[French national standard for the treatment of squamous cell carcinoma of upper aero-digestive tract - General principles of treatment]. / Référentiel national de traitement des carcinomes épidermoïdes des voies aérodigestives supérieures ­ Principes généraux de traitement.

OBJECTIVES: The management of upper aerodigestive tract cancers is a complex specialty. It is essential to provide an update to establish optimal care. At the initiative of the INCa and under the auspices of the SFORL, the scientific committee, led by Professor Béatrix Barry, Dr. Gilles Dolivet, and Dr. Dominique De Raucourt, decided to develop a reference framework aimed at defining, in a scientific and consensus-based manner, the general principles of treatment for upper aerodigestive tract cancers applicable to all sub-locations. METHODOLOGY: To develop this framework, a multidisciplinary team of practitioners was formed. A systematic analysis of the literature was conducted to produce recommendations classified by grades, in accordance with the standards of the French National Authority for Health (HAS). RESULTS: The grading of recommendations according to HAS standards has allowed the establishment of a reference for patient care based on several criteria. In this framework, patients benefit from differentiated care based on prognostic factors they present (age, comorbidities, TNM status, HPV status, etc.), conditions of implementation, and quality criteria for indicated surgery (operability, resectability, margin quality, mutilation, salvage surgery), as well as quality criteria for radiotherapy (target volume, implementation time, etc.). The role of medical and postoperative treatments was also evaluated based on specific criteria. Finally, supportive care must be organized from the beginning and throughout the patients' care journey. CONCLUSION: All collected data have led to the development of a comprehensive framework aimed at harmonizing practices nationally, facilitating decision-making in multidisciplinary consultation meetings, promoting equality in practices, and providing a state-of-the-art and reference practices for assessing the quality of care. This new framework is intended to be updated every 5 years to best reflect the latest advances in the field.

Geriatric assessment and quality of life for 2 years in older patients with head and neck cancer.

Due to the location and toxicity of treatments, head and neck cancer (HNC) has a major impact on quality of life (QoL). Objective: to assess the effects of geriatric-assessment (GA)-driven interventions on QoL over 2 years in older adults with HNC.EGeSOR was a randomized study of HNC patients aged ≥65, receiving a pretreatment GA, a geriatric intervention and follow-up (intervention) or standard of care (control). The primary endpoint was QoL score using the European Organisation for Research and Treatment of Cancer's (EORTC QLQ-C30) and HNC (QLQ-HN35) QoL questionnaires over 24 months.In total, 475 patients were included (median age: 75.3; women: 31%; oral cancer: 44%). QoL scores improved over 24 months with various trajectories, without significant differences between the groups. A total of 74% of patients (interventional group) did not receive the complete intervention. Cancer characteristics, functional status, and risk of frailty were associated with change in the Global Health Status QoL score.There is a need to develop an alternative model of implementation such as patient-centered health-care pathways. TRIAL REGISTRATION: NCT02025062.

Effectiveness of Geriatric Assessment-Driven Interventions on Survival and Functional and Nutritional Status in Older Patients with Head and Neck Cancer: A Randomized Controlled Trial (EGeSOR).

This study assesses the efficacy of Geriatric Assessment (GA)-driven interventions and follow-up on six-month mortality, functional, and nutritional status in older patients with head and neck cancer (HNC). HNC patients aged 65 years or over were included between November 2013 and September 2018 by 15 Ear, Nose, and Throat (ENT) and maxillofacial surgery departments at 13 centers in France. The study was of an open-label, multicenter, randomized, controlled, and parallel-group design, with independent outcome assessments. The patients were randomized 1:1 to benefit from GA-driven interventions and follow-up versus standard of care. The interventions consisted in a pre-therapeutic GA, a standardized geriatric intervention, and follow-up, tailored to the cancer-treatment plan for 24 months. The primary outcome was a composite criterion including six-month mortality, functional impairment (fall in the Activities of Daily Living (ADL) score ≥2), and weight loss ≥10%. Among the patients included (n = 499), 475 were randomized to the experimental (n = 238) or control arm (n = 237). The median age was 75.3 years [70.4-81.9]; 69.5% were men, and the principal tumor site was oral cavity (43.9%). There were no statistically significant differences regarding the primary endpoint (n = 98 events; 41.0% in the experimental arm versus 90 (38.0%); p = 0.53), or for each criterion (i.e., death (31 (13%) versus 27 (11.4%); p = 0.48), weight loss of ≥10% (69 (29%) versus 65 (27.4%); p = 0.73) and fall in ADL score ≥2 (9 (3.8%) versus 13 (5.5%); p = 0.35)). In older patients with HNC, GA-driven interventions and follow-up failed to improve six-month overall survival, functional, and nutritional status.

Donor site sequelae and patient satisfaction after head and neck reconstruction with a radial forearm free flap.

PURPOSE: Radial forearm free flap (RFFF) being a workhorse flap in head and neck reconstruction, we investigated its donor site delayed consequences. METHODS: Multicentric case series evaluating 189 patients who underwent RFFF for carcinologic reasons at least 6 months before. Patients and surgeon's appreciation regarding the aesthetic and functional consequences of the flap harvest on their daily life were evaluated by questionnaires using likert scales. Medical data were collected from patients' charts retrospectively. RESULTS: Thirty percent of patients had at least one sequelae. Experiencing a graft necrosis did not worsen long-term results. Cosmetic satisfaction was significantly worst for women, according to patients' and surgeons' opinion. For 81% and 92% patients, respectively, the flap harvest had no impact on daily life nor sport practice. Ratio between the benefits of reconstruction and the sequelae at the donor site was judged "excellent" for 77% patients. CONCLUSIONS: Although objectively important, RFFF morbidity has little impact in head and neck cancer patient's life.

[Classification of vascular tumours and vascular malformations. Contribution of the ISSVA 2014/2018 classification]. / Classification des tumeurs et malformations vasculaires. Apport de la classification ISSVA 2014/2018.

The study of vascular anomalies, "angiomas", vascular tumours and vascular malformations is made difficult by the great variety and confusion of the names used in the literature for these diseases, some of which are rare. The great merit of the classification proposed by the International Society for the Study of Vascular Anomalies (ISSVA), adopted in 2014 and modified in 2018, is to propose a unambiguous nomenclature and to try to group these lesions in a logical way, contrasting with the lists of the usual "classifications". This classification is based on the distinction between proliferative lesions (tumours and reactive lesions) and those which are due to a congenital anomaly of vascular morphogenesis (vascular malformations). It incorporates recent data on the molecular causes of these diseases. The major groups of lesions recognised in this classification will be presented and some lesions of interest briefly discussed. This classification aims to be usable by all medical specialties and applicable to all tissues and organs, even if efforts are still needed to integrate organ-specific names in order to unify the nomenclature and eliminate confusion. Even if it does not solve all the problems in this complex field, the unification of the nomenclature is a major contribution of this classification and pathologists are strongly encouraged to refer to it in daily practice.

Wall Shear Stress in the Feeding Native Conduit Arteries of Superficial Arteriovenous Malformations of the Lower Face is a Reliable Marker of Disease Progression.

PURPOSE: To assess the prognostic value of the wall shear stress (WSS) measured in the feeding native arteries upstream from facial superficial arteriovenous malformations (sAVMs). Reliable prognostic criteria are needed to distinguish progressive from stable sAVMs and thus support the indication for an aggressive or a conservative management to avoid severe facial disfigurement. MATERIALS AND METHODS: We prospectively included 25 patients with untreated facial sAVMs, 15 patients with surgically resected sAVMs and 15 controls. All had undergone Doppler ultrasound examination (DUS) with measurements of inner diameters, blood flow velocities, computation of blood flow and WSS of the feeding arteries. Based on the absence or presence of progression in clinical and imaging examinations 6 months after, we discriminated untreated patients as stable or progressive. RESULTS: WSS in the ipsilateral external carotid artery was higher in progressive compared to stable sAVMs (15.8 ±â€Š3.3dynes/cm² vs. 9.6 ±â€Š2.0dynes/cm², mean±SD, p < 0.0001) with a cut-off of 11.5dynes/cm² (sensitivity: 92 %, specificity: 92 %, AUC: 0.955, [95 %CI: 0.789-0.998], p = 0.0001). WSS in the ipsilateral facial artery was also higher in progressive compared to stable sAVMs (50.7 ±â€Š14.5dynes/cm² vs. 25.2 ±â€Š7.1dynes/cm², p < 0.0001) with a cut-off of 34.0dynes/cm² (sensitivity: 100 %, specificity: 92 %, AUC: 0.974, [95 %CI: 0.819-1.000], p = 0.0001). The hemodynamic data of operated patients were not different from those of the control group. CONCLUSION: WSS measured in the feeding arteries of an sAVM may be a simple reliable criterion to distinguish stable from progressive sAVMs. This value should be considered to guide the therapeutic strategy as well as the long-term follow-up of patients with facial sAVMs.

Diode endovascular laser treatment in venous malformations of the upper aerodigestive tract.

PURPOSE: Venous malformations of the upper aerodigestive tract can cause pain, dysphagia, obstructive sleep apnea, and rarely bleeding. We studied 980-nm diode endovenous laser therapy. MATERIAL AND METHODS: This is a 2007-2014 retrospective study in our vascular anomalies center. Data on patients' clinical history, polysomnography, magnetic resonance imaging, and treatment were collected. Patients were contacted for Epworth Sleepiness Scale and Eating Assessment Tool (EAT-10) scores to evaluate sleepiness and dysphagia before and after laser therapy. RESULTS: We included 32 patients (mean age 41 years) presenting with obstructive sleep apnea (n = 18) and dysphagia (n = 13). With a mean follow-up of 39 months, average Epworth Sleepiness Scale score fell from 17.3 to 10.4 (p = 0.015), EAT-10 score from 8.2 to 3.5 (p = 0.002) and apnea-hypopnea index from 47.5 to 24.7 (p = 0.01). Of the sleep apnea patients, 89% required continuous positive airway pressure before and 50% afterward (p = 0.016). CONCLUSIONS: Diode endovascular laser treatment seems to be a safe and effective treatment option in venous malformations of the upper airways.

Lengthening temporalis myoplasty versus hypoglossal-facial nerve coaptation in the surgical rehabilitation of facial palsy: evaluation by medical and nonmedical juries and patient-assessed quality of life.

BACKGROUND: To compare the results of 2 techniques of facial rehabilitation, lengthening temporalis myoplasty and 2 types of hypoglossal-facial (XII-VII) coaptation as evaluated by medical and nonmedical teams and patient self-assessment of quality of life (QOL). MATERIALS AND METHODS: Videos of 42 consecutive patients with complete facial palsy who underwent surgery from 1998 to 2005 were reviewed. Facial rehabilitation was by temporalis myoplasty (n = 10) or by XII-VII coaptation (n = 32) either end-to-end (n = 16) or end-to-side with a jump interpositional graft (n = 16). Evaluation was by (i) a medical jury using 4 facial nerve grading systems and 3 other measurements for the face at rest and during voluntary and emotional motions, (ii) a nonmedical jury using the 3 measures described above, and (iii) patient self-assessment of QOL by questionnaires. RESULTS: Whatever the grading systems used, the medical jury rated facial rehabilitation with XII-VII coaptation better than myoplasty. Scores did not differ between the 2 types of coaptation: synkinesis was severe with end-to-end and almost absent with end-to-side coaptation. However, muscle tone was stronger in the end-to-end than end-to-side coaptation. The nonmedical jury considered that XII-VII coaptation, whatever the type, led to better results than myoplasty. Patients in all groups considered their QOL improved by surgery, whatever the format, with no significant differences between the groups. CONCLUSION: This study revealed XII-VII coaptation with better results than myoplasty. End-to-end coaptation should be restricted to patients with a strong emotional expression or those with a long-standing facial palsy because it provides a strong muscle tone but significant synkinesis.

A rare clival and sellar fracture with pneumatocephalus.

We present a case of clival and sellar complex fracture produced by an indirect mechanism. This previously healthy patient had an occipital trauma followed by epistaxis. CT showed a clival and sellar fracture with pneumatocephalus. The probable fracture mechanism was contre-coup injury, linked to cerebral shock-wave transmission. This type of fracture is generally observed in the anterior part of the skull base, in a low resistance area. Severe osteoporosis probably accounted for the unusual fracture site in this patient. A mechanism of direct clival transmission is discussed, together with the usual complications of sphenoid injuries.