Results of surgical treatment of inferior vena cava tumor thrombi in renal cell carcinoma.

INTRODUCTION: Thrombosis of inferior vena cava (IVC) is an important complication amongst oncological patients. Tumor thrombus of IVC is characteristic for patients with renal cell carcinoma, occurring in 1018%. The aim of the work is to analyze of surgical treatment in patients with cancer thrombosis of inferior vena cava in kidney cancer. METHODS: Between 2010 and 2019 we treated 32 patients with kidney cancer complicated by thrombotic infiltration of the inferior vena cava. According to Nesbitt classification the levels of thrombotic infiltration of the inferior vena cava were: I-8 (25%), II-14 (43.8%), III-6 (18.8%), and IV-4 (12.5%). Nephrectomy with thrombectomy of the cancer thrombus in the inferior vena cava was performed in all patients. In addition to laparotomy, sternotomy was approached in 4 patients with Nesbitt IV and in 2 patients with Nesbitt III. RESULTS: Primary suture of IVC was performed in 26 patients; angioplasty of IVC was performed in 4 patients; and resection of IVC with replacement using a polytetrafluoroethylene interposition graft was done in 2 patients. Radical surgical treatment was performed in 27 (84.3%) patients, and palliative in 5 (15.6%) patients. In the postoperative period, 1 (3.1%) patient (Nesbitt IV) died of cardiac failure during hospitalisation. Two-year survival was observed in 75% of the cases. CONCLUSION: Tumorous infiltration of IVC is associated with a high potential for tumour embolisation to the lungs, leading to the formation of multiple metastases and spreading of the underlying disease. Postoperative comfort is improved considerably after nephrectomy of the affected kidney and removal of the tumour thrombus, including IVC resection as appropriate, and when combined with oncological treatment, the survival rate is increased significantly, as well.

HPV prevalence and p16INKa overexpression in non-smoking non-drinking oral cavity cancer patients.

OBJECTIVE: Our aim was to compare HPV and p16INK4a (p16) expression and their influence on survival and prognosis in oral cavity squamous cell cancer (OCSCC), between non-smokers and non-drinkers (NSND) and smokers and drinkers (SD). SUBJECTS AND METHODS: Patients with OCSCC treated with surgery from 2000 to 2010 were included in the study. Patients who did not smoke at all or smoked less than 10 pack per years and did not drink alcohol on a daily basis were considered the NSND group. An equal number of SD were the control group. HPV presence was determined from paraffin-embedded blocks investigated by PCR analysis. p16 expression was evaluated with immunohistochemistry. RESULTS: The NSND group were mostly younger or older female patients with tongue or gingival cancers. p16 expression was significantly more frequent in NSND patients (27% vs 10%). Patients with stronger p16 expression had significantly worse survival, especially for tongue cancers (P = 0.026). In Cox multivariate analysis, both HPV and p16 expression carried a negative prognosis for NSND patients (P = 0.0351 and P = 0.0260). CONCLUSIONS: NSND are a specific population of OCSCC patients. In contrast to oropharyngeal cancer, HPV and p16 expression in OCSCC are negative predictive factors, especially in NSND patients.

Significance of myofibroblast appearance in squamous cell carcinoma of the oral cavity on the occurrence of occult regional metastases, distant metastases, and survival.

The aim of the present study was to assess the frequency of appearance of stromal myofibroblasts in patients with oral squamous cell carcinoma (OSCC) and to further clarify whether myofibroblasts influence tumour suppression or progression. Surgical resection specimens from 152 patients with cT1-T3N0 OSCC were analysed. The frequency of myofibroblasts within the tumour stroma was assessed immunohistochemically and compared with other clinical and histopathological factors. The immunohistochemical reaction for alpha-smooth muscle actin showed positive cells in the stroma of 84.2% of OSCC (n=128). An increased presence of myofibroblasts in the tumour stroma was significantly correlated with T stage (P=0.019), the presence of occult neck metastasis (P<0.001), regional recurrence (P=0.037), and distant metastasis (P=0.008). There was also an association between the presence of myofibroblasts and patient survival (P=0.009). The presence of myofibroblasts was not associated with local recurrence, tumour cell differentiation, mode of invasion, or bone invasion. The results of this study suggest that myofibroblast proliferation facilitates tumour invasion, the occurrence of occult neck disease, and distant metastasis. The survival rate was poorer in patients with abundant myofibroblasts. Further investigations on tumour-associated stroma at the invasive front are needed in order to establish new diagnostic markers and therapeutic strategies.

Lymphatic drainage patterns of head and neck cutaneous melanoma: does primary melanoma site correlate with anatomic distribution of pathologically involved lymph nodes?

The aim of this study was to analyse patterns of metastatic spread from cutaneous head and neck melanoma, which are said to be highly variable. The medical records of 145 patients with pathologically proven metastatic melanoma were reviewed retrospectively. The location of pathologically positive lymph nodes was compared with clinically predicted spread, and patients with metastatic disease in areas outside of predicted drainage patterns were considered aberrant. There were 33 curative and 73 elective neck dissections. 21 of 77 patients undergoing parotidectomy had positive results for metastases. Clinical prediction proved to be correct in 33 of 45 cases (73.3%). Two patients with lateralized melanomas were initially seen with contralateral metastases. Six of 45 patients (13.3%) developed contralateral metastases after neck dissection. Patients with clinical involvement of the parotid gland were at high risk of occult neck disease (40%). Patients undergoing neck dissection for primaries originating in face, forehead, coronal scalp, periauricular area, and upper neck should be considered for parotidectomy. Patients with posterior scalp and posterior neck primaries should be considered for selective neck dissection in conjunction with posterior lymphadenectomy. In patients with coronal scalp and periauricular primaries, a complete neck dissection including parotidectomy is the recommended approach.

Evaluation of sensitivity of teeth after mandibular fractures.

The sensitivity of teeth anterior to a fracture between the mental and mandibular foramina has been tested and followed up until reinnervation or 3 years has passed. This study assessed the reinnervation period, the number of denervated teeth, and their clinical importance. Fifty patients and 459 teeth were examined. Two hundred and seventy-three teeth were affected and had potentially impaired innervation. Tests after injury showed non-responsive teeth in 81% of affected teeth. Six weeks after injury, 19% of teeth were reinnervated; by 1 year after injury, 92% of initially non-responsive teeth were reinnervated. Most teeth (34%) were reinnervated from 6 weeks to 3 months. All 23/186 initially non-responsive, unaffected, contralateral corresponding teeth were reinnervated within 6 weeks. A year after injury, 95% of incisors, 91% of canines, 94% of premolars, and 82% of molars were reinnervated. Three years after injury, 8% of teeth remain denervated. During the second and third years, no reinnervation occurred, but clinical signs of pulp devitalisation of denervated teeth occurred in 18% or 1% of the initially non-responsive affected teeth. The results revealed the stability of pulp 1 year after injury. Denervated teeth should not be treated if no clinical or radiological signs of devitalisation exist.

Salivary and serum interleukin 6 and basic fibroblast growth factor levels in patients with oral squamous cell carcinoma.

AIM: A role of various cytokines has been implicated in the pathogenesis of many carcinomas, and albeit the role of interleukin 6 (IL-6) and basic fibroblast growth factor (bFGF) in sera has been studied in patients with oral carcinomas, data upon salivary IL-6 and bFGF are lacking. The aim of this study was to evaluate levels of IL-6 and bFGF in the saliva and serum of patients with oral squamous cell carcinoma. METHODS: Salivary and serum IL-6 and bFGF were evaluated in a group of 33 patients (28 men, 5 women) with oral squamous cell carcinoma (OSCC), age range 40-73 years , mean 54.05 years. Control group consisted of 23 healhy participants, mean age 25 years. RESULTS: Serum IL-6 and bFGF levels were not significantly different between patients with OSCC and healthy controls. Elevated levels of salivary IL-6 and bFGF in patients with OSCC when compared to the healthy controls were found (p<0.001). CONCLUSIONS: The conclusion is drawn that higher levels of salivary IL-6 and bFGF in patients with OSCC might originate from the local production, probably from carcinoma cells.

Emphysematous gastritis -- case report and review of the literature.

Emphysematous gastritis is a rare form of phlegmonous gastritis caused by invasion of the stomach wall by gas-forming bacteria. This clinical entity was first described by Fraenkel in 1889. The authors report the case of a 58-year-old patient with end-stage renal failure under treatment with hemodialysis for the past year. He was admitted on account of pain in the lower abdomen. During the diagnostic procedure, emphysematous gastritis and acute cholecystitis were confirmed. An acute abdomen developed and an emergency laparotomy was performed. During the procedure, the necrotic gallbladder was removed. The patient died on the following day due to multiorgan failure and septic shock. According to the literature, emphysematous gastritis is generally a fatal disease. Air in the wall of the stomach is a rare finding with a broad differential diagnosis.

Microvascular free flap reconstructive options in patients with partial and total maxillectomy defects.

OBJECTIVE: To evaluate and discuss the free flap reconstructive options for patients with partial and total maxillectomy defects. DESIGN: Retrospective review of cases. SETTING: Two tertiary referral centers. PATIENTS: Fifty-one patients had partial or total maxillectomy defects resulting from oncologic surgical resection, and 7 had partial maxillectomy defects resulting from trauma. Inferior or partial maxillectomy defects included 10 anterior arch and hemipalate defects and 12 subtotal or total palate defects. Total maxillectomy defects with and without orbital exenteration included 36 maxilla defects with hemipalate and malar eminence. INTERVENTION: There were 11 fibula, 14 rectus abdominis, 9 scapular, 10 radial forearm, 5 latissimus dorsi, and 13 combination latissimus dorsi and scapular flaps. MAIN OUTCOME MEASURES: Separation of the oral cavity from the sinonasal cavities, diet, type of dental restoration, type of orbital restoration, speech intelligibility, and complications. RESULTS: Only 1 flap failure was reported. There was loss of bone in 2 flaps and loss of the skin paddle in 1 flap. All palatal defects were sealed by the separation of the oral and sinonasal cavities. Thirty-eight patients were able to eat a regular diet while the remaining patients maintained a soft diet. All patients conversed on the telephone without difficulty in intelligibility. Eight patients had an implant-borne dental prosthetic, and 30 patients had a conventional partial prosthetic. Orbit restoration was achieved in 2 patients with an implant-borne prosthetic, and 6 patients retained a standard orbit prosthetic. CONCLUSIONS: Free flap reconstruction of the maxilla creates reproducible permanent separation of the oral and sinonasal cavities in a single-stage procedure. In addition, there exists the potential for dental rehabilitation with restoration of masticatory and phonatory function. Free flap reconstruction also provides a good cosmetic result, which improves patients' outlook and contributes to their overall well-being. Reconstructive flaps are designed to fit specific maxillary defects and patient needs to provide optimally functional and cosmetic results.

Reconstruction following radical maxillectomy with flaps supplied by the subscapular artery.

The authors present their experience of 27 cases with repairs of defects following radical maxillectomies with free flaps. A total of 28 flaps were used (five latissimus dorsi, six scapula, 16 combination flaps of scapula and latissimus dorsi and one combination of scapula, latissimus dorsi and serratus anterior flap). Only one scapula flap was completely lost and in three cases where a combination of scapula and latissimus dorsi flap was used, partial necrosis of one component occurred. The authors first choice for reconstruction is a scapula bone flap raised on the angular artery combined with the latissimus dorsi flap. The combination of flaps with a long pedicle and of the bony and muscular components provides the surgeon with the option of customizing the flap to meet individual patient needs. For intraoral closure the authors prefer the latissimus dorsi muscle which rarely requires secondary procedures for prosthesis placement following epithelialization and atrophy. The main disadvantage of the flap is the difficulty of two teams working simultaneously, thus increasing the average operating time. All postoperative corrections and prosthetic rehabilitation should be postponed for at least 2 months following surgery because of postoperative swelling.

[Preparation and steric structure elucidation of saturated or partially saturated isoindolo[2,1-a][3,1]benzoxazinones, -[1,2-b][2,4]benzoxazepinones, cyclopentane- and -cyclohexane[b]pyrrolo[2,1-a][3,1]-benzoxazines]. / Telített és részlegesen telített izoindolo[2,1-a] [3,1]benzoxazinok, -[1,2-b][2,4]benzoxazepinonok, ciklopentán- és -hexán[b]pirrolo[2,1-a][3,1]benzoxazin izomerek szintézise.

The reactions of 2-carboxybenzaldehyde (1) with 1,3- or 1,4-aminoalcohols (2a-i, 3a,b) were used to prepare partially or fully saturated tetra- and pentacyclic compounds containing a condensed 1,3-oxazino- or oxazepinoisoindolone moiety and one terminal saturated carbocycle. Isoindolo[2,1-a][3,1]benzoxazinones (4a-d, 6, 7), stereoisomeric isoindolo[1,2-b][2,4]benzoxazepinones (5a-c) hexahydrocyclopentane[b]pyrrolo[1,2-a][3,1]-benzoxazinone (10a,b), octahydroindolo[1,2-b]- and decahydroindolo[1,2-a]benzoxazinone (11a,b and 12a,b) and related pentacyclic derivatives (4e-g) were prepared. The diastereomers 5a-c differ in the ring annelation or in the position of the NCHO hydrogens and annelational hydrogens. The stereostructures of these compounds were elucidated by means of 1H and 13C NMR spectroscopy, including DNOE, DEPT, 2D-HSC measurements and X-ray analysis.

Are the new staging rules better for T4 oral cancer?

BACKGROUND: In order to find whether the changes in primary tumor definition influence the distribution of T (tumor extent) stages and prognoses, a retrospective study was undertaken. PATIENTS AND METHODS: There were 1,040 patients with adequate data for staging and 868 of those patients underwent surgical treatment. Among the surgically treated patients, 187 fulfilled the new (American Joint Committee on Cancer [AJCC]/International Union Against Cancer 1988) and 77 fulfilled the old (AJCC 1977) criteria for T4 tumors. The distribution of all patients, rate of patients initially treated with surgery, incidence of metastases, and survival were analyzed. RESULTS: The neck was clinically positive (N+) in 50% of T4 patients staged according to the new rules and 69% of patients staged according to the old rules. The 5-year overall survival rate for T4-staged patients irrespective of therapy was 29% using the new rules and 13% using the old rules. The 5-year disease-free survival rate for T4-operated patients was 60% using the new rules and 45% using the old rules. CONCLUSIONS: The previous AJCC rules for the T4 tumors were a better indicator of poor prognosis.

Extended anterior subcranial approach for skull base tumors: long-term results.

The extended anterior subcranial approach differs significantly from more traditional surgical approaches to the skull base in that it allows a broad inferior access to the anterior skull base planes with tumor exposure from below rather than via the transfrontal route. The authors initially used the subcranial approach in 1978 for the treatment of high-velocity skull base trauma and certain craniofacial anomalies. In 1980 they expanded the indications to include the combined neurosurgical-otolaryngological resection of various skull base tumors. Osteotomy of the frontonasoorbital external skeletal frame provides optimum anterior access to the orbital and sphenoethmoidal planes as well as to the nasal and paranasal cavities while avoiding frontal lobe retraction and the external facial incisions characteristic of transcranial and transfacial approaches. The improved visualization of the anterior skull base and clival-sphenoidal region facilitates en bloc tumor removal, optic nerve decompression, exposure of the medial aspect of the cavernous sinus, and watertight realignment of the anterior cranial base dura. In this report the authors present their experience over the past 13 years with 104 patients who underwent operation via the extended subcranial approach. Because extensive frontal lobe manipulation and external facial incisions are avoided with this approach, intensive care unit and overall hospital stay are reduced, related complications are minimized, and postoperative cosmetic appearance is enhanced. The extended anterior subcranial method is therefore an excellent alternative to traditional transfacial-transcranial skull base approaches for the removal of selected skull base tumors.

Maxillofacial war injuries in civilians and servicemen during the aggression against Croatia.

Although civilian populations have been heavily involved in most of the recent wars and conflicts throughout the world, most reports analyzed casualty data of military personnel, often leaving civilian casualties excluded or underestimated. A comparison of epidemiologic and medical data for maxillofacial injuries between civilians and servicemen (policemen, soldiers, and United Nations Protection Forces) during the aggression against Croatia is attempted. Of the 220 casualties admitted to the Department of Maxillofacial Surgery in Zagreb between August 1991 and December 1992, almost one-fourth were civilians. A significant difference between civilians and servicemen was noted in age and sex distribution. The incidence and severity of maxillofacial and associated injuries is almost equal, and the pattern of injuries is of the same type for civilian and military personnel.

Musculomucosal nasolabial island flaps for floor of mouth reconstruction.

A modification of the musculomucosal nasolabial island flap based on the facial artery for reconstruction of anterior floor of mouth defects is presented. Surgical technique and advantages in comparison to conventional nasolabial flaps are described. A series of 14 flaps in 8 patients is presented.

A method of zygomatic arch stabilization.

A new method for zygomatic arch stabilization with a silicone tube placed under the zygomatic arch is described. The method is safe, easy to perform and, in our experience, without complications.

Evaluation of mandibular fracture treatment.

A total of 124 patients treated for mandibular fractures were analyzed. Patients were divided into three groups according to treatment: intermaxillary fixation, wire fixation and mini-plate fixation. For each method, the success of treatment was evaluated with respect to surgical approach, fracture site and injury to treatment interval. Five basic parameters were used for evaluation of the outcome: occlusion, appearance, mastication, duration of IMF and complications. The treatment was surveyed based on both the surgeon's and patient's-evaluation. All parameters were scored and average values for every parameter calculated. The most successful treatment was achieved with mini-plate fixation in symphyseal and angle fractures. Intermaxillary fixation is indicated for mandibular body fractures with or without minimal displacement and a sufficient number of teeth. However, mini-plate fixation should be used for fractures with displacement. Wire fixation has been shown to be the poorest choice for all sites. Results showed that the intraoral approach has advantages over the extraoral one. The optimal time for treatment of mandibular fractures is within 72 h from time of injury. Even in fractures older than 7 days we recommended mini-plate fixation.

Recurrences of oral cancer due to discontinuous periosteal involvement.

In order to determine whether an in-transit metastasis on the lingual periosteum might be a cause for recurrences of oral cancer, a retrospective review of 576 surgically treated patients was undertaken. In two patients, a simultaneous discontinuous involvement of the periosteum was verified. In 91 patients, a local recurrence was found, and, in 19, it was explained by periosteal involvement. In these patients, the recurrent tumor was distinct in appearance: a submucosal mass attached to the lingual aspect of the mandible with or without a submandibular fistula. Osteolysis was visible on radiographs in some cases, although it was a late sign. The recurrences on the periosteum appeared later (11.9 months) than other recurrences (8.2 months). Almost half of tongue cancer recurrences (9 of 22) were due to periosteal involvement; this type of recurrence was less frequent at other sites. The presumed lymphatic pathway was confirmed by the results of perlingual lymphography, with the contrast material reaching the lingual aspect of the mandible after 60% of the injections. Both the clinical and experimental results of this study suggest that a pathway exists for discontinuous periosteal involvement from lower oral cavity cancer.