Usefulness of neuromonitoring in thyroid surgery.

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.

Rhabdomyolysis in head and neck surgery.

OBJECTIVES: Rhabdomyolysis is increasingly recognized as a cause of acute renal failure. Although it is often the result of extensive trauma, rhabdomyolysis may also appear as a rare and serious complication during the postoperative period. Postoperative rhabdomyolysis is a rare but serious complication. Early diagnosis of postoperative rhabdomyolysis is based on laboratory tests and clinical examination. Renal hyperperfusion with hydration and diuretics may prevent a nephrotoxic reaction. We describe two recent cases in patients undergoing head and neck surgery. METHODOLOGY: Between 2007 and 2010, 22 patients with advanced pharyngo laryngeal cancer were treated. Patients records were retrospectively analyzed for preoperative, operative, postoperative, and convalescence data. Demographics, co-morbidities, duration of operation, and postoperative creatine kinase (CK) levels were evaluated. RESULTS: All patients (n = 20 men; n = 2 women) underwent (pharyngo)laryngectomy to treat advanced (stage T4) head and neck tumors. The mean surgical procedure time among these patients was 6.4 h. (range 5.0 to 7.5 h.). The mean peak serum CK was 1725 U/L (range 456 to 3745 U/L). The mean rise of CK level was 268 U/L, in affected patients ranged from 2636 to 3745 U/L. Rhabdomyolysis occurred in two patients, presenting as excessive, immediate postoperative muscular pain in the "downside" hip/flank. These two patients experienced acute renal failure with an average peak CK of 2700 U/L. Bicarbonate alkalinization and diuretic administration were initiated at a mean of 24 h. (range, 4 to 48 h.). One patient required hemodialysis for 1 month postoperatively, but had stable serum within 2 months. Patients did not experience extended recovery. CONCLUSION: Early recognition and aggressive treatment with intravenous fluids and diuresis may prevent the development of acute renal failure due to rhabdomyolysis. Rhabdomyolysis causing acute renal failure is a rare but serious postoperative complication. Adequate prevention in high-risk patients, early diagnosis and, aggressive treatment are the keys to a successful recovery.

The role of thyroidectomy in advanced laryngeal and pharyngolaryngeal carcinoma.

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.

Epidemiology and clinical characteristics of larynx and hypopharynx carcinoma: a comparative study in the Hainaut and review of the literature.

INTRODUCTION: The epidemiology and clinical picture of laryngeal and hypopharyngeal carcinomas have changed significantly in the past 50 years. The aim of this study was to analyze selected epidemiological and clinical characteristics of laryngeal and hypopharyngeal carcinoma. METHODS: A complete chart review of all patients records was conducted. All the patients who were diagnosed as having laryngeal or hypopharyngeal cancer from January 1, 2004 through December 31, 2009 were included in the study. The demographics of the patient population, the disease profile were analyzed. RESULTS: 138 patients with laryngeal or hypopharyngeal disease were treated. 76 patients presented a laryngeal cancer. Disease characteristics indicated that most cases of supraglottic cancer were in a locally advanced stage (84.4%), whereas most patients with glottis cancer were diagnosed with early stage (63.3%). A hypopharyngeal cancer was diagnosed in 62 cases. A significant increasing trend in hypopharyngeal cancer has been seen in males. The majority of the patients was alcohol consumers and had a histology showing squamous cell carcinoma. There were 33 females and 105 males whose ages ranged at presentation from 47 to 86 years. Of the 138 patients treated, 24 and 47 patients were respectively T3 and T4 and 37 patients were N1, 37 patients N2 and 10 patients N3 (Table I). Most patients had stage IV disease (65/138). Majority of cases presented with local advanced stage. Of the 138 patients treated, 24 and 47 patients were respectively T3 and T4. The highest rate of local advanced stage was observed in patients with pyriform sinus carcinomas (81%); the lowest rate was observed for glottis tumors (41.8%). Regional lymph node metastases were diagnosed in 61% of the analyzed cases. 37 patients were N1, 37 patients N2 and 10 patients N3. The highest rate (82.2%) of regional lymph node metastases were observed in cases of pyriform sinus carcinomas, and the lowest (31.7%) in glottis carcinomas. Most patients had stage IV disease (65/138). 49 patients received radiotherapy; 48 patients were treated by surgery followed by (chemo)radiotherapy. 41 patients were treated initially by concomitant chemoradiotherapy. CONCLUSION: A tendency for increasingly younger patients to develop larynx and hypopharynx carcinomas was observed. Most patients had stage IV disease but no trend for a percentage increase in locally advanced tumors was observed. A significant increasing trend in hypopharyngeal cancer has been seen in males.

Serum albumin concentration and surgical site identify surgical risk for major post-operative complications in advanced head and neck patients.

INTRODUCTION: To determine the relationship between peri-operative predictors of morbidity and mortality in advanced head and neck cancer patients. METHODS: The records of 37 consecutive patients who underwent major surgery for advanced head and neck cancer were reviewed. We evaluated factors potentially predisposing to major complications after major surgery for treating advanced head and neck cancer. RESULTS: Twenty-seven men and ten women with a median age of 59 years were included. Eighteen of the thirty-seven had an albumin level < 3.5 g/dl. All the post-operative complications occurred in hypoalbuminemic patients (p = 0.001). The fatal complication appeared in the patient with a albumin level < 0.5 g/dl. The definitive model with logistic regression analysis showed that peri-operative albumin level and the site of origin of the tumour involved a five- and twofold increase respectively in the risk of major complications after major surgery in advanced head and neck patients. CONCLUSION: The results suggest that hypoalbuminemia is common among head and neck patients. Hypoalbuminemia, as the site of origin of the tumour, is associated with an increased risk of morbidity and mortality in head and neck patients who receive surgical treatment.

[Medullary thyroid cancer: surgical results and prognostic factors]. / Cancer médullaire de la thyroïde: résultats du traitement chirurgical et analyse des facteurs de pronostic.

Medullary thyroid carcinoma is a rare tumour (5 to 10% of all thyroid cancers). A number of factors influencing prognosis have been suggested, but their relative significance is not clear. This retrospective study was performed on 44 consecutive patients treated from 1965 to 2003. The aim of the study was to identify prognostic factors, and to assess the results of treatment and associated complications. Mean age was 53.8 years. 5 patients were stage I, 15 in stage II, 22 in stage III and 2 in stage IV. Total thyroidectomy was performed in all cases and 33 also underwent neck dissection. No postoperative complications were observed in 36 patients. Overall survival was 76% at 5 years and 57% at 10 years. In univariate analysis, the factors which were significant predictors of survival were stage III and IV, metastases at presentation, cervical lymph node dissection, postoperative external beam radiotherapy and elevated postoperative calcitonin. In the multivariate analysis, stage IV, metastases at presentation and persistent postoperative elevated calcitonin were significant predictors of survival.

Palliative treatment of malignant pleural effusions.

AIM: The aim of the current study was to analyse the results of video assisted thoracoscopic (VATS) talc pleurodesis for malignant pleural effusion. MATERIAL AND METHODS: From January 2002 to December 2004, 50 VATS procedures were performed under general anaesthesia on 48 patients for malignant pleural effusion. There were 45 women and 3 men with a median age of 57 years. The most common primary neoplasms were breast cancer (68%), ovarian cancer (6%), colon cancer (4%) and lung cancer (4%). Five patients had other types of tumour, including malignant lymphoma, fibrosarcoma, renal cell carcinoma, malignant pleural mesothelioma, acute myeloblastic leukaemia. RESULTS: The average duration of the operation was 46 min (range 20-120). Median duration of postoperative drainage was 5 days (range 2-13) and postoperative hospitalisation was 8 days (range 2-13). Four patients had postoperative complications. Thirty-day mortality was 1/48. One patient died from myocardial infarction. Three postoperative complications were noted (one non-septic febrile episode, one bilateral pneumopathy and one transitory hypoxaemia, treated by non invasive ventilation). Patients were relieved from dyspnoea in 34/48 of the cases (71%). Median survival was 6 months (ranging from 14 days to 2 years). CONCLUSIONS: Early talc pleurodesis via VATS is a safe technique for successfully treating pleural effusion and preventing recurrence in palliative patients with a symptomatic malignant pleural effusion.

The role of salvage surgery in organ preservation strategies in advanced head and neck cancer.

UNLABELLED: It is now established that head & neck squamous cell carcinomas represent a major group of tumours for which an improvement in the overall survival rate could be achieved by a multimodality approach. Surgery as salvage treatment also continues to play an important role in organ preservation strategies in advanced head and neck cancer. METHODS: Before the prospective randomised organ preservation trial conducted by the Department of Veterans Affairs Laryngeal Cancer Study Group demonstrating the benefits of induction chemotherapy, the standard of care for most advanced laryngeal/pharyngo-laryngeal carcinomas was total laryngectomy/pharyngo-laryngectomy and postoperative radiotherapy. The new approach was also supported by a similar prospective trial from the EORTC Head & Neck Cooperative Group dealing with advanced hypopharyngeal squamous cell carcinomas. Currently, advanced laryngeal/pharyngo-laryngeal carcinomas are treated with chemoradiotherapy but some patients will require a more complex salvage laryngectomy/pharyngo-laryngectomy. RESULTS: In a first group of 44 patients treated with sequential chemotherapy and radiotherapy, median survival was 6.7 years. The overall 5-year survival rate was 52.2%. Disease-free survival at 5 years was 50%. 20/44 (50%) of patients retained their larynx. Only 5 patients needed complex salvage surgery. In the second group of 19 patients who received concomitant chemoradiotherapy, 78.9% of the patients retained their larynx. Salvage surgery was performed in five patients. CONCLUSION: CTx and RT is an effective strategy for organ preservation without compromising the survival of patients with locally advanced pharyngo-laryngeal carcinoma, keeping surgery for salvage.

Severe pericardial effusion in patients with concurrent malignancy: a retrospective analysis of prognostic factors influencing survival.

BACKGROUND: The treatment of massive and/or symptomatic pericardial effusion in patients with cancer remains a subject of discussion. Medical and surgical management have been proposed. In the present study, we aimed to determine the prognostic factors influencing survival of cancer patients admitted in intensive care unit (ICU) with severe pericardial effusion to better select the treatment strategies. METHODS: All patients with cancer and massive or symptomatic pericardial effusion were retrospectively analyzed. Patients were followed up until death or last time known to be alive. Univariate and multivariate analyses were performed to determine prognostic factors influencing survival. RESULTS: Between January 1999 and August 2004, 55 eligible patients were admitted in the ICU for pericardial effusion, including 30 with lung cancer, 9 with breast cancer, 5 with hematological malignancies, and 11 patients with other types of solid tumors. Forty-three patients underwent a surgical drainage. No operative death occurred. Four patients presented with an asymptomatic recurrence. Median survival of the entire group was 112 days. Survival rates for 1, 2, and 3 years were 27%, 17%, and 12%, respectively. In univariate analysis, the following variables were significantly associated with a reduced survival: histopathological diagnosis of malignant pericardial effusion, age (>60 years), the volume of pericardial effusion (<550 cc), and the cancer status (complete or partial response). After multivariate analysis, the cancer status was the only statistically significant clinical factor influencing overall survival (P = .005). CONCLUSION: In this series of patients presenting with severe pericardial effusion, the control of the underlying neoplasm was the only significant factor influencing survival and could be helpful in making decision to the optimal (invasive) treatment that should balance treatment efficacy with life expectancy.

Fistula and stenosis after 135 (pharyngo)laryngectomies.

BACKGROUND: Despite progress made with reconstruction, morbidity is still elevated after (pharyngo)laryngectomy. The present study was designed to determine the incidence and predisposing factors of the complications following (pharyngo)laryngectomy. METHODS: Primary surgical treatment was delivered in 60 patients. Seventy-five patients underwent surgical salvage following radiotherapy. Different factors were evaluated as potentially predisposing to fistula formation. RESULTS: Stenosis is rare: 5.1% in the present series. A pharyngocutaneous fistula developed in 48.8% of patients. After a multivariate analysis, the site of the tumour was defined as a significant risk factor for pharyngocutaneous fistula formation. CONCLUSIONS: Despite progress made with reconstruction, morbidity is still elevated after major resection of the phary golarynx. Stenosis, a frequent complication when partial pharyngectomy is needed, is rare: 5.1% in the present series. Fistulas are relatively frequent but the majority resolved either with local irrigation or with subsequent flaps. The site of the tumour was a significant risk factor for pharyngocutaneous fistula formation, as defined by a multivariate analysis.

[Interest of the chest CT scanning in head and neck cancer]. / Intérêt du scanner thoracique dans le bilan initial et le suivi des patients traités pour un cancer des voies aérodigestives supérieures.

INTRODUCTION: The overall survival rate for patients with head and neck squamous cell carcinoma remains disappointingly static despite improved locoregional control. This has been attributed to the development of distant metastases and second primary malignancies in these patients, a large proportion of which occur in the thorax. The goal of this study is to determine the incidence of newly thoracic malignancies diagnosed initially and during the follow-up in head and neck patients by chest computed tomography. METHODS: We retrospectively analysed the incidence of thoracic malignancies in 77 patients presented newly diagnosed cancer of the head and neck. RESULT: 15/77 patients were found to have thoracic malignancies. In 10/77 patients (14%) the diagnosis was made at the same time that the initial head and neck cancer In 5/77 patients, the thoracic malignancies were diagnosed during the follow-up. In 3 of the 5 cases, the pulmonary lesion was diagnosed in patients with local recurrent tumours. The primary site or the stage had an effect on the incidence of simultaneous thoracic malignancies. CONCLUSION: The presence of distant metastases and second primary malignancies has major implications in the management and prognosis of patients presenting with head and neck carcinoma. We recommend a CT scanning of the thorax in the staging of patients presenting with head and neck cancer but also in the follow-up, particularly in patients with an advanced pharyngolaryngeal cancer.

[Secondary malignant tumors of the parotid]. / Les tumeurs malignes secondaires de la parotide.

AIM OF THE STUDY: Secondary malignant tumors of the parotid gland are uncommon. They arise from primary tumors located in the head and neck or from distant primary tumors. The formers are dominated by squamous cell carcinomas and melanomas, the latters by renal and lung cancers. Distinction between malignant primary tumors and metastasis of other primary tumors to the parotid gland is very important to appreciate, because the result of this will change therapeutic procedure and the evaluation of prognosis. METHODS: A series of 23 patients with tumors metastatic to the parotid gland are reported. All clinical and pathological data were reviewed. The management of secondary tumors of the parotid gland and the results were analyzed in order to try to identify common features and implications for management. RESULTS: The most frequent histologic types were squamous cell carcinoma and melanoma. Most primary tumors occurred in the head and neck. Metastasis to the parotid gland presented with a median time of 18 months after diagnosis of the primary tumor. All the patients had a parotid mass. No patient had facial nerve weakness. Parotid metastases were treated by superficial parotidectomy with preservation of the facial nerve in all cases, associated in 14 cases with a homolateral selective neck dissection and in 6 cases with a homolateral radical neck dissection. Twenty-one patients were submitted to radiation therapy. Seven patients died after the treatment: in 3 cases, death was due to a local recurrence with cervical relapse; 4 patients presented cervical and metastatic lesions. CONCLUSION: This retrospective review confirmed that patients with involvement of cervical nodes and metastatic parotid tumors have a worse prognosis than those without involvement of cervical nodes. The addition of postoperative radiotherapy provides no additional benefit.

Wide localized excision and reconstruction for minor salivary gland tumours.

BACKGROUND: Insufficient excision is one of the main factors leading to recurrence of minor salivary gland tumours. Our aim is to perform large resections with immediate reconstruction in order to provide local control, as well as to achieve better cosmetic and functional results. METHODS: Four consecutive patients suffering from minor salivary gland tumours of the upper aerodigestive tract were treated: two had adenoid cystic carcinomas (one of the lateral oropharyngeal mucosa, one of the retromolar area); one had a polymorphous low-grade carcinoma (at the base of the tongue); and one had mucoepidermoid carcinoma (on the floor of the mouth). Two radial forearm free-flaps, a trapezius myocutaneous pedicled flap (including an adjacent osseous part of the scapula), and a sternocleidomastoid muscular pedicled flap were used, respectively, for reconstruction. Additional external radiation was used for three patients (60 cGy). RESULTS: The postoperative course was uneventful for each patient, and the ability to chew and swallow was rapidly restored. Two patients, locally controlled, with adenoid cystic carcinomas died: one from brain metastases (four years post-surgery), the other with pulmonary metastases (eight-years post-surgery). One patient is alive with a recurrent tumour of the pterygomaxillary fossa (without trismus) sixteen years after the original operation; another patient is free of recurrent disease at the base of the tongue but has recently undergone surgery, with success, for two pulmonary metastases sixty months after the initial surgery. CONCLUSIONS: For minor salivary gland carcinoma of the head and neck, large resection with immediate reconstruction affords fast recovery and long-lasting locoregional control. Additional radiotherapy is feasible.

[Pharyngolaryngectomy for advanced and recurrent cancer: prognostic factors and complications]. / Pharyngolaryngectomies des cancers avancés et récidivants : etude des facteurs de pronostic et complications.

INTRODUCTION: The aim of this study was to evaluate the results of the initial surgical treatment and salvage treatment for advanced laryngopharyngeal cancer. METHODS: From 1984 to 1997, primary surgical treatment was undertaken in 60 patients. 75 patients underwent surgical salvage following radiotherapy. RESULTS: 55/135 patients (40.7%) experienced local regional relapse. The overall survival at 5 years was 43.9% in the first group of patients treated initially with surgery. In the group of patients treated with salvage surgery, the overall survival at 5 years was 40.2%. A multivariate analysis showed that involved lymph nodes (p = 0.0004), a nutritional score inferior to 5 (p = 0.03), positive resection margins (hazard ratio 2.05; 95% c.i. 1.03 to 4.04 ; p = 0.03), a local-regional relapse (p = 0.04) and appearance of metastasis (p = 0.03) were independent risk factors for overall survival. Survival is dependent from each factor, and each factor is independent from each other Stenosis was rare: 5.1% in the present series. A pharyngocutaneous fistula developed in 49.6% of patients. After a multivariate analysis, the site of the tumor (odds 2.26; 95% c.i. 1.05 to 4.85; p = 0.03) had an influence for apparition of a fistula. CONCLUSION: Initial surgical surgery and salvage surgery of respectively 43.9% and 40.2% overall survival compares favorably with the literature. Despite progress made with reconstruction, morbidity is still elevated in a selected group defined after analysis of pronostic factors.

[Intrathyroid metastasis: 11 cases]. / Métastases intrathyroïdiennes: série de 11 cas.

INTRODUCTION: Non-thyroid cancers rarely metastasize into the thyroid gland. The aim of this retrospective study was to report a series of thyroid metastases and to emphasize their unusual occurrence and their poor prognosis. METHODS: Between January 1987 and June 1999 eleven patients underwent thyroidectomy for isolated, metastatic diseases of non thyroidal origin (mean age 61 yrs, 54.5% female). The primary tumors were: pulmonary squamous cell carcinoma (n=5), renal cell carcinomas (n=2), esophageal squamous cell carcinoma (n=1), leiomyosarcoma (n=1), oropharynx squamous cell carcinoma (n=1), and breast carcinoma (n=1). Analyzing these cases, there is a marked preponderance of lung cancers, renal cancer coming second in order of frequency. Clinical manifestations are: thyroid nodule without hormonal disturbance; others signs are dysphonia and/or dysphagia. RESULTS: Ten patients underwent preoperative fine-needle aspiration, nine of ten were suggestive of metastatic disease. The mean time from resection of the primary tumor to thyroid metastases was 25 months (range 1-96 months). Total thyroidectomy (n=9) or lobectomy (n=2) was performed without morbidity or mortality. No patients have had recurrent disease in the neck. Median survival after treatment was 10 months (range 1-29 months). Course of death were mainly disseminated metastases. CONCLUSION: For isolated metastatic cancer to the thyroid, surgical resection should be performed in order to avoid potential morbidity of tumor recurrence in the neck, even if the prognosis remains poor, for the majority of the cases.

[Percutaneous gastrostomy for cervicofacial cancer: Bordet Institute experience]. / Gastrostomies percutanées en carcinologie cervico-faciale: expérience de l'Institut Bordet.

INTRODUCTION: The establishment of a direct enteral feeding route is critical in the overall treatment of many patients with head and neck cancer. This study evaluated the indications, success rate, and complications associated with endoscopic gastrostomies. MATERIALS & METHODS: 71 endoscopic percutaneous gastrostomies were created in 67 patients. The main indication for gastrostomy was the need for nutritional support in malignant head and neck tumors. Two localizations, buccal cavity and oropharynx, comprised 45% of the cases (32/71). RESULTS: All the procedures were successful. The one severe complication (peritonitis) required laparotomy. The duration of enteral nutrition via gastrostomy varied from two days to more than two years. There were no long-term complications. CONCLUSION: The method is simple, cost-saving and is very important to prevent malnutrition, the most predictive parameter for the occurrence of major postoperative complications.