Reconstruction of irradiated bone segmental defects with a biomaterial associating MBCP+®, microstructured collagen membrane and total bone marrow grafting: An experimental study in rabbits

The bone tissue engineering models used today are still a long way from any oncologic application as immediate postimplantation irradiation would decrease their osteoinductive potential. The aim of this study was to reconstruct a segmental critical size defect in a weight-bearing bone irradiated after implantation. Six white New Zealand rabbits were immediately implanted with a biomaterial associating resorbable collagen membrane EZ® filled and micro-macroporous biphasic calcium phosphate granules (MBCP+®). After a daily schedule of radiation delivery, and within 4 weeks, a total autologous bone marrow (BM) graft was injected percutaneously into the center of the implant. All the animals were sacrificed at 16 weeks. Successful osseous colonization was found to have bridged the entire length of the defects. Identical distribution of bone ingrowth and residual ceramics at the different levels of the implant suggests that the BM graft plays an osteoinductive role in the center of the defect. Periosteum-like formation was observed at the periphery, with the collagen membrane most likely playing a role. This model succeeded in bridging a large segmental defect in weight-bearing bone with immediate postimplantation fractionated radiation delivery. This has significant implications for the bone tissue engineering approach to patients with cancer-related bone defects

Maxillofacial brown tumours: Series of 5 cases.

OBJECTIVES: Brown tumours are benign bone tumours secondary to hyperparathyroidism. The authors describe the various clinical features, diagnostic methods and treatment modalities for maxillofacial brown tumours. MATERIAL AND METHODS: This multicentre retrospective study comprised 5 patients (four women and one man, between the ages of 29 and 70 years) with one or several maxillofacial brown tumours observed over a 16-year period from January 2000 to December 2016. RESULTS: Four patients presented secondary hyperparathyroidism in a context of chronic renal failure, one patient presented primary hyperparathyroidism due to parathyroid adenoma. Three patients presented a mandibular brown tumour, and two patients presented a maxillary brown tumour. The diagnosis was based on histological examination and laboratory tests. Brown tumours were treated either surgically or conservatively. A favourable outcome was observed in all cases. CONCLUSION: Brown tumours are rare lesions. This diagnosis must be considered in a context of giant cell tumour associated with hyperparathyroidism. Brown tumours should be treated conservatively

Radiation effects on bone healing and reconstruction: interpretation of the literature

Objective Reconstructing irradiated mandibles with biomaterials is still a challenge but little investigated. We collected data that could help us understand studies in the field of regeneration with biomaterials and irradiated bone. Study design Systematic review of the literature. Results Delay and duration of radiation delivery and total equivalent dose are the most variable parameters in the various studies, resulting in confusion when interpreting the literature. Most reproducible experiments show that radiation reduces osteogenic cell numbers, alters cytokine capacity, and delays and damages bone remodeling. Interindividual variations and how such changes become irreversible lesions are still uncertain. In the case of regeneration using biomaterials, most studies have addressed the question of reconstruction in previously irradiated bone. The results show that osseointegration is often possible, although the failure rate is higher. The sooner the implantation takes place after the end of the radiation, the higher the likelihood of failure. Few studies have focused on primary reconstruction followed by early irradiation, and most of the currently available engineering models would be altered by radiation. Good outcomes have been obtained with bone morphogenetic protein and with total bone marrow transplanation. Conclusion This review points out the difficulties in achieving reproducible experiments and interpreting literature in this underinvestigated field

Does intraoperative neuromonitoring of recurrent nerves have an impact on the postoperative palsy rate? Results of a prospective multicenter study

BACKGROUND: The impact of intraoperative neuromonitoring on recurrent laryngeal nerve palsy remains debated. Our aim was to evaluate the potential protective effect of intraoperative neuromonitoring on recurrent laryngeal nerve during total thyroidectomy. METHODS: This was a prospective, multicenter French national study. The use of intraoperative neuromonitoring was left at the surgeons\u27 choice. Postoperative laryngoscopy was performed systematically at day 1 to 2 after operation and at 6 months in case of postoperative recurrent laryngeal nerve palsy. Univariate and multivariate analyses and propensity score (sensitivity analysis) were performed to compare recurrent laryngeal nerve palsy rates between patients operated with or without intraoperative neuromonitoring. RESULTS: Among 1,328 patients included (females 79.9%, median age 51.2 years, median body mass index 25.6 kg/m), 807 (60.8%) underwent intraoperative neuromonitoring. Postoperative abnormal vocal cord mobility was diagnosed in 131 patients (9.92%), including 69 (8.6%) and 62 (12.1%) in the intraoperative neuromonitoring and nonintraoperative neuromonitoring groups, respectively. Intraoperative neuromonitoring was associated with a lesser rate of recurrent laryngeal nerve palsy in univariate analysis (odds ratio = 0.68, 95% confidence interval, 0.47; 0.98, P = .04) but not in multivariate analysis (oddsratio = 0.74, 95% confidence interval, 0.47; 1.17, P = .19), or when using a propensity score (odds ratio = 0.76, 95% confidence interval, 0.53; 1.07, P = .11). There was no difference in the rates of definitive recurrent laryngeal nerve palsy (0.8% and 1.3% in intraoperative neuromonitoring and non-intraoperative neuromonitoring groups respectively, P = .39). The sensitivity, specificity, and positive and negative predictive values of intraoperative neuromonitoring for detecting abnormal postoperative vocal cord mobility were 29%, 98%, 61%, and 94%, respectively. CONCLUSION: The use of intraoperative neuromonitoring does not decrease postoperative recurrent laryngeal nerve palsy rate. Due to its high specificity, however, intraoperative neuromonitoring is useful to predict normal vocal cord mobility. From the CHU de Nantes, Clinique de Chirurgie Digestive et Endocrinienne, Nantes, France; CHU Lille, Université de Lille, Chirurgie Générale et Endocrinienne, Lille, France; CHU Nancy-Hôpital de Brabois, Service de Chirurgie Digestive, Hépato-Biliaire, et Endocrinienne, Nancy, France; CHU Angers, Chirurgie Digestive et Endocrinienne, Angers, France; CHU de Toulouse-Hôpital Larrey, Chirurgie Thoracique, Pôle Voies Respiratoires, Toulouse; CHU Saint-Etienne-Hôpital Nord, ORL et Chirurgie Cervico-Faciale et Plastique, Saint-Etienne, France; CHU de Limoges-Hôpital Dupuytren, Chirurgie Digestive, Générale et Endocrinienne, Limoges, France; CHU de Besançon-Hôpital Jean Minjoz, Chirurgie Digestive, Besançon, France; Centre Hospitalier du Mans, Service ORL et Chirurgie Cervico-Faciale, Le Mans, France; Centre Hospitalier Lyon-Sud, Chirurgie Générale, Endocrinienne, Digestive et Thoracique, Pierre Bénite, France; AP-HM-Hôpital de La Conception, Chirurgie Générale, Marseille, France; CHU de Rennes-Hôpital Pontchaillou, Service ORL et Chirurgie Maxillo-Faciale, Rennes, France; CHU de Caen, ORL et Chirurgie Cervico-Faciale, Caen, France; CHU d\u27Angers, ORL et Chirurgie Cervico-Faciale, Angers, France; CHU de Nantes, Service ORL, Nantes, France; AP HP URCEco île-de-France, hôpital de l\u27Hôtel-Dieu, Paris, France; DRCI, département Promotion, Nantes, France

Impact of body mass index on post-thyroidectomy morbidity

BACKGROUND: The impact of obesity on total thyroidectomy (TT) morbidity (recurrent laryngeal nerve palsy and hypocalcaemia) remains largely unknown. METHODS: In a prospective study (NCT01551914), patients were divided into five groups according to their body mass index (BMI): underweight, normal weight, overweight, obese, and severely obese. Preoperative and postoperative serum calcium was measured. Recurrent laryngeal nerve (RLN) function was evaluated before discharge, and if abnormal, at 6 months. RESULTS: In total 1310 patients were included. Baseline characteristics were similar across BMI groups except for age and sex. Postoperative hypocalcaemia was more frequent in underweight compared to obese patients but the difference was not statistically significant in multivariate analysis. There was no difference between groups in terms of definitive hypocalcaemia, transient and definitive RLN palsy, and postoperative pain. CONCLUSION: Obesity does not increase intraoperative and postoperative morbidity of TT, despite a longer duration of the procedure

Advanced age does not increase morbidity after total thyroidectomy. Result of a prospective study

BACKGROUND: It is well known that total thyroidectomy is feasible on elderly patients but is linked to complications because of their underlying comorbidities. In this study we analyzed the specific risks linked to surgery, hypoparathyroidism and recurrent nerve palsy. METHODS: materials-methods:Prospective, multicentre trial conducted at 13 hospital sites. The primary endpoint was the percentage of patients with postoperative hypocalcaemia (albumin-corrected serum calcium level <2 mmol/L at day 2). Secondary endpoints included recurrent nerve palsy rate at day 2, the percentage of patients with hypocalcaemia (serum calcium level <2 mmol/L) and recurrent nerve palsy at month 6, operating durations and postoperative pain. Patients were separated in two groups: <70 years and ≥70 years old. RESULTS: In total, 1329 patients who underwent total thyroidectomy were included (median age 51.17 years [18.10; 80.90], 80% women, and hyperthyroidism in 20%, 101 ≥ 70 years old). Rates of hypocalcaemia at day 2 and month 6 were 20.02% and 1.98% respectively. Nasofibroscopy showed postoperative abnormal vocal cord motility in 9.92% cases (hypo-motility 5.76% - immobility 4.16%) and 0.95% at month 6 (hypo-motility 0.48%, immobility 0.48%). Patients ≥70 years had a lower (but non-significant) postoperative and definitive hypocalcaemia rate than patients < 70 years: 14.85% vs 20.44% at day 2 (p = 0.1773) and 0% vs 2.15% at month 6 respectively (p = 0.2557). Abnormal vocal cord motility rate was 12.00% in patients ≥70 years vs 9.75% in patients <70 years at day 2 (p = 0.4702), and 2.06% in patients ≥70 years vs 0.86% at month 6 (p = 0.2340). CONCLUSIONS: Total thyroidectomy in patients ≥70 years is feasible and safe. Age does not increase the morbidity. The study is registered with ClinicalTrials.gov number NCT01551914

Pattern of lateral neck metastases in N0 papillary thyroid carcinoma

<p>Abstract</p> <p>Background</p> <p>Indication and extent of lateral prophylactic neck dissection (PLND) in papillary thyroid carcinoma (PTC) is very controversial.</p> <p>Methods</p> <p>We retrospectively analysed 131 patients who underwent thyroidectomy and prophylactic lateral neck dissection from level II to V for PTC.</p> <p>Results</p> <p>140 PLND were performed. The occult lymph node metastases (OLNM) overall rate was 18.6%. The incidence of node involvement was 10% at level III and 6.4% at level IIa. Level IV and level Vb were both concerned by 5.7% OLNM. Only 2.9% of level IIb contained OLNM. None of the level Va ND revealed OLNM.</p> <p>Conclusions</p> <p>OLNM from PTC occurs commonly in level IIa, III, IV and Vb. Incidence in other levels is low. For surgeons that usually perform PLND, we believe that a selective neck dissection of levels IIa, III, IV and Vb in N0 neck PTC is sufficient for the clearance of occult metastases.</p

Oncological outcome after free jejunal flap reconstruction for carcinoma of the hypopharynx

It has been a common practice among the oncologist to reduce the dosage of adjuvant radiotherapy for patients after free jejunal flap reconstruction. The current aims to study potential risk of radiation to the visceral flap and the subsequent oncological outcome. Between 1996 and 2010, consecutive patients with carcinoma of the hypopharynx requiring laryngectomy, circumferential pharyngectomy and post-operative irradiation were recruited. Ninety-six patients were recruited. TNM tumor staging at presentation was: stage II (40.6%), stage III (34.4%) and stage IV (25.0%). Median follow-up period after surgery was 68 months. After tumor ablation, reconstruction was performed using free jejunal flap (60.4%), pectoralis major myocutaneous (PM) flap (31.3%) and free anterolateral thigh (ALT) flap (8.3%). All patients underwent adjuvant radiotherapy within 6.4 weeks after surgery. The mean total dose of radiation given to those receiving cutaneous and jejunal flap reconstruction was 62.2 Gy and 54.8 Gy, respectively. There was no secondary ischaemia or necrosis of the flaps after radiotherapy. The 5-year actuarial loco-regional tumor control for the cutaneous flap and jejunal flap group was: stage II (61 vs. 69%, p = 0.9), stage III (36 vs. 46%, p = 0.2) and stage IV (32 vs. 14%, p = 0.04), respectively. Reduction of radiation dosage in free jejunal group adversely affects the oncological control in stage IV hypopharyngeal carcinoma. In such circumstances, tubed cutaneous flaps are the preferred reconstructive option, so that full-dose radiotherapy can be given