RESUMEN
OBJECTIVE: Free anterolateral thigh flap has many applications in head and neck reconstruction surgery. The aims of the present study were: (1) to assess functional and esthetic sequelae of harvesting for oncologic purposes; and (2) to assess long-term impact of harvesting on quality of life according to patient and to physician. MATERIALS AND METHODS: Forty-one patients undergoing reconstruction by free anterolateral thigh flap following oncologic head and neck surgery were assessed by questionnaire at>6 months postoperatively. Donor site sequelae were assessed in consultation. Harvesting impact was assessed on 5-point Likert scales by patient and by surgeon. RESULTS: Thirty nine percent of patients showed≥1 sequelae. Donor site sequela impact on sport, daily living and work was assessed by patients as none or mild in 94%, 98% and 100% of cases, respectively. Sixty-one percent of patients and 58.5% of surgeons considered scar esthetics to be discreet or very discreet. CONCLUSION: Morbidity related to anterolateral thigh flap harvesting was low, and functional sequelae at the donor site were well tolerated. The scar was only moderately satisfactory, but could easily be hidden.
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Colgajos Tisulares Libres , Neoplasias de Cabeza y Cuello , Procedimientos de Cirugía Plástica , Neoplasias de Cabeza y Cuello/cirugía , Humanos , Calidad de Vida , Muslo/cirugíaRESUMEN
The purpose of this technical note is to illustrate a simple and economical preoperative method for preshaping a reconstructive titanium plate in a fibula free flap (FFF) by using 3D printing of a virtually reconstructed mandible haptic model. The whole process consisted in creating a 3D model of the patient's mandible based on a CT-scan using a combination of free software (3Dslicer and ITK-snap), and simulating the surgical osteotomies and reconstruction, and print it as a guide for bending a reconstruction titanium plate. Reconstruction is performed using virtual cubes (1 to 3 cubes, according the number of FFF osteotomies). This virtual lab work is performed using 3D Builder® (Microsoft, Redmond) software. This technique allows obtaining an optimal plate application on the bony fragments. It facilitates reconstructive surgery with good functional (putting the patient back in an optimal dental occlusion based on the native maxilla) and aesthetic results. This technical note presents a simple and economical preoperative fabrication of a reconstructive plate through freeware and a low-cost 3D printer accessible to all surgeons.
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Colgajos Tisulares Libres , Reconstrucción Mandibular , Procedimientos de Cirugía Plástica , Cirugía Asistida por Computador , Diseño Asistido por Computadora , Peroné/cirugía , Humanos , Mandíbula/cirugía , TitanioRESUMEN
The restoration of mandibular bone defects after cancer can be facilitated by computer-assisted preoperative planning. The aim of this study was to assess an in-house manufacturing approach to customized cutting guides for use in the reconstruction of the mandible with osteocutaneous free flaps. A retrospective cohort study was performed, involving 18 patients who underwent mandibular reconstruction with a fibula free flap at three institutions during the period July 2012 to March 2015. A single surgeon designed and manufactured fibula and mandible cutting guides using a computer-aided design process and three-dimensional (3D) printing technology. The oncological outcomes, production parameters, and quality of the reconstructions performed for each patient were recorded. Computed tomography scans were acquired after surgery, and these were compared with the preoperative 3D models. Eighteen consecutive patients with squamous cell carcinoma underwent surgery and then reconstruction using this customized in-house surgical approach. The lengths of the fibula bone segments and the angle measurements in the simulations were similar to those of the postoperative volume rendering (P=0.61). The ease of access to 3D printing technology has enabled the computer-aided design and manufacturing of customized cutting guides for oral cancer treatment without the need for input from external laboratories.
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Carcinoma de Células Escamosas/cirugía , Peroné/trasplante , Neoplasias Mandibulares/cirugía , Reconstrucción Mandibular/métodos , Cirugía Asistida por Computador , Anciano , Angiografía por Tomografía Computarizada , Diseño Asistido por Computadora , Femenino , Colgajos Tisulares Libres , Humanos , Masculino , Persona de Mediana Edad , Impresión Tridimensional , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Preoperative evaluation of the bone for invasion by oral cavity squamous cell carcinoma remains challenging. The aim of our study was to compare the accuracy of MRI and CT in detecting mandibular invasion by oral squamous cell carcinoma of the oral cavity, with histologic results as the reference standard, and to assess the influence on surgical management and post-operative course. PATIENTS AND METHODS: Patients who were clinically suspected of having bone invasion from oral cavity carcinoma were retrospectively included. A single senior radiologist reviewed MRI images and CT-scans, independently, for the presence or absence of mandibular invasion. The different surgical procedures were compared in terms of length of hospital stay and occurrence of surgical complications. RESULTS: Histological mandibular invasion occurred in 9 of 35 patients (25.7%). None of the preoperative imaging tests failed to detect bone invasion which resulted in a sensitivity of 100% for both MRI and CT. CT had slightly higher specificity than MRI (61.9% and 57.1% respectively) in predicting bone invasion, but no statistically significant difference was found (P=0.32). Specificity of CT and MRI was higher in the edentulous group (75% and 625% respectively) than in the dentate group (53.8% both), although no statistically significant difference was found. The length of hospital stay was increased in the segmental resection group (25±14.5 days) compared to the marginal resection group (13±4.6 days; P=0.004) and to the hemimandibulectomy group (15±7.2 days; P=0.014). Occurrence of post-operative complications, across all categories, was increased in the segmental resection group (70%, n=7/10; P=0.006) compared to the marginal resection group (8.3%, n=1/12) and to the hemimandibulectomy group (23.1%, n=3/13; P=0.04). CONCLUSION: MRI and CT being equivalent in detecting mandibular invasion, we suggest MRI as single imaging technique in the preoperative assessment of oral cavity SCC. Specificity could be increased if combined with PET/CT, in order to reduce the number of unnecessary mandibular interruptions.
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Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/patología , Imagen por Resonancia Magnética , Neoplasias Mandibulares/diagnóstico , Neoplasias Mandibulares/secundario , Neoplasias de la Boca/diagnóstico , Neoplasias de la Boca/patología , Tomografía Computarizada por Rayos X , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/cirugía , Femenino , Humanos , Masculino , Neoplasias Mandibulares/cirugía , Persona de Mediana Edad , Neoplasias de la Boca/cirugía , Invasividad Neoplásica , Procedimientos Quirúrgicos Orales/métodos , Tomografía Computarizada por Tomografía de Emisión de Positrones , Periodo Posoperatorio , Estudios RetrospectivosRESUMEN
BACKGROUND: Mandibular osteosarcomas (MOS) mostly affect young adults. Their treatment is extrapolated from that of extragnathic osteosarcomas. MATERIAL AND METHODS: A retrospective multicooperative group study was conducted to determine the impact of chemotherapy, adjuvant radiation therapy and surgery on outcomes and to identify prognostic factors. This ethical committee-approved study included a centralized review of histology slides and operative reports. RESULTS: Of 111 patients, 58.6% were male, median age 35 years (13%, ≤18 years). Histology was osteoblastic, chondroblastic, fibroblastic, conventional not otherwise specified and others in 39.6%, 30.6%, 8.1%, 12.6% and 8.0%, respectively. Pathological World Health Organisation grades were low, intermediate and high grade in 6.4%, 11.8% and 81.8%, respectively. Surgery was carried out for 94.5% of patients. Neoadjuvant chemotherapy (mixed protocols) was carried out in 93.1% of patients. Postoperative chemotherapy and radiotherapy were carried out in 54.7% and 23.8%, respectively. Median follow-up was 59.6 months (range). Five-year local control, metastasis-free, disease-free and overall survival rates were 64.6%, 68.9%, 53.2% and 69.2%, respectively. Survival was significantly associated with age, tumor size and surgery. Wide surgery with clear margins and free flap reconstruction was the strongest prognostic factor. Neoadjuvant chemotherapy improved disease-free and metastatic-free survival and increased clear margins rates from 50% to 68%. Intermediate grades behaved like high grades in terms of metastatic-free and disease-free survival. CONCLUSION: This homogeneous series is the largest to date and emphasizes the major impact of clear margins and multidisciplinary management. Neoadjuvant chemotherapy improves disease-free survival and should be recommended for both high and intermediate grade MOS.
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Manejo de la Enfermedad , Neoplasias Mandibulares/terapia , Recurrencia Local de Neoplasia/prevención & control , Osteosarcoma/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Neoplasias Mandibulares/mortalidad , Neoplasias Mandibulares/patología , Persona de Mediana Edad , Análisis Multivariante , Recurrencia Local de Neoplasia/mortalidad , Osteosarcoma/mortalidad , Osteosarcoma/secundario , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
INTRODUCTION: Fewer than 250 primary tumors of the lacrimal duct have been reported in the international literature. Because their signs and symptoms are nonspecific and usually subclinical, delayed diagnosis is common. Treatment for malignant epithelial tumors is surgical, with or without radiation. PATIENTS AND METHODS: The present study is a retrospective analysis of five patients with malignant lacrimal duct tumors. RESULTS: Three patients were diagnosed with carcinoma requiring wide en bloc surgical resection with surgical reconstruction. One underwent adjuvant radiation therapy. Another experienced simultaneous local and lymph node recurrence after 3 years and underwent curative surgery. Two additional patients were diagnosed with diffuse malignant large B-cell non-Hodgkins lymphoma. DISCUSSION: Early symptoms of lacrimal duct tumors are nonspecific and mimic acute dacryocystitis. Lacrimal system CT, MRI and rhinoscopy may allow for earlier diagnosis. Surgical treatment requires resection with wide margins and reconstruction of the medial canthal region. CONCLUSION: Only an early diagnosis can reduce the impairment related to surgery and the extent of the required reconstruction, as well as improve survival.
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Carcinoma/patología , Carcinoma/cirugía , Neoplasias del Ojo/patología , Neoplasias del Ojo/cirugía , Enfermedades del Aparato Lagrimal/patología , Enfermedades del Aparato Lagrimal/cirugía , Conducto Nasolagrimal/patología , Conducto Nasolagrimal/cirugía , Dacriocistitis/patología , Diagnóstico Precoz , Femenino , Humanos , Linfoma de Células B/patología , Imagen por Resonancia Magnética , Masculino , Melanoma/patología , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
Intensity-modulated radiation therapy (IMRT) is an evolution of 3D conformal radiation therapy, which is the current standard radiation therapy technique in head-and-neck cancer. Modulating the radiation intensity of each beam by dynamic interposition of the computer-assisted collimator leaves yields dose distributions that are particularly well adapted to head-and-neck tumor volumes. It is thus possible to predetermine dose per element: i.e., the minimum effective dose to be delivered to tumor areas, and the maximum to be safely delivered to organs at risk. The technique thereby enables complex tumoral targets to be optimally covered, while sparing healthy tissue, and salivary glands in particular. In addition, the technique allows dose-escalation, with a higher dose per session delivered to the macroscopic tumor than to other irradiated areas. The first results of ongoing randomized trials confirmed those of earlier comparative studies, showing marked improvement in side effects, including post-radiation xerostomia. Although the positive impact of this technique on tumor control remains to be proven, salivary function conservation currently makes IMRT the standard treatment in most head-and-neck cancer.
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Neoplasias de Cabeza y Cuello/radioterapia , Radioterapia de Intensidad Modulada , Humanos , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador , Radioterapia AdyuvanteRESUMEN
OBJECTIVE: To measure patient-reported quality of life before and after botulinum toxin A treatment of post-parotidectomy Frey's syndrome (gustatory sweating). PATIENTS AND METHODS: A questionnaire concerning functional, social and emotional aspects of Frey's syndrome (14 questions, with responses on a zero to three point scale) was administered to 17 patients (13 women and four men) before and one month after intradermal injection of botulinum toxin A. Parotidectomy had been performed one to 19 years previously, for benign (n = 10) or malignant (n = 7) tumours, with gustatory sweating occurring a median of 15 months after surgery (range: one month to 14 years). Pre- and post-treatment quality of life scores were compared using Wilcoxon's test (p < 0.05). RESULTS: Patients' reported functional quality of life improved significantly (p = 0.0004). Their social and emotional scores were not significantly modified (p = 0.155 and 0.142, respectively). Seven patients (41 per cent) found the injections painful, but all patients said that the effects were beneficial, that they would undergo new injections if necessary and that they would recommend this treatment to other patients. The benefit lasted over 1.5 years for 60 per cent of patients. No correlation was found between duration of the effect and the extent of parotidectomy (p = 0.067). CONCLUSIONS: Botulinum toxin A significantly improved patients' functional quality of life, without significant improvement in their social or emotional quality of life, according to our questionnaire results. The duration of the effect was longer than the reported physiological effect of botulinum toxin A on acetylcholine receptors.
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Toxinas Botulínicas Tipo A/uso terapéutico , Fármacos Neuromusculares/uso terapéutico , Glándula Parótida/cirugía , Calidad de Vida , Sudoración Gustativa/tratamiento farmacológico , Femenino , Humanos , Inyecciones Intradérmicas , Masculino , Complicaciones Posoperatorias , Encuestas y Cuestionarios , Sudoración Gustativa/psicologíaRESUMEN
AIM: To report our experience in free flap reconstruction of the hard palate after malignant tumor resection, in terms of reconstruction method, immediate post-operative course and subjective functional results. PATIENTS AND METHODS: Files from 1988 to 1999 were reviewed for patients having undergone microvascular reconstruction of the hard palate. The immediate post-operative course (during the first month) was reviewed to determine the occurrence of complications. The surgeon's evaluation 1 year post-operatively was used to determine the intelligibility of speech, type of diet and the quality of nasal permeability. RESULTS: Thirty eight patients (28 men and 10 women) with malignant tumors involving the hard palate had undergone surgical reconstruction using microvascular free flap techniques: free radial forearm flap (13 cases), scapular flap (24 cases) or fibular flap (five cases). Two different flaps were employed in two cases (scapula plus fibula). A second flap was used with success in two cases of failure of the first flap, for a total of 42 free flaps for 38 patients. Complications occurred in seven cases, with two cases of flap necrosis. At 1 year, 33 patients achieved a normal diet and 35 normal or easily intelligible speech. CONCLUSIONS: Microsurgical reconstruction using free tissue transfer allows reconstruction of large defects of the hard palate, with low morbidity and an excellent functional outcome. We propose criteria for free flap reconstruction and choice of flap.
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Procedimientos Quirúrgicos Orales/métodos , Neoplasias Palatinas/cirugía , Colgajos Quirúrgicos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Imagen por Resonancia Magnética , Masculino , Microcirugia , Persona de Mediana Edad , Neoplasias Palatinas/diagnóstico , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Oncologic cervicofacial surgery and plastic surgery have had a common evolution over the last 50 years where progress erasing from one was beneficial to the other one. We review here the historical evolution of these specialties and present the state of the art of plastic surgery in the field of cervicofacial oncology.
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Neoplasias de Cabeza y Cuello/cirugía , Procedimientos de Cirugía Plástica/métodos , Cara/anatomía & histología , Cara/cirugía , Humanos , Oncología Médica/tendencias , Procedimientos Quirúrgicos Ortognáticos , Factores de RiesgoRESUMEN
PATIENTS AND METHODS: Between 1974 and 1997, 297 patients underwent a subtotal laryngectomy at the Institut Gustave-Roussy; 146 of these patients underwent cricohyoidopexy (CHP) for a supraglottic primary as their first treatment. The majority of patients were men (137) aged from 33 to 78 years (median 54 years). The tumour stage at presentation was T1 in 2, T2 in 87, T3 in 53 (preepiglottic space involvement), and T4 (minimal thyroid cartilage invasion) in 4 patients. One hundred and twenty-five patients were N0 (86%) and 21 patients were Np (palpable); 98% had homolateral and 55% had bilateral neck dissections. RESULTS: One patient died postoperatively of a myocardial infarction and 68% patients had an uneventful course. Aspiration was the commonest complication (23 patients, 19%). The median time to removal of the tracheotomy cannula was 10 days and for the nasogastric tube 21 days during the past 10 years. Completion of subtotal laryngectomy into total laryngectomy was done in 21 cases (15%): eight times because of oncological events [five local failures, two second primary (hypopharynx), one positive margin] and 13 times because of aspiration (9%). There were six local failures (4%) and eight nodal failures (5%). The rates of distant metastases and second primaries were 6% and 16% respectively. Half of the local and nodal failures were subsequently sterilized. Findings at death were two local recurrences, four nodal recurrences, eight distant metastases, and 11 second primaries. The 3- and 5-year overall survival rates were 92% and 88% respectively, with an overall laryngeal preservation rate of 86%. CONCLUSION: When supraglottic laryngectomy is not feasible for supraglottic cancer, subtotal laryngectomy with CHP is a safe and effective oncological procedure, with preservation of satisfactory laryngeal function.
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Cartílago Cricoides/cirugía , Glotis/cirugía , Hueso Hioides/cirugía , Neoplasias Laríngeas/mortalidad , Neoplasias Laríngeas/cirugía , Laringectomía , Adulto , Anciano , Cartílago Cricoides/patología , Femenino , Estudios de Seguimiento , Francia , Glotis/patología , Humanos , Hueso Hioides/patología , Neoplasias Laríngeas/patología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Tasa de Supervivencia , Factores de Tiempo , Insuficiencia del TratamientoRESUMEN
BACKGROUND: The optimal primary treatment for posterior pharyngeal wall tumors remains controversial. METHODS: To assess the relevance of surgical treatment from a functional and oncologic point of view, we reviewed the cases of 77 patients surgically treated between 1984 and 1995. Among them 23 had been previously irradiated. Fifty-five patients underwent a conservative surgery (CS) sparing the larynx; 19 direct closures, 6 reconstructions of the posterior wall with a thoracic myocutaneous flap, 15 with a platysma flap, and 15 with a free forearm flap were performed. Twenty-two patients underwent radical surgery (RS). All previously untreated patients had postoperative radiotherapy. The functional assessment concerned the CS group. Oncologic results, especially local control and survival were studied for the whole group. RESULTS: Of the 55 patients who underwent CS, 53 (96%) had their canula and 49 (89%) their feeding tube removed. At 1 year, in the platysma and free forearm groups, 21 of the 24 assessable patients were back to exclusive oral intake. For patients treated by primary surgery followed by radiotherapy, the rate of local failure was 11% (18% for tumors greater than 4 cm), and the 5-year survival rate was 35%. For patients who had previous radiotherapy, the rates were, respectively, 52% and 16%. CONCLUSION: The satisfactory functional results, caused by the improvement of reconstructive procedures, allow conservative surgery even in the case of large tumors. Oncologic results, especially local control, suggest that primary surgery followed by radiotherapy is effective for the treatment of posterior wall cancer. The oncologic results of surgery in a previously irradiated area are poor, and CS is not recommended in these cases.
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Carcinoma de Células Escamosas/cirugía , Neoplasias Faríngeas/cirugía , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/radioterapia , Terapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Neoplasias Faríngeas/mortalidad , Neoplasias Faríngeas/radioterapia , Cuidados Posoperatorios , Tasa de Supervivencia , Factores de TiempoRESUMEN
Reconstruction of the oropharynx and the hypopharynx is difficult due to their wide diameters. We report eight cases of circumferential pharyngolaryngectomies for epidermoid carcinomas of the hypopharynx extended to the oropharynx and classified T4. Reconstruction was performed with a U-shaped free jejunal transplantation. This specific technique consists of a side to side anastomosis between two loops of jejunum. It facilitates reconstruction at the level of the oropharynx and diminishes postoperative complications.
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Carcinoma de Células Escamosas/cirugía , Neoplasias Hipofaríngeas/cirugía , Yeyuno/trasplante , Neoplasias Orofaríngeas/cirugía , Colgajos Quirúrgicos , Anciano , Anastomosis Quirúrgica , Carcinoma de Células Escamosas/radioterapia , Terapia Combinada , Femenino , Humanos , Neoplasias Hipofaríngeas/radioterapia , Masculino , Microcirugia , Persona de Mediana Edad , Neoplasias Orofaríngeas/radioterapiaRESUMEN
STUDY AIM: Midface is situated between the occlusal plane and the transverse midorbital plane. The aim of midface reconstruction is to restore the bony and soft tissue contour of the face, to obtain a rigid support for the velum, to allow oronasal separation, and to allow support for the orbit and obliteration of the maxillary sinus in order to restore the main functions: respiration, speech, deglutition, mastication, olfaction, vision. PATIENTS AND METHODS: Between 1988 and 1997, 65 patients with defects to the midface in relation with cancer (n = 60), gunshot (n = 3), or congenital malformation (n = 2), underwent reconstruction with one or more transplants: forearm (n = 21), latissimus dorsi (n = 23), scapula (n = 12), composed subscapula (n = 10), and fibula (n = 4). Forty-seven of the patients were men and 18 were women. The mean age was 56 years (12-90 years). In patients with cancer, tumoral resection was immediately followed by midface reconstruction in the last 43 cases. Free flaps were selected for reconstruction of each part of the midface: cheek, nose, orbit floor, maxillary and palate. RESULTS: One post-operative death occurred (1.5%). The morbidity rate (18.7%) included necrosis of the free flaps in four cases. Average resumption of oral intake was ten days. The mean time to discharge was 17 days. Aesthetic and functional results were rated good or excellent in 53 patients. After one year, 52 patients were alive. Oral intake was normal in 48 patients, and mixed in four. Speech was excellent or good in 49 patients. From amongst the patients, 80% were able to find a job. CONCLUSION: Free flaps with micro surgery provides an optimal, functional, morphological and aesthetic outcome. Patients with advanced cancer of the midface are best managed through a multidisciplinary team approach. Microsurgical reconstruction represents the technical state of the art in case of extensive and complex midface defect.
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Fisura del Paladar/cirugía , Traumatismos Faciales/cirugía , Neoplasias Faciales/cirugía , Procedimientos de Cirugía Plástica , Colgajos Quirúrgicos , Heridas por Arma de Fuego/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Fisura del Paladar/diagnóstico por imagen , Traumatismos Faciales/diagnóstico por imagen , Neoplasias Faciales/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Factores de Tiempo , Heridas por Arma de Fuego/diagnóstico por imagenRESUMEN
This report presents the result of our experience with 13 primary synovial sarcoma of the head and neck. The 9 males and 4 females had a median age of 32 years. The predominant location of the tumor was the pharynx, treatment consist of surgical excision alone or associated with post-operative radiotherapy or chemotherapy. Mean follow-up was 48 month. Local recurrence occurred in 2 patient, 4 patient died of pulmonary metastasis. The five year survival rate was 55%. Favorable prognostic findings included age < 20 years and complete initial resection.
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Neoplasias de Cabeza y Cuello/patología , Sarcoma Sinovial/patología , Centros Médicos Académicos , Adolescente , Adulto , Niño , Preescolar , Terapia Combinada , Femenino , Neoplasias de Cabeza y Cuello/radioterapia , Neoplasias de Cabeza y Cuello/cirugía , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Cuidados Posoperatorios , Pronóstico , Estudios Retrospectivos , Sarcoma Sinovial/radioterapia , Sarcoma Sinovial/cirugíaRESUMEN
PURPOSE: To review our experience using full-dose external reirradiation given with a curative intent for patients with unresectable head and neck carcinoma (HNC). PATIENTS AND METHODS: Between January 1980 and December 1996, 169 patients who presented with unresectable nonmetastatic HNC in a previously irradiated area were included in this series. The median time between the first and the second irradiation was 33 months. Reirradiation protocols were as follows: radiotherapy alone (65 Gy over 6.5 weeks at 2 Gy/d), 27 patients; Vokes protocol, ie, five to six cycles of radiotherapy (median total dose, 60 Gy; 2 Gy/d) with simultaneous fluorouracil (5-FU) and hydroxyurea, 106 patients; and bifractionated radiotherapy (median total dose, 60 Gy; 2 x 1.5 Gy/d) with concomitant mitomycin, 5-FU, and cisplatin, 36 patients. The median cumulative dose of the two irradiations was 120 Gy. Eighty-five percent of the tumors were squamous cell carcinoma, 14% undifferentiated carcinoma of nasopharyngeal type, and 1% adenocarcinoma. Forty-four percent were local recurrences, 23% nodal recurrences, 14% both local and nodal, and 19% second primary tumors. RESULTS: Mucositis grade 3 (World Health Organization [WHO]) was found in 32% and grade 4 in 14% of cases. Four patients presented with neutropenia or thrombocytopenia (grade 3 or 4 WHO). Late toxicities (> 6 months) were as follows: cervical fibrosis (grade 2 to 3 Radiation Therapy Oncology Group [RTOG]), 41%; mucosal necrosis, 21%; osteoradionecrosis, 8%; and trismus, 30%. Five patients died of carotid hemorrhage, apparently in complete remission. Six months after the onset of reirradiation, 37% of patients were in complete response. Patterns of failure were local only (53%), nodal only (20%), metastatic only (7%), and multiple (20%). Median follow-up time was 70 months. Overall survival rate (Kaplan-Meier) was 21% (95% confidence interval [CI], 15% to 29%) at 2 years and 9% (95% CI, 5% to 16%) at 5 years. Median survival time was 10 months for the entire population. Thirteen patients, of whom 12 were treated with the Vokes protocol, were long-term disease-free survivors. In a multivariate analysis, the volume of the second irradiation was the only factor significantly associated with the risk of death: relative risk=1.8 (95% CI, 1.13 to 5.7) (P=.01). CONCLUSION: Full-dose reirradiation combined with chemotherapy was feasible in patients with inoperable HNC. The incidence and severity of late toxicity was markedly increased in comparison to that observed after the first irradiation. Median survival was better than that generally obtained using palliative chemotherapy alone. A small proportion of patients were long-term disease-free survivors.
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Carcinoma/radioterapia , Neoplasias de Cabeza y Cuello/radioterapia , Adulto , Factores de Edad , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma/tratamiento farmacológico , Quimioterapia Adyuvante , Fraccionamiento de la Dosis de Radiación , Femenino , Neoplasias de Cabeza y Cuello/tratamiento farmacológico , Humanos , Masculino , Persona de Mediana Edad , Membrana Mucosa/efectos de la radiación , Recurrencia Local de Neoplasia/radioterapia , Pronóstico , Radioterapia/efectos adversos , Retratamiento , Factores Sexuales , Estomatitis/etiología , Análisis de SupervivenciaRESUMEN
Forty patients were treated or followed up for aesthesioneuroblastoma between 1980 and 1995 at Institut Gustave Roussy, France. There were three T1, seven T2, 15 T3 and 15 T4 lesions. The cervical metastatic rate at presentation was 18 per cent. Distant metastases were detected by bone marrow biopsy and bone scan in three patients at presentation. Treatment modalities included surgery alone in eight patients, radiotherapy alone in three patients, combined modality surgery plus radiotherapy in 11 patients, chemotherapy alone in two patients, chemotherapy plus radiotherapy in 10 patients, and multimodality therapy chemotherapy plus surgery plus radiotherapy in six patients. The five-year survival rate was 51 per cent. Multimodality treatment offered better survival (63 per cent at five years) and disease-free interval (54 months). Overall local, regional, and distant failure rates were 58 per cent, 15 per cent and 40 per cent respectively. Distant metastases commonly occurred in bone (82 per cent). Cervical metastasis was an unfavourable prognostic indicator (0 per cent survival at two years). In conclusion, aesthesioneuroblastoma is sensitive to chemotherapy and radiotherapy. Multimodality therapy should be used initially.
Asunto(s)
Estesioneuroblastoma Olfatorio/radioterapia , Cavidad Nasal , Neoplasias Nasales/radioterapia , Adolescente , Adulto , Anciano , Niño , Preescolar , Terapia Combinada , Supervivencia sin Enfermedad , Estesioneuroblastoma Olfatorio/tratamiento farmacológico , Estesioneuroblastoma Olfatorio/cirugía , Femenino , Estudios de Seguimiento , Humanos , Lactante , Masculino , Persona de Mediana Edad , Neoplasias Nasales/tratamiento farmacológico , Neoplasias Nasales/cirugía , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Forty-nine cases of circumferential pharyngolaryngectomy with total esophagectomy (PLTE) done between 1982 and 1996 were studied retrospectively. These procedures were performed for advanced squamous cell tumors of the superior esophageal sphincter (n = 23), for hypopharyngeal tumors with synchronous esophageal carcinoma (n = 15), and for hypopharyngeal tumors extensively invading the cervical esophagus (n = 11). METHODS: Ninety-six percent of the patients had T3-4 lesions, and it was impossible to use a free jejunal graft reconstruction. Patients underwent primary surgery in 70% of the cases, and salvage surgery (after failure of chemoradiotherapy) in 30%. In most patients, esophagectomy was performed without thoracotomy (n = 45). Resection was curative (R0) in 70% of the cases, in spite of lymph node invasion in 94%. Reconstruction of the digestive tract was achieved with the stomach in 33 patients (67%) or with the colon in 16 patients (33%). RESULTS: Before 1989, postoperative mortality was high, was correlated with the high frequency of palliative surgery, and resulted in unsatisfactory survival results (overall 5-year survival rate of 7%). After 1989, as a result of better selection of patients and appropriate training of our team, postoperative mortality decreased from 33% to 10%, R1-2 resections decreased from 39% to 26%, and a 3-year overall survival rate of 28% was obtained for the last 25 patients, all of whom were able to eat without difficulty. These results are superior to the survival rates and functional results obtained with radiochemotherapy alone for such advanced tumors, even though the voice is preserved with radiochemotherapy alone. CONCLUSIONS: PLTE for advanced pharyngeal or cervical esophageal tumors is the best treatment currently available, but it is indicated only in very selected cases: when it is technically impossible to perform reconstruction with a free jejunal graft after circumferential pharyngolaryngectomy; as primary surgery, rather than as salvage surgery following chemoradiotherapy; after careful preoperative morphologic and endoscopic assessment of the extent of the tumor; and in patients able to tolerate a thoracotomy for an esophagectomy with lymphadenectomy. Selection according to these guidelines should improve results.
Asunto(s)
Carcinoma de Células Escamosas/cirugía , Neoplasias Esofágicas/cirugía , Esofagectomía , Laringectomía , Neoplasias Primarias Múltiples/cirugía , Neoplasias Faríngeas/cirugía , Faringectomía , Adulto , Anciano , Femenino , Neoplasias de Cabeza y Cuello/cirugía , Humanos , Masculino , Persona de Mediana Edad , Cuidados Paliativos , Estudios Retrospectivos , Terapia Recuperativa , Análisis de SupervivenciaRESUMEN
In order to understand the risks and benefits of a combined transfacial and neurosurgical procedure for neoplasms of the ethmoid sinus, we reviewed all patients who underwent this surgical approach in our department between 1986 and 1994. The study included 41 patients. Pathological diagnoses included adenocarcinoma (31 patients), squamous cell carcinoma (three patients), aesthesioneuroblastoma (three patients), other (four patients). The overall morbidity rate was 39 per cent, and the post-operative mortality rate was 2.5 per cent. Complications were statistically more likely in patients with bone skull base reconstruction. The main carcinologic failures were local recurrences (24 per cent) and metastases (22 per cent). The one-year, three-year and five-year Kaplan Meir survival rates were respectively 84 per cent, 53 per cent and 36 per cent. In conclusion, the mortality and morbidity were acceptable, especially when no bone skull base reconstruction was performed. Better local control justifies a combined procedure with post-operative radiotherapy when tumours involve or reach the skull base.
Asunto(s)
Adenocarcinoma/cirugía , Senos Etmoidales , Neoplasias de los Senos Paranasales/cirugía , Adenocarcinoma/secundario , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Metástasis de la Neoplasia , Recurrencia Local de Neoplasia , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Quirúrgicos Otorrinolaringológicos/métodos , Complicaciones Posoperatorias , Tasa de SupervivenciaRESUMEN
UNLABELLED: The treatment of synchronous esophageal and head and neck carcinomas is difficult. MATERIAL AND METHOD: Retrospective study of 33 patients treated with esophagectomy for an intrathoracic squamous cells carcinoma discovered during pan-endoscopy for a synchronous head and neck cancer. RESULTS: In 7 cases (21%) it was advanced (pT3-4) esophageal cancers. The hospital mortality was 9%. Five year survival was 18% without stabilization of the survival curve, 60% of patients died of recurrence of tumor. CONCLUSION: Esophagectomy is suitable for usT1-2 tumors if surgery is also indicated for the head and neck tumor. Radiochemotherapy is indicated for advanced usT3-4 esophageal tumors or when the treatment of the head and neck tumor is not surgery.