[Show abstract][Hide abstract] ABSTRACT: The growing practice of endoscopic surgery has changed the therapeutic management of selected head and neck cancers. Although a negative surgical margin in resection of neoplasm is the most important surgical principle in oncologic surgery, controversies exist regarding assessment and interpretation of the status of margin resection. The aim of this review was to summarize the literature considering the assessment and feasibility of negative margins in transoral laser microsurgery (TLM) and transoral robotic surgery (TORS). Free margin status is being approached differently in vocal cord cancer (1-2 mm) compared with other sites in the upper aerodigestive tract (2-5 mm). Exposure, orientation of the pathological specimen, and co-operation with the pathologist are crucial principles needed to be followed in transoral surgery. Piecemeal resection to better expose deep tumor involvement and biopsies taken from surgical margins surrounding site of resection can improve margin assessment. High rates of negative surgical margins can be achieved with TLM and TORS. Adjuvant treatment decision should take into consideration also the surgeon's judgment with regard to the completeness of tumor resection.
Rambam Maimonides medical journal. 04/2014; 5(2):e0016.
[Show abstract][Hide abstract] ABSTRACT: Malignant tumours of the salivary glands (MSGT) are rare and pleomorphic entities. Patients with advanced disease may benefit from targeted therapy; however, specific targets for optimising and personalising treatments are yet to be identified.
Immunohistochemistry for C-KIT, EGFR, HER2, MUC1, phospho-mTOR, androgen/estrogens/progesterone receptors and Ki67 was carried out and evaluated in terms of progression-free and overall survival. High throughput molecular screening of key oncogenes was done in 107 patients using routine diagnostic methods and Sequenom technology.
Several therapy leads were identified, including high levels of HER2 and androgen receptors in salivary duct carcinomas, C-KIT in myoepithelial carcinomas and EGFR in mucoepidermoid carcinomas. Recurrent mutations involving downstream elements of the EGFR pathway were found in HRAS, notably in tumours with a myoepithelial component, and in other key oncogenes (KRAS/NRAS/PI3KCA/BRAF/MAP2K). On the other hand, <1% of samples had EGFR or HER2 mutations.
Several tumour subtypes overexpressed targets of directed therapies suggesting potential therapy leads. Genotyping results suggest activation downstream of EGFR in 18 of the 107 samples that could be associated with low efficacy of EGFR inhibitors. Other molecules, such as PI3K/MEK or mTOR inhibitors, may have anti-tumour activity in this subgroup. The high mutation rate in HRAS highlights a novel key oncogenic event in MSGT.
[Show abstract][Hide abstract] ABSTRACT: Laryngeal plasmacytosis (LP) is a rare benign lesion of mature polyclonal plasma cells, which should be differentiated from extramedullary plasmacytoma.
Isolated laryngeal plasmacytosis was discovered in a 59-year-old woman, free of symptoms other than chronic hoarseness.
Histological presentation, treatment modalities and prognosis are discussed.
Laryngeal plasmacytosis is a rare benign lesion that must be considered in case of submucosal polyclonal plasma cell infiltrate.
European Annals of Otorhinolaryngology, Head and Neck Diseases 07/2013;
[Show abstract][Hide abstract] ABSTRACT: Various arguments support the development of a vaccine targeting human papillomavirus (HPV) for the treatment of HPV-associated head and neck cancer. However, the mucosal localization of this tumor, the HPV-driven downregulation of MHC Class I molecules and various other immunosuppressive mechanisms must be carefully considered to improve the clinical efficacy of such an immunotherapeutic strategy.
[Show abstract][Hide abstract] ABSTRACT: The objective was to assess the feasibility and safety of transoral robotic surgery (TORS)-assisted free flap reconstruction for hypopharyngeal carcinoma after radiation therapy. The study evaluated the feasibility, surgical margins, the need for a tracheotomy, a nasogastric tube as well as surgery-related complications. Two patients underwent TORS-assisted free flap reconstruction after radiation therapy. The resection margins were free of tumor in both patients. A tracheotomy was performed in one patient who had been decannulated on the sixth postoperative day. One patient resumed satisfactory oral feeding in the fourth postoperative month and the second patient on postoperative day 7. No intraoperative complication and one postoperative complication (neck hematoma) were reported. After a follow-up period of 24 and 30 months, no local recurrence was observed. TORS is feasible for hypopharyngeal resection and assisted free flap reconstruction after radiation therapy. It represents a further step in the development of minimally invasive surgery for the treatment of head and neck cancers with laryngeal preservation.
Archives of Oto-Rhino-Laryngology 05/2013; · 1.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The human beatbox is the art of reproducing all types of sounds with the mouth while 'adapting' them for better control. To understand how these 'voice virtuosos' juggle with so many different sounds-instrumental, rhythmic, and vocal-at the same time, we have performed a descriptive analysis of three beatboxers by observing their vocal tract behaviour by fiberscopic imaging using an OCM visual scale. From an anatomical-dynamic point of view, beatboxers mobilize all the structures of their laryngopharynx separately. With this first physiological study of the human beatbox, we could observe a well-developed laryngopharyngeal system with extreme articulatory configurations to perform their art.
[Show abstract][Hide abstract] ABSTRACT: Endoscopic laser medial arytenoidectomy for bilateral vocal fold paralysis has the advantage of preserving the structure and the position of the vocal fold, contrary to a transverse cordotomy or total arytenoidectomy. Our objective was to evaluate the functional results of this procedure. This is a prospective non-randomized study. Twenty patients were included: five patients had a tracheotomy preoperatively and 15 patients had dyspnea on exertion. Acoustic voice measurements, spirometric parameters and the voice handicap index 120 (VHI), were evaluated 1 week before surgery and 3 months after. All the five patients with tracheotomy were successfully decannulated. Acoustic records and VHI were available for eight patients. Jitter and shimmer were worse (p = 0.0078), whereas the VHI was not significantly different after surgery. Spirometric records, available for six patients, were not modified. Endoscopic laser medial arytenoidectomy allowed decannulation and subjective improvement of quality of life in patients with bilateral vocal fold paralysis.
Archives of Oto-Rhino-Laryngology 03/2013; · 1.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES/HYPOTHESIS: Minimally invasive surgery has become the standard of care in many organ systems. Head and neck surgery has incorporated transoral surgery, either laser microsurgery or robotic resection, in the management of pharyngeal and laryngeal cancers. To date, the laryngeal procedures have taken the form of partial laryngectomy, as transoral approaches have not allowed reconstruction following total laryngectomy. We present the first series of transoral total laryngectomies. STUDY DESIGN: Multinational, multi-institutional prospective consecutive case series. METHODS: Case series of completed and attempted transoral robotic surgery (TORS) total laryngectomy performed under an institutional review board protocol. The procedure was developed in the cadaver laboratory and applied to selected individuals requiring total laryngectomy for recurrent laryngeal cancer or post-therapeutic organ dysfunction. RESULTS: TORS total laryngectomy was successfully performed in five patients and was unsuccessful in two others. Two of the patients had postoperative fistulae, and all seven are without evidence of recurrent cancer and are swallowing orally without gastrostomy supplementation. CONCLUSIONS: TORS total laryngectomy is feasible and can be taught to other surgeons. Potential benefits of this approach are present for patients undergoing salvage laryngectomy and include improved wound healing and functional results. This procedure further extends the applications of robotic head and neck surgery. Laryngoscope, 2012.
[Show abstract][Hide abstract] ABSTRACT: To present the preliminary results of the qualiit of life and quality of swallowing in a series of 15 patien! treated with oropharyngectomy by transoral robotic-assisted (CTAR) (robot da Vinci, Intuitive Surgical ).
A prospective monocentric non-randomized study of 15 patients with cancer of the oropharynx. Were analyzed: demographics, quality of life questionnaires (QLQ-C30 and H&N 35 EORTC) and quality of swallowing questionnairex (MDADI, DHI and EAT 10) with an average of 1 year after the end of the treatment.
Fifteen patients (10 males and 5 females), mean age of 65 years (47-73 years) were included. The tumours were classified as: cT1: 4; cT2: 10 cT3: 1. Five of the 15 patients received postoperative chemoradiotherapy as histo-pathological studies showed multiple metastatic cervical lymph nodes +/- capsular rupture. For the analysis of the quality of life and quality of swallowing, the patients were divided into two groups. Group A included patients who underwent CTARs and group B, patients operated by CTAR with adjuvant chemoradiotherapy. At 12 months of the procedure, all patients had a deglutition considered as normal without feeding tube nor tracheostomy. With the three scales used, the quality of swallowing was satisfactory for all patients. It was better for patients in group A than for patients in group B. In terms of quality of life, the EORTC QLQ-C30 scale showed our patients had a high rate of satisfaction scale in "health and overall quality of life". For the EORTC H&N35 questionnaire, mean scores for "specific symptoms" were also low except for the following three items "dry mouths", "sticky saliva" and "sexuality problem". The first two items were statistically more frequent (p = 0.02 and p = 0.001) in group B patients.
After transoral robotic-assisted oropharyngectomy, patients have a good quality of life and swallowing. Postoperative chemoradio-therapy compromises the quality of swallowing. Multicentric studies are required to confirm these preliminary results.
Revue de laryngologie - otologie - rhinologie 01/2013; 134(1):49-56.
[Show abstract][Hide abstract] ABSTRACT: Introduction
La plasmocytose laryngée (PL), est une lésion bénigne rare à plasmocytes matures et polyclonaux, qu’il faut savoir distinguer du plasmocytome extramédullaire.
Présentation du cas
Nous rapportons l’observation d’une patiente âgée de 59 ans, ayant une dysphonie chronique comme unique symptôme, chez qui une PL isolée à localisation laryngée a été découverte.
Nous discutons la présentation histopathologique, les modalités thérapeutiques, et le pronostic de cette entité.
La PL est une lésion bénigne et rare, dont le diagnostic est à évoquer devant une infiltration plasmocytaire polyclonale de la sous-muqueuse.
Annales françaises d'Oto-rhino-laryngologie et de Pathologie Cervico-faciale. 01/2013; 130(5):299–301.
[Show abstract][Hide abstract] ABSTRACT: Head and neck cancers positive for human papilloma virus (HPV) have a more favorable clinical outcome than HPV-negative cancers, but it is unknown why this is the case. We hypothesized that prognosis was affected by intrinsic features of HPV-infected tumor cells or differences in host immune response. In this study, we focused on a comparison of regulatory Foxp3+T cells and PD-1+T cells in the microenvironment of tumors that were positive or negative for HPV, in two groups that were matched for various clinical and biological parameters. HPV-positive head and neck cancers were more heavily infiltrated by regulatory T cells and PD-1+ T cells in this group were positively correlated with a favorable clinical outcome. In explaining this paradoxical result, we showed that these PD-1+T cells expressed activation markers and were functional after blockade of the PD-1-PDL-1 axis in vitro. Approximately 50% of PD-1+ tumor-infiltrating T cells lacked Tim-3 expression and may indeed represent activated T cells. In mice, administration of a cancer vaccine increased PD-1 on T cells with concomitant tumor regression. In this setting, PD-1 blockade synergized with vaccine in eliciting antitumor efficacy. Our findings prompt a need to revisit the significance of PD-1-infiltrating T cells in cancer, where we suggest that PD-1 detection may reflect a previous immune responses against tumors that might be reactivated by PD-1/PD-L1 blockade.
[Show abstract][Hide abstract] ABSTRACT: Squamous cell carcinoma (SCC) of the larynx is extremely rare in adolescent or younger adult and typically has an aggressive nature. The mechanism of laryngeal oncogenesis is complex and little is known about the role of human papillomaviruses (HPVs) in SCC in young age. HPV infection may occur during birth or latter by oro-genital contact. Most HPV genotypes detected were HPV 6, 11, 16, 18, 33 and 51. Herein, we report a case of invasive laryngeal SCC expressing an HPV 82 in an 18 year-old man with a history of unexplored severe acute dysphonia that started in early childhood.
Journal of clinical virology: the official publication of the Pan American Society for Clinical Virology 04/2012; 54(2):190-3. · 3.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Les robots ont envahi le monde industriel et récemment médical. En chirurgie, après la mise au point de différents prototypes, Intuitive Surgical® a développé le robot chirurgical Da Vinci. Ce robot conçu pour la chirurgie abdominale s’est imposé en urologie au cours des années 2000. Les avantages de cette chirurgie minimale invasive assistée par robot (CMIR) sont multiples et sont décrits dans l’article. Les inconvénients sont dominés par le prix et l’absence de retour de force. En cancérologie des voies aérodigestives supérieures, les premières études de faisabilité chez des animaux, des mannequins et des cadavres datent de 2005, suivies en 2006 par les premières publications chez des patients. Les premières séries comprenant plus de 20 patients traités par CMIR ont permis de souligner la faisabilité pour les localisations suivantes : oropharynx, larynx supraglottique et hypopharynx. Ces études ne permettent pas de valider la technique de CMIR en terme carcinologique. La CMIR permet de diminuer le nombre de trachéotomies nécessaires, une réhabilitation de la déglutition plus rapide et une durée d’hospitalisation plus courte. Des améliorations techniques sont attendues. Des robots de nouvelle génération de volume plus réduit, plus ergonomiques, et donc plus adaptés aux voies aérodigestives supérieures (VADS) seront probablement disponibles.
Annales françaises d'Oto-rhino-laryngologie et de Pathologie Cervico-faciale. 02/2012; 129(1):39–45.
[Show abstract][Hide abstract] ABSTRACT: It is a major clinical challenge to predict which patients, with advanced stage head and neck squamous cell carcinoma, will not exhibit a reduction in tumor size following induction chemotherapy in order to avoid toxic effects of ineffective chemotherapy and delays for instituting other therapeutic options. Further, it is of interest to know to what extent a gene signature, which identifies patients with tumors that will not respond to a particular induction chemotherapy, is applicable when additional chemotherapeutic agents are added to the regimen.
To identify genes that predict tumor resistance to induction with cisplatin/5-fluorouracil (PF) or PF and a taxane, we analyzed patient tumor biopsies with whole genome microarrays and quantitative reverse transcriptase-PCR (TLDA) cards. A leave one out cross-validation procedure allowed evaluation of the prediction tool. A ten-gene microarray signature correctly classified 12/13 responders and 7/10 non-responders to PF (92% specificity, 82.6% accuracy). TLDA analysis (using the same classifier) of the patients correctly classified 12/12 responders and 8/10 non-responders (100% specificity, 90.9% accuracy). Further, TLDA analysis correctly predicted the response of 5 new patients and, overall, 12/12 responders and 13/15 non-responders (100% specificity, 92.6% accuracy). The protein products of the genes constituting the signature physically associate with 27 other proteins, involved in regulating gene expression, constituting an interaction network. In contrast, TLDA-based prediction (with the same gene signature) of responses to induction with PF and either of two taxanes was poor (0% specificity, 25% accuracy and 33.3% specificity, 25% accuracy).
Successful transfer of the microarray-based gene signature to an independent, PCR-based technology suggests that TLDA-based signatures could be a useful hospital-based technology for determining therapeutic options. Although highly specific for tumor responses to PF induction, the gene signature is unsuccessful when taxanes are added. The results illustrate the subtlety in developing "personalized medicine".
PLoS ONE 01/2012; 7(10):e47170. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Robots have invaded industry and, more recently, the field of medicine. Following the development of various prototypes, Intuitive Surgical® has developed the Da Vinci surgical robot. This robot, designed for abdominal surgery, has been widely used in urology since 2000. The many advantages of this transoral robotic surgery (TORS) are described in this article. Its disadvantages are essentially its high cost and the absence of tactile feedback. The first feasibility studies in head and neck cancer, conducted in animals, dummies and cadavers, were performed in 2005, followed by the first publications in patients in 2006. The first series including more than 20 patients treated by TORS demonstrated the feasibility for the following sites: oropharynx, supraglottic larynx and hypopharynx. However, these studies did not validate the oncological results of the TORS technique. TORS decreases the number of tracheotomies, and allows more rapid swallowing rehabilitation and a shorter length of hospital stay. Technical improvements are expected. Smaller, more ergonomic, new generation robots, therefore more adapted to the head and neck, will probably be available in the future.
European Annals of Otorhinolaryngology, Head and Neck Diseases 12/2011; 129(1):32-7.
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was prospectively to assess the feasibility and safety of transoral robotic surgery (TORS) in head and neck carcinomas and to report our learning curve and 2-year outcomes. Patients with oropharyngeal, hypopharyngeal and laryngeal tumors treated with TORS were prospectively included. We evaluated: the feasibility of TORS, robotic set-up time, transoral robotic surgery time, blood loss, surgical margins, tracheotomy, feeding tube, time to oral feeding and surgery-related complications. Twenty-three patients were treated for 25 carcinomas. Twenty-two patients underwent successful robotic resection for 24 carcinomas (96%). One patient required conversion to open surgery due to massive bleeding. The mean robotic set-up time was 25 min (range: 15-100 min) and mean TORS operating time was 70 min (range: 20-150 min). Positive margin of resection was observed in one patient (classified pT3) out of the 24 cancers and was managed by postoperative chemoradiation. No tracheotomy was performed. Three patients required prolonged intubation for a mean of 22 h. Two patients required a temporary gastrostomy (for 2 and 3.5 months, respectively). All other patients resumed oral feeding between the first and third postoperative day. The mean hospital stay was 6.4 days (range: 4-19 days). No postoperative complication occurred. Mean follow-up was 20 months (median: 19, range: 14-26). No death and no case of local or metastatic failure were observed. TORS is feasible and safe for the resection of selected head and neck carcinomas. The occurrence of intraoperative bleeding emphasizes the need for surgeons to be skilled in both transoral and open approaches.
Archives of Oto-Rhino-Laryngology 12/2011; 269(8):1979-84. · 1.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: For the first time in 1979, it was described by Wang that the infrahyoid musculocutaneous flap (IHMC flap) appears to be extremely suitable for medium-sized head and neck defect. Nevertheless, this flap remains unpopular because of its pretended lack of reliability. The aim of this study is to describe the surgical key points and to expose its main advantages. An IHMC flap was achieved on 32 patients to repair tissue loss due to surgical resection of a squamous cell carcinoma of the upper aero-digestive tract, from March 2006 to January 2010. Medical records of each of these patients were retrospectively analysed by the investigators including the detailed clinical, pathological and operative reports. No patient presented with total flap necrosis. However, we experienced four skin paddles necrosis. In two cases, the necrosis was total and in two cases partial. All donor sites were closed primarily without any tension. One patient showed a major dehiscence of the neck skin incision that required a pectoralis major flap. The IHMC flap is reliable and the harvesting technique is simple when the surgical key points are respected. Its advantages make it a convenient flap for medium-sized head and neck defect.
Archives of Oto-Rhino-Laryngology 08/2011; 269(4):1213-7. · 1.29 Impact Factor