Aggressive fibromatosis (non-familial desmoid tumour): therapeutic problems and the role of adjuvant radiotherapy.

Aggressive fibromatosis is a rare soft tissue tumour with a high tendency to local recurrence, even after apparently adequate resection. Wide local excision with a margin of at least 3 cm, depending on the anatomical location, should be performed to improve rates of recurrent disease. There is no consensus concerning the role of radiotherapy in the treatment of these lesions. The clinical findings of 39 cases diagnosed between 1972 and 1991 were reviewed retrospectively. Local control was effected in 19 of 32 patients treated with surgery alone after a median (range) follow-up of 72 (18-236) months. There were 40 cases of recurrent fibromatosis in 15 patients. Local control was obtained in 13 of 14 patients who received radiotherapy using a wide-field technique and doses of more than 50 Gy over a period of 5 weeks after marginal or incomplete resection of primary or recurrent lesions (P < 0.001). The results suggest that in a selected group of patients with aggressive fibromatosis radiotherapy may effectively achieve control of residual disease after surgery without marked disfigurement and loss of function.

Juvenile ossifying fibroma. An analysis of 33 cases with emphasis on histopathological aspects.

Juvenile ossifying fibroma (JOF) is a maxillofacial fibro-osseous lesion that may show cell-rich osteoid strands or psammoma-like ossicles. Whether both types are variants of a single entity or different lesions under the same diagnostic label is a subject of debate. This problem was investigated by analyzing a series of 33 patients with lesions having one or both of the above histological appearances. It was concluded that osteoid strands define a unique fibro-osseous lesion but that lesions with psammoma-like ossicles fall within the morphological spectrum of cemento-ossifying fibroma. Therefore the term juvenile ossifying fibroma should be reserved for the lesion with the osteoid strands.

Psammomatoid ossifying fibroma of the paranasal sinuses. An extragnathic variant of cemento-ossifying fibroma. Report of three cases.

Psammomatoid ossifying fibroma (POF) is a diagnostic designation for a sinonasal or orbital fibroosseous lesion characterized by numerous small round mineralized spherules lying in a fibroblastic stroma. We report 3 cases. One occurred in the frontal sinus of an 18-years-old male; 1 in the frontal sinus of a 20-year-old male and 1 in the maxillary sinus of a 36-year-old male. Rather limited excision resulted in a disease-free follow-up time from 2 to 6 years. The histomorphology of POF was compared with other fibro-osseous lesions of the craniofacial skeleton including the jaws. It appeared that POF is similar to cemento-ossifying fibroma occurring in the jaws and the necessity for different names for lesions only differing in their site of occurrence is considered to be at least debatable.

Malignant parotid tumors: clinical use of MR imaging and histologic correlation.

Magnetic resonance (MR) imaging was performed in 116 patients in whom a parotid mass lesion was clinically suspected. Eighty-six patients had benign disease. The 30 patients in whom a malignant tumor was found were further evaluated. To determine which features are characteristic of malignant parotid tumors, spin-echo T1- and T2-weighted images of malignant lesions in the parotid gland were compared with those of benign disease. In our series, tumor margins, homogeneity, or signal intensity were not discriminative factors to correctly predict benign or malignant disease. Infiltration into deep structures (eg, the parapharyngeal space, muscles, and bone) was observed only in malignant tumors. Infiltration into subcutaneous fat was noticed in malignant as well as in inflammatory disease. No statistically significant correlation was found between tumor grade and MR imaging features in malignant disease. MR imaging is useful in delineating malignant tumors but is unreliable in correctly predicting the histologic nature of a mass lesion in the parotid gland.

Protocol for the prevention and treatment of oral sequelae resulting from head and neck radiation therapy.

In addition to the desired antitumor effects, head and neck radiation therapy induces damage in normal tissues that may result in oral sequelae such as mucositis, hyposalivation, radiation caries, taste loss, trismus, soft-tissue necrosis, and osteoradionecrosis. These sequelae may be dose-limiting and have a tremendous effect on the patient's quality of life. Current policies to prevent these sequelae primarily are based on clinical experience and show great diversity. A protocol for the prevention and treatment of oral sequelae resulting from head and neck radiation therapy, based on fundamental research and data derived from the literature, is presented. The protocol is particularly applicable in centers with a dental team. This team should be involved at the time of initial diagnosis so that a successful preventive regimen is an integral part of the overall cancer treatment regimen.

Peripheral ameloblastoma. A case report and review of the literature.

Peripheral ameloblastoma is a benign odontogenic tumor with the same histological characteristics as the centrally located ameloblastoma, but appearing in the gingiva and mucosa of the tooth-bearing area of the jaws. A review is presented of 53 cases: 45 being reported as peripheral ameloblastoma and 8 as basal cell carcinoma of the gingiva, including the case presented. Based on the review it is recommended to treat this lesion by local excision including a small margin of healthy tissue. Local recurrence is unlikely, unless incomplete removal is performed.

A survey of prevention and treatment regimens for oral sequelae resulting from head and neck radiotherapy used in Dutch radiotherapy institutes.

Radiation treatment plays an important role in the management of head and neck cancer. Unfortunately several radiation-induced side effects may occur including mucositis, hyposalivation, radiation caries, trismus and osteoradionecrosis. It is generally accepted that most side effects can be prevented or reduced in severity. The purpose of this investigation was to make a survey of the prevention and treatment regimens for oral sequelae resulting from head and neck radiotherapy applied in all radiotherapy institutes in the Netherlands, and to evaluate the differences in these regimens. In all Dutch centers (n = 20) in which irradiation of head and neck cancer patients is performed, members of the staff responsible for prevention and treatment of oral side effects were interviewed. Questions referred to composition of the dental team, screening and care pre-irradiation, care during irradiation, and care post-irradiation. There appeared to be a great diversity in the preventive approach of the head and neck cancer patient in Dutch radiotherapy institutes. The most comprehensive counseling was performed by those centers in which a dental team was active, particularly when an oral hygienist was a member of such a team. The diversity is among others based on lack of well-defined guidelines in many centers, the spread of a relatively small patient group over a rather large number of centers, absence of a dental team in some centers, absence of an oral hygienist in some dental teams, and the observation that a rather large number of patients were not referred, or not timely referred to the dental team. There seems to be a need for the development of a general protocol for the prevention of oral complications applicable in all centers.

Carbon dioxide laser surgery of oral leukoplakia.

Oral leukoplakia is a precancerous lesion of the oral mucosa. The risk of malignant transformation depends on the clinical and histologic classification and the location of the lesion. For a nonhomogeneous leukoplakia, this risk is 23.4% to 38.0%. In the presence of epithelial dysplasia, the possibility of malignant transformation is 36.3% to 43.0%. Leukoplakia is limited to the epithelium, so a selective removal of this part of the mucosa seems to be the best preventive treatment. Carbon dioxide laser surgery accomplishes a superficial removal by evaporation. A total of 70 patients with 103 oral leukoplakias were treated with carbon dioxide laser evaporation. This resulted in an excellent wound healing with virtually no scarring. The patients were followed up during a period of up to 12 years (mean 5.3 years), showing a cure rate of 90%.

Effect of selective elimination of the oral flora on mucositis in irradiated head and neck cancer patients.

Recently it has been reported that chlorhexidine 0.1% rinsing was not successful in eradication of gram-negative bacilli in patients who have head and neck cancer. These bacilli could play a role in irradiation mucositis. This study reports the effect of lozenges containing 2 mg polymyxin E, 1.8 mg tobramycin, and 10 mg amphotericin B qid on the oropharyngeal flora in 15 irradiated head and neck cancer patients. The results were compared with those of a previous study in two groups of 15 patients comparing chlorhexidine rinsing with placebo. In all patients using lozenges, eradication of gram-negative bacilli and yeasts was achieved within 3 weeks. A significant increase of enterococci was found. Mucositis was significantly reduced compared with the previous two groups. All patients showed erythema only, whereas 80% of both the placebo and chlorhexidine rinsing patients suffered from severe mucositis, with signs of pseudomembranes developing from the third week of conventional irradiation protocol. The effect of selective elimination of gram-negative bacilli from the oropharynx and the prevention of severe mucositis may be explained by the eradication of these bacteria and/or neutralization of salivary endotoxin, released by gram-negative bacilli, mediating the inflammatory processes.

[Prevention of oral mucositis in head and neck irradiation]. / Preventie van bestralingsmucositis.

Head-neck irradiation is associated with oral complications. During the irradiation period patients are most burdened by mucositis. Changes of the oral flora with colonisation with the more pathogenic aerobic Gram-negative bacilli seems crucial in the development and severity of mucositis. Prevention of mucositis is reported to be successful during selective oral flora elimination.

Mucositis prevention by selective elimination of oral flora in irradiated head and neck cancer patients.

Mucositis induced by irradiation is the reactive inflammatory-like process of the oropharyngeal mucous membranes following irradiation. Bacteria colonizing the oral tissues are thought to contribute to this inflammatory process. The eradication of Gram-negative bacilli (selective elimination of oral flora) in fifteen comparably irradiated head and neck cancer patients was found to be associated with a significant reduction in mucositis compared with two groups of 15 patients receiving either placebo or chlorhexidine rinsing. Criteria used were the extent of local mucositis signs (mucositis score), as well as generalized side-effects such as the need of nasogastric tube feedings following severe feeding problems. Mucositis signs were confined to erythema only in all selectively decontaminated patients. No pseudomembranes were observed and artificial feeding was completely prevented. These promising results need further confirmation in larger (multicenter) studies.

Chlorhexidine inactivation by saliva.

Chlorhexidine mouth rinsing is commonly used for oral flora reduction. Indigenous microorganisms (viridans streptococci) are significantly suppressed, while "hospital-acquired" gram-negative bacilli are not affected in vivo. To explain the discrepancies between good in vitro and poor in vivo activity of chlorhexidine, minimum bactericidal concentration values for 120 isolates were studied by means of a standard dilution method in fresh whole saliva, broth, and glucose 5%. Both saliva and broth significantly reduced the bactericidal activity of chlorhexidine against all microorganisms tested as compared to glucose 5% (p less than 0.01). Minimum bactericidal concentrations for indigenous flora were significantly lower than the values obtained for the "hospital-acquired" microorganisms (p less than 0.05). These observations of chlorhexidine inactivation by saliva may explain why chlorhexidine mouth rinsing is of limited value in decontaminating the oral cavity.

[Oral aspects of radiotherapy and/or chemotherapy in the head and neck area]. / Radio- en/of chemotherapie in het hoofd-halsgebied.

Patients who are treated with irradiation and/or chemotherapy for head and neck cancer are at risk for several oral complications. The most frequent occurring complications, the prevention of these complications, and the responsibilities of the general practitioner are described.

[Treatment of oral cancer]. / Behandeling van lip- en mondholtecarcinomen.

Patients with oral cancer are usually treated in cancer units. Surgery and radiotherapy are the most important treatment modalities, as has been discussed in this review article. The prognosis of small cancers, that have not yet produced metastatic lymph nodes is excellent. Therefore, early diagnosis is of vital importance.

Scoring irradiation mucositis in head and neck cancer patients.

Irradiation mucositis is defined as an inflammatory-like process of the oropharyngeal mucosa following therapeutic irradiation of patients who have head and neck cancer. Clinically, it is a serious side effect because severe mucositis can cause generalized problems (weight loss, nasogastric tube feedings) and interferes with the well-being of the patient seriously. Grading mucositis is important for the evaluation of preventive and therapeutic measures. The object of this study was to develop a scoring method based on local mucositis signs only. Four clinical local signs of mucositis were used in this score: white discoloration, erythema, pseudomembranes and ulceration. Mucositis of the oral cavity was calculated during conventional irradiation protocol for 8 distinguishable areas using the 4 signs and their extent. A prospective evaluation of this method in 15 irradiated head and neck cancer patients displayed an S-curve reflecting a symptomless first irradiation week, followed by a rapid and steady increase of white discoloration, erythema and pseudomembranes during the second and third week. Oral candidiasis, generalized symptoms such as weight loss and the highest mucositis scores were seen after 3 weeks irradiation. The novel mucositis scoring method may be of value in studying the effect of hygiene programs, topical application of disinfectants or antibiotics on oral mucositis.

Effect of chlorhexidine rinsing on the oropharyngeal ecology in patients with head and neck cancer who have irradiation mucositis.

Oral flora is thought to contribute to irradiation mucositis in patients with head and neck cancer. Neglect of oral hygienic care may also contribute to mucositis. The purpose of this prospective, randomized, placebo-controlled, double-blind study was to evaluate the effect of chlorhexidine 0.1% mouthrinses on oral flora and irradiation mucositis. This study included 30 patients with head and neck cancer who had comparable irradiation portals. One group (N = 15) rinsed four times daily with chlorhexidine 0.1%, the other group (N = 15) with a placebo. The oral flora was cultured (oral washing technique) twice before and three times per week during the period of radiotherapy. On the same days, the severity of mucositis was determined. The colonization index of viridans streptococci was significantly reduced only after 5 weeks of chlorhexidine 0.1% treatment. The colonization patterns of Candida species, Streptococcus faecalis, staphylococci, and Enterobacteriaceae, Pseudomonadaceae, and Acinetobacter species were not influenced by 5 weeks of use of chlorhexidine rinses when compared with the placebo. No differences were seen between the two study groups in the development and severity of mucositis. In conclusion, suppression of oral flora and a lowering of the severity of mucositis by means of disinfecting mouthrinses were not successful.

Xeroderma pigmentosum: squamous cell carcinoma of the tongue.

A case report is presented of a 9-year-old boy with xeroderma pigmentosum complementation group C, who died from a squamous cell carcinoma arising from the tip of the tongue. Treatment with etretinate and in a later phase with indomethacin and prednisolone was not effective, except for a limited initial response of the tumour to etretinate.