Morphologic assessment of mandibular reconstruction by free fibula flap and donor-site functional impairment in a series of 23 patients.

INTRODUCTION: Micro-anastomosed free fibula flap is an attitude of choice in mandibular defect repair in oncology, enabling effective functional rehabilitation. The present study assessed donor and recipient site morphology and donor-site sequelae. PATIENTS AND METHODS: The study consecutively recruited patients undergoing mandibular resection with free fibula flap reconstruction in our centre between December 2003 and September 2008. Assessment on adapted scales was performed by two independent expert physicians and patient self-assessment. RESULTS: Out of 49 mandibular reconstructions performed in the centre over the 5-year study period, 23 patients free of recurrence were included. Satisfaction rates were 73% for the recipient site and 70% for the donor-site, with patient/expert agreement of 47% and 49.5% respectively. Donor-site impact was mainly in terms of reduced ankle range of motion (43% of cases) and flexion strength (39%) and discomfort in running (35%) and walking (26%). Risk factors for dissatisfaction were more than 5% weight loss at admission for recipient site dissatisfaction (patient, P=0.012; expert, P=0.046), and skin graft for donor-site dissatisfaction (patient, P=0.04; expert, P=0.035). CONCLUSION: Free fibula flap was associated with high satisfaction rates, but non-negligible donor-site impact.

Management of the neck in the setting of definitive chemoradiation: is there a consensus? A GETTEC study.

BACKGROUND: The management of the neck remains controversial in the definitive chemoradiation setting of advanced N2-3 head and neck squamous cell carcinoma. Most published data favor omission of neck dissection (ND) after complete response for N2-3 or selective ND for residual disease METHODS: We studied the patterns of care in the French-Belgian Groupe d'Etude des Tumeurs de la Tête Et du Cou (GETTEC) through a questionnaire-based survey. RESULTS: Eighteen percent of institutions never performed up-front ND, 20% rarely, 40% sometimes, 14% often, and 8% systematically. Induction chemotherapy was indicated in 30% of the cases, and most ND were performed either between induction and radiation or after chemoradiation for residual disease. Response to chemoradiation was assessed by computed tomographic scan and positron emission tomography in 72% of cases. Selective ND was more common than radical ND. CONCLUSIONS: Omission of ND based on computed tomographic scan and positron emission tomography-based complete response to chemoradiation is the most common strategy for advanced nodal disease among centers. However, neck management strategies vary among institutions, and some institutions continue advocating systematic ND before irradiation. The new treatment options and the changing epidemiology, namely docetaxel-based induction chemotherapy and human papilloma virus-related head and neck squamous cell carcinoma having better response profiles and prognosis, are adding to the nonconsensual approach. The best therapeutic index in terms of neck management remains to be defined in this evolving context.

Totally implantable venous access port systems and risk factors for complications: a one-year prospective study in a cancer centre.

BACKGROUND: Totally Implantable Venous Access Port Systems (TIVAPS) are widely used in oncology, but complications are frequent, sometimes necessitating device removal and consequently delays in chemotherapy. The aim of this study was to investigate possible risk factors for morbidity. METHODS: A total of 815 consecutive cancer patients (median age: 56.2 years [0.8-85.2]; 522 female) were enrolled in this observational, single-centre study between May 2nd 2006 and April 30th 2007. TIVAPS implantation involved principally cephalic or external jugular vein access. Patients were followed up for one year unless the device was removed earlier. RESULTS: The overall morbidity rate was 16.1% (131/815). Complications necessitated device removal in 55 patients a mean of 3.7 months [0.2-12.0] after implantation. These comprised TIVAPS-related infection (19), port expulsion (14), catheter migration (6), venous thrombosis (5), mechanical problems (3), skin disorders (2), pain (2), drug extravasation (2) infection unrelated to TIVAPS (1) and inflammation (1). No patient died during the study. The factor most strongly predictive of complications was the interval between insertion and first use of the TIVAPS, ranging from 0 to 135 days (median: 8.0 days). The morbidity rate was 24.4% when this interval was 0-3 days, 17.1% when it was 4-7 days and 12.1% when it exceeded 7 days (p < 0.01; Chi(2) test). The median interval was 6 days (0-53) and 8 days (0-135), respectively, in patients with and without complications (p < 0.001). CONCLUSION: To reduce complications, an interval of at least 8 days between placement of the TIVAPS and its first use may be advisable.

Nasal septum perforation: a side effect of bevacizumab chemotherapy in breast cancer patients.

BACKGROUND: Bevacizumab is an anti-vascular endothelial growth factor approved in association with paclitaxel or docetaxel as first line in patients (pts) with metastatic breast cancer. Rare cases of nasal septum perforations have been reported. We report our experience of nasal perforation in breast cancer pts receiving bevacizumab and chemotherapy either in the adjuvant or in the metastatic settings. METHODS: Between 1 January and 31 December 2009, 70 pts received bevacizumab together with chemotherapy. All the pts who had received bevacizumab were referred to the ENT specialist. Symptoms potentially related were looked for. Side effects were graded according to CTCAE. RESULTS: Five nasal septum perforations were diagnosed (5 out of 70; 7.14%). Bevacizumab dose was 15 mg kg(-1) 3 weekly. Three pts were metastatic. Bevacizumab was associated with docetaxel (100 mg m(-2) every 3 weeks) in two pts and with weekly paclitaxel in one. The last two pts received bevacizumab in combination with anthracyclin and then taxanes in the adjuvant setting. In these two cases, nasal septum perforation occurred at the time of docetaxel treatment. CONCLUSION: A high incidence of nasal septum perforation has been shown in pts with breast cancer receiving bevacizumab together with chemotherapy. Several mechanisms could be involved (mucositis, delayed tissue repair, antiangiogenic action of taxanes).

[New challenge in head and neck oncology surgery: the transoral robotic surgery]. / Nouveaux aspects télérobotiques en cancérologie tête et cou.

Robotic assisted surgery is a new field of developing program for many specialties. As to head and neck oncology, the new procedure potentially offers alternatives to conventional surgery with decreased morbidity. The aim of this article is a description of the state of the art via a review of the literature. We emphasize limits and future prospects on this topic with a special focus on dependability. Transoral robotic surgery (TORS) is a promising surgical procedure contingent on the development of new associated functions like an image guidance system or a force feedback control. The good developing of this new tool will also depend on the quality of clinical works and research programs.

The free vascularized flap and the pectoralis major pedicled flap options: comparative results of reconstruction of the tongue.

Reconstruction after extensive resection of the tongue remains a surgical challenge. Free soft-tissue transfer is now favored for head and neck reconstruction following cancer resection. However, the choice of either free tissue transfer (FTT) or of the pedicled Pectoralis Major Musculocutaneous Flap (PMMF), the workhorse in head and neck reconstruction, remains controversial. The purpose of this study is to assess the post-operative outcomes after radical ablative surgery and reconstruction for patients with a tongue cancer. We conducted a retrospective comparison of two different reconstruction techniques. From January 2000 to December 2006, 70 consecutive patients with tongue cancer had been treated with curative intent by extensive ablative surgery and soft-tissue reconstruction. Sixty percent of tumors were T3 or T4. We compared the post-operative outcomes of both populations: 25 patients underwent FTT and 45 underwent pedicled PMMF. Fifty-seven men and 13 women with a mean age of 55 years constitute the study population. The two groups were comparable in terms of age, gender, and addiction. The choice of flap technique was independent of the ASA scale (p=1.00), the weight of comorbidities (p=0.13), previous radiation therapy (p=0.09), the T-stage (p=0.44) or N-stage (p=0.21). Apart from the rate of flap necrosis, which occurred significantly more often in the PMMF group (p=0.02), post-operative complication rates did not differ between the two groups. The success rate of FTT was 96% (24/25). The duration of the post-operative stay was longer after use of the pedicled flap technique, but the difference did not reach statistical significance (mean duration in days: 23.2 vs. 18.1; p=0.10). Both groups did not differ as regards duration of use of a feeding tube (p=0.84) or of tracheostomy (p=0.54). Local disease-free survival was also similar (p=0.65). The two groups were similar in terms of patients' characteristics. The reliability of free flaps was higher than that of PMMF. The assessment of our practice in the case of extensive tongue defect suggests that reconstruction with free soft-tissue transfer, whenever feasible, should be the first-choice treatment option.

[Sensory function of FAMM flap: a report of 15 cases]. / Etude de la sensibilité du lambeau de FAMM : à propos de 15 cas.

INTRODUCTION: The facial artery musculomucosal (FAMM) flap described by Pribaz in 1992 is a musculomucosa flap of the cheek plugged into the higher or lower facial pedicle artery. Indications in terms of substance losses in the oral cavity are numerous. PATIENTS AND METHODS: Twenty cases carried out from 2003 to 2006 at the Oscar-Lambret Neck Surgery Cancer Center are reported with a study first on record, then a study on 15 patients (three deaths, two flaps take away for local recurrence). The dimensions of the flap, its epicritic sensitivity, its sensitivity to hot and cold temperatures, the Semmes-Weinstein test and a key test of pique were analyzed. A neck dissection was most often done in the cases studied, and did not advise against the flap. RESULTS: The main indication was represented by tumors of the floor of the mouth. Individual susceptibility testing were broadly similar to the flap and on the opposite side healthy. The results seem to show that, as with skin flaps, there is a complete recovery of sensation. CONCLUSION: This flap is very reliable and most often resensitizes. The low ligation of the artery during neck dissection does not jeopardize the survival (rich regional anastomoses). The FAMM flap makes up for the loss of medium size substance, it represents a very good solution between directed healing and more consistent skin flaps.

Prognostic factors for adult sarcomas of head and neck.

The optimal management of adult soft-tissue sarcomas is not clearly established. To assess prognostic factors and survival, the experience of 45 recent successive cases was reviewed. Data were collected from a retrospective database (1993-2005) and statistically analyzed. Rhabdomyosarcomas were excluded. The mean age was 50.1 years; there were 24 men and 21 women. The main histological subtypes were undifferentiated sarcoma (14) and angiosarcoma (10); 21 tumours were grade 3 (46%). The most frequent primary sites were neck muscles (15, 33%) and scalp (11, 24%). At presentation, 5 (20%) cases with lymph-node involvement and another 11 cases (24%) with distant metastasis were observed. The treatment was with curative intent in 33 cases (73%). This entailed surgery, with adjuvant radiotherapy in 15 cases and adjuvant chemotherapy in 5 cases. The 5-year overall survival was 52% (+/-8%). In univariate analysis, the poor prognostic factors were high grade, initial metastasis or lymph nodes, absence of surgery, and number of surgical procedures. In multivariate analysis, two factors remained significant: grade (P=0.006) and absence of surgery (P=0.005). After taking into account grade and metastasis at presentation, quality of surgery has prognostic value. The primary aim of a multidisciplinary approach to these tumours must favour complete resection.

[Radiological and surgical classification of head and neck lymph node anatomy]. / La classification radio-chirurgicale des niveaux ganglionnaires cervicaux.

OBJECTIVE: The purpose of this review is to present a systematic description of cervical lymph drainage by nodal level. MATERIAL AND METHODS: We present, in French, the radiological and surgical classification of the cervical lymph nodes with numerous illustrations. A critical analysis of the advantages and limitations of this tool is presented together with practical guidelines. RESULTS: This classification system is a useful tool for the evaluation of cervical metastases. It provides for more precise treatment and better understanding and communication between specialists, offering the standardization necessary for comparing results obtained by different teams and for multicenter studies. CONCLUSION: This classification of cervical lymph nodes by level is a useful tool for the management of cervical node involvement in head and neck cancer.

Aggressiveness and quantification of epithelial proliferation of middle ear cholesteatoma by MIB1.

OBJECTIVE: To assess an easy method that predicts cholesteatoma aggressiveness. STUDY DESIGN: An experimental prospective study. METHODS: Monoclonal antibody MIB1 was used to determine epithelium proliferation in 91 cholesteatomatous ears. Clinical and surgical parameters were compared with proliferation activity to determine pathological and clinical correlation. RESULTS: Statistical correlations were established between hyperproliferation of the cholesteatoma and severe bone erosion (leading to major cholesteatoma complications) and between hyperproliferation and middle ear inflammation (associated with more surgical difficulties and a higher risk of recurrence). A high proliferation index was also found in children's cholesteatoma, which is known to have more aggressive behavior. CONCLUSION: Immunohistochemical use of the MIB1 antibody is a simple technique that can help to determine the aggressiveness of a cholesteatoma.

Near total laryngectomy with epiglottic reconstruction. our experience of 65 cases.

From 1980 to 1998, 65 patients whose glottic lesions were classified T1 or T2 were operated with a reconstructive anterior frontal laryngectomy with epiglottoplasty such as described by Tucker (Arch Otolaryngol Head Neck Surg 115:1341-1344). This procedure consists of resection of the two vocal cords, in some cases one arytenoid, the anterior commissure with a part of the thyroid cartilage, the anterior part of both false vocal cords, and of 1 cm of the subglottis. The epiglottis is grasped downward to close the larynx. There were no per or postoperative deaths. Our functional results confirm those reported in the previous publications. The mean time of removal of the nasogastric tube was about 12 days and the patients were generally satisfied about their residual voice. Decannulation was performed after satisfactory peroral feeding, generally about 2 weeks postoperatively. Three patients only required subsequent procedures which can be considered due to functional failures. There were four recurrences, which means a 5-year actuarial local control rate of 94%. This operation takes place as part of our surgical treatment policy of laryngeal carcinomas, considering that this surgery is like an extensive frontolateral laryngectomy. In case of an infiltrating tumor or in case of invasion to the arytenoid cartilage, we perform a supracricoid partial laryngectomy with crico-hyoido-epiglottopexy (the Majer-Piquet's procedure).