Long-term survival after head and neck cancer surgery with immediate free flap reconstruction.

BACKGROUND: Head and neck cancer is one of the most frequent cancers worldwide. A combination treatment including surgery is known to have a better survival rate than exclusive radiotherapy-chemotherapy. In extreme cases of non-metastatic patients who have voluminous tumor, or complex location, surgery with immediate reconstruction by free flap could be an option to improve long term survival. PURPOSE: To share experience of long-term survival of patients with head and neck cancer who underwent oncologic surgery with immediate free flap reconstruction, and to analyze influencing factors. METHODS: All consecutive patients treated with free flaps for reconstruction of extensive defects after resection of head and neck cancer in our center (Nancy, France) were retrieved from the hospital database. Data was recorded in a systematic way. Bivariate and multivariate Cox proportional hazards models were used for statistical analysis. RESULTS: Between 1997 and December 2007, 70 patients underwent surgical resection of head and neck tumor with free flap reconstruction. 11 patients were excluded because of missing data. Follow-up time was 7.4 years, IQR from 4.3 to 11.3. Overall survival was 53.8%, 95% CI [39.9%; 65.8%] at 5 years and 38.6% [24.8%; 52.3%] at 10 years. Age>60 years at the surgery HR 2,373 (1,143; 4,927) and TNM score 3-4 HR 2,524 (1,093; 5,828) were statistically associated to a lesser survival rate. CONCLUSION: The ability to successfully and safely perform free flaps increases treatment options for patients with advanced head and neck cancer in a selected population. it seems worthwhile to perform these microvascular reconstructions.

Transoral robotic surgery for squamous cell carcinomas of the posterior pharyngeal wall.

Posterior pharyngeal wall squamous cell carcinomas (SCCs) are rare and have an associated poor prognosis. Progress in transoral resection techniques, in particular, transoral robotic surgery (TORS), have renewed the role of surgery in their treatment. This article presents the oncological and functional results obtained by the French Group of Head and Neck Robotic Surgery for TORS for posterior pharyngeal wall SCC-curative surgery. This retrospective, multicentre study presents data collected between September 2009 and November 2013 for patients treated with TORS for posterior pharyngeal wall SCCs. Analysis of patient characteristics, tumour and treatment details were completed. Kaplan-Meier analysis was used to calculate overall survival rates and recurrence-free survival rates. Student's t test and Chi2 test were also calculated. 23 patients were included (mean age of 62 years). 12 patients had a prior HNSCC. Ten patients had pT1 cancers. The overall two-year survival rate was 59%, but 89% for pT1 compared to 28% for pT2-T3 (p = 0.01). It was noted that TORS was simple to perform, but generated significant post-operative dysphagia. Two cases of spondylodiscitis were reported as specific post-operative complications of TORS. In conclusion, TORS is a treatment solution for selected posterior pharyngeal wall SCCs. It provides a possible alternative to medical treatment for early pT1 lesions and is often the only remaining curative solution in patients previously treated with radiotherapy. In cases of bulky resection, or when there is a past medical history of radiotherapy, a tissue reconstruction by forearm free-flap may be indicated.

Review of sentinel node procedure in cN0 head and neck squamous cell carcinomas. Guidelines from the French evaluation cooperative subgroup of GETTEC.

The reliability of the sentinel lymph node (SN) technique has been established for more than ten years in T1-T2 oral cavity and oropharynx squamous cell carcinoma. Although most authors stress the necessity of rigorous implementation, there are no agreed guidelines. Moreover, other indications have been described, in other anatomical areas of the upper aerodigestive tract and in case of previous surgery or radiotherapy. SN expert teams, under the GETTEC head and neck tumor study group, conducted a review of the key points for implementation in head and neck cancers through guidelines and a review of classical and extended indications. Reliability depends on respecting key points of preoperative landmarking by lymphoscintigraphy, and intraoperative SN sampling and histological analysis. The SN technique is the best means of diagnosing occult lymph node involvement, whatever the primary tumor location, T stage or patient history.

Plasmablastic lymphoma: oral presentation in patient suffering from osteradionecrosis of the jaw.

INTRODUCTION: We describe here an unusual presentation of a plasmablastic lymphoma in a patient suffering from an osteoradionecrosis of the jaw. PRESENTATION OF CASE: We report the case of a 64-year-old patient who was followed up on oncology because of an oropharyngeal cancer treated by a combined procedure of both surgery and radio-chemotherapy procedure. This patient developed an osteoradionecrosis of the jaw. In the vicinity of this necrotic area appeared an ulceration which could evoke a new necrotic area. Given the persistence of this ulceration, a biopsy was performed which highlighted a plasmablastic lymphoma oral localization. DISCUSSION: The plasmablastic lymphoma, belonging to the diffuse large B-cell lymphoma family, is a very aggressive and unusual form of cancer with poor prognosis. If it is found mainly in patients with positive HIV, in whom it was first described, it is also found in immunosuppressed patients such as transplanted patients or patients suffering from leukaemia. CONCLUSION: Plasmablastic lymphoma is a rare and an aggressive pathology in immunocompetent patients.

Morbidity and mortality revue of the French group of transoral robotic surgery: a multicentric study.

Transoral robotic assisted surgery (TORS) represents an innovative endoscopic therapeutic alternative in the treatment of head and neck tumors. Many publications favor this surgery, especially in terms of functional results. The aim of this study was to investigate the TORS morbidity and mortality and to identify the risk factors for complications. It is a multicenter retrospective study. All head and neck tumor patients treated by TORS were included in the study over a period of 5 years (2009-2014). The studied parameters were the intraoperative and post-operative complications including hemorrhage, fistula, tracheotomy, aspiration pneumonia and death. The parameters were correlated with age, tumor location, tumor stage, endoscopic exposure and patient's co-morbidities. 178 patients were included in the study. Malignant tumors classified as T1 were found in 169 cases (n = 51), T2 (n = 100), T3 (n = 16) and T4 (n = 2). The tumor locations were distributed as follows: larynx (n = 84), oropharynx (n = 51), and hypopharynx (n = 43). Fifty-three patients followed post-radiation therapy. We observed 12 intraoperative complications including 6 hemorrhage, 3 pharyngeal fistulas and 3 external surgical conversions. Postoperatively, we detected 33 hemorrhage, 27 aspiration pneumonia, 9 tracheostomy, 2 pharyngostomes, 2 cervical spondylitis and 2 deaths. The risk factors identified were (i) anticoagulant and/or antiplatelet therapy for hemorrhage, (ii) tumoral stage and the laryngeal location for aspiration pneumonia and (iii) laryngeal location for tracheostomy. Higher age over 65 years has been identified as a risk factor for all post-operative complications. TORS is a safe technique for the treatment of head and neck tumors. We identified some risk factors for complications which should systematically be studied in order to reduce its morbidity.

Detection of disseminated tumor cells in aspirative drains after neck dissection.

The dissemination of individual tumor cells is a common phenomenon in solid cancers. Detection of tumor cells in bone marrow disseminated tumor cells (DTC) and in peripheral blood circulating tumor cells (CTC) in nonmetastatic situation is of high prognostic significance. Compared to breast, colon and prostate cancers, the studies on CTC and DTC in head and neck cancers are sparse. The objective of our study was to detect DTC in drains after neck dissection. Fourteen patients undergoing surgery for stages III and IV head and neck cancers were enrolled in this study--twelve presenting with squamous cell carcinoma and two with adenocarcinoma. Redon drain analysis was performed by the Cellsearch method using immunomagnetic and fluorescence approaches. A positivity threshold value was set at 2DTC/7.5 ml of the sample. Tumor cells were detected in drains of 69 % of patients a few days after surgery. The range of quantification was 3-2,094 DTC/5 ml and we showed morphological differences between the two types of carcinoma cells. DTC were detected after neck dissection both in squamous cell carcinoma and in adenocarcinoma. Potential clinical significance of tumor cells needs to be further investigated as their presence could affect pre-surgical and post-operative treatments.

Head and neck reconstruction with pedicled flaps in the free flap era.

Nowadays, the transposition of microvascular free flaps is the most popular method for management of head and neck defects. However, not all patients are suitable candidates for free flap reconstruction. In addition, not every defect requires a free flap transfer to achieve good functional results. The aim of this study was to assess whether pedicled flap reconstruction of head and neck defects is inferior to microvascular free flap reconstruction in terms of complications, functionality and prognosis. The records of consecutive patients who underwent free flap or pedicled flap reconstruction after head and neck cancer ablation from 2006 to 2015, from a single surgeon, in the AOUC Hospital, Florence Italy were analysed. A total of 93 patients, the majority with oral cancer (n = 59), were included, of which 64 were pedicled flap reconstructions (69%). The results showed no significant differences in terms of functional outcome, flap necrosis and complications in each type of reconstruction. Multivariate regression analysis of flap necrosis and functional impairments showed no associated factors. Multivariate regression analysis of complicated flap healing showed that only comorbidities remained an explaining factor (p = 0.019). Survival analysis and proportional hazard regression analysis regarding cancer relapse or distant metastasis, showed no significant differences in prognosis of patients concerning both types of reconstruction. In this retrospective, non-randomised study cohort, pedicled flaps were not significantly inferior to free flaps for reconstruction of head and neck defects, considering functionality, complications and prognosis.

Occult cancer in specimens of reduction mammaplasty aimed at symmetrization. A multicentric study of 2718 patients.

Women who have undergone surgical treatment for breast cancer often benefit from a contralateral reduction mammaplasty (CRM) aimed at symmetrization of the contralateral breast unaffected by the initial cancer. In our 7-year multicentric study (12 centers) of 2718 patients, incidence of CRM cancers (CRMc) was 1.47% (n = 40) [95% CI 1.05%-2.00%]. The CRMc group had significantly more initial mammary cancers of invasive lobular carcinoma (ILC, 22.5% vs 12.0%) and ductal carcinoma in situ (DCIS, 35.0% vs 21.6%) types than the healthy CRM group (p = 0.017). 35.0% (n = 14) of patients had en bloc resection; 25.0% (n = 10) of surgical specimens were correctly oriented. En bloc resection and orientation of surgical specimens enable precise pinpointing of the CRMc. A salvage lumpectomy may be proposed as an option when margins are invaded. The histological distribution of the 40 CRMc (mean size 12.7 mm) was carcinoma in situ (CIS) 70%, ILC 12.5%, invasive ductal carcinoma (IDC) 12.5% and tubular carcinoma (TC) 5.0%.

Value of the preservation of an osseous mandibular rim with a fibula free flap reconstruction.

BACKGROUND: Reconstruction of the mandible with microvascularized fibula transplants is actually a well-established procedure, yet the major component is the limited diameter of the diaphysis that can induce oral rehabilitation's failure, especially in dentate patients. In this paper, we report our surgical procedure allowing preservation of the mandibular height. The primary objective was to assess aesthetic and functional improvements of preservation of an osseous mandibular rim with a fibula free flap reconstruction. PATIENTS AND METHODS: Five patients (all males, mean age of 60 years) were treated with this method. Aetiologies were tumour in 3 cases, and osteoradionecrosis in the two others cases. We described all step of our surgical procedure and the functional, aesthetic and carcinologic results were evaluated. The follow up varies from 6 to 30 months. RESULTS: One patient died at 12 days from unrelated affection. For the other patients, both the aesthetics and functional outcomes were better than in case of mandibular interruption surgery. In fact, the mandibular contour of the mandibule was preserved and the height of mandible was restored. One patient is in progress of dental rehabilitation with osseous implants. Carcinologically, no local recurrence was observed. CONCLUSION: This technique is reliable and enables to optimize oral rehabilitation with endosteal implants. Nevertheless, we consider that the 3D scanner is essential before the intervention to evaluate the osseous reach. Moreover, if necessarily the procedure can be modified intraoperatively.

Guidelines of the French Society of Otorhinolaryngology (SFORL), short version. Extension assessment and principles of resection in cutaneous head and neck tumors.

Cutaneous head and neck tumors mainly comprise malignant melanoma, squamous cell carcinoma, trichoblastic carcinoma, Merkel cell carcinoma, adnexal carcinoma, dermatofibrosarcoma protuberans, sclerodermiform basalioma and angiosarcoma. Adapted management requires an experienced team with good knowledge of the various parameters relating to health status, histology, location and extension: risk factors for aggression, extension assessment, resection margin requirements, indications for specific procedures, such as lateral temporal bone resection, orbital exenteration, resection of the calvarium and meningeal envelopes, neck dissection and muscle resection.

Incidence of occult contralateral carcinomas of the breast following mastoplasty aimed at symmetrization.

INTRODUCTION: Breast carcinomas are the most frequent form of cancer in French women. Following a total mastectomy, only an estimated 25% of patients wish to undergo breast reconstruction. After mammary volume reconstitution, the plastic surgeon often attempts to harmonize the two breasts by carrying out contralateral reduction mammaplasty (CRM). In the literature, the incidence of occult contralateral carcinomas incidentally discovered in surgical specimens ranges from 1.12 to 4.5%. The main objective of this study was to evaluate occurrence of carcinoma in the CRM specimens in the framework of a breast reconstruction operation. The secondary objective was to determine the consequences of the incidentally discovered carcinoma in the contralateral breast. MATERIAL AND METHODS: This was a 6-year, bicentric, retrospective study involving women having undergone breast cancer surgery who later underwent contralateral reduction mammaplasty (CRM), that is to say reconstruction aimed at harmonization of the two breasts. RESULTS: Three hundred and nineteen patients were included in the study. Mean age during the CRM was 55years (29-79). Mean weight of the surgical specimens was 323grams (12-2500). Incidence of occult carcinomas found in the specimens was 0.94% (3 patients). The mean age for these 3 cases was 58years (47-64). All 3 patients had superior pedicle mammaplasty. One of the patients benefited from monobloc resection with orientation of the surgical specimen. In the other 2 cases, there existed 3 surgical resection specimens; in one case, they were oriented; in the other, they were not. In all 3 cases, the histological findings were unifocal ductal carcinomas in situ (DCIS). Mean tumor size was 5.7mm (3-9). Only the patient having had monobloc resection with orientation of the specimen underwent salvage surgery, which consisted in partial mastectomy, otherwise known as secondary lumpectomy. Adjuvant radiotherapy was administered to all of the patients. After 17months of mean follow-up (12-22), no recurrence was found in any of the three cases. CONCLUSION: Incidence of occult contralateral breast carcinomas after symmetrization CRM approximates 1%. Our observations are in agreement with the data in the literature. Incidence is greater than in mammaplasty carried out for esthetic or functional reasons; this is probably due to the higher age and the previous breast cancer history of the breast reconstruction population. Monobloc resection and orientation of the surgical specimens with surgeon's knots facilitate precise pinpointing of the occult carcinoma. A secondary lumpectomy may take place when margins of excision are invaded or inadequate.

Laryngeal chondrosarcoma: repeated laser and radiofrequency ablation in the palliative setting.

OBJECTIVE: The purpose of this article is to illustrate the use of radiofrequency and laser ablation in head and neck oncology and to describe the management of a case of laryngeal chondrosarcoma in a 90-year-old patient. CASE REPORT: A 90-year-old man, WHO performance status 3, with low-grade laryngeal chondrosarcoma was seen in the outpatients department at the end of 2008 for assessment of dysphonia. Total laryngectomy was considered to be too invasive and was consequently excluded. The patient was initially tracheotomized under local anaesthesia to relieve dyspnoea and was subsequently managed symptomatically by radiofrequency and laser ablation to ensure laryngeal disobstruction, allowing the patient to be extubated followed by speech therapy and oral feeding rehabilitation. DISCUSSION/CONCLUSION: This patient received symptomatic palliative treatment with a combination of radiofrequency and laser. Radiofrequency ablation can be applied in head and neck oncology as an alternative treatment to surgery allowing improvement of quality of life and survival.

Oral metastasis: a report of 23 cases.

The authors describe a pooled analysis of 23 French patients presenting with oral metastasis between 1981 and 2008. The reviewed cases were collected from the medical records of two cancer institutes. The inclusion criteria were: the histology of the metastases must be known; the primary location must be known; metastasis and primary location must be physically separated; and oral primary locations were excluded. This sample represent 0.48% of all oral malignancies treated during the period. The sex-ratio was 2.3:1 in favour of men, the mean age was 64.5 years (±13.2). Lungs and kidneys represent 52.2% of the primary cancer locations. In most cases, the primary cancer was a carcinoma or an adenocarcinoma (82.6%). The most affected oral regions were the gingiva and alveolar mucosa (60.7%), followed by the tongue (17.9%). The mean survival was 16.6 months. This sample is characterized by the relative absence of specific symptoms and quite different distribution in primary sites. Even if oral metastases are rare, their semiological value necessitates the histopathological examination of any oral tumour, and a systematic search in all patients with cancer history.

Development of an osteosarcoma following dental extraction after allogeneic stem cell transplantation.

OBJECTIVES: Radio-induced sarcoma is known to occur several years following bone irradiation especially when this treatment is combined to high dose chemotherapy regimens prior to allogeneic haematopoietic stem cell transplantation (HSCT) in very young children. However, little is known about the stimulus of aggressive bony surgery in the development of these tumours. MATERIAL AND METHODS: We report the case of a young girl in whom dental extraction was rapidly followed by the occurrence of a localized tumour 11 years after allogeneic haematopoietic stem cell transplantation using total body irradiation (TBI) for a haemophagocytic lymphophistiocytosis (HLH). RESULTS: This tumour involved tooth socket and all the right side of the mandible and was diagnosed as an osteogenic osteosarcoma of the zygomatic bone. CONCLUSION: This tumour had the characteristics of a radio-induced sarcoma. Thanks to the very short time between the dental extraction and the occurrence of the osteosarcoma at the same location, we discuss the role of the dental extraction as a trigger of osteosarcoma development.

Combined transoral and suprahyoid approach for oropharyngeal cancers: an alternative to mandibulotomy.

UNLABELLED: Surgical treatment of oropharyngeal tumours usually requires mandibular osteotomy. Using this technique allows a better exposure and an easier excision, but this approach often generates complications. Since 1995, we used a less aggressive surgical technique, with a suprahyoid pharyngotomy when the oral approach was not sufficient, thus sparing the mandible. OBJECTIVE: The purpose of this study is to evaluate this technical evolution, ensuring that mandibular preservation doesn't affect quality of exeresis, local control and survival, while allowing a lower complication rate. MATERIAL AND METHODS: All patients who have had a surgical treatment for an oropharyngeal carcinoma between 1995 and 2001 in our center were included in this study. RESULTS: Mandibular sparing was used for 55 patients; 19 patients underwent mandibulotomy. The surgical procedure's quality was classified as clear, close, or insufficient margins. All adjuvant treatments were noted, functional and carcinologic results were evaluated. No significant differences are found for exeresis quality and local control. There are less complications (p = 0.045) and less surgical revisions (p = 0.023) in the preservation group. Survival and functional results are better in the preservation group, but without significant difference. For oropharyngeal tumours, survival is dependent on tumoural aggressivity, on general condition and co-morbidity and on the development of a second tumour. Results in local control rate (83.7% at 1 year) are satisfying compared to literature. CONCLUSION: Mandibular preservation is an efficient and safe procedure, even for T3/T4 tumours. Most of oropharyngeal tumours can be removed without mandibulotomy. The suprahyoid approach provides a good exposure when oral approach is insufficient, thus avoiding mandibulotomy and its complications.

Navigation in head and neck oncological surgery: an emerging concept.

Navigation surgery, initially applied in rhinology, neurosurgery and orthopaedic cases, has been developed over the last twenty years. Surgery based on computed tomography data has become increasingly important in the head and neck region. The technique for hardware fusion between RMI and computed tomography is also becoming more useful. We use such device since 2006 in head and neck carcinologic situation. Navigation allows control of the resection in order to avoid and protect the precise anatomical structures (vessels and nerves). It also guides biopsy and radiofrequency. Therefore, quality of life is much more increased and morbidity is decreased for these patients who undergo major and mutilating head and neck surgery. Here we report the results of 33 navigation procedures performed for 31 patients in our institution.

[Sentinel lymph node biopsy for lymphophilic conjunctival and eyelid tumors: report of 8 cases]. / Biopsie du ganglion sentinelle dans les tumeurs lymphophiles conjonctivales et palpébrales: à propos de 8 cas.

OBJECTIVE: To report our experience in sentinel lymph node biopsy for lymphophilic conjunctival and eyelid tumours. METHODS AND RESULTS: Preliminary study (2005-2007) on 8 patients with conjunctival and or eyelid tumours (melanomas, epidermoid carcinoma, Merkel cell carcinoma). All patients underwent preoperative lymphoscintigraphy 18 FdG pet CT Surgery was performed with complete neck dissection. Sentinel nodes and other nodes harvested were processed separately for histopathologic study; the sentinel were confirmed as histologicaly positive for five patients. Additional positive nodes were found in two out of those five patients. No positive lymph node was found in patients with negative lymphoscintigraphy. After a follow up ranging from 12 to 43 months: two patients died, and 6 are free of disease. CONCLUSIONS: These results demonstrate a very hight level of invaded NO lymph node and confirm the interest of sentinel node technique for optimisation of the therapeutic strategy in lymphophilic conjunctival and eyelid tumours.