Serge Bobin

Potential doubling time and clinical outcome in head and neck squamous cell carcinoma treated with 70 GY in 7 weeks

PURPOSE To study the predictive value of pretreatment potential doubling time and labeling index, as measured by flow cytometry in patients with head and neck squamous cell carcinoma treated with conventional radiotherapy. METHODS AND MATERIALS 70 patients with a squamous cell carcinoma of the oropharynx and 4 patients with another involved head and neck site were entered in this prospective study. The duration of the S phase (TS), the labeling index (LI), and the potential doubling time (Tpot) were obtained by flow cytometry measurements of a tumor biopsy obtained after i.v. injection of 200 mg bromodeoxyuridine to the patient. The treatment consisted of 70 Gy in 7 weeks, 2 Gy per fraction and five fractions per week. RESULTS The mean and median LI were 7.7% (standard deviation, SD: 5.0) and 6.3%, respectively. The mean and median TS were 9.3 h (SD: 3.6) and 8.3 h, respectively. The mean and median Tpot were 5.6 days (SD: 5.4) and 4.6 days, respectively. No significant relationship was found between the Tpot or LI and the tumor stage (T), nodal status (N), histological grade, and the site of the primary within the oropharynx. The only parameter significantly associated with an increased risk of local relapse was the tumor stage (p < 0.001). The mean Tpot for the group of tumors that relapsed locally was 5.3 days (SD: 3.3), compared to 6.1 days (SD: 4.08) for those who did not relapse locally (NS). Two parameters were significantly associated with a decrease in disease-free (DFS) and overall survival, namely the tumor stage (p < 0.005, and p < 0.001, respectively, for DFS and overall survival) and nodal involvement (p = 0.02 and (p < 0.005, respectively, for DFS and overall survival). The TS, LI, DNA index, and Tpot were not significantly associated with local relapse, DFS, and survival, either in the univariate or in the multivariate analysis. CONCLUSIONS The method used to evaluate tumor cell kinetics did not provide clinically relevant kinetic parameters for this type of cancer. The classic prognostic factors (tumor stage and nodal status) were strongly associated with clinical outcome.

Congenital tracheoesophageal fistula without esophageal atresia.

The authors report a series of eight cases of isolated tracheoesophageal fistula without esophageal atresia (or an H type fistula), treated in three pediatric ENT departments. This is a rare malformation whose diagnosis requires investigation for associated anomalies. The clinical signs are mainly respiratory but also digestive and the symptomatology can be severe. The diagnosis can be made with a barium swallow combined with cineradiography, but a tracheoesophageal endoscopy remains the investigation of choice. The treatment is surgical. In most cases, the fistula is accessible by a right or left cervicotomy, depending on the surgeons practice, with a much lower postoperative morbidity as compared to a thoracotomy. The postoperative management was straightforward in most of our cases. We discuss the role of gastro-esophageal reflux with respect to postoperative morbidity as well as systematic treatment for reflux peri-operatively. The pros and cons of the various surgical approaches are also discussed.

Characterization of endolymphatic sac tumors and von Hippel–Lindau disease in the International Endolymphatic Sac Tumor Registry

Endolymphatic sac tumors (ELSTs) are, with a prevalence of up to 16%, a component of von Hippel–Lindau (VHL) disease. Data from international registries regarding heritable fraction and characteristics, germline VHL mutation frequency, and prevalence are lacking.

Impact of Successful Treatment of Acromegaly on Overnight Heart Rate Variability and Sleep Apnea

BACKGROUND Successful treatment of acromegaly improves disease-related cardiovascular mortality and morbidity, but its effects on autonomic modulation of the heart rate are unknown. OBJECTIVES We documented treatment-induced changes in time-domain heart rate variability, taking into account the confounding effects of obstructive sleep apnea. PATIENTS AND METHODS Sixteen consecutive patients (12 males, aged 43 ± 12 y) with newly diagnosed acromegaly underwent overnight (12:00-7:00 am) cardiac Holter recordings coupled with polysomnography. Data were obtained before and 10 ± 6 months after successful treatment of acromegaly. RESULTS IGF-1 levels fell from 807 ± 333 to 207 ± 69 μg/L and normalized in all patients. Seven patients (44%) had obstructive sleep apnea (apnea-hypopnea index 33 ± 21/h) at baseline. Treatment had no significant effect on polysomnographic indices. After treatment, increases were noted in the normal-to-normal heart period (NN), SD-NN, the percentage of NN differing from the previous NN by greater than 50 msec, and the root mean square of successive differences in NN (each P < .05). These heart rate variability results were not influenced by the type of treatment, and there was no relationship between changes in NN and changes in the apnea-hypopnea index (P = .58). CONCLUSION Early after successful treatment of acromegaly, we observed increased parasympathetic modulation/decreased sympathetic modulation of the nighttime heart rate, an effect that seems unrelated to changes in sleep apnea status. Treatments aimed at normalizing IGF-1 may improve cardiovascular homeostasis through improved cardiac autonomic nervous system modulation.

Management of endolymphatic sac tumors: sporadic cases and von Hippel-Lindau disease.

Objective To analyze the difference between the endolymphatic sac tumors (ELSTs) in sporadic cases and in von Hippel-Lindau (VHL) disease. Study Design Retrospective case review in a tertiary referral center. Patients and Methods Fourteen cases of ELST, occurring since 1998, were reviewed. We analyzed the initial symptoms, characteristics of the tumor, treatment, sequelae, and follow-up for each group. Results The ELSTs were sporadic in 6 cases and associated with VHL disease in 8 cases. The mean age at the time of the first surgery was 26 years (range, 12–41). All except two of the patients presented with a unilateral tumor. The initial symptoms were hearing loss (n = 9), tinnitus (n = 7), and/or vertigo (n = 5). Hearing loss was more prevalent in the sporadic cases. Preoperative arteriography was performed for 4 patients, with embolization performed for 1 patient. The size of the tumor was significantly larger in the sporadic cases (31.7 mm) than in the cases of VHL disease (19.3 mm). The surgical approach was more extensive in the sporadic cases. The surgeons found 2 types of tumors. Cystic tumors with massive bleeding invading the surrounding structures (the dura mater or jugular bulb) were more common in the sporadic cases. Fibrous tumors that infiltrate the bone and have moderate bleeding were more common in the cases associated with VHL disease. Two patients with small lesions were not operated on but were followed for 6 years without tumor growth. They died of metastasis from gastric and kidney cancer. Four recurrences occurred during the 14 years of follow-up. Four facial palsies and 8 cases of profound deafness were encountered postoperatively. Conclusion Sporadic tumors are more aggressive than those associated with VHL disease. Complete surgical resection should be the goal of treatment. Preoperative angiography with embolization is recommended. In some cases, embolization may be impossible, and preoperative or postoperative radiotherapy should be discussed.

Prise en charge des fistules labyrinthiques cholestéatomateuses : A propos de 22 cas

Objective: To study the incidence, location, pre- and postoperative symptoms (hearing loss, tinnitus, vertigo, facial palsy), preoperative diagnostic imaging, and surgical treatment of labyrinthine fistulae (LF). Design: Retrospective case review. Patients: Twenty-two cases of LF over 382 mastoid operations performed in a 168-month period. Main Outcome Measures: Clinical, imaging, and surgical correlation of extensive fistulae and bone fistulae. Results: LF prevalence was 5.8%. The main primary symptoms were otorrhea and hypoacusis. Only four patients presented vertigo as their main complaint. All patients underwent preoperative computed tomographic (CT) scans and preoperative audiometry. LF diagnosis was made before surgery for 100% of patients on the basis of CT scan. A second fistula was, however, misdiagnosed by imaging in two patients. With respect to surgical technique, a canal wall down procedure was performed in 77% and a conservative procedure was performed in 23%. Fistula was located in the horizontal semicircular canal in 100% of cases, and in 9%, a second fistula was operatively diagnosed. In 91% of cases, the matrix was removed, whereas it was left in the course of a canal down procedure in 9%. With a follow-up of 5.7 years, hearing remained unchanged in 80% of patients. Conclusions: Surgery with removal of the cholesteatoma matrix and sealing of the fistula with temporalis fascia is a safe procedure that can help preserve cochlear function. The choice of a canal down procedure would be influenced by cholesteatoma characteristics rather than by the finding of an LF.

Carcinome épidermoïde sur kyste du tractus thyréogosse

Objectif Les auteurs presentent un cas de carcinome epidermoide developpe sur un kyste du tractus thyreoglosse chez une adulte. Les modalites de prise en charge et la necessite d’une prevention sont discutees. Patient et methode Patiente de cinquante-cinq ans suivie pour un kyste du tractus thyreoglosse en raison d’un refus parental d’une chirurgie au cours de l’enfance. Resultats Le diagnostic a ete evoque sur une augmentation de volume et des douleurs cervicales. En raison d’un envahissement carotidien et de l’axe larynge, le traitement radiochirurgical n’a pas permis de guerison bien que l’evolution locale soit controlee par une chimiotherapie palliative avec deux ans de recul. Discussion L’exerese dans l’enfance des kystes du tractus thyreoglosse (KTT) est davantage pratiquee afin de prevenir des poussees infectieuses qu’une transformation maligne. Bien que faible, le risque de developpement d’un carcinome sur kyste du tractus thyreoglosse est certainement sous-evalue en raison d’une chirurgie d’exerese preventive tres souvent realisee dans l’enfance. Conclusion L’evolution dramatique du cas presente nous amene a recommander encore une fois une chirurgie d’exerese preventive de ce type de malformation, et a discuter les modalites de prise en charge de ce type d’evolution.

Status of accelerated fractionation radiotherapy in head and neck squamous cell carcinomas.

Considerable interest has been shown in recent years about hyperfractionated and accelerated radiation therapy for head and neck squamous cell carcinomas. The first randomized trial showing an advantage for hyperfractionation in terms of tumor control was the European Organization for Research and Treatment of Cancer 22791 trial. More recently, accelerated radiotherapy has been tested in many studies showing that high total doses of radiation could be delivered in overall treatment time shorter than conventional radiation therapy. The benefit of accelerated radiation therapy has been reported in some recently completed randomized trials, which suggests that rapid repopulation of surviving tumor cells during radiation therapy is a major determinant to obtain cure in this type of cancer.

Comparative study of four radiofrequency generators for the treatment of snoring.

OBJECTIVE: To compare the efficacy and safety of four radio-frequency generators (Ellman, Select Sutter, Coblator, Somnus) for the treatment of simple snoring. MATERIALS AND METHODS: Multicenter, randomized, prospective single-blind study on 120 selected patients with simple snoring (apnea/hypopnea index <10/h of sleep). Snoring sound intensity was measured on a visual analog scale and the partners short-term satisfaction rate was evaluated after two treatment sessions maximum. Discomfort, pain, and medication intake were compared. RESULTS: Radiofrequency decreased the snoring sound intensity from 7.9 ± 1.7 to 4.4 ± 2.7 (P < 0.0001). The four radio-frequency generators had a statistically comparable efficacy. The Ellman generator caused less discomfort and required less antiinflammatory drugs. CONCLUSION: Despite different technical characteristics, the four generators had a comparable efficacy with good safety. The Ellman generator induced the least discomfort.

Traitement orthodontique accéléré par corticotomies alvéolaires chirurgicales chez l’adulte

Resume La duree moyenne d’un traitement orthodontique conventionnel chez l’adulte est comprise entre 18 et 24 mois. Cette duree peut etre un frein a la motivation des patients pour qui le traitement multi-attache peut etre considere comme deletere a l’insertion socioprofessionnelle. Plusieurs techniques ont ete proposees afin de tenter de diminuer la duree d’un traitement. Les techniques chirurgicales de corticotomies alveolaires ont fait l’objet de travaux cliniques et experimentaux. Cependant, elles ont toujours ete realisees de facon segmentaire, sur une dent ou un groupe de dents, mais jamais de molaire a molaire sur une meme mâchoire. Nous nous sommes interesses a cette technique, tant du point de vue de son efficacite et de sa tolerance chez l’animal que par les applications cliniques qui peuvent en decouler chez l’homme. Nous presentons 3 cas de patients adultes relevant d’un traitement orthodontique et chirugical qui ont beneficie de corticotomies vestibulaires et palatines, interdentaires et sus- apexiennes, realisees de facon concomitante a l’ensemble du maxillaire et la mandibule. La duree globale du traitement a ete divisee par deux avec une tolerance excellente. Les avantages et les inconvenients des corticotomies sont discutes a la lumiere de nos resultats cliniques.