Late metastasis from renal cell carcinoma to the thyroid and nasal cavity: report of a case.

Multifocal cervico-facial metastases are very rare. Medical history of the patient and clinical context make easier the diagnosis. A 54-year-old woman presenting with a nasal obstruction, was referred to our department. She had a past medical history of an operated renal cancer 12 years ago and a right hemithyroidectomy 30 years ago. Clinical examination revealed a polypoid lesion obstructing the right nasal cavity and a thyroid goiter. Fine-needle aspiration was positive for a renal metastasis. Computed tomography confirmed the nasal lesion without bone destruction and a cervical cystic lesion into the left thyroid lobe. Completion thyroidectomy and polyp excision were performed. The final histologic examination revealed a metastasis from a renal cancer. The association of intra-thyroid and nasal cavity metastases is uncommon and not related in the literature, the practitioner must suspect the diagnosis if the patient had a thyroid tumor, a suspicious nasal lesion and a past history of cancer. The surgical management is recommended for isolated metastasis to the nasal cavity and the thyroid gland especially in renal cancer.

[Metastatic melanoma to the oropharynx]. / Métastase oropharyngée d'un mélanome cutané.

INTRODUCTION: Metastatic mucosal melanoma to the oropharyngeal area is extremely rare. Only 0.6% to 3% of patients with cutaneous malignant melanoma will have metastases to the mucosa of the upper aerodigestive tract. CASE REPORT: A 60-year-old woman presented with a past history of dorsal melanoma and metastatic inguinal node was referred to our department for odynophagia. Physical examination revealed a mass of the right tonsil. A cervico-facial computed tomography, a magnetic resonance imagery and PET-scanner were performed and showed the tumefaction located at the right tonsil. Biopsy was performed under general anesthesia. The histological examination revealed a metastatic melanoma. After discussion a palliative treatment with chemotherapy was begun. The patient died of disseminated disease 2 months after the beginning of the chemotherapy, only 4 months after the initial diagnosis. DISCUSSION/CONCLUSION: The case presentation indicates that careful examination of the head and neck should be part of the routine follow-up examination in all melanoma patients. The discovery of mucosal metastasis in head and neck indicated widespread dissemination and a poor prognosis.

Cholesterol granuloma of the maxillary sinus.

INTRODUCTION: Cholesterol granuloma (CG) can be found in several areas of the body. Maxillary sinus localization is considered rare. CASE REPORT: A 37-year-old male presented with acute febrile sinusitis. Nasal endoscopy showed a nasal polyp at the middle meatus. Computed Tomography (CT scan) of the sinus showed complete opacity of the right maxillary sinus without calcification and partial opacification of frontal and ethmoidal sinuses. Functional endoscopic sinus approach was performed. Marsupialization of the cyst which a brownish fluid, which evoked the diagnosis of cholesterol granuloma. CONCLUSION: The definite diagnosis is made by histology, although intra-operative finding could be suggestive. Complete excision is achievable by endoscopic approach.

[Swallowing sound signal: description in normal and laryngectomized subjects]. / Le signal acoustique de la déglutition pharyngée: description chez les sujets normaux et chez les patients laryngectomisés.

OBJECTIVES: Recently, we described three sound components in the pharyngeal swallowing sound. The aim of the present study was to identify the origin of these components using modern techniques providing numeric, synchronized acoustic-radiological data in a normal population and in a partial supracricoid laryngectomized population (SCL group) and a total laryngectomized (TL group) population in pre- and postoperative situations. PATIENTS AND METHODS: We enrolled 15 normal subjects (10 men and five women; mean age, 29.5+/-8 years), 11 patients in the SCL group (11 men; mean age, 62; range, 45-75 years), and nine patients in the TL group (three women, six men; mean age, 56; range, 39-73). An X-ray camera was connected to a video acquisition card to obtain acoustic-radiological data (2 images/s). The microphone was attached to each subject's skin overlying the lateral border of the cricoid. The subjects were asked to swallow 10 ml of a barium suspension. We performed the acoustic-radiological analysis using Visualisation and Cool Edit Pro software. Each sound component was associated with a specific position of the bolus and the moving anatomic structure. Three sound components were identified: the laryngeal ascension sound (LAS), the upper sphincter opening sound (USOS), and the laryngeal release sound (LRS). We quantified the total duration of the pharyngeal sound and its components, as well as the duration of the interval. RESULTS: The average duration of the normal pharyngeal sound was 690+/-162 ms and was significantly decreased in the TL group (296+/-105 ms) and increased in the SCL group (701+/-186 ms). The USOS was present in 100% of the recordings. A typical profile of the swallowing sound for each group was obtained. CONCLUSION: This study allowed us to determine the origin of the three main sound components of the pharyngeal swallowing sound with respect to movements in anatomic structures and the different positions of the bolus, and to describe the main variations induced by a partial and a total laryngectomy.

[Subglottic stenosis in Wegener's granulomatosis]. / Maladie de Wegener et sténose sous glottique.

OBJECTIVE: Describe the management of subglottic stenosis in a patient with Wegener's granulomatosis. MATERIAL AND METHOD: Case report. RESULTS: We report the case of a 26-year-old woman who presented Wegener granulomatosis and subglottic stenosis, with renal, skin, oropharyngeal, nasal, and paranasal locations. Medical treatment had cured all the locations except the subglottic stenosis. An endoscopic dilatation was performed. Two months later, the endoscopic treatment was repeated twice with intralesional corticosteroid injection. One year later, the patient was in complete functional remission. CONCLUSION: Respiratory obstruction in Wegener granulomatosis can result from subglottic stenosis. In this case, intralesional corticosteroid injection seemed to be a good adjunct to local treatment with an effective long-term result.

[Metastasis of renal carcinoma to the thyroid gland]. / Métastase thyroïdienne d'un cancer rénal.

INTRODUCTION: Intrathyroid metastases are uncommon. Clinically, the distinction may be difficult with thyroid malignant tumor. CASE REPORT: A 76-year-old woman was referred to our department for an evaluation of a dysphonia. She had a past history of renal cancer 6 months ago. A multinodular goiter was noticed at the palpation. Left recurrent laryngeal nerve palsy was observed; there was no cervical lymph node. Fine-needle aspiration was not contributive. Computed tomography confirmed the multinodular goiter. Total thyroidectomy was performed and final histologic examination revealed a metastasis of a renal cancer. CONCLUSION: Even if intrathyroid metastasis are rare, the practitioner must suggest the diagnosis if the patient had a thyroid tumor and a past history of cancer. A fine-needle aspiration can help the diagnosis. The surgical management is recommended for isolated metastasis to the thyroid gland especially in renal cancer.

[Differenciated thyroid carcinomas with laryngo-tracheal invasion]. / Carcinomes différenciés de la thyroïde avec envahissement laryngo-trachéal.

OBJECTIVES: Analyze the diagnosis and treatment of differentiated thyroid carcinomas with laryngo-tracheal invasion. MATERIALS AND METHODS: Among the 117 patients operated for a differentiated thyroid carcinoma in the ENT department of Tours Hospital (France) between January 1990 and December 2003, seven presented laryngo-tracheal invasion and were included in this retrospective study. RESULTS: Laryngo-tracheal resection resulted in a thyroid cartilage-shaving in two patients. We performed a resection of one side of the thyroid cartilage in one patient, a thyro-tracheal resection-anastomosis with a partial cricoidectomy in one patient, a partial vertical laryngectomy extended to the first tracheal ring in one patient and a total laryngectomy in one patient. No laryngo-tracheal resection was done in one patient. Early complications were swallowing disorders (n = 2), transitory hypoparathyroidism (n = 1), definitive recurrent nerve paralysis (n = 2), subcutaneous emphysema and hematoma (n = 1) and Claude Bernard-Horner's syndrome (n = 1). Locoregional recurrences (n = 2) and distant metastasis (n = 2) were discovered six months to four years after the laryngo-tracheal resection. With a mean follow-up of 40 month, four patients were alive (two disease free) two patients had died and one was lost of follow-up at three months. CONCLUSION: The frequency of locoregional recurrences and distant metastasis is higher for the differentiated thyroid carcinomas with laryngo-tracheal invasion than the others. In these cases, we performed macroscopic carcinological surgery preserving laryngeal functions as much as possible.

[Chondrosarcoma of the cricoid]. / Chondrosarcome du cricoïde.

OBJECTIVE: Chondrosarcoma of the larynx is a rare neoplasm generally observed on the cricoid. The purpose of this study was to define the most appropriate surgical management depending on tumor extension and histological grade. PATIENTS AND METHODS: Three males and one female were treated for chondrosarcoma of the cricoid between 1990 and 2003 in the Ear, Nose and Throat department in Tours, France. There were three grade I tumors and one grade II tumor. Tumor resection by thyrotomy was performed in two patients, total laryngectomy in one and laser desobstruction in one. RESULTS: The patient who underwent total laryngectomy remained in complete remission at five years. Among the two patients who had thyrotomy, one remained in remission at three years and the other experienced recurrence at four years and underwent a second operation. He died five years later due to another disease. Total follow-up was nine years. The patient treated by laser therapy achieved stabilization at twelve months. CONCLUSION: Computed tomography and histological grading enable choosing the best surgical procedure. Partial laryngeal surgery is indicated for small or low-grade chondrosarcomas. For large or high-grade tumors, total laryngectomy must be performed. In the event of patient refusal, laser desobstruction can provide clinical stabilization.

Carcinoma of the laryngeal margin.

The laryngeal margin constitutes an anatomic and clinical entity that differs from what is commonly referred to as supraglottic. The present retrospective study reviews 189 cases of carcinomas occurring in this specifically defined region. Local, nodal, and distant metastatic spread of these tumors varied depending on whether the initial tumor site was located in the anterior or lateral margin. Treatment regimens were planned according to the tumor's origin. Primary tumor site surgery associated with a modified or radical neck dissection according to N staging, followed by postoperative radiation is advocated for treatment of these tumors. Cervical nodal metastases are frequent and often bilateral (36%) in cases of anterior margin carcinoma suggesting that bilateral neck dissection sparing two jugular veins for N0 staged carcinoma and one jugular vein when there is evidence of a palpable node, be routinely used. Nodal involvement in cases of lateral margin carcinoma is also frequent but is almost exclusively confined to the ipsilateral nodes. It is suggested that homolateral neck dissection therefore be systematically associated with primary tumor site surgery for these tumors. The various anatomical aspects and pathways of extension of laryngeal margin carcinoma are discussed and a modified TNM classification is proposed.

Oropharynx carcinoma: irradiation alone versus induction chemotherapy plus irradiation--5 year results.

Induction chemotherapy (CT) has demonstrated overall response rates of 80% for oropharynx carcinomas, but no overall survival benefit has been reported. In order to determine the value of induction CT for such patients, we conducted a retrospective study: 121 patients were treated with CT and radiotherapy (RT) (Group 1). This group was compared with a historical group of 84 patients treated by RT alone (Group 2). The CT used was Cisplatinum associated with Bleomycin and Vincristin or Vindesin and with 5 Fluoro-uracil. An objective response to CT was observed for 41% of patients. The 5 year actuarial survival rate was 19% for Group 1 and 24% for Group 2. Patterns of failure were identical in the two groups. The only difference observed was for patients with N3 nodes (26% of 5 year survival rate in Group 1 versus 9% in Group 2) (p = 0.05). The results did not depend on the histological differentiation, the tumour site or the type of CT. We conclude that this retrospective study failed to demonstrate an advantage for induction CT in oropharynx carcinoma except for patients with N3 nodes.

[Advanced carcinoma of the oropharynx: the value of induction chemotherapy before locoregional treatment. A retrospective study of 138 cases]. / Carcinomes avancés de l'oropharynx: valeur d'une chimiothérapie d'induction précédant le traitement locorégional. Etude retrospective de 138 cas.

Induction chemotherapy in oropharynx carcinomas had demonstrated overall response rates of 80%, but no overall survival benefit have been reported. In order to determine the value of induction chemotherapy for these patients, we conducted a retrospective study: 86 patients were treated with chemotherapy (CT) and RT (group 1) and 52 patients were treated by radiotherapy (RT) alone (group 2). All patients had T3 or T4 tumors. CT used was cisplatinum based associated with bleomycin and vincristine or vindesine and actually with 5 fluoro-uracil. Objective response to the CT was observed for 34% patients. Five years actuarial survival rate was 18% for group 1 and 17% for group 2. Patterns of failure were identical in the 2 groups. A difference was observed only for patients with N3 nodes (24% 5 years survival rate in group 1 versus 6% in group 2) (P = 0.05). According to the histologic differentiation, the tumor site or the type of CT, no difference was observed. We concluded that this study failed to demonstrate an advantage for induction chemotherapy in advanced oropharynx carcinoma excepted for patients with N3 nodes.

[Carcinomas of the base of tongue: analysis of treatment results in 115 patients]. / Carcinomes de la base de la langue: analyse des résultats du traitement de 115 patients.

Between 1976 and 1986, we have treated 115 patients with base of the tongue carcinomas. The mean age was 53.8 years. Staging system used was the UICC TNM classification of 1979. 70% of the tumors were T3 or T4 and 42% had N2 or N3 lymph nodes. Loco-regional treatment was irradiation alone (98/115) or surgery and post-operative radiotherapy (17/115). 67 patients received an induction chemotherapy. 3 and 5 years actuarial survival was 25% and 23%, and 42, 48, 20 and 17% at 3 years for T1, T2, T3 and T4 lesions respectively. Local control rate at the primary sites was 55%, local control rate in the neck was 78%. Distant metastases occurred for 10% and 8% had a second primary. Nodal status was the only other prognostic factor. Local control rate obtained with irradiation alone was not good. For limited tumors T1 and T2, a better local control rate can be obtained with interstitial therapy or surgery.

[Prognostic value of the number of involved nodes after neck dissection in oropharyngeal and oral cavity carcinoma]. / Valeur pronostique du nombre de ganglions envahis après curage cervical pour carcinome de l'oropharynx et de la cavité buccale.

PURPOSE: To evaluate the relationship between the number of positive nodes and probabilities of locoregional control and survival in patients with invasive squamous cell carcinomas of the oral cavity and oropharynx. MATERIAL AND METHODS: Between 1976 and 1993, we treated with curative intent 183 patients (median age: 56 years; standard deviation: 10 years). Seventy-nine patients (43%) had oropharyngeal primary invasive carcinoma and 104 (57%) had oral cavity (excluding the lip) primary invasive carcinoma. Patients with simultaneous primary lesion or visceral metastases were excluded from the analysis. All the patients had neck dissection with at least six nodes to analyse. One-hundred fifty-nine patients (87%) underwent resection of the primary lesion and 158 (86%) were treated postoperatively with external beam irradiation alone or combined with interstitial implant (median dose: 60 Gy; standard deviation: 10 Gy). Average follow-up was 52 months. RESULTS: The overall 5-year survival rate using the Kaplan-Meier method was 42.6%. The 5-year survival rates were 60.0% when lymph nodes were histologically negative, 39.5% when one lymph node was positive, 28.0% when two lymph nodes were positive and 24.4% when three or more lymph nodes were positive (P = 0.0004). The number of positive nodes did not significantly influence the specific disease-free survival and locoregional control rates. CONCLUSION: Patients with one or more positive neck nodes must have postoperative treatment.

[Lateral efferent system and evoked auditory potentials. Response in tinnitus]. / Système efférent latéral et potentiels évoqués auditifs. Réponse des porteurs d'acouphènes.

The effects of ipsi- or contralateral masking have been studied in 45 normal hearing subjects and in 49 tinnitus patients. With normal subjects, ipsilateral masking during auditory stimulation involves--in opposition to contralateral masking which does not alter any latencies--a significant lengthening of all the latencies in the brainstem, except that of the first wave (right and left), and a significant decreasing of the amplitudes of the waves I L and R. It was important to know whether the lengthening of the latencies in the brainstem--which we suppose to be due to the stimulation of the lateral efferent system--was not in fact due to a preferential stimulation of the auditory cells from the basis of the cochlea. Yet experiments have shown that continuous masking of 40 dB at 750 Hz or 4000 Hz added to stimulation, involved no significant modification of the latencies in normal subjects. Therefore the lengthening of the latencies obtained with white noise masking, belonged to an other sphere. The second problem concerned the responses of tinnitus patients. Ipsilateral masking in white noises does not alter any latencies in the patients' brainstem. They seem to have lost the possibility of reacting to any additional noise coming from the outside. As we have already noticed, their latencies before masking were different from those of normal subjects. With masking the patients, latencies remained unchanged whereas the latencies of normal subjects lengthened and caught up the patients. To conclude, we suppose the lateral efferent system can be explored by the adjunction of white noise masking, ipsilateral to the stimulation. The expected response is a lengthening of interpeak I-V latency, without any modification of the latency of the first wave. Tinnitus patients generally do not have that type of response to white noise masking. Their lateral efferent system may not be operating.

Bacteriology of chronic purulent secretions in chronic rhinosinusitis.

The aim of this work was to study the bacterial flora of purulent secretions during chronic rhinosinusitis. We studied a total of 533 patients divided into two groups. The control population consisted of 139 adults (> 16 years) of both sexes seen in the community or hospitalized for less than 72 hours for non-rhinological conditions. The rhinosinusitis group consisted of 394 patients referred to the ENT clinic with chronic rhinosinusitis. All the patients with rhinosinusitis had had a post-nasal discharge for at least three months, associated with purulent or mucopurulent secretions originating from the involved sinus cavity. All samples were obtained endonasally under endoscopic guidance from the sinus ostium or from the sinus cavity during surgery. Cultures were positive in 81.3 per cent of the control subjects and 83.1 per cent of the patients with rhinosinusitis. Corynebacteria, coagulase-negative staphylococci, propionibacteria and peptostreptococci were the main commensal organisms, while Haemophilus influenzae, streptococci, Streptococcus pneumoniae, Prevotella spp and Fusobacterium spp were probable causative pathogens. Anaerobes were isolated from approximately 25 per cent of the patients in the rhinosinusitis group. Betalactamase producers represented 27.5 per cent of H. influenzae and 28 per cent of Prevotella spp isolates. Diminished susceptibility to penicillin was found in 13 per cent of S. pneumoniae isolates. The amoxycillin-clavulanate combination was the most active oral antibiotic tested against the pathogenic species in vitro.

Solitary fibrous tumour of the larynx: report of a case.

Solitary fibrous tumour is a particular kind of mesenchymal tumour, classically arising in the pleura. We report the first case arising in the larynx, associated with a metastasizing adenocarcinoma. The diagnosis is mainly histopathological, especially when strong immunoreactivity for the CD34 antibody is present.

Bacteriology of the adult middle meatus.

The aim of this work was to assess the commensal flora in the adult middle meatus. Thus, 139 samples were taken from subjects of both sexes, over 16 years of age, seen in the community or hospitalized for less than 72 hours for non-rhinological conditions. They had had no nasal or sinus conditions in the previous three months. One hundred and thirteen samples contained at least one aerobic or anaerobic bacterium. Fifty-nine samples yielded a single organism in culture. A maximum of five organisms were isolated from a given patient. These results show that the adult middle meatus contains a mixed commensal flora and should prove useful in interpreting endonasal swab cultures during acute and chronic sinus infection.

[Tracheal carcinoma infiltrating the thyroid gland and mimicking subacute thyroiditis. Contribution of Doppler to differential diagnosis]. / Carcinome trachéal envahissant la thyroïde et mimant une thyroïdite subaiguë. Apport du Doppler au diagnostic différentiel.

In the present case Color Coded Doppler showed a marked increase in vascularization in the right lobe of the thyroid with high systolic velocities (1 m/s). This sign was only doubtful compared with clinical, biological and isotopic data. Because of dramatic laryngeal dyspnea, surgery was conducted which allowed the final diagnosis of thyroid invasion by tracheal epidermoid carcinoma. This demonstrates the particular role of Color Coded Doppler in the management of inflammatory thyroid diseases.

[Esophageal morphology with ultrasound imaging after laryngectomy: effect on quality of esophageal speech]. / Morphologie oesophagienne par échographie après exérèse laryngée: influence sur la qualité de la voix oesophagienne.

PURPOSE: In patients with aerodigestive cancer, laryngectomy places the esophagus in a superficial position, allowing easy ultrasound examination of this organ. The purpose of the present study was to assess oesophagus morphology after laryngectomy using echotomography and to compare this morphology with voice quality. MATERIAL AND METHODS: In the present study, ultrasonography was performed in 28 patients (delay from surgery: 3 +/- 3 years): 15 were operated using laryngectomy technique (LT) and 13 with pharyngolaryngectomy technique (PLT). On transversal echography, antero-posterior and latero-lateral diameters, esophagus area and dilatation during phonation were systematically measured. These data were compared to the voice quality assessed by two independent observers. RESULTS: A smaller latero-lateral diameter and area were found in the PLT group than in the LT group (p < 0.05) with a flat aspect in group LT. This was associated with faster and better voice acquisition in the PLT group. CONCLUSION: Morphologic study of the esophagus after laryngectomy using ultrasound is in favor of pharyngolaryngectomy technique which allows better conditions for acquiring esophageal voice in better conditions. This could be due to the small area, circle shape and tonicity of the esophagus after this type of surgery.

[Pure primary retroperitoneal seminoma in a woman. Apropos of a case]. / Séminome rétropéritonéal primitif pur chez la femme. A propos d'un cas.

The authors report a case of a stage IV retroperitoneal seminoma in a patient of 43 years of age diagnosed after histological examination of a biopsy specimen from the left sub clavicular lymph mode showed metastatic seminomatosis. After complete assessment including and abdominal and pelvic ultrasound, a CT scan of the abdomen and pelvis, an intravenous urogram, a lymphogram and serial estimations of tumour markers (alpha feta protein and beta HCG) a laparotomy was carried out. This made it possible to take a retroperitoneal biopsy as well as to carry out a total hysterectomy without conservation of the ovaries. From all this we concluded that we were dealing with a straightforward very large retroperitoneal seminoma. The treatment was continued with large doses of chemotherapy using Vinblastin, Cisplatin and Bleomycin (V.C.B.). She received 5 treatments of this and then had radiotherapy. The authors report this first case described in the literature (because they found no other in women) and what made them decide on the therapy.