OP0076 L-ARGININE REPROGRAMS OSTEOCLAST PURINE METABOLISM AMELIORATING BONE LOSS IN RHEUMATOID ARTHRITIS

Background

Bone erosion is a clinical feature of rheumatoid arthritis related to disease severity and poor functional prognosis. Excessive osteoclast differentiation and insufficient osteoblast function are the main reasons for the erosive process in RA. Our previous investigation indicated that L-arginine supplementation not only diminished arthritic inflammation in the serum-induced arthritis (K/BxN) model but also decreased inflammatory joints osteoclast numbers (1).

Objectives

In the present study, we aim to investigate the metabolic action of L-arginine supplementation in RA, especially on periarticular bone erosion and systemic bone loss. We plan to depict the metabolic features of TNFα induced inflammatory osteoclasts after in vitro L-arginine supplementation.

Methods

Three murine arthritis models (serum-induced arthritis (K/BxN) model, collagen-induced arthritis model, and hTNFtg mice model) were analysed in this study. L-arginine was supplemented within the drinking water after the onset of arthritis. Bone parameters for axial skeleton (spine) and peripheral skeleton (tibia) from the respective group were quantified by μCT. HE and TRAP staining were performed to address further the erosion area and osteoclast numbers in periarticular sites. In vitro osteoclast differentiation was conducted with or without L-arginine treatment, in the presence or not of TNFα activation. Seahorse and SCENITH analyses were adopted to delineate the metabolic features. JC-1 staining and transmission electron microscopy (TEM) were used to depict the mitochondria metabolism. RNA-seq and mass spectrometry (MS) were performed to investigate the underlying molecular mechanism.

Results

Inflammation was diminished in all three arthritis models after L-arginine supplementation with a significant reduction in arthritic score. Moreover, an amelioration of periarticular bone erosion, systemic bone loss, and decreased osteoclast numbers in periarticular sites were observed in arthritic mice after L-arginine treatment. L-arginine also inhibited osteoclastogenesis in vitro, particularly under TNFα activation. Seahorse and SCENITH analyses indicated TNFα promoted glycolysis while blocking mitochondria-driven oxidative phosphorylations (OXPHOS) in pre-osteoclasts. Meanwhile, JC-1 staining and TEM images also showed that TNFα decreased mitochondria membrane potential and prompted damage of mitochondria. Surprisingly, L-arginine rescued the TNFα inhibition of OXPHOS while promoting ATP production.

RNA-seq and MS data confirmed the boost of OXPHOS after L-arginine treatment under TNFα activation. To interfere with OXPHOS, L-arginine inhibited cJun thus altered arginase-1 and arginase-2 expression. Moreover, the increased ATP in L-arginine treated cells facilitated purine metabolism, especially the production of inosine and hypoxanthine, contributing to the inhibition of osteoclastogenesis. Increasing Adenosine deaminase (ADA) is essential for the production of inosine and hypoxanthine due to the decreased inhibitory regulation of the transcription factor c-Jun.

Conclusion

These data strongly demonstrated that L-arginine ameliorates bone erosion in RA through metabolic reprogramming and perturbation of purine metabolism in osteoclasts. L-arginine might therefore benefit RA therapy by reducing joint inflammation and also ameliorating bone destruction.

References

[1]Hannemann, Nicole, et al. “Transcription factor Fra-1 targets arginase-1 to enhance macrophage-mediated inflammation in arthritis.” The Journal of clinical investigation 129.7 (2019): 2669-2684.

Disclosure of Interests

Shan Cao: None declared, Rui Song: None declared, Xianyi Meng: None declared, Katerina Kachler: None declared, Maximilian Fuchs: None declared, Xinyu Meng: None declared, Yixuan Li: None declared, Verena Taudte: None declared, Meik Kunz: None declared, Ursula Schloetzer-Schrehardt: None declared, Ulrike Schleicher: None declared, Xiaoxiang Chen Speakers bureau: AbbVie, Roche and Novartis, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Aline Bozec: None declared.

POS0409 INTESTINAL HIF1α EXPRESSION PROTECTS AGAINST EPITHELIAL CELL DEATH IN ARTHRITIS

Background

While a so-called gut-joint axis is supported by many clinical observations, the current knowledge on such axis is mostly confined to descriptive and correlative data, e.g. showing the microbiota changes are associated with arthritis. In contrast, mechanistic data on how molecular changes in the intestinal epithelium influence the development of arthritis are scarce.

Objectives

To investigate, whether the mucosal barrier in the intestine dependent of the epithelial cell survival maintenance, influences the development of arthritis.

Methods

Intestinal hypoxia inducible factor (HIF)-1α expression was assessed before, at onset and during experimental arthritis and human rheumatoid arthritis (RA). Intestinal epithelial cell-specific HIF1α conditional knock-out mice were generated (HIF1αΔIEC) and subjected to collagen-induced arthritis (CIA). Clinical and histological courses of arthritis were recorded, and T and B cell subsets were analyzed in the gut and secondary lymphatic organs, and intestinal epithelial cells were subjected to molecular mRNA sequencing in HIF1αΔIEC and littermate control mice. Furthermore, pharmacologic HIF1α stabilization by PHD inhibitor was used for the treatment of arthritis.

Results

Intestinal HIF1α expression peaked at onset and remained high in experimental arthritis and RA. Conditionally deletion of HIF1α in gut epithelial cells strongly exacerbate arthritis and was associated with increased gut epithelial cell death, intestinal and lymphatic Th1 and Th17 activation. Mechanistically, HIF1α inhibits the transcription of necroptotic and apoptotic markers, which leads to a defect in the intestinal barrier integrity. Furthermore, treatment with HIF1α stabilization reinforced the gut epithelial cell survival and inhibited arthritis.

Conclusion

These findings show that the HIF1α regulating epithelial cells survival is critical for the breakdown of the intestinal barrier function in arthritis highlighting the functional link between intestinal homeostasis and arthritis.

Disclosure of Interests

None declared.

OP0101 MECHANICAL LOADING-INDUCED BHLHE40 PROMOTES INFLAMMATORY ARTHRITIS

Background

Force induced microdamage to joint tissue is hypothesized to trigger inflammatory events in the joint leading to arthritis. Patients with inflammatory arthritis, such as rheumatoid arthritis (RA) and spondyloarthritis (SpA), are found to have inflammation in “mechanical hotspots” and mechanical loading in mouse models of these diseases is pro-arthritogenic1,2. To date, the molecular mechanism involved in converting force to a biological signal that promotes arthritis is not known.

Objectives

This study aims to identify stretch induced genes in synovial fibroblasts, and the effect of these “mechano-sensitive” genes on arthritis.

Methods

Human synovial fibroblasts were stretched in vitro for 4hrs using the FlexCell system and analysed by microarray. Top stretch induced genes were measured in RA, SpA and healthy synovial tissue by qPCR. Patient synovium was further analysed by immunohistochemistry. Bhlhe40 deficient mice were subjected to collagen induced arthritis (CIA) and KBxN serum transfer arthritis (STA). FACS was performed on ankle synovium. uCT was performed on whole ankles, with morphological changes scored by blinded readers, and calcaneus erosions by customs scripts in FIJI.

Results

600 genes were found to be differentially expressed in stretched synovial fibroblasts (fold change > +/-1.5, adjusted p<0.05). 25% of these genes were found to be transcription factors, which included BHLHE40. BHLHE40 mRNA was elevated in the synovial tissue of RA/SpA vs healthy subjects (1.56 fold change), and BHLHE40 protein was widely detectable in synovial fibroblasts and macrophages (Figure 1). Bhlhe40 deficient mice were completely protected against CIA (incidence: 0% vs 40%, n=30 per group), but Bhlhe40 did not block the generation of anti-collagen antibodies. Bhlhe40 deficient mice were partially protected against STA (peak clinical score at day 7; 5.2 vs 6.8, n=15 per group), with reduced synovial macrophage (CD11b+Ly6G-F4/80+) and neutrophil (CD11b+Ly6G+) frequency observed in the arthritic Bhlhe40 deficient mice compared to wildtype controls. Bhlhe40 had no impact on bone erosions with STA.

Figure 1.

BHLHE40 is widely expressed in human synovium. Synovium obtained from total knee replacement. FFPE samples were stained for synovial macrophages (HLADR+) and fibroblasts (FAP+). Images acquired with the Zeiss LSM 780.

Conclusion

BHLHE40 was identified as a force-induced gene in synovial fibroblasts and was found to be upregulated in patients with inflammatory arthritis. Importantly, Bhlhe40 strongly promotes joint inflammation in murine models of arthritis and uncouples systemic autoimmunity from joint tissue inflammation. Thus, we have identified BHLHE40 as a novel regulator of mechanical loading-associated inflammation.

References

[1]Cambré, I. et al. Mechanical strain determines the site-specific localization of inflammation and tissue damage in arthritis. Nat. Commun.9, 4613 (2018).

[2]Jacques, P. et al. Proof of concept: enthesitis and new bone formation in spondyloarthritis are driven by mechanical strain and stromal cells. Ann. Rheum. Dis.73, 437–445 (2014).

Disclosure of Interests

None declared

Tracheoesophageal fistula and pharyngoesophageal stenosis repair by double skin paddle radial forearm flap

Tracheoesophageal fistula (TEF) constitutes a rare, but serious complication in laryngectomized patients, usually occurring after radiotherapy. TEF may occur spontaneously or may be due to enlargement of the TEF created for placement of a voice prosthesis. Surgical treatment of TEF can be complex, especially in the presence of a concomitant pharyngoesophageal stenosis (PES), and is associated with a high failure rate. In this article, we describe the surgical reconstruction technique for TEF associated with PES using a double skin paddle fasciocutaneous radial forearm free flap. The key points of this technique consist of correct positioning of the 2 skin paddles in order to reconstruct the anterior pharyngoesophageal wall and posterior tracheal wall, as well as de-epidermization of the intermediate part of the flap, which is then placed in the tracheoesophageal space.

Functional evaluation of mandibular reconstruction with bone free flap. A GETTEC study

OBJECTIVES

To assess the functional results of oromandibular reconstruction by free bone flap, in terms of swallowing, speech and esthetics.

MATERIALS AND METHODS

A transverse multicenter study included 134 patients reconstructed by free bone flap between 1998 and 2016, with more than 6 months' follow-up, in 9 centers. A standardized questionnaire collected data on patients and treatment. Study endpoints comprised: weight loss, mouth opening, gastrostomy dependence, type of feeding, and DHI score. The impact of patient baseline characteristics on these functional criteria was explored by uni/multivariate analysis.

RESULTS

Ninety of the 134 patients had cancer. Fibula flap was mainly used (80%). 94% of reconstructions were primary successes. 71% of patients had pre- or post-operative radiation therapy. 88% had less than 50% lingual resection. 97% recovered oral feeding. 89% had intelligible speech. 86% judged their esthetic appearance as good/average. 9% had dental prosthetic rehabilitation. Radiation therapy and extensive lingual resection significantly impacted swallowing function (P=0.04 and P=0.03, respectively). Radiation therapy and oropharyngeal extension significantly increased gastrostomy dependence (P=0.04 and P=0.02, respectively).

CONCLUSION

Oromandibular reconstruction by free bone flap enabled return to oral feeding in most cases. More than 80% of patients were satisfied with their result in terms of speech and esthetics. However, the rate of dental rehabilitation was low and the rate of complications was high.

OP0132 ALLERGIC ASTHMA INDUCES THE ACCUMULATION OF SYNOVIAL RESIDENT EOSINOPHILS, TRIGGERING THE RESOLUTION OF INFLAMMATORY ARTHRITIS

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory disorder, involving synovial joints, which affects approximately 1 percent of the world population[1]. Our former work demonstrated that the Th2-eosinophil pathway is a strong anti-inflammatory mediator of inflammatory arthritis[2]. Allergic asthma is an inflammatory disease of the airway, triggered by type 2 immune response. Hitherto, clinical observations on the impact of asthma on RA showed controversial results. Herein, we investigated the action of allergic asthma on inflammatory arthritis.

Objectives:

We aimed to delineate the molecular and cellular responses induced by allergic asthma on inflammatory arthritis, particularly depicting the role of eosinophil subsets in arthritic synovium.

Methods:

Allergic asthma was induced in wild type and genetically modified mice by ovalbumin (OVA) treatment. After the initiation of allergic asthma, K/BxN serum was transferred into the asthmatic mice or control mice to trigger serum induced arthritis (SIA). Then, arthritis severity, circulating cytokines and the cytology of lung and synovium were analyzed. Eosinophil subsets were studied by flow cytometry, single cell RNA sequencing analysis, and were isolated and transferred into the synovial cavity of eosinophil deficient arthritic mice. Clinical data of patients with both RA and asthma were collected and checked for the relapse of RA after asthma treatment with anti-interleukin (IL)-5 antibody.

Results:

Mice induced with allergic asthma exhibited a rapid resolution of SIA. The OVA-triggered resolution disappeared in eosinophil deficient mice (ΔdblGATA), and was partially blocked by IL-5 neutralization. We could detect that IL-5 was mainly produced by type 2 innate lymphoid cell (ILC2) in the lung. Allergic asthma exclusively induced the proliferation (Ki67+) and accumulation of synovial resident eosinophils (rEos, Siglec-Fint), which switched classical macrophages into alternatively activated macrophages. Synovial induced eosinophils (iEos, Siglec-Fhigh) appeared only in the acute phase of SIA. Single cell RNA sequencing analysis showed that rEos played an anti-inflammatory role, while iEos had pro-inflammatory properties in arthritis. The roles of rEos and iEos in arthritis were confirmed by transferring rEos/iEos into the synovial cavity of arthritic mice. Patiens with both RA and asthma showed a remission relapse of RA after using humanized monoclonal IL-5 antibody for treating sever eosinophilic asthma.

Conclusion:

Allergic asthma induced an IL-5 mediated proliferation and accumulation of synovial rEos. The latter triggered the resolution of inflammatory arthritis. In human, eosinophils induced by asthma were essential for the sustaining of RA remission.

References:

[1]Myasoedova, E., et al., Is the incidence of rheumatoid arthritis rising?: results from Olmsted County, Minnesota, 1955-2007. Arthritis Rheum, 2010.62(6): p. 1576-82.

[2]Chen, Z., et al., Th2 and eosinophil responses suppress inflammatory arthritis. Nat Commun, 2016.7: p. 11596.

Acknowledgments:

Mengdan Liu and Darja Andreev contributed equally to this study

Disclosure of Interests:

Mengdan Liu: None declared, Darja Andreev: None declared, Katerina Kachler: None declared, Julia Koelle: None declared, Simon Rauber: None declared, Andreas Ramming Grant/research support from: Pfizer, Novartis, Consultant of: Boehringer Ingelheim, Novartis, Gilead, Pfizer, Speakers bureau: Boehringer Ingelheim, Roche, Janssen, Susetta Finotto: None declared, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Aline Bozec: None declared

THU0068 COMPARISON OF INFLAMMATION DURING METABOLIC CHANGES IN RHEUMATOID AND OSTEOARTHRITIS MOUSE MODELS

Background:

Arthritis is influenced by metabolic changes. Adipokines are bioactive factors produced by adipose tissue with important effects on energy homeostasis and immune responses but are also involved in the pathogenesis of rheumatoid arthritis (RA) and osteoarthritis (OA).

Objectives:

To evaluate inflammation during metabolic and adipokine induced changes in experimental models of RA and OA at different time points, an obesity model (high-fat-died, HFD) was therefore combined with an OA (DMM, destabilization of the medial meniscus) and RA (collagen induced arthritis, CIA) mouse model.

Methods:

Mice were fed with HFD or ND (normal diet) for 12 (OA) or 6 (RA) weeks prior to arthritis induction. DMM was performed in C57Bl/6 mice and CIA was induced in DBA/1Rj mice. After 4, 6 and 8 (DMM) or after 4, 5 and 7 weeks (CIA) of arthritis induction animals were sacrificed to collect histological and serological data. Clinical scoring for CIA and histological scorings for both models were performed to evaluate disease development and progression. Diet-induced effects were monitored by weight, fatty liver score and crown-like structures (CLS) counts in adipose tissue. To evaluate HFD-induced adipokine levels adiponectin, leptin and visfatin serum concentrations were measured in parallel to the CRP. Local tissue adipokine expression was evaluated by immunohistochemistry.

Results:

Induction of OA and RA was successful in an HFD setting, shown by histological joint destruction and the increased fatty liver score and bodyweight. Compared to healthy animals, CRP levels were significantly increased after CIA induction, confirming systemic inflammation. In DMM, the number of CLS were significantly higher in HFD (0.2 ± 0.16, n=7) compared to ND (5.2 ± 0.98, n=8). No difference was found in CIA-severity between HFD and ND. However, CIA induction increased the number of CLS in HFD (2.77 ± 1.07, n=6) and interestingly in ND animals (8.14 ± 0.23, n=5) compared to healthy ND (0.45 ± 0.03, n=4) and healthy HFD mice (2.57 ± 0.53, n=4) without CIA. As expected, HFD led to a significant increase in systemic leptin in healthy animals in both models. Interestingly, CIA and DMM induction decreased systemic leptin levels significantly in ND and HFD, which was more prominent in CIA. The systemic effect was not reflected by local leptin distribution in the joints (CIA) which were not altered by diet. 5. and 7 weeks after CIA induction HFD led to a reduction in local adiponectin and visfatin expression, which were not reflected in systemic levels.

Conclusion:

The data show that HFD deteriorates OA, which is similar to observations in humans. In contrast, HFD induction showed no significant difference in CIA severity compared to ND. Furthermore, CIA reduced local adipokine expression under HFD at later time points but not under ND. According to high numbers of CLS in ND/CIA animals and the strong reduction of leptin in CIA with HFD, CIA onset and severity seems to be obesity independent and more dependent on inflammation while OA appears to be directly influenced by obesity. However, HFD-induced obesity seems to alter local and systemic adipokine expression also in CIA. Interestingly, local adipokine distribution in affected joints was independent from systemic adipokine levels.

Disclosure of Interests:

Hani Manfred Sauermilch: None declared, Marie-Lisa Hülser: None declared, Carina Schreiyäck: None declared, Yubin Luo: None declared, Aline Bozec: None declared, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Ulf Müller-Ladner Speakers bureau: Biogen, Elena Neumann: None declared

Consensus français sur la pratique de la chirurgie oncologique ORL pendant la pandémie de COVID-19

Dans le contexte de la pandémie de COVID-19, des conseils spécifiques semblent nécessaires concernant la prise en charge des patients atteints de cancers ORL. La règle est de limiter au maximum le flux de patients afin de réduire les risques de contamination par le virus SARS-Cov-2 aussi bien des patients que du personnel soignant, particulièrement exposé en ORL. L’objectif est de limiter le risque de perte de chance pour le patient et d’anticiper le flux de patients atteints de cancers à traiter à la fin de l’épidémie, en tenant compte du degré d’urgence, de la lourdeur de la chirurgie, du risque de contamination de l’équipe soignante (trachéotomie) et de la situation locale (saturation ou non de l’hôpital et des services de réanimation).

French consensus on management of head and neck cancer surgery during COVID-19 pandemic

In the context of the current pandemic, there is a need for specific advice concerning treatment of patients with Head and Neck cancers. The rule is to limit as much as possible the number of patients in order to reduce the risks of contamination by the SARS-Cov-2 virus for both patients and the caregivers, who are particularly exposed in ENT. The aim is to minimize the risk of loss of opportunity for patients and to anticipate the increased number of cancer patients to be treated at the end of the pandemic, taking into account the degree of urgency, the difficulty of the surgery, the risk of contaminating the caregivers (tracheotomy) and the local situation (whether or not the hospital and intensive care departments are overstretched).

French Society of ENT (SFORL) guidelines for care pathway organization in head and neck oncology (short version). Early management of head and neck cancer

Early management in oncology is based on coordination and high-quality exchange between the various health-care partners. The present guidelines are based on a literature search with levels of evidence. Treatment waiting time can be optimized by performing assessment as early as possible (Expert opinion), to limit the interval (ideally, less than 4 weeks) between first consultation and data collection. In the first specialist consultation, diagnostic work-up should be scheduled and the data required for management should be determined (Grade B). Work-up may be conducted on a day-care basis or with conventional admission (Expert opinion). The patient's medico-social context should be taken into account from the outset, with social work involvement whenever necessary (Expert opinion). Pain and nutritional management should be planned for (Grade A) and realistic therapeutic education be provided (Expert opinion). Community-hospital teamwork for supportive care should be optimized (Expert opinion). Management should be early and multidisciplinary, to shorten delay between diagnosis and treatment initiation.

Guidelines (short version) of the French Otorhinolaryngology - Head and Neck Surgery Society (SFORL) on patient pathway organization in ENT: The therapeutic decision-making process

OBJECTIVES

The authors present the guidelines of the French Otorhinolaryngology - Head and Neck Surgery Society (SFORL) for patient pathway organization in head and neck cancer, and in particular for multidisciplinary team meetings. The present article concerns the therapeutic decision-making process.

METHODS

A multidisciplinary work group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work group. The final version was established in a coordination meeting. The guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence.

RESULTS

It is recommended that: an organ specialist should contribute to all multidisciplinary meetings on head and neck cancer; all members of the multidisciplinary meeting should have specific knowledge in head and neck cancer; any referring physician who does not follow the multidisciplinary meeting's advice should justify that decision; there should be sufficient time to prepare, discuss and sum up the cases dealt with in the multidisciplinary team meeting.

[Ectopic thyroid basi-lingual: A case report]

INTRODUCTION

The thyroid ectopic gland is a rare anomaly, especially when it’s a lingual thyroid. It is characterized by aspecific clinical presentation, causing a diagnostic problem. The diagnosis is based on a combination of imaging techniques as well as histological examination.

CASE PRESENTATION

We are presenting a case of a patient with thyroid basi-lingual treated surgically.

DISCUSSION

The low incidence of ectopic lingual thyroid , and their clinical variability requires radiological and isotopic investigations.

CONCLUSION

The diagnosis of this disease is primarily histological. The management of these ectopic thyroid is surgical.

Usefulness of ancillary methods for diagnosis, prognosis and targeted therapy in thyroid pathology

The development of molecular analyses for thyroid pathologies is on going. These analyses provide new diagnostic tools with the aim of accurately distinguishing malignant and benign thyroid tumors. They are particularly useful as most of them can be done preoperatively on thyroid fine-needle aspiration biopsy samples. Furthermore, molecular biomarkers may play a promising role since they are able to predict the prognosis of patients with thyroid tumors. Moreover, identification of molecular markers as well as a better understanding of thyroid carcinogenesis will help develop innovative targeted therapies, particularly in patients with metastatic iodo-resistant thyroid carcinoma. To date, four types of somatic genetic alterations are known to hold potential interest for the diagnosis and/or prognosis of follicular cell-derived thyroid carcinomas: BRAF and RAS mutations, and RET/PTC and PAX8/PPARγ rearrangements. Other recent molecular biomarkers have been investigated in thyroid oncology, in particular different microRNA signatures. This review describes the different aspects of ancillary methods, including those bassed on molecular biology, that are of current interest for the diagnosis, prognosis and treatment of follicular cell-derived thyroid carcinomas.

[Free flap reconstruction after oral and oropharyngeal advanced stage carcinoma surgery]

INTRODUCTION

The aim of the study was to evaluate the survival and locoregional recurrence in patients with advanced oral and oropharyngeal squamous cell carcinoma treated by surgery with free flap reconstruction followed or not by radiochemotherapy.

POPULATION AND METHODS

A retrospective study was performed on 188 patients treated by surgery with microvascular reconstruction with or without postoperative radiochemotherapy for an advanced stage squamous carcinoma of the oral cavity and/or of the oropharynx. All patients underwent free flap reconstruction. The study parameters were survival and recurrence rates.

RESULTS

The 5-year overall survival, disease specific survival, and disease free survival rates were 54%, 65%, and 61% respectively. A high level of comorbidity was the only factor that influenced the survival rate. The overall recurrence rate was 34%. Only 9% of patients having recurred were treated successfully. The survival rate after locoregional recurrence and metastasis was 6% at 2 years.

DISCUSSION

Surgery and postoperative radiochemotherapy allows for an acceptable survival rate for patients with advanced oral and oropharyngeal squamous cell carcinoma.

Patient information ahead of thyroid surgery. Guidelines of the French Society of Oto-Rhino-Laryngology and Head and Neck Surgery (SFORL)

OBJECTIVE

The authors present the guidelines of the French Society of Oto-Rhino-Laryngology and Head and Neck Surgery (SFORL) on patient information ahead of thyroid surgery.

METHODS

A multidisciplinary medical team was tasked with a scientific literature review on this topic. The texts retrieved were analyzed by an independent committee. A joint meeting drew up the final guidelines. The strength of the recommendations (grade A, B or C) was based on levels of evidence.

RESULTS

It is recommended that the results of preoperative exploration and the indications for surgery should be explained to the patient. Patients should be informed as to the type of surgery, surgical objectives, risks and consequences. It is mandatory to obtain the patient's written consent before surgery.

CONCLUSION

Appropriate medical information is a critical step in patient management.

Conservative multimodal management of a primitive neuroectodermal tumor of the thyroid

Abstract

Primitive neuroectodermal tumors (PNET) represent 1% of sarcomas. Head and neck peripheral PNETs have an intermediate prognosis between abdominopelvic disease and extremities. We here report the case of a 40-year old male who presented with primitive neuroectodermal tumor of the thyroid and was treated by multimodal treatment, including surgery, chemotherapy and intermediate dose radiotherapy. The patient is alive and fit with a functional larynx at 27 months. Multimodal treatments yield five-year survival rates of about 60%. Major drug regimens use vincristine, doxorubicin, ifosfamide or cyclophosphamide, dactinomycin and/or etoposide. Complete surgical excision is undertaken whenever possible to improve long-term survival. However, the relative radiosensitivity of tumors of the Ewing family, suggest multimodal treatment including adjuvant conformal radiotherapy in case of positive margins or poor response to chemotherapy rather than resection with 2-3 cm margins, which would imply laryngeal sacrifice for thyroid tumors. The role of expert rare tumor networks is crucial for optimal decision-making and management of such rare tumors on a case by case basis.

Impact of preoperative radiotherapy on head and neck free flap reconstruction: a report on 429 cases

BACKGROUND

The primary objective of this study was to evaluate the impact of preoperative radiotherapy on the outcomes of head and neck microvascular reconstruction. The secondary objective was to assess the specific effects of irradiation doses (IDs) ≥60 Gy on the outcomes of head and neck microvascular reconstruction.

METHODS

All patients who underwent head and neck free-flap reconstruction in our institution between 2000 and 2010 were included in this retrospective study. A total of 429 patients were enrolled including 136 patients previously irradiated on the head and neck. The impact of preoperative radiotherapy on free-flap success, local and general complications, postoperative mortality, time of decannulation, duration of enteral nutrition and length of stay was assessed in univariate and multivariate analyses.

RESULTS

In multivariate analysis, preoperative radiotherapy (irrespective of ID) was a significant risk factor for fistula formation (p = 0.003) and wound infection (p = 0.005). Previous neck irradiation at doses ≥60 Gy was associated with an increased risk of free-flap failure (p = 0.04), overall local complications (p = 0.05), haematoma (p = 0.04) and longer duration of enteral nutrition (p = 0.006) and hospital stay (p = 0.004).

CONCLUSIONS

Preoperative radiotherapy, particularly for ID ≥ 60 Gy, is one of the main determinants of the outcomes of head and neck microvascular reconstruction.

Clinical and histological prognostic factors in locally advanced oral cavity cancers treated with primary surgery

OBJECTIVE

The primary objective of this study was to determine the clinical and pathological prognostic factors in locally advanced oral cavity cancers treated by primary surgery.

METHODS

All patients treated by primary surgery with free-flap reconstruction for locally advanced oral cavity squamous cell carcinoma in our institution between 2000 and 2010 were included in this retrospective study. Overall, cause-specific and locoregional disease-free survivals were determined by Kaplan-Meier analyses. Clinical and histological prognostic factors were assessed by univariate (Log Rank tests) and multivariate (Cox models) analyses.

RESULTS

A total of 149 patients (102 men and 47 women; mean age=61.3±12.1 years) were included in the study. Five-year overall, cause-specific and locoregional disease-free survivals were 55%, 68% and 71%, respectively. Age, comorbidity and tumour size (histological evaluation) were significantly correlated with overall survival (P<0.05). Age, tumour size, bone invasion and surgical margins were significantly correlated with locoregional disease-free survival (P<0.05).

CONCLUSION

The main prognostic factors identified in this study were clinical (age and comorbidity) and histological (pathological tumour size, bone invasion and surgical margins).

Prognostic impact of tumour multifocality in thyroid papillary microcarcinoma based on a series of 160 cases

OBJECTIVE

The objective of this study was to evaluate the prognostic impact of tumour multifocality in papillary thyroid microcarcinoma (PTMC).

METHODS

All patients who underwent total thyroidectomy and central neck dissection for PTMC in our institution between 1990 and 2007 were included in this retrospective study. Statistical correlations between tumour multifocality and various clinical or pathological prognostic parameters were assessed by univariate and multivariate analyses.

RESULTS

A total of 160 patients (133 women and 27 men; mean age: 47.8±13.7 years) were included in this study. Tumour multifocality was demonstrated in 59 (37%) patients. Central neck metastatic lymph node involvement was identified in 46 (28%) patients. No statistical correlation was demonstrated between tumour multifocality and the following factors: age, gender, tumour size, extension beyond the thyroid, metastatic central neck lymph node involvement and risk of recurrence. A tumour diameter greater than 5mm was associated with a higher risk of recurrence (P=0.008).

CONCLUSION

Tumour multifocality does not appear to have a prognostic impact in PTMC.

Dentalmaps: automatic dental delineation for radiotherapy planning in head-and-neck cancer

PURPOSE

To propose an automatic atlas-based segmentation framework of the dental structures, called Dentalmaps, and to assess its accuracy and relevance to guide dental care in the context of intensity-modulated radiotherapy.

METHODS AND MATERIALS

A multi-atlas-based segmentation, less sensitive to artifacts than previously published head-and-neck segmentation methods, was used. The manual segmentations of a 21-patient database were first deformed onto the query using nonlinear registrations with the training images and then fused to estimate the consensus segmentation of the query.

RESULTS

The framework was evaluated with a leave-one-out protocol. The maximum doses estimated using manual contours were considered as ground truth and compared with the maximum doses estimated using automatic contours. The dose estimation error was within 2-Gy accuracy in 75% of cases (with a median of 0.9 Gy), whereas it was within 2-Gy accuracy in 30% of cases only with the visual estimation method without any contour, which is the routine practice procedure.

CONCLUSIONS

Dose estimates using this framework were more accurate than visual estimates without dental contour. Dentalmaps represents a useful documentation and communication tool between radiation oncologists and dentists in routine practice. Prospective multicenter assessment is underway on patients extrinsic to the database.

[Total pharyngolaryngectomy in the 21st century: indications, oncologic and functional outcomes]

INTRODUCTION

The development of laryngeal preservation protocols has considerably modified the indications for total (pharyngo-)laryngectomy (TPL). The objectives of our study are to analyze the current indications for TPL and to evaluate the oncologic and functional outcomes after TPL and their predictive factors.

METHODS

All patients who underwent TPL for squamous cell carcinoma of the larynx or hypopharynx, at our institution, between 2000 and 2009, were included in this retrospective study. Predictive factors of oncologic and functional outcomes were assessed in univariate and multivariate analyzes.

RESULTS

A total of 130 patients were enrolled in our study including 119 men and 11 women, with a mean age of 65.9 years. TPL was realized for salvage in 65 patients. Extra-laryngeal tumor extension (n = 42) was the main indication for TPL in the 65 remaining patients. Overall survival was 49 and 41% at 3 and 5 years respectively. In multivariate analysis, primary tumor site (hypopharynx in comparison to larynx; p = 0.04) has a significant pejorative impact on overall survival. Oral alimentation (no enteral nutrition) was recovered successfully by 94% of the patients. In multivariate analysis, primary tumor site (hypopharynx) has a significant pejorative impact on functional results (deglutition: p < 0.0001; phonation: p = 0.03).

CONCLUSION

Primary tumor site is one of the main predictive factor of oncologic and functional outcomes after TPL.

[Risk factors for dryness or irritation of staff hands in nine healthcare institutions]

OBJECTIVE

We performed a prospective multicenter study to assess dryness and irritation of hands of staff in care facilities, and to show that disinfection with alcohol-based hand rub is better tolerated than classic hand washing with mild soap.

METHOD

Dryness and irritation were self-evaluated by volunteers and hetero-evaluated by a team of investigators. The study took into account most of the individual and environmental risk factors of dryness and irritation (season, age, gender, use of protective agent, constitutional, personal and external factors, institution, function, number of consecutive working days).

RESULTS

The results from the 1932 assessments collected showed that traditional hand washing was a risk factor for dryness or irritation, while alcohol-based hand rubs caused no skin deterioration and had a protective effect even when used intensively.

COMMENT

These results should help to fight non-adherence to the use of alcohol-based hand rubs.