M. Gavid

[18F]-FDG PET-CT prediction of response to induction chemotherapy in head and neck squamous cell carcinoma: Preliminary findings

OBJECTIVESnThe present study assessed the predictive value of [18F]-FDG PET-CT (positron emission tomography with 18-fluoro-eoxyglucose radiotracer, coupled to computerized tomography) for response to induction chemotherapy in head and neck squamous cell carcinoma (HNSCC).nnnMATERIAL AND METHODSn[18F]-FDG PET-CT was systematically performed before treatment initiation and after the first cycle of chemotherapy. Results were compared with those of endoscopy and pathologic analysis of biopsy and surgical specimens.nnnRESULTSnThis preliminary study included 21 previously untreated HNSCC patients. A decrease of more than 30% in SUVmax (maximum standard uptake value) during induction was predictive of tumor response to chemotherapy (P=0.04). PET-CT measurement of hypermetabolic volume based on a predetermined SUV threshold (SUV=2.5), on the other hand, proved non-predictive.nnnCONCLUSIONnThese preliminary findings are promising. A larger sample, however, would be required in order to determine a more precise SUVmax reduction cut-off threshold during induction. Other methods for determining metabolic volume thresholds will be investigated. If functional imaging proves contributive, it could enable early screening of non-responders, avoiding unnecessary intoxication.

Anterior laryngeal commissure: Histopathologic data from supracricoid partial laryngectomy.

OBJECTIVESnTo analyze histopathologic invasion of the anterior laryngeal commissure on surgical specimens from patients operated on for stage-2 squamous-cell carcinoma managed by supracricoid partial laryngectomy (SCL).nnnPATIENTS AND METHODSnTwenty-five patients with previously untreated stage-2 squamous-cell carcinoma were selected. Preoperative endoscopy confirmed anterior commissure involvement; CT found no cartilage lysis. SCL was performed in all cases: 15 anterior frontal SCLs with epiglottoplasty, 8 with cricohyoidepiglottopexy, and 2 with cricohyoidopexy. Histopathology analyzed resection margins (< 1 mm, 1-5 mm, > 5 mm), cartilage extension and vascular embolism. Mean time to observation was 18 months (range, 12-36 months).nnnRESULTSnResection margins were < 1 mm in 7 cases (28%), 1-5 mm in 9 and > 5 mm in 9 patients. Vascular emboli were found in 15 patients (60%). Twenty patients were free of medial thyroid cartilage involvement; 5 showed cartilage extension (20%), restricted to the internal cortical layer in 4 cases (stage T3) and transfixing in 1 (stage T4a). Mucosal extension appeared non-predictive of cartilage invasion. The T4a patient showed local laryngeal recurrence at 12 months.nnnCONCLUSIONSnIn laryngeal commissure squamous-cell carcinoma, SCL enables pathologic analysis of the entire anterior commissure as organogenetically defined: medial thyroid wing, in which the three laryngeal regions are inserted. Microscopic cartilage invasion is poorly predicted by mucosal extension, and may affect 20% of initially T2 patients.

Surgical anatomy of the styloid muscles and the extracranial glossopharyngeal nerve

PurposeThe purpose of the study was to determine the relationships between the extracranial glossopharyngeal (IX) nerve and the muscles of the styloid diaphragm. In humans, the IX nerve is a hidden retrostyloid nerve which plays a critical role notably in swallowing and has to be preserved during infratemporal fossa and parapharyngeal spaces surgical procedures.MethodIn ten adult heads from cadavers (20 sides) fixed in formalin, dissection of the extracranial IX nerve was performed under operating microscope with special attention given to the relationships between this nerve and the styloid muscles of the styloid diaphragm. The three styloid muscles delimit three triangular intermuscular intervals which were each thoroughly explored. Different osseous landmarks were investigated for easy nerve location.ResultsThe styloid process (SP) is the main superior osseous landmark for the three muscles of the styloid diaphragm. The stylohyoid muscle (SHM) is anteromedially located to the posterior belly of the digastric muscle. The styloglossus muscle (SGM) is medial and anterior to the SHM. The stylopharyngeal muscle (SPM) is the most vertical and medial of the three styloid muscles. It courses from the medial surface of the SP in a deep plane hidden between the SHM and the SGM. The extracranial IX nerve turns around the SPM superiorly with a vertical segment posterior to the SPM and inferiorly with a horizontal segment lateral to the SPM. The meeting point of the two segments of the IX nerve is about 10xa0mm anteriorly located from the transverse process of the atlas. The external carotid artery and some of its branches lie in contact with the lateral side of the IX nerve.ConclusionSuch relationships between the extracranial IX nerve, the styloid muscles and the transverse process of the atlas should be appreciated by clinician who treats patients with stylohyoid complex syndromes and by the surgeon for the parapharyngeal spaces approach.

Endoscopic surgery of the parathyroid glands: methods and principles.

Targeted endoscopic parathyroidectomy without gas insufflation is a relatively non-invasive means of discovering and resecting parathyroid adenomas in sporadic primary hyperparathyroidism. This standardized technique depends on the quality of the preoperative imaging: cervical ultrasound and sestamibi scintigraphy, and can be optimized by preoperative insertion of an ultrasound-guided harpoon and rapid peroperative parathyroid hormone analysis. Failure rates range between 1.7% and 4%.

Thyroid nodule surgery: Predictive diagnostic value of fine-needle aspiration cytology and frozen section

OBJECTIVESnThe authors analyse the predictive diagnostic accuracy of fine-needle aspiration cytology (FNAC) and frozen section examination in adult patients operated for thyroid nodules.nnnPATIENTS AND METHODSnThe same pathologist performed macroscopic and cytological examination, followed by frozen section examination on each operative specimen. FNAC results were classified into three groups: benign, malignant or suspicious of malignancy. Frozen section examination was also classified into three categories: benign, malignant or suspicious of malignancy when not all criteria of malignancy were present.nnnRESULTSnOne hundred and sixty-six (82%) of the 202 patients included in the study were females. Patients had a mean age of 51 years. Thyroid carcinoma was diagnosed on final pathology in 22% of women and 25% of men. FNAC results were benign in 85% of cases, malignant in 9% of cases and atypical or suspicious in 6% of cases, with a specificity of more than 99% and a sensitivity, including and excluding microcarcinomas, of 36% and 48%, respectively. The diagnostic accuracy of FNAC was 84% and 89%, after excluding micro-carcinomas. Frozen section was benign in 85% of cases, malignant in 13% of cases and suspicious in 2% of cases, with a specificity of more than 99% and a sensitivity, including and excluding microcarcinomas, of 56% and 68%, respectively. The diagnostic accuracy of frozen section was 89% and 90%, after excluding microcarcinomas. The diagnostic accuracy of the combination of the two examinations was 94% after excluding microcarcinomas.nnnCONCLUSIONnFNAC and frozen section have a comparable predictive diagnostic accuracy. Frozen section is requested by the surgeon not only on the basis of preoperative FNAC, especially when it is suspicious, or even indeterminate, but also in the light of the macroscopic surgical findings.

Infracentimetric cervical lymph node metastasis in head and neck squamous cell carcinoma: Incidence and prognostic value.

OBJECTIVESnSupracentimetric cervical lymph node metastasis is classically a poor prognostic factor for locoregional recurrence and survival in head and neck cancer. Causality, however, is more controversial for infracentimetric cervical lymph node metastases. The objective of this study was to evaluate the incidence and prognostic value of infracentimetric lymph node metastasis.nnnMATERIALS AND METHODSnTwo hundred and forty-three neck dissections from 150 head and neck cancer patients were analyzed. A single pathologist exhaustively inventoried the number and size of all adenopathies in the surgical specimen.nnnRESULTSnCervical lymph node metastases were infracentimetric in 38% of cases, with 72% extracapsular spread (versus 91% for supracentimetric adenopathies; P<0.01). Infracentimetric metastases were more often associated with other cervical lymph node metastases (mean 5.3 versus 3.9; P=0.14). Fifty three percent of specimens showed only supracentimetric metastases (versus 13% infracentimetric metastases; P<0.01). Disease-specific and failure-free survival were lower in case of infracentimetric metastasis, associated with supracentimetric metastasis or not, than in case of macrometastasis only.nnnCONCLUSIONnInfracentimetric cervical lymph node metastasis is a factor of poor prognosis, and may represent a different, more aggressive lymphatic process. We suggest complete neck dissection by the surgeon and meticulous analysis by the pathologist, the results of which guide complementary therapy. Close surveillance of recurrence is also recommended.

Préservation de la motricité du muscle trapèze lors des évidements ganglionnaires cervicaux : étude anatomique et fonctionnelle

But de la presentation L’objectif de ce travail a ete d’etudier les modalites de l’innervation motrice du muscle trapeze par le nerf accessoire et par les racines nerveuses du plexus cervical lors d’evidements ganglionnaires cervicaux. Materiel et methodes Dans un premier temps, des dissections cervicales sur cadavre ont ete realisees sous microscope operatoire afin de mettre en evidence les anastomoses entre le nerf accessoire et le plexus cervical. Dans un deuxieme temps, ce travail a permis d’analyser 20 enregistrements electromyographiques realises au cours d’evidements ganglionnaires bilateraux. Pour chaque patient inclus, la branche trapezienne du nerf accessoire et les racines C3 et C4 du plexus cervical ont ete preservees et dissequees. Ces branches nerveuses ont ete stimulees a 1xa0mA. Un enregistrement electromyographique a ete realise par trois electrodes transcutanees inserees chacune dans un des trois faisceaux du muscle trapeze (Systeme NIM Medtronic). Resultats Vingt-trois dissections cervicales sur 12 cadavres ont pu etre realisees. Elles ont permis de mettre en evidence des anastomoses entre la branche trapezienne et les racines C3 ou C4 du plexus cervical dans respectivement 47xa0% et 65xa0% des cas. L’analyse electromyographique peroperatoire des 10 patients a permis de montrer que la stimulation de la branche trapezienne entrainait une contraction des trois faisceaux du muscle trapeze dans 100xa0% des cas. La stimulation de la racine cervicale C3 etait responsable d’une contraction musculaire dans 22xa0% des cas et la stimulation de C4 dans 22xa0% des cas. Chez un patient, les stimulations a la fois de C3 et de C4 etaient a l’origine d’une contraction du muscle trapeze. Au total, une motricite trapezienne est assuree par le plexus cervical chez 30xa0% des patients analyses. Conclusion De nombreuses anastomoses anatomiques sont presentes entre les racines du plexus cervical et la branche trapezienne du nerf accessoire. Ces anastomoses peuvent etre sensitives et/ou motrices. Sur le plan electromyographique, une motricite trapezienne a ete mise en evidence dans 30xa0% des anastomoses entre le plexus cervical (C3 et/ou C4) et la branche trapezienne du nerf accessoire. La faible proportion de reponses motrices lors des stimulations des racines cervicales souligne donc l’importance de la preservation de la branche trapezienne du nerf accessoire pour la conservation d’une bonne mobilite de l’ensemble de l’epaule lors des evidements ganglionnaires cervicaux.

Anse cervicale et réinnervation laryngée chez l’homme : données anatomiques et résultats cliniques préliminaires

But de la présentation.— La paralysie laryngée unilatérale est à l’origine d’une dysphonie mais aussi de fausses routes alimentaires pouvant mettre en jeu le pronostic vital. Parmi les techniques de ré-innervation laryngée, l’anastomose entre l’anse cervicale et le nerf laryngé récurrent autorise une amélioration de la tonicité et du volume du muscle vocal à long terme. Le but de ce travail a été d’analyser les variations anatomiques des branches terminales de l’anse cervicale, susceptibles d’être les plus adaptées pour une ré-innervation laryngée. Matériel et méthodes.— Dix extrémités céphaliques (20 côtés) non formolées ont été disséquées. Le microscope opératoire est nécessaire pour la recherche des racines de l’anse cervicale et des branches distales basi-cervicales. Des prélèvements nerveux des racines de l’anse cervicale et de ses branches mais aussi du nerf laryngé récurrent ont été étudiés pour des comparaisons morphométriques de diamètre. Trois patients adultes porteurs d’une paralysie laryngée unilatérale depuis plus de six mois ont bénéficié d’une anastomose entre la branche commune des nerfs des muscles sterno-thyroïdiens et sterno-hyoïdiens et le nerf laryngé inférieur. Résultats.— L’origine apparente de la racine inférieure (postérieure) de l’anse cervicale provient des racines C2 et C3 (75 % des cas). L’origine apparente de la racine supérieure (antérieure) naît le plus souvent de la portion verticale du nerf hypoglosse. L’anse cervicale est située le plus souvent à 20—25 mm de part et d’autre du tendon intermédiaire du muscle homo-hyoïdien. Les branches collatérales distales s’organisent dans plus de 70 % des cas avec une branche motrice commune destinée aux muscles sternohyoïdien et sternothyroïdien, dont le diamètre en morphométrie est proche du nerf laryngé récurrent. Avec un recul de six à 12 mois, les trois patients opérés ont une amélioration phonatoire significative et l’un a retrouvé une mobilité laryngée à neuf mois. Conclusion.— Ainsi, en raison de sa proximité topographique avec le larynx et de son diamètre, la branche motrice commune de l’anse cervicale apparaît comme une branche nerveuse de choix pour une ré-innervation laryngée chez l’homme.