Functional results with advanced hypopharyngeal carcinoma treated with circular near-total pharyngolaryngectomy and jejunal free-flap repair

BACKGROUND: Patients treated by a circular pharyngolaryngectomy for advanced hypopharyngeal carcinoma have a poor prognosis and disappointing speech restoration. METHODS: Three carefully selected patients underwent a near-total laryngectomy circular pharyngectomy with jejunal free flap repair and dynamic tracheopharyngeal shunt for treatment of advanced hypopharyngeal carcinoma. They received induction chemotherapy and postoperative radiotherapy. We assessed the functional outcome. RESULTS: There was no major local complication. One year after the end of radiotherapy, all patients were able to eat solid diets. Two patients were able to speak immediately after the end of the treatment. After speech re-education, a high-quality tracheopharyngeal voice was restored in all three patients. Performance Status Scale for Head and Neck Cancer Patients (PSSHN) showed a mean score equal to 81/100 at 1 year. CONCLUSIONS: In selected patients, near-total laryngectomy circular pharyngectomy with tracheopharyngeal shunt and jejunal free-flap repair offers good voice rehabilitation without impairing swallowing function.     

Adenoid cystic carcinoma of the head and neck: evaluation with MR imaging and clinical-pathologic correlation in 27 patients.

Twenty-seven adenoid cystic carcinomas (ACCs) of the head and neck in 27 patients were evaluated in a retrospective study based on findings at magnetic resonance (MR) imaging and pathologic and clinical examination. Clinical follow-up was obtained over a mean period of 6.3 years (range of follow-up, 3 months to 17 years); all patients underwent one to seven MR examinations. On T2-weighted images, lesions with low signal intensity corresponded to highly cellular tumors (solid subtype) with a poor prognosis; lesions with high signal intensity corresponded to less cellular tumors (cribriform or tubular subtype) with a better prognosis. MR images were not specific in differentiation of ACCs from other types of tumors; this result underscores the need for biopsy to ensure correct diagnosis. Local, intracranial, osseous, and perineural invasion was depicted, but because of its lack of specificity, MR imaging caused overdiagnosis of tumor extension, particularly perineural spread and bone abnormalities.     

Functional surgery for head and neck squamous cell carcinoma

Surgery for head and neck squamous cell carcinoma can alter speech, swallowing, and cosmoses. Recent tendency is to avoid mutilating surgery unless the tumour is aggressive or resistant to chemotherapy and or radiotherapy. Functional surgery is being widely employed, and for example it may vary between conventional partial surgery and endoscopic laser surgery for small sized vocal cord cancers. Various new reconstructive procedures have been developed to help early functional restoration. Loco-regional flaps can be used to replace gums and avoid dental extractions. Free flaps with micro-vascular anastomosis can be employed for immediate reconstruction of extensive surgical defects involving pharyngeal wall, tongue, mandible and mid-face to restore better function and cosmoses. Few recently developed techniques can be also employed in selected cases of laryngo-pharyngeal cancers to avoid permanent laryngeal mutilation. Another goal of functional surgery is to decrease the postoperative radiotherapy or chemo-radiotherapy sequelae, and obtain successful postoperative functional rehabilitation.     

Midface reconstruction with free flaps]

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.     

Free myocutaneous flap of the latissimus dorsi in cervicofacial surgery]

Free myocutaneous latissimus dorsi transplants are exceptionally used in cervicofacial surgery. The authors have performed an anatomical study of 23 non-embalmed subjects, using injections of neoprene latex and barium sulfate into the axillary artery and dye injections. Dissections, arteriographs and corrosion show that the lower scapular pedicle is constant, with an average length of 9.5 cm and a caliber that is sufficient for vasuclar microsurgery. Eight patients with large T4 cervicocephalic neoplasms were operated, including two with tongue tumors, one with a tumor of the oropharynx, two oromandibular lesions, two lesions of the maxillary sinus and a neuroblastoma involving the middle level of the facial structures. A free myocutaneous latissimus dorsi transplant was used. The transplant was revascularised by neck vessels using microsurgical techniques. Complete success was obtained in all eight patients. Good functional, cosmetic and morphological results were obtained as a rule. In cervicofacial surgery, the authors have thus chosen and used a free myocutaneous latissimus dorsi transplant in three topographic indications: for the oropharynx, to fill large cavities, especially the maxillary sinus, and to fill the middle level of the facial structures and of the base of the skull.     

Treatment of the N0 neck during salvage surgery after radiotherapy of head and neck squamous cell carcinoma

BACKGROUND: The morbidity and mortality rates of salvage surgery in patients with local recurrence of head and neck squamous cell carcinoma (HNSCC) after radiotherapy are high. The aim of this study was to determine the rate of occult neck node metastasis and the surgical morbidity of patients after salvage surgery for local relapse after definitive radiotherapy. METHODS: Thirty patients who underwent salvage surgery with a simultaneous neck node dissection for a local relapse after definitive radiotherapy for HNSCC between 1992 and 2000 were included in this study. The primary tumor sites were oral cavity in six patients, oropharynx in 17, supraglottic larynx in three, and hypopharynx in four. Initially, seven patients had T2 disease, eight had T3, and 15 had T4. RESULTS: Twelve patients (40%) experienced postoperative complications, including two deaths. There was no cervical lymph node metastasis (pN0) in 29 of the 30 patients. Fifteen patients (50%) had a recurrence after salvage surgery, including 11 new local recurrences and four patients with distant metastasis. CONCLUSIONS: The risk of neck node metastasis during salvage surgery for local recurrence in patients treated initially with radiation for N0 HNSCC is low. Neck dissection should be performed in only limited area, depending on the surgical procedure used for tumor resection.