.8±13.7 years) were included in this study. Tumour multifocality was demonstrated in 59 (37%) patients. Central neck metastatic lymph node involvement was identified in 46 (28%) patients. No statistical correlation was demonstrated between tumour multifocality and the following factors: age, gender, tumour size, extension beyond the thyroid, metastatic central neck lymph node involvement and risk of recurrence. A tumour diameter greater than 5mm was associated with a higher risk of recurrence (P=0.008). CONCLUSION: Tumour multifocality does not appear to have a prognostic impact in PTMC.

Cervical sympathetic chain schwannoma.

INTRODUCTION: Cervical schwannoma is a benign peripheral nerve tumor specifically developing from Schwann cells. Cervical sympathetic chain schwannoma is rare. Following a case report, the authors describe its specific radiological and histological characteristics. Treatment is surgical. CLINICAL CASE: A 56-year-old woman consulted for an isolated left lateral cervical mass of several years' standing, but with recently associated pharyngeal discomfort. Cervical CT revealed a vascularized retrostyloid mass with venous-time enhancement, inducing anterior displacement of the jugulo-carotid axis. The tumor could not be identified on fine-needle aspiration cytology, and surgical resection was performed by cervicotomy. Surgical exploration found a tumor developing from the cervical sympathetic nerve, posterior to the jugular vein and carotid sheath. Histopathologic examination diagnosed schwannoma. Postoperative outcome featured Horner's syndrome. CONCLUSION: Cervical sympathetic chain schwannoma is a rare benign tumor, to be suspected in the presence of an isolated lateral cervical mass. Preoperative CT is mandatory to guide diagnosis; treatment is surgical, to confirm histologic diagnosis. Postoperative Horner's syndrome often confirms cervical sympathetic chain involvement.