[French national standard for the treatment of squamous cell carcinoma of upper aero-digestive tract - General principles of treatment]

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.

Is Revision Surgery Necessary for Patients With High Risk of Recurrence After Parotidectomy? A Multicenter Retrospective Study

OBJECTIVES

Close margin is a frequent situation after parotidectomy. The need for systematic prophylactic revision surgery is a question that arises regularly for malignant tumors, as it exposes to a high risk of facial palsy, while oncological benefits are unclear.

STUDY DESIGN

retrospective study.

SETTING

Multicentric.

SUBJECTS AND METHODS

We included all patients operated for systematic revision surgery in case of close margins after parotidectomy for a malignant tumor and analyzed the rate of tumor residue and its risk factors.

RESULTS

A tumor residue was identified in 43.5% of 23 cases, but none in case of initial complete excision with supra-millimetric margins. Invaded lymph nodes were identified in 6 cases, but none in case of low-grade tumors.

CONCLUSIONS

Systematic revision seems mandatory in case of infra-millimetric margins and high-grade tumors or positive lymph node; further studies are needed to confirm whether it can be spared for T1-T2/N0 low-grade tumors, with close margins but complete initial excision.

Refractory lymphorrhoea of the neck treated with etilefrine

BACKGROUND

Intraoperative injury of the thoracic duct is an uncommon complication of head and neck surgery, which is difficult to manage and associated with serious consequences. We report a case of lymphorrhoea of the neck refractory to all the usual treatments that resolved in response to a treatment strategy described in thoracic and visceral surgery: use of a sympathomimetic drug, etilefrine. To our knowledge and after review of the literature, this is the first reported case of lymphorrhoea of the neck treated by etilefrine.

CASE REPORT

Our patient presented massive lymphatic fluid leakage following left neck dissection as part of the management of oropharyngeal cancer with lymph node metastases. The treatments usually proposed, such as intraoperative repair and appropriate dietary and drug management, were not effective, resulting in multiple, severe complications. After evaluation of the benefit-risk balance, treatment with etilefrine was introduced at the dosages proposed in the literature for the management of chylothorax. This treatment allowed complete resolution of the lymphatic fluid leak after one week.

DISCUSSION

Etilefrine can therefore be added to the treatment options for the management of lymphatic fluid leaks refractory to the usual treatments.

Use of a navigation system in endonasal surgery: Impact on surgical strategy and surgeon satisfaction. A prospective multicenter study

OBJECTIVES

Surgical navigation systems (SNS) are now widely used in endoscopic endonasal surgery. Benefit, however, has not been fully studied. The objective of this study was to evaluate the impact of an SNS in terms of performance of the surgical procedure and of surgeon satisfaction, in a prospective multicenter study.

MATERIALS AND METHODS

A multicenter prospective study included patients undergoing endoscopic endonasal surgery using the electromagnetic DigiPointeur® (DGP) SNS in 16 French hospitals. An observation form, completed by the surgeon immediately at end of procedure, included type of procedure, and any changes in strategy or extent of surgery related to use of the SNS. Surgeon satisfaction was rated on an analog scale, with self-assessment of stress experienced during the procedure.

RESULTS

The study included 311 patients operated on by 36 surgeons in 16 French hospitals. Ethmoidectomy was the most frequent procedure (90%); tumor resection was performed in 5.1% of cases. The SNS enabled more extensive surgery in 81% of cases, in particular by identifying and opening additional cells (57% of cases). Mean satisfaction was 8.6/10; surgeons reported decreased surgical stress thanks to the SNS in 95% of cases.

CONCLUSION

In this observational study, the use of an SNS increased the extent of surgery in 81% of cases, and had a positive impact on the stress perceived by the surgeon in 95% of cases.

[Acute acoustic trauma, a retrospective analysis about 225 military cases]

OBJECTIVES

Studying the epidemiology, the evolutionary audiometric profile and the after-effects of acute acoustic trauma managed in military environment. Assessing the influence beyond the audiometric recovery of earplugs, precocity of the treatment and hyperbaric oxygen therapy.

MATERIALS AND METHODS

This retrospective cohort gathered 225 military cases of acute acoustic trauma hospitalized between 2003 and 2008. The cochlear supportive therapy associated intravenous methyl-prednisolone and pentoxyfilline, completed sometimes with hyperbaric oxygen therapy. The evolution was appreciated with pure-tone audiometry at the admission, at the end of hospitalization and one month after. Perceptive deafness and recovery shifts were statically calculated on 109 ears.

RESULTS

On the 225 cases, 90% were males, middle-aged of 23 years. Initially 95% of the patients complained about tinnitus, associated with hearing loss felt for 71%. The left ear was more frequently affected. The initial audiometric loss was average of 34 dB HL, concentrated on 4000 and 6000 Hz frequencies. The therapy allowed an average recovery of +18,3 dB in a month. The audiometric sequela concerned 40% of the cases, and residual tinnitus a third. These rates were significantly higher with people whose initial hearing loss average exceeded 40 dB HL. Concerning the audiometric recovery and the after-effects, no significantly difference was found between the groups treated before or after 12 hours. There were either no difference with the earplugs and hyperbaric oxygen groups.

CONCLUSION

Despite the effectiveness of early corticotherapy, after-effects of acute acoustic trauma remain frequent and invalidating. Its prevention suffers from non-observance and malposition of earplugs.

Septorhinoplasty by disarticulation: early assessment of a new technique for morphological correction of crooked noses

OBJECTIVE

This study was aimed to assess the early morphological results of a new septorhinoplasty technique based on disarticulation (SRD) between bony and cartilaginous nose structures.

METHODOLOGY

A retrospective, multi-judge, blind comparison of pre- and post-operative photographs displayed on Google documents was designed. A nasal morphology analysis grid based on 10 items was fulfilled independently by 6 judges to assess pre- and post-operatively, two times with a 15 day interval, the severity of each deformity by a score between 0 and 2. The sum of all deformities in a single patient produced the individual global score of nasal deformity, which was set between 0 and 20 for each patient. Pre- and post-operative individual global scores were compared using Student`s t test on paired samples. Percentages of post-operative improvement and deterioration were calculated for each item.

RESULTS

Thirty-five SRD were analyzed. Before surgery, 80% of noses were humped and 86% were crooked; three months after surgery, 64% of noses had a rectilinear nasal crest on profile and 57% on facial view. The mean global score of deformities drop- ped from 11.1 before surgery to 5.8 after surgery, an improvement of 47% . Improvement rates of 82% and 74.3% were obtained, respectively, for hump profiles and orbitonasal lines.

DISCUSSION

The early morphological results of SRD allow to propose this technique as a possible solution to correct crooked noses with humps.

[A locally advanced intrathyroid metastasis of bronchial cancer]

PURPOSE

To assess the characteristics, the diagnosis and the treatment of intrathyroid metastasis.

METHOD

The authors report a case of a locally advanced intrathyroid metastasis of a bronchial cancer.

RESULTS

A 60-year-old woman, treated seven years before for a well-differentiated bronchial adenocarcinoma, developed enlargement of the thyroid gland. Metastatic disease was confirmed by a surgical biopsy. Following incomplete radiochemotherapy, a palliative surgical debulking was performed, associating an isthmolobectomy with a large skin excision and closure with a pectoralis major myocutaneous flap.

CONCLUSION

Intrathyroid metastases are rare and usually treated by surgery. Surgical management is decided taking into account the type and the kinetics of the primary tumor, the location of the thyroid metastasis, and the extension of the metastatic disease. Except for isolated intrathyroid metastasis of kidney cancer, prognosis remains poor.

Use of a scapular free flap for reconstruction of the cricoid cartilage in pharyngolaryngeal oncology

A newly developed technique for cricoid reconstructive surgery is presented and discussed. This method allows us to increase the number of patients presenting with squamous cell carcinoma who may benefit from partial laryngectomy. The method is based on the transfer of a vascularized scapular flap to reconstruct half a resected cricoid. Two alternatives may be used whether anterior laryngectomy preserves the half posterior cricoid and both arytenoids or a hemilateral laryngectomy leaves one arytenoid and half the cricoid. Complementary radiotherapy may be performed after surgery. Satisfactory results are reported from an initial series of three patients.

[An original technique of reconstruction of the cricoid cartilage by vitalized scapular flap. Application to pharyngolaryngeal carcinology]

A personal technique for cricoid reconstructive surgery is presented and discussed. A transfert of a free living scapular flap by microvascular anastomoses is used for reconstructing half cricoid resection. We can with this technique increase the number of partial laryngectomy in patients with squamous cell carcinoma. Two techniques are possible: The half anterior laryngectomy conserves only the half posterior cricoid and the twice arytenoids. The half lateral laryngectomy conserves one arytenoid and a half cricoid.