Aberrant beta-catenin and LEF1 expression may predict the clinical outcome for patients with oropharyngeal cancer.

Beta-catenin, normally expressed on the epithelial cell surface, plays a crucial role in cadherin-mediated cell adhesion. Recent evidence suggests that beta-catenin is also involved in other functions such as intracellular signaling via the Wnt pathway by creating a nuclear complex with members of the Lymphoid-Enhancer-Factor/T-Cell-Factor (LEF/TCF) family of transcription factors, and gene regulation that it is implicated in the development of several tumors. Little information is available on beta-catenin expression and its main partner in the Wnt signaling pathway, LEF1, in oropharyngeal squamous cell carcinomas (OP-SCCs). The aim of this study is to investigate the expression of beta-catenin and LEF1 expression in human primary OP-SCCs and to evaluate their clinical and prognostic significance. OP-SCCs and normal peritumoral areas were analyzed by immunohistochemistry, Western-blot and RT-PCR. Beta-catenin was overexpressed in tumors in comparison to normal peritumoral areas and displayed predominantly intracellular (cytosolic/nuclear) localization in 62% of the tumors. Immunoreactivity was correlated with clinicopathological parameters and long-term follow-up, and a significant association was found between protein expression and development of local recurrences (P =0.03). The OP-SCCs with poor clinical outcome, which displayed intracellular beta-catenin expression, were also strongly positive for LEF1, with their co-expression statistically significant (P = 0.040). All (100%) advanced (stages 3+4) SCCs, 66.7% of the SCCs with positive lymph nodes and 80% of the SSCs that developed local recurrences were LEF1 positive. Cox regression analysis confirmed a poorer overall survival in cases with high expression of beta-catenin and LEF1. Our results suggest that assessing intracellular beta-catenin and LEF1 expression might help in patient risk stratification and outcome prediction, and serve as novel therapeutic targets in advanced OP-SCC.

Advanced carcinoma of the tongue: total glossectomy without total laryngectomy. Review of 80 cases.

Opinions are divided over the validity of total glossectomy without associated total laryngectomy for advanced carcinoma of the tongue. This retrospective study evaluates the oncologic and functional results obtained in 80 patients who underwent total glossectomy as a primary procedure or as salvage surgery. Satisfactory swallowing ability was obtained in 41 patients, and speech was understandable in 49 patients. The survival rate at 1 year was 65%, with early recurrence of the disease, which was especially frequent in patients with prior radiotherapy, being the major cause of death. The study confirms the poor prognosis of cases with mandibular involvement, and the fact that partial laryngectomy, when required, impairs functional results. In the light of the authors' experience, total glossectomy without total laryngectomy should only be undertaken in motivated and well-supported patients able to accomplish the difficult rehabilitation process.

Prognostic value of lymph node involvement in oral cancers: a study of 137 cases.

OBJECTIVE: The aim of this study was to assess the prognostic value of lymph node involvement in patients with squamous cell carcinoma of the oral cavity. STUDY DESIGN: Retrospective study of 137 patients with T4 squamous cell carcinoma of the oral cavity treated by surgery and radiotherapy (84 N0, 23 N1, 16 N2,14 N3). Twenty-three patients in the N0 group had a history of surgery or radiotherapy. One hundred fourteen patients underwent limited or radical neck dissection unilaterally or bilaterally. METHODS: The histological charts were reviewed and correlated with preoperative lymph node clinical stage. The local failure rate and the overall survival curves were calculated with respect to clinical and histological stages. The causes of death were analyzed. RESULTS: No evidence of lymph node metastasis was found in 47.4% of cases (54 of 114 patients). Among the node-positive (N+) patients, 39 had rupture of the lymph node capsule (R+). In the N0 group, 27.8% of patients were N+. Regional control rates after surgery and radiotherapy were 95% at 1 year and 85.4% at 5 years. The local failure rates were 6% in N0, 8.7% in N1, 31.2% in N2, 51.7% in N3, 9% in node-negative (N-), and 29% in N+R+ patients. The overall survival rates at 3 and 5 years were, respectively, 44.7% and 34.8% in the N0 group, 37.7% and 37.7% (same rate at 3 and 5 years) in the N1 group, and 31.2% and 15.8% in the N2 group. None of the patients in the N3 group survived beyond 2 years. The overall survival rates at 5 years were 42.8% and 17.5% in the N- and N+ groups, respectively. CONCLUSIONS: In patients with locally advanced tumors (T4), clinical nodal status and histological nodal invasion were key prognostic factors. The presence of occult metastases in the N0 group justifies routine neck dissection.

Laryngectomized patients' education and follow-up.

Functional and aesthetic problems due to mutilating surgical excisions and adjuvant radiotherapy prolonging the therapeutic period and increasing consequences, are common to all cervicofacial tumors. Laryngectomy is the most representative example, because it affects the aero-digestive tract, the site of major functions; breathing, phonation and swallowing. It necessitates excellent information to the patient post-operatively, and then adapted rehabilitation requiring the learning of oesophageal speech. A close follow-up is required to track loco-regional relapses, secondary neoplastic sites and metastases, cessation of alcohol and tobacco use, and to provide family, social and professional rehabilitation. There are often problems to manage with socio-culturally disadvantaged classes, and physically and psychologically fragile patients, whose hope of surviving is, in general, mediocre.

[Diagnosis of acute aortic dissection by echocardiography]. / Diagnostic des dissections aortiques aiguës par l'échocardiographie.

Until recently, the diagnosis of aortic dissection rested on aortography. The purpose of this study was to evaluate the diagnostic value of echocardiography in that disease and its ability to inform on the extent of the dissection and on the presence of associated lesions. Twenty-six patients (mean age 64 +/- 10 years) admitted for suspected aortic dissection were explored by echocardiography and the results were compared with those of angiography and/or anatomical findings. Echocardiography provided the diagnosis in 14 of the 16 patients with aortic dissection and excluded it in the remaining 10 patients. The sensitivity and specificity of the method were 87.5 p. 100 and 100 p. 100 respectively. The type of dissection was correctly determined in 90 p. 100 of the patients whose aorta had been totally explored by echocardiography. Aortic regurgitation and pericardial effusion were detected in 81 p. 100 and 50 p. 100 respectively of patients with aortic dissection. These results confirm the diagnostic value of echocardiography in dissection of the aorta. The extent of the lesion can only be evaluated when the whole of the aorta is visualized. The echocardiographic diagnosis is easier when the ascending aorta is involved (type I), while in type III aortic dissection there is a risk of missing a retrograde lesion of the aorta and confusing this type with type I. In this study two kinds of intimal flap motion were observed: in the first one the motion was independent of that of the aorta, while the second one resembled a division of the aortic, wall the motion of which is parallel to that of the aorta.

[Compression of the left renal artery by the diaphragm]. / Compression de l'artère rénale gauche par le diaphragme.

Investigation of hypertension in a 21 year old man detected the presence of stenosis of the left renal artery. The arteriographic appearance of this stenosis, associated with the presence of stenosis of the celiac trunk of identical morphology, was suggestive of extrinsic pressure by the diaphragm and excluded endoluminal dilatation. Section of the left diaphragmatic crus released the renal artery and celiac trunk with complete recovery from the hypertension.

[Endoscopic treatment of a Zenker diverticulum. 50 cases]. / Traitement endoscopique des diverticules de Zenker. 50 cas.

OBJECTIVES: Endoscopy has been used for many years as an alternative to surgery for the treatment of Zenker's diverticulum. We report our experience in 50 cases. METHODS: From 1979 to 1995, we treated 50 cases of Zenker's diverticulum endoscopically. Patients' age ranged from 59 to 98 years. All patients had contraindications for conventional surgery or deep anesthesia. The surgical technique of endoscopic treatment is performed under general anesthesia using a specially designed endoscope for exposure. Scissors, then after 1990, CO2 LASER, was used to divide the posterior crico-pharyngeal muscle fibers. RESULTS: There were no major complications. Our results, 95% success, were comparable with those reported in the literature even though, paradoxically, a small diverticulum may remain. Our experience also showed that it may be necessary to perform two sessions for diverticula larger than 3 cm. CONCLUSION: This safe and efficient treatment can be recommended for patients of all ages with a contraindication for conventional surgery.

[Plastic surgery of aplasia of the external ear. Apropos of 65 cases]. / La chirurgie plastique des aplasies du pavillon. A propos de 65 cas.

Principles underlying reconstructive surgery of external ear for major aplasia are described and results presented for 65 patients treated using a cartilaginous framework of a costal autograft as described by B. Brent. Possibilities are discussed of combining this technic with auditory function surgery and the wearing of an auditory prosthesis within the framework of general care of major aplasias.

[Malignant tumors of the petrous bone. Apropos of 25 cases]. / Tumeurs malignes du rocher. A propos de 25 cas.

Twenty five cases of malignant tumors of the petrous bone are presented. Prognosis depends on the histology and on the local invasion which dictate the possibility of curative surgery. Squamous cell carcinoma of the middle ear and other invasive tumors have a bad prognosis, and in spite of the progress of modern image technology, the peripetrous extension of the tumors are often underestimated. Actuarial two years survival for squamous cell carcinoma was 38%. Total excision needs at least a subtotal petrous resection with, in some cases meningal and internal carotid resection. In all cases, surgery was followed by radiation. Low grade malignant tumors had a better prognosis and required a more limited resection. In these cases, when necessary, facial nerve can be repaired by a cable graft at the time of initial surgery.

[Cancer of the tongue in women. A propos of 40 cases]. / Cancer de langue chez la femme. A propos de 40 cas.

Forty women, average age of 54, have been treated in first intention or after the failure of a previous treatment, for a squamous cell carcinoma of the tongue. Eighteen (45%) had no risk factors and 9 were under forty years of age. The oral tongue was the most frequent localisation in the group of patient without risk factors. Nineteen local failures were observed. Actuarial three-years survival was 36%. We believe that the poor prognosis of female tongue squamous carcinoma requires aggressive treatment with combined surgery and brachytherapy on the primary lesion and prophylactic neck dissection even in patients without palpable cervical nodes.

[Postoperative infection in ORL oncologic surgery. The choice of preventive antibiotherapy. Experience of the ORL Department of Hôpital Claude Bernard]. / L'infection postopératoire en chirurgie carcinologique ORL. Le choix de l'antibiothérapie prophylactique. L'expérience du Service ORL de l'Hôpital Claude Bernard.

The incidence of infection after cervicofacial surgery for ENT cancer varied between 38 and 60% as a function of the type of operation, and prophylactic antibiotic therapy administered, in a series of 133 cases. Contamination was greatest after operations of longest duration and with the largest exposure of tissue. Previous cobalt therapy was an aggravating factor. The highest risk of infections complications resulted therefore from combined salvage operations and the use of a musculocutaneous flap. Among these infections, a purulent bronchorrhea was a frequent and potentially serious complication sometimes the cause of septicemia. A review of 4 different antibiotic therapy regimens showed the pre-operative administration failed to alter the outcome. Combined penicillin-5 imidazole treatment, effective in preventing local and regional anaerobic infection, resulted in secondary infection developing in about 56% of cases. It was not able, in fact, to cover under certain circumstances during prolonged surgery, the postoperative risk of inhalation of gram-negative anaerobic and aerobic bacteria form the buccal cavity. Short-term antibiotic therapy was totally ineffective. It is suggested that combined penicillin-5 imidazole be reserved for operations provoking little contamination of the tracheobronchial region, such as total laryngectomy and total pharyngo-laryngectomy, and that prophylactic therapy using an antibiotic with a wide spectrum against gram negative germs be administered prior to major buccopharyngeal operations with tracheotomy.

[Endoscopic surgical treatment of Zenker hypopharyngeal diverticuli. Apropos of 59 cases]. / Traitement par chirurgie endoscopique des diverticules hypopharyngés dits de Zenker. A propos de 59 cas.

We report our experience with 59 cases of Zenker's diverticulum, all treated endoscopically from 1979 to 1998. The ages ranged from 59 to 98 years. There were contraindications for conventional surgery or deep general anesthesia for all the patients. The surgical technique of endoscopic treatment was performed under general anesthesia, using a specially designed endoscope for exposure. Scissors, and after 1990 CO2 LASER, were used to divide the posterior cricopharyngeal muscle fibers. There was no major complication. Our results are comparable with literature, 92% success, even though a small diverticulum may paradoxically remain. Besides, from our experience, it may be necessary to perform two sessions for diverticulum larger than 3 cm. This safe and efficient treatment can be recommended for patients of all ages with a contraindication for conventional surgery.

[Conservative transmandibular lateral pharyngectomy in cancer of the lateral oropharyngeal wall]. / Pharyngectomie latérale transmandibulaire conservatrice (PLTC) dans les cancers de la paroi oropharyngée latérale.

The authors present conservative transmandibular lateral pharyngectomy (CTLP) as a substitute for BPTM operations in cancers of the tonsillar region. The mandible is sectioned along the symphyses and the oropharynx is widely exposed through an incision of the pelvilingual sulcus. The authors propose a primary operability criterion that allows to salvage the mandibular angle, which is usually sacrificed. This can be assessed peroperatively by testing the possibility to cleave and spread inwardly the pharyngomandibular region following detachment of the pterygoid muscles. The functional and cosmetic benefits of this method are obvious and should commend its more frequent utilization.

[Conservative trans-mandibular lateral pharyngectomy. Functional results in a series of 38 patients]. / La pharyngectomie latérale transmandibulaire conservatrice. Résultats fonctionnels sur une série de 38 patients.

The authors present their experience with conservative transmandibular lateral pharyngectomy used for access to oropharyngeal tumours of the buccal cavity. This study was conducted to evaluate both early results and later aesthetic and functional sequelae after a simplified operation using mini-plaques. This surgical route was used for 38 patients since 1985, including 9 for salvage operations. Surgical indications were tumours of the posterior wall of the pharynx (28), the posterior part of the tongue (8), the retromolar tigone (1), the intramaxillary commissure (2) and the pelvi-lingual region (2). Access via the mandibulotomy was always evaluated peroperatively on the basis of the cleavability of the periosteum of the medial mandibular table. Immediate follow-up was uneventful in 74% cases. Post-operative complications included two general decompensations due to the original lesion, four minor local complications (spontaneous by regressive non-unions) and four local complications requiring a second intervention (flap necrosis, 2; orostomy, 2). Five of the complications were directly related to the mandibulotomy, giving an overall rate of 13%; the rates for first intention and salvage surgery were 9% and 18% respectively. Functional capacity was considered excellent in 75% of the cases and the aesthetic results were good in 94%. The satisfactory post-operative course, the low rate of major complications both after first intention and salvage surgery, and the excellent functional and aesthetic results suggest that transmandibular bucco-pharyngectomy should be preferred whenever the state of the cancerous lesion does not require exeresis of the ramus.

[Prognostic influence of cutaneous involvement in malignant tumors of the oral cavity]. / Incidence pronostique de l'envahissement cutané dans les cancers évolués de la cavite buccale.

The aim of this study was to assess the prognostic influence of cutaneous involvement in T4 squamous cell carcinoma of the oral cavity. The population was a homogeneous group of 137 patients. Cutaneous tumor localizations were observed in 20 of them. Surgery and radiotherapy were given in 103 cases and salvage surgery was performed in 34. Local control at 5 years was achieved in 68.5 % of the patients. Carcinologic failure rate was 55 % and 27.3 % in patients with and without cutaneous involvement respectively (p =0. 013). 5-year survivor rate was also correlated with cutaneous involvement: 10 % versus 32.2 % (p <0.0001).

[Lymphoepithelial hyperplasia of the parotid gland and HIV infection]. / Hyperplasie lymphoépithéliale de la parotide et infection par le VIH.

A retrospective review of 10 patients with parotid enlargement is presented. Nine patients were known to be antibody positive for the HIV and one was subsequently tested to be positive. Parotid enlargement was nodular in 9 patients, bilateral in 7, unilateral in 2. One patient had a diffuse enlargement with xerostomia and xerophtalmy. Histological results confirmed begnin lymphoepithelial lesion in all patients. Pathogenesis, diagnostic, pronostic and therapeutic problems are discussed in a literature review.

[Cervicofacial lymphangiomas in children]. / Les lymphangiomes cervico-faciaux chez l'enfant.

Of 41 children, 22 girls and 19 boys, with cervicofacial lymphangioma, 31 had congenital lymphangiomas, 30 lymphangiomas with cervical expression but only 9 were restricted to the neck region. Operation in 35 children showed that in 12 cases the lymphangioma was limited in extent and failed to extend to the neck or parotidojugular region, and excision was complete and there were no recurrences. Partial excision was performed in 23 children in whom the lymphangioma extended to various degrees into the tongue, pharynx or larynx, and tracheotomy was necessary in 10 of these cases. Several operations, and particularly endoscopic resections, are often necessary in this type of dysembryoplasia in order to obtain a sufficient airway. Esthetic results are often disappointing.

[T3 and T4 cancer of the oral cavity, surgical treatment with oral tongue resection]. / Cancers T3 et T4 de la cavité buccale, traitement chirurgical par amputation de la langue mobile.

Amputation of the oral tongue is required to treat T3 and T4 bilateral tumors of the anterior two third of the tongue with or without extension to the floor of the mouth. This partial glossectomy was performed initially for 27 patients and as salvage therapy for 35 patients with recurrent diseases. The reconstruction required a flap in all cases, including 8 microvascular free flaps. Two months after surgery, two third of patients had a satisfactory swallowing hability. The functional results were worst for patients operated after radiotherapy. Actuarial survival rates were 37.5% and 22.1% at 3 and 5 years respectively. The survival rate of patients who had surgery as primary modality of treatment was significantly better as compared with those who had radiotherapy before surgery (p=0,018). This surgery offers a perfect control of tumors of the anterior floor and oral tongue and good rehabilitation provided by the conservation of the posterior tongue.

[Supraglottic laryngectomy with arytenoidectomy]. / Laryngectomie supra-glottique avec aryténoïdectomie.

Relearning to swallow is frequently difficult after supraglottic laryngectomy requiring arytenoid cartilage resection. We propose a surgical procedure in which a local flap is used to close the pharyngeal defect without approximating the laryngeal remnants and the base of tongue. The procedure opens the median raphe and cuts the hyoid bone along the midline. The strap muscles, the perichondrium from the thyroid cartilage and thyroid lobe on the ispilateral side to the tumor are retracted laterally to be used to close the mucosal defect. Sixty-eight patients with T1-T3 carcinomas of the laryngeal margin with extension to an arytenoid in all cases and limited extension to the medial wall and/or anterior angle pyriform fossa in 33 underwent this surgical procedure. Only 5 patients had local recurrence and 8 a lymph node recurrence. Visceral metastases occurred in 21 patients (33%) and second primary tumors were diagnosed at the time of surgery or during follow-up in 19 patients (28%). Three and 5-year actuarial survival rates were 57 and 51%, respectively. Despite post operative radiotherapy, functional success was obtained in 50 patients (75%). This technique provided good tumor control and a high rate of satisfactory functional results in patients with tumors of lateral margin extended to one arytenoid.

[Laryngeal dyspnea of infectious origin in the adult. Apropos of 54 cases]. / Dyspnées laryngées de l'adulte d'origine infectieuse. A propos de 54 cas.

Principal etiologies in 54 patients with acute laryngeal dyspnea of infectious origin were epiglottitis (35 cases), glotto-subglottal laryngitis (8 cases) and adjacent infections (9 cases). These cases are reviewed together with the relevant published literature and various conclusions drawn. The affection is serious (35 deaths out of 425 cases in the literature), and requires careful examination, immediate treatment and routine hospital care under surveillance. Apart from cases where the condition of the patient necessitates urgent intubation, those cases with rapidly evolving signs over 24 hours must be admitted to intensive care since worsening of dyspnea can lead to delayed decompensation. Wide spectrum antibiotic therapy is necessary for patients with epiglottitis and adjacent infective ulcerations since many germs may be implicated, while for the always benign glotto-subglottal laryngitis Amoxicillin + clavulinic acid is sufficient.