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One of the most important complications during thyroid surgery is injury to the recurrent laryngeal nerve (RLN) which leads to dysfunction and palsy of the vocal folds. Adequate knowledge about the location of the RLN supported by neuromonitoring can help the operating surgeon to prevent this complication. Visualization of the nerve alone seems not enough. An estimation of the function of the RLN is very important. Recently, the use of neuromonitoring has been increasingly employed to predict and document nerve function at the end of thyroidectomy. The aim of the study was to verify the usefulness of neuromonitoring in identifying the recurrent laryngeal nerve and to predict postoperative outcome in patients undergoing thyroid surgery for different indications. Between March 2009 and October 2010, 91 patients (26 men, 65 women; mean age 53 (range 26-83) underwent thyroidectomy. Intraoperative neuromonitoring (IONM) was registered for 91 patients. Eighty-four total thyroidectomies and seven lobectomies were performed with IONM. Eight unilateral postoperative transient paresis were identified without any permanent paralysis. Intraoperative neuromonitoring has an excellent specificity and negative predictive value in which an unchanged positive signal is highly predictive of intact nerve function. Intraoperative neuromonitoring during thyroid surgery is a reliable tool for early recurrent laryngeal nerve localization and identification, certainly in complicated thyroid operations. The probability is high for correctly predicting an intact postoperative nerve function by neuromonitoring.

Annales Francaises d'Oto-Rhino-Laryngologie et de pathologie cervico-faciale - Vol. 130 - N° 1 - p. 4-7

Resume Objectifs Dans notre societe vieillissante, le nombre de seniors avec une tumeur des voies aerodigestives est croissant. Le but de cette etude etait d’evaluer l’adequation d’une therapeutique agressive administree a but curatif chez ces personnes âgees. Patients et methodes De maniere retrospective, de 2005 a 2007, les patients âges de plus de 70 ans et ayant presente une tumeur des voies aerodigestives superieures localisee au niveau de la cavite buccale, du pharynx et du larynx, pris en charge primairement dans nos services, ont ete evalues, apres un suivi de 36 mois. Les donnees demographiques, l’evaluation des facteurs de comorbidite, les modalites therapeutiques ainsi que leur morbidite et mortalite associees ont ete evaluees. Resultats Trente-deux hommes et 12 femmes avec un âge median de 77 ans (extremes de 70 a 88 ans) ont ete traites avec intention curative. La majorite des patients presentaient un ou plusieurs facteurs de comorbidite. Sept patients avaient pour antecedent une ischemie du myocarde, 15 patients une bronchopathie chronique obstructive, dix patients un diabete non insulinodependant. Dix-sept patients avaient une hypertension arterielle medicalement traitee. Quatre patients avaient une insuffisance renale chronique, deux patients une cirrhose. Neuf patients ont ete traites par radiotherapie exclusive. Dix-huit patients ont ete traites par radiochimiotherapie concomitante. Quatorze patients ont beneficie d’une chirurgie suivie d’un traitement adjuvant par radiochimiotherapie concomitante. Trois patients ont ete traites par une chirurgie de rattrapage. Parmi les 44 patients, 12 deces ont ete observes, dont sept associes a une recidive, deux a des complications secondaires au traitement, un a un infarctus, un a une peritonite et un a une pneumonie. Apres un suivi de 36 mois, 32 des 44 patients etaient en vie. Conclusion Les tumeurs des voies aerodigestives superieures representent une pathologie grave, qui souvent exige une attitude agressive. Tous les patients âges aptes medicalement doivent beneficier du traitement optimal ; l’âge chronologique ne doit pas servir de facteur d’exclusion. En revanche, la connaissance des facteurs de comorbidite du patient permettra de decider idealement la therapeutique.

Resume Introduction Le diagnostic d’un second primitif pulmonaire est generalement associe a un mauvais pronostic chez les patients ayant presente initialement un carcinome epidermoide des voies aerodigestives superieures (VADS). Methodes De janvier 2000 a juin 2008, 39 patients ayant eu une tumeur cervicofaciale et ayant developpe un second primitif pulmonaire ont ete inclus. Resultats Quatorze secondes primitifs pulmonaires ont ete classes comme synchrones et 25 comme metachrones. Le stade du second primitif pulmonaire etait correle au stade du primitif cervicofacial ( p = 0,0496). Les patients avec une tumeur pulmonaire metachrone ont presente une survie globale prolongee par rapport aux patients avec une tumeur pulmonaire synchrone (92,9 mois vs 15,7 mois ; HR 0,323 ; 95 % IC 0,042–0,559, p = 0,0045). Dans le sous-groupe de 11 patients diagnostiques avec une tumeur plus de cinq ans apres le primitif pulmonaire cervicofacial, le pronostic etait meilleur (128,1 mois vs 29,7 mois ; HR 0,288 ; 95 % IC 0,053–0,353 ; p Discussion Dans notre etude, au contraire des donnees publiees dans la litterature, de maniere plus specifique, une survie et un pronostic favorable ont pu etre determine dans un sous-groupe de patients ayant eu un primitif des VADS et qui ont developpe dans le suivi un second primitif pulmonaire plus de 12 mois apres le diagnostic du premier primitif et, encore plus specifiquement, dans le groupe de patients ayant developpe le second primitif pulmonaire plus de cinq ans apres le diagnostic du primitif des VADS. Conclusion Un second primitif pulmonaire diagnostique chez un patient ayant presente un carcinome epidermoide des VADS est decrit, sans nuance, comme est une entite agressive, associee a un mauvais pronostic. Cependant, les tumeurs pulmonaires metachrones et surtout les tumeurs pulmonaires diagnostiquees plus de cinq ans apres le primitif cervicofacial sont clairement associees a un meilleur pronostic.

Summary Introduction The present study sought to determine the necessity and prognostic impact of superior mediastinum (SM) dissection in advanced upper aerodigestive tract squamous cell carcinoma (SCC). Methods A retrospective review was made of the records of 31 patients who had undergone (pharyngo-) laryngectomy for advanced SCC. Statistical analysis examined correlations between the presence of SM lymph node metastasis and clinical factors, with a significance threshold of P Results Positive cervical and/or SM lymph nodes were found in 20 cases, including six with isolated positive SM nodes. Positive SM nodes were found in none of the patients with laryngeal SCC, versus six of the 13 patients with hypopharyngeal SCC, where they were associated with tumors greater than 35 mm. Presence of paratracheal lymph node metastasis showed a strong but not statistically significant association with the primary site (larynx vs. hypopharynx: P = 0.08). Conclusions In the present series, advanced laryngeal carcinoma was never associated with positive SM nodes, whereas advanced hypopharyngeal carcinoma showed a trend in favor of paratracheal lymph node involvement.

The 1997 International staging system (ISS) classification separated stage III non-small cell lung cancer (NSCLC) into stages IIIA and IIIB. In a previous study including unresectable NSCLC initially treated with chemotherapy, we analysed survival according to tumour (T) and node (N) stages and derived a classification into stages IIIbeta (T3-4N3) and IIIalpha (other TN stage III) that had a better discrimination on survival distribution. The aim of this study was to validate these results in a further set of patients. Patients with unresectable stage III NSCLC included in a phase III trial assessing the role of increased dose chemotherapy (SuperMIP: mitomycin 6 mg/m2, ifosfamide 4.5 g/m2, cisplatin 60 mg/m2, carboplatin 200 mg/m2) in comparison to standard chemotherapy MIP (mitomycin 6 mg/m2, ifosfamide 3 g/m2, cisplatin 50 mg/m2), before thoracic irradiation (60 Gy in 30 fractions over 6 weeks) were the subject of this study. Survival distributions were assessed by the method of Kaplan-Meier. Survival comparisons were made by the log-rank test. Multivariate analyses using Cox regression models, included all potential prognostic factors for survival with a P-value0.2 in univariate analysis. According to the 1997 International staging system classification, 328 eligible patients were included in the study. There was no imbalance between the two arms. Five parameters were significantly associated (Por = 0.05) with survival in univariate analysis: European lung cancer working party (ELCWP) staging (IIIalpha[n = 294 pts] versus IIIbeta [n = 46]), Karnofsky index, weight loss, platelet count and haemoglobin level. These variables as well as the 1997 ISS staging, white blood cell (WBC) count, LDH and sodium levels were included in a multivariate analysis. Two models were constructed, including either the ELCWP or the 1997 ISS. In model 1 (ISS included), Karnofsky index (HR 0.69; 95% confidence interval (CI) 0.47-1.00; P = 0.05) and haemoglobin (HR 1.49; 95% CI 1.11-1.99; P = 0.007) were found significant. In model 2, including ELCWP staging, two variables were associated with survival: ELCWP staging (HR 1.68; 95% CI 1.20-2.35; P = 0.002) and haemoglobin (HR 1.54; 95% CI 1.15-2.07; P = 0.01).In initially unresectable stage III NSCLC treated by chemotherapy and radiotherapy, we validated the results of our previous study. The classification into stages IIIbeta (T3-4N3M0) and IIIalpha (other TN stage III) better discriminates the patients in term of survival than the 1997 ISS classification.

Resume Introduction. – Le melanome est caracterise par sa tendance a metastaser. Sur le tractus digestif, les sites les plus frequemment envahis sont par ordre decroissant l'intestin grele, l'estomac et le colon. Le traitement chirurgical des metastases digestives de melanome est mal connu et son interet est discute. Patients et methodes. – Les dossiers de dix patients (6 femmes et 4 hommes) operes d'une metastase digestive de melanome entre 1980 et 2001 ont ete revus afin de preciser les resultats du traitement chirurgical. Resultats. – Les metastases gastro-intestinales etaient symptomatiques chez huit patients (douleurs abdominales 3 fois, syndrome occlusif 3 fois, masse abdominale et ictere obstructif une fois chacun). Deux patients avaient une anemie. Le diagnostic a ete evoque par l'imagerie sept fois et l'endoscopie trois fois. Tous les patients ont ete operes par laparotomie pour resection de metastases localisees au niveau de l'intestin grele quatre fois, sur la vesicule biliaire deux fois, l'estomac deux fois, et le colon deux fois. Une resection complete a supprime les symptomes dans neuf cas. Dans un cas, la resection etait incomplete mais a fait disparaitre les symptomes de facon satisfaisante. Un patient est decede a J3 ; chez les autres patients, la survie mediane etait de 18 mois (extremes 3–120 mois). Conclusion. – Chez un patient ayant un antecedent de melanome, des symptomes digestifs doivent faire realiser des explorations morphologiques a la recherche d'une metastase gastro-intestinale. Le traitement chirurgical de ces metastases est le plus souvent palliatif mais, dans de rares cas, autorise une survie prolongee.

Total thyroidectomy or hemithyroidectomy together with a total laryngectomy (TL) or pharyngo laryngectomy (TPL) for (pharyngo) laryngeal cancer often renders the patient hypothyroid and commits them to life-long thyroid hormone replacement. To determine the incidence of thyroid gland invasion (TG) in patients undergoing TL or TPL with total thyroidectomy (TThy) or lobectomy (HThy) for advanced laryngeal or hypo pharyngeal cancer and to assess predicative factors. Retrospective analysis of 35 patients from 2007 to 2010. Specimens were examined to determine the incidence of TG invasion and relevant predicative factors such as histological grade and subglottic extension. Pre-operative imaging was reviewed to assess for radiological evidence of TG invasion. TL and TThy was performed in 13 patients. TL and HThy was performed in four patients and TPL and TThy was performed in 18 patients. Surgery was performed for primary and recurrent cancer in 29 and six patients, respectively. Histological evidence of invasion of the TG was found in three patients. Relationship was found between TG invasion and subsite of primary carcinoma and the presence of subglottic extension. No relationship was found between TG invasion and patient’s sex, stage of primary disease at surgery, degree of differentiation. In addition, no significant relationship was found between the presence of TG invasion and recurrent disease. Invasion of the TG in patients undergoing a TL or TPL is a rare event and limits the need for a TTHy in most cases.

Summary Introduction Second primary lung cancer (SPLC) is generally of poor prognosis in patients presenting with head and neck cancer. Methods Between January 2000 and June 2008, 39 patients with head and neck squamous-cell carcinoma (HNSCC) patients diagnosed with SPLC were included. Results Fourteen SPLC were classified as synchronous and 25 as metachronous. SPLC and HNSCC staging correlated ( P = 0.0496). Patients with metachronous tumor showed longer median overall survival than those with synchronous tumor (92.9 months versus 15.7 months; Hazard ratio (HR), 0.323; 95% CI, 0.042–0.559; P = 0.0045). In the subgroup of 11 patients with SPLC diagnosed more than 5 years after HNSCC, prognosis was better (128.1 versus 29.7 months; HR, 0.288; 95% CI, 0.053–0.353; P Discussion In the present study, in contrast to the literature, improved prognosis and survival were found in the subgroup in which SPLC developed more than 12 months after initial HNSCC diagnosis, and even more specifically in that in which SPLC developed more than 5 years after initial HNSCC diagnosis. Conclusion SPLC in HNSCC is generally described as unequivocally aggressive and of poor prognosis. Metachronous SPLC, however, especially when diagnosed more than 5 years after HNSCC, was clearly associated with better prognosis.

Summary Objectives Carotid blowout syndrome is a rare but devastating complication in patients with head and neck malignancy, and is associated with high morbidity and mortality. Bleeding from the carotid artery or its branches is a well-recognized complication following treatment or recurrence of head and neck cancer. It is an emergency situation, and the classical approach to save the patient's life is to ligate the carotid artery. But the surgical treatment is often technically difficult. Endovascular therapies were recently reported as good alternatives to surgical ligation. Methods Retrospective review of three cases of acute or threatened carotid hemorrhage managed by endovascular therapies. Results Two patients presented with acute carotid blowout, and one patient with a sentinel bleed. Two patients had previously been treated with surgery and chemo radiation. One patient was treated by chemo radiation. Two had developed pharyngocutaneous fistulas, and one had an open necrosis filled wound that surrounded the carotid artery. In two patients, stent placement resolved the acute hemorrhage. In one patient, superselective embolization was done. Mean duration follow-up was 10.2 months. No patient had residual sequelae of stenting or embolization. Conclusion Management of carotid blow syndrome is very critical and difficult. A multidisciplinary approach is very important in the management of carotid blow syndrome. Correct and suitable management can be life saving. An endovascular technique is a good and effective alternative with much lower morbidity rates than surgical repair or ligation.

The recent publication of many randomised trials about (neo)adjuvant chemotherapy in resectable non-small cell lung cancer (NSCLC) has prompted our group to update a prior meta-analysis of the literature. Randomised studies published in French and English between 1965 and June 2004 were included in this analysis. A qualitative assessment of each trial was first performed using the European lung cancer working party (ELCWP) and the Chalmers' scales. In absence of statistically significant quality difference between positive and negative trials, a quantitative aggregation (meta-analysis) of the individual results was performed. Two trials for which data were available on ASCO virtual meeting website were also included in the meta-analysis. Twenty-five studies eligible for this analysis assessed chemotherapy as induction (n = 6) or adjuvant to surgery (n = 19). No quality difference was detected between positive and negative trials according to the two scores, whatever all trials were combined or only adjuvant chemotherapy studies were considered. The overall meta-analysis showed that the hazard ratio (HR) of the combined results was 0.66 (95% CI 0.48-0.93) in favour of the addition of induction chemotherapy to a standard surgical procedure and 0.84 (95% CI 0.78-0.89) in favour of adjuvant chemotherapy. The effect was significant for adjuvant chemotherapy in stages I and II with a HR of 0.88 (95% CI 0.83-0.94). It was not statistically significant in stage III although the trend was in favour of chemotherapy whatever adjuvant (HR = 0.85; 95% CI 0.69-1.04) or (neo)adjuvant (HR = 0.65; 95% CI 0.41-1.04) chemotherapy was tested. In conclusion, our meta-analysis shows the efficacy of adjuvant chemotherapy in stages I and II resected NSCLC. More data are needed to confirm such a role for induction chemotherapy. Further trials should separate stage III disease from earlier stages.

Small cell lung carcinoma (SCLC) initially presents with regional and/or distant metastases in the majority of patients. The mediastinum usually shows bulky involvement with massive lymph node metastases. Superior vena cava obstruction syndrome is found in more than 10% of all cases, and other complications, such as dysphagia or dysphonia, are not rare. In two-thirds of the cases, there is hematogenous dissemination, with metastases to the liver, adrenals, bone marrow or brain. When the neoplasm cannot be treated in a single irradiation field, the disease is called extensive, according to the definition of the Veterans Administration Lung Cancer Study Group, and treatment is based on chemotherapy. When the neoplasm is ipsilateral and can be included in a single irradiation field, it is called limited and the therapeutic approach is based on a combination modality of chemotherapy and irradiation (Pignon et al. 1992).

Objectives Growing life expectancy is resulting in an increasing number of elderly patients with upper aero digestive tract tumor. The objective of this study was to assess the appropriateness of aggressive curative treatment for these older patients. Patients and Methods Patients over the age of 70 years, with head and neck squamous cell carcinoma (HNSCC) of the oral cavity, pharynx or larynx, primarily treated in our department between 2005 and 2007, were assessed retrospectively at 36 months’ follow-up. Demographics, comorbidity and treatment strategies and their associated morbidity and mortality were reviewed. Results Thirty-two males and 12 females with a median age of 77 years (range, 70–88 yrs) were given curative treatment. The majority presented with a least one comorbidity. Seven had a history of myocardial ischemia, 15 of chronic obstructive bronchopathy, and 10 of type-2 diabetes; 17 were under treatment for arterial hypertension, four had chronic renal insufficiency, and two had cirrhosis. Nine patients received radiation therapy alone; 18, concomitant chemoradiotherapy; 14, surgery with adjuvant chemoradiotherapy; three were treated by salvage surgery after failure of radiation therapy. In the 44 patients, there were 12 deaths: seven from recurrence, two from treatment complications, one from MI, one from peritonitis and one from pneumonia. At 36 months’ follow-up, 32 of the 44 patients were alive. Conclusion HNSCC is a serious disease that often necessitates aggressive treatment. All patients who are medically eligible should receive curative treatment, without age being an exclusion criterion. Taking comorbidity into account, on the other hand, enables treatment options to be optimized.