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Published on: February 14, 2018
Systematic surgical reassessment combined with liposomal Amphotericin B: the MICA protocol
Maxime Gervais1, Mathilde Aubertin2, Benjamin Verillaud1
1Department of Otorhinolaryngology, Skull Base Surgery, Lariboisière University Hospital, University of Paris Cité, Paris, France.
Background And Objective:
Rhino-orbito-cerebral mucormycosis (ROCM) is a life-threatening fungal infection in immunocompromised or diabetic patients, with mortality between 56 and 73% when the brain is involved. Standard management often fails to halt progression. The MICA (French to summarize the therapeutic strategy combining Mucormycosis management with Invasiveness and Cranial involvement treated with surgery and high-dose Amphotericin B therapy), protocol evaluated whether systematic surgical reassessment combined with liposomal amphotericin B could improve outcomes.
Methods:
Patients underwent extensive surgery reaching the skull base, followed by liposomal amphotericin B. Three-month survival was the primary endpoint. Baseline CT/MRI guided staging and resection; second-look imaging and surgery were performed on day 7.
Results:
Six patients with advanced ROCM (hematologic malignancy or diabetes) were treated. Mortality was 66.7%, driven by rapid progression, skull base invasion and systemic complications; only one patient achieved complete remission.
Conclusion:
Early surgical reassessment and close monitoring may enhance survival, but mortality remains high in cases with hematologic malignancies, and brain involvement.
Significance:
This study highlights the critical need for early, multimodal management, optimized control of comorbidities, and enhanced therapeutic strategies, including timely surgical re-exploration, to reduce the persistently high mortality associated with ROCM.
Insights
Rhino-orbito-cerebral mucormycosis (ROCM) is a severe fungal infection. The MICA protocol combining surgery and amphotericin B showed high mortality, emphasizing early multimodal management for better outcomes.
Area of Science:
- Infectious Diseases
- Surgical Oncology
- Mycology
Background:
- Rhino-orbito-cerebral mucormycosis (ROCM) is a life-threatening fungal infection, particularly in immunocompromised and diabetic patients.
- High mortality rates (56-73%) are observed when the brain is involved, and standard treatments often prove insufficient.
- The MICA protocol was developed to address invasive ROCM with cranial involvement.
Purpose of the Study:
- To evaluate the efficacy of the MICA protocol, which combines systematic surgical reassessment with liposomal amphotericin B therapy, in improving outcomes for patients with advanced ROCM.
- To assess the impact of early surgical intervention and high-dose antifungal therapy on survival rates.
Main Methods:
- The MICA protocol involved extensive surgery reaching the skull base followed by liposomal amphotericin B administration.
- Baseline CT/MRI guided initial staging and resection, with second-look imaging and surgery performed on day 7.
- The primary endpoint was three-month survival.
Main Results:
- Six patients with advanced ROCM (hematologic malignancy or diabetes) were treated.
- A high mortality rate of 66.7% was observed, primarily due to rapid progression, skull base invasion, and systemic complications.
- Only one patient achieved complete remission.
Conclusions:
- Early surgical reassessment and close monitoring may improve survival in ROCM cases.
- Mortality remains high, especially in patients with hematologic malignancies and brain involvement.
- Multimodal management, comorbidity control, and timely surgical re-exploration are critical to reduce ROCM mortality.
