Patients' survival after free flap reconstructive surgery of head and neck squamous cell carcinoma: a retrospective multicentre study.

Head and neck squamous cell carcinoma of the (HNSCC) represents approximately 5% of malignant tumours in Italy. HNSCC are commonly treated with surgery or radiotherapy, or a combination of such therapies. The objectives of treatment are maximum cure rate balanced with organ preservation, restoration of form and function, reduction of morbidities and improvement or maintenance of the patient's quality of life. Immediate reconstructive surgery: local, regional or free flaps are now widely advised in the treatment of these patients. Microsurgical transfer requires expertise, is time and resource consuming, and as a whole requires substantial costs. These considerations introduce some concerns about the wide or indiscriminate use of free flap reconstructive surgery. When considering cost-benefit outcomes of such treatment, the main objective is undoubtedly, survival. This data is underreported in the current literature, whereas functional outcomes of free flaps have been largely diffused and accepted. This study collects data from 1178 patients treated with free flap reconstructive surgery following ablation of HNSCC in a group of Italian tertiary hospitals, all members of the Head & Neck Group affiliated with the Italian Society of Microsurgery. According to many authors, free flap surgery for HNSCC seems to be a beneficial option for treatment even in terms of survival.

Quality of life in patients treated for cancer of the oral cavity requiring reconstruction: a prospective study.

Surgical treatment for cancer of the oral cavity can result in dramatic aesthetic and functional sequelae partially avoidable by reconstructive techniques. Many studies concerning quality of life have been carried out in order to retrospectively assess outcomes after such major oncological procedures. Aim of this study was to evaluate, in a prospective fashion, the quality of life as a primary endpoint in patients treated for cancers involving the oral cavity and requiring reconstruction. The study design consisted of a prospective evaluation of pre- and post-operative quality of life at 3, 6, and 12 months to assess variations during follow-up using two different questionnaires: the University of Washington Quality of Life and the Head and Neck Performance Status Scale. Between May 1999 and October 2004, 92 patients with oral cancer requiring reconstruction were treated. All were included in the study, but only 35 (38%) concluded the evaluation protocol at one year after surgery without evidence of disease. The mean pre- and post-operative (3, 6, and 12 months) scores of the questionnaires and the scores of specific University of Washington Quality of Life categories (disfigurement, chewing, swallowing, comprehension of speech) were evaluated. The impact on residual quality of life of different factors such as gender, extension of tongue and mandibular defects, type of reconstruction, and radiotherapy was statistically quantified with a Wilcoxon non-parametric test and logistic regression for multivariate analysis. Comparison of mean pre- and post-operative scores between the University of Washington Quality of Life and Head and Neck Performance Status Scale, showed a similar trend during the study period with a significant decrease at 3 months after surgery and subsequent gradual improvement at 6 and 12 months. The majority of patients (77%) preserved normal or near normal functions at 12 months after surgery. The chewing domain worsened considerably (p <0.05), with poorer outcome in patients undergoing segmental mandibulectomy (p <0.05). By multivariate analysis, mandibular resection maintained its statistical significance in the chewing domain (p = 0.038). Moreover, the type of reconstruction was an independent factor (p = 0.038) that influenced the University of Washington Quality of Life total score, with better functional results after free flap reconstruction. Despite the dismal prognosis of patients affected by advanced oral cavity cancer, reconstructive techniques play a crucial role in maintenance of satisfactory quality of life.

Stereoselective synthesis of pseudopeptide microbial agent AI-77-B.

[structure: see text]. An efficient and highly stereoselective synthesis of the gastroprotective natural product AI-77-B is described. The stereocenters of the hydroxy amino acid moiety were generated by an ester-derived titanium-enolate-mediated syn-aldol reaction, a Curtius rearrangement, and application of Dondoni's aldehyde homologation. Condensation with the dihydroisocoumarin fragment and subsequent deprotecting transformations furnished optically active AI-77-B.

CT appearance of the larynx after conservative and radical surgery for carcinomas.

The purpose of this study was to evaluate the normal CT appearance of the larynx after conservative and radical surgery. Postoperative (conservative surgery n = 52, radical surgery n = 21) CT examinations of 73 patients suspected of local/regional recurrence (n = 53) or asymptomatic (n = 20) were retrospectively analysed. The CT findings of 45 patients negative at biopsy were utilised to assess the normal appearance after surgery. Changes in the laryngeal framework represented constant landmarks, whereas the variety of soft tissues resection often resulted in a more unpredictable appearance of the neolarynx. Considerable thickening of the mucosa covering the arytenoid cartilage(s) has been detected after horizontal supraglottic laryngectomy (40 %) or supracricoid laryngectomies (SL; 100 %). A "pseudocord" due to scar tissue appeared to be a constant finding following vertical haemilaryngectomy, frequently after SL. Dilation of a lateral recess of the hypopharynx was observed after SL. This "pharyngeal pouch" had considerable size and air or liquid content. The most frequent CT findings among 28 tumours recurrent after conservative or total surgery were a mass larger than 10 mm spreading beyond the larynx (63.1 %), thickening of anterior commissure (57.9 %), erosion of residual cartilages (16.9 %). Although CT detected one subclinical recurrence, its employment is justified only to assess the submucosal extent of the lesion. This requires a thorough knowledge of normal postoperative findings.

Effective communication and supervision in the biomedical engineering department.

It is important for biomedical engineering supervisors to master the art of effective communication. Supervisors who have effective communication skills can successfully initiate creative programs and generate a harmonious working atmosphere. Using effective communication, they can promote good working conditions, such as high morale, worker initiative and loyalty to the department, which are almost impossible to measure but imperative for a successful department. However, effective communication tends to be neglected by supervisors who are either functional specialists or managerial generalists. This paper presents several cases of what effective communication truly is and discusses some potential factors that may lead to ineffective communication.

Up-regulation of urokinase-type plasminogen activator in squamous cell carcinoma of human larynx.

The expression of urokinase-type plasminogen activator (uPA) was investigated in squamous cell carcinoma of the human larynx. For this purpose, tissue extracts from 25 matched samples of normal mucosa and neoplastic larynx were compared for the levels of uPA activity as evaluated by a chromogenic PA assay and sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) zymography. Also, uPA antigen was quantified by enzyme-linked immunosorbent assay (ELISA) in 19 cases. The results demonstrate a significant increase in the levels of uPA activity and protein in tumour tissue extracts, more pronounced in tumours with lymph node metastases. Immunohistochemistry performed on 70 biopsies showed that uPA positivity is present both in neoplastic cells and in fibroblast-like cells and macrophages. However, depending on the histological grading and invasive capacity of the tumour, a pronounced intra- and intertumoral heterogeneity in uPA staining was observed. In situ hybridisation confirmed the presence of uPA mRNA in both tumour and stromal cells. The present study provides experimental evidence for a role of uPA in the invasive growth of human laryngeal carcinoma.

Metastatic neoplasms to the larynx: report of three cases.

Metastatic involvement of the larynx by distant malignancies is a rare event that can occur by hematogenous or lymphogenous spread through a retrograde or anterograde route. Only 143 cases of secondary laryngeal tumors have been reported in the literature. Metastases from cutaneous melanoma and renal carcinoma are the most common, whereas only sporadic cases stemming from lung and colon adenocarcinoma have been documented. The authors report a case of lung adenocarcinoma and two cases of colonic adenocarcinoma metastatic to the larynx and discuss the problems related to the pathogenesis, diagnosis, and management of secondary laryngeal neoplasms.

DNA index, cellular proliferative activity and nucleolar organizer regions in cancers of the larynx.

The DNA index, expression of cell-cycle-related proteins--proliferating cell nuclear antigen (PCNA, cyclin) and Ki-67--and the content of silver-binding nucleolar organizer regions (AgNORs) were evaluated in 30 unselected consecutive primary squamous cell carcinomas of the larynx. Results were compared and subsequently related to histological grading, lymph node status, pT category, and pathological stage. DNA content was non-diploid in 9 cases (30%). Mean AgNOR counts per tumor ranged from 2.52 to 8.76. PCNA and Ki-67 expressions were similar in 10 cases (33%). In the remaining cases, PCNA-positive cells usually outnumbered Ki-67-positive cells. No significant correlation was found among DNA index, PCNA and Ki-67 expressions, and AgNOR counts. Although there was a positive trend when Ki-67 was compared with histological grading, findings were not statistically significant. In contrast, a significant correlation was found between DNA index and lymph node status (P = 0.035), with a higher incidence of neck node metastases in non-diploid tumors. These data suggest that tumor ploidy can be correlated with lymph node spread in laryngeal squamous cell carcinoma and might be used as an additional prognostic factor when planning treatment.

Endoscopic laser excisional biopsy for selected glottic carcinomas.

From January 1988 to December 1990, 44 previously untreated patients with squamous cell carcinomas (SCCs) of the true vocal cord (33 T1a, 11 Tis) underwent carbon dioxide laser excision. The mean follow-up was 28 months (range, 12 to 44 months). Endoscopic excisional biopsy was the primary treatment in 38 of the 44 patients, whereas postoperative radiotherapy was added in 6 cases in which the pathology report showed positive margins. Recurrent vocal cord SCC developed in 8 (18%) of the cases, with an average interval of 17.8 months. Re-treatment consisted of a second laser excision in 4 cases, radiotherapy in 1, hemilaryngectomy in 1, and total laryngectomy in 2. The definitive cure rate with endoscopic excisional biopsy for the patients originally treated with laser excision alone was 94.7% (36/38). Endoscopic laser treatment for selected glottic SCC proves to be an excellent alternative to radiotherapy or open neck surgery.

Basement membrane components in normal, dysplastic, neoplastic laryngeal tissue and metastatic lymph nodes.

The immunohistochemical localization of the basement membrane (BM) components laminin, type IV collagen and fibronectin was analyzed in normal, dysplastic and neoplastic laryngeal specimens. The distribution of these macromolecules was also investigated in metastatic lymph nodes. A regular and continuous staining for laminin and type IV collagen was present in normal and mild dysplastic epithelium (LIN I); interruptions and reduplications were more evident in severe dysplasia (LIN III), together with an increased positivity for fibronectin in the subepithelial connective tissue. In squamous cell carcinomas the distribution of BM components was related to the degree of cellular differentiation, with a decreased immunostaining being evident in moderately and poorly differentiated carcinomas. Furthermore, the positivity for laminin and type IV collagen was influenced by the pattern of neoplastic growth, being continuous around the "pushing" border and discontinuous where the neoplastic front had an "invading" appearance. Similar changes were present in cervical metastatic lymph nodes. These observations tend to support the theory that the neoplastic growth is a cyclic process, with BM component synthesis and reabsorbtion related to the shifts of cellular metabolism.

[Melanoma metastatic to the trachea and nasal cavity: description of a case and review of the literature]. / Melanoma metastatico alla trachea e alla cavità nasa-le: descrizione di un caso e revisione della letteratura.

Secondary tumors of the trachea are exceedingly rare, only 14 cases having been reported in the literature. Moreover, metastatic involvement of naso-paranasal cavities can be considered quite unusual. Approximately 150 cases have been drawn from the literature, most of which presented a metastatic deposit from a renal adenocarcinoma. Report is then made of a case of cutaneous melanoma metastatic to the trachea and nasal cavity. The tracheal lesion was repeatedly treated with Nd Yag laser, whereas no treatment was considered eligible for nasal metastasis. The patient succumbed to the tumor 16 months after diagnosis of tracheal involvement had been made. The tendency for malignant melanomas to metastasize to distant organs via the bloodstream is well known, yet trachea and nasoparanasal involvement by metastatic melanoma has been reported, respectively, in only three and six cases, including the present one. Prognosis is unfavorable due to the unusual coexistence of metastases to other organs and the lack of an adequate treatment.

[Distribution of laminin, type IV collagen and fibronectin in normal, dysplastic and neoplastic laryngeal tissue]. / Distribuzione di laminina, collagene di tipo IV e fibronectina nel tessuto laringeo normale, displastico e neoplastico.

The main components, both intrinsic (laminin and type IV collagen) and extrinsic (fibronectin), of the basement membrane (BM) were analyzed by immunohistochemical methods in normal, dysplastic and neoplastic laryngeal mucosa specimens. The material was obtained from 35 patients who had undergone surgery for glottic or supraglottic cancer. Fibronectin proved to be absent from normal mucosa whereas an immunopositivity was observed close to the dysplastic epithelium, especially around inflammatory cells. Positivity increased as the degree of dysplasia increased from LIN I to LIN III. A strong staining was also seen around nests of well and moderately differentiated squamous cell carcinoma. These findings are in agreement with the theories about the main sites of origin for fibronectin, both from plasma and connective tissue. Laminin and type IV collagen showed the same staining characteristics. In normal and mild dysplastic samples a regular and continuous positivity was found at the boundaries between the epithelium and the mesenchymal stroma. Focal discontinuities were present in areas of intense subepithelial inflammation only. Interruptions and reduplications were more evident in severely dysplastic epithelium. In invasive squamous cell carcinomas a strong correlation has been found between the degree of cell differentiation and the pattern of distribution of the intrinsic BM components. Immunostaining was usually evident and continuous around nests of well differentiated squamous cell carcinoma, whereas positivity progressively decreased in moderately and poorly differentiated neoplasms. Furthermore, staining for intrinsic BM components was also related to the pattern of tumor growth: continuous around the "pushing" edge of neoplastic growth and discontinuous when the neoplastic front had an "invading" appearance. These observations tend to support the theory which considers neoplastic growth a cyclic process. BM components are most likely synthesized during the phases of quiescence and reabsorbed during the phase of invasiveness, following shifts in neoplastic cell metabolism.

Lesion detection in MS patients with and without clinical brainstem disorders: magnetic resonance imaging and brainstem auditory evoked potentials compared.

The findings of the present study can be summed up in the following points: (1) brainstem auditory evoked potentials (BAEP), as compared with magnetic resonance imaging (MRI), has a greater capacity and a lower cost in disclosing brainstem plaques both in MS patients with symptoms or signs of actual brainstem involvement and in clinically silent ones. This makes BAEP a useful technique for the neurologist, who can confirm the clinical suspicion of a brainstem lesion and follow the evolution of the disease in the patient. (2) The sensitivity of BAEP is lower than that of MRI as far as the anterior lesions of the brainstem are concerned. (3) MRI is more specific than BAEP, inasmuch as several types of injuries can alter the BAEP, while the demyelinating plaque has a specific image and can only be confused with little lacunar infarcts. (4) Plaques that produced symptoms or signs in the past can eventually disappear and be no longer detected by a subsequent MRI.

Auditory evoked potentials test battery related to magnetic resonance imaging for multiple sclerosis patients.

The results of the recording of the Auditory Brainstem Responses (ABR) in 32 patient with "definite" multiple sclerosis (MS) according to Poser et al. (1983) were contrasted with the brain stem anatomic lesions evidenced by Magnetic Resonance Imaging (MRI) and with the neurologic signs and symptoms found at clinical examination (BS). Twenty-one patients showed ABR abnormalities (65.5%); in 15 cases MRI visualized demyelinization plaques in the brain stem (46.8%); 12 patients had neurological signs of brain stem involvement (37.5%) at the time of the electrophysiological and radiological assessment. When the observation was restricted to the group of 21 patients with past or present BS neurological signs, ABR sensitivity resulted 81% (17/21), while MRI obtained a value of 57% (12/21).

Diagnosis, staging, and treatment of juvenile nasopharyngeal angiofibroma (JNA).

Nineteen patients with juvenile nasopharyngeal angiofibroma (JNA) were surgically treated with different techniques from January 1968 through December 1985. Two patients had undergone a previous operation at another hospital; all patients were males (mean age 15.4), and the most common symptom was nasal obstruction (84.2%). Lateral extension into the pterygomaxillary fossa occurred in 14 patients (73.6%), and 2 also had intracranial invasion (10.5%). In five cases, the tumor's cytosol was analyzed for hormonal receptors. Negative values for estrogen and progesterone receptors were obtained, although the content of dehydrotestosterone receptors was highly positive. These results tend to support the hypothesis of JNA's androgen-dependence. The authors emphasize the need of a preoperative staging classification based on clinicoradiological data in selecting the most adequate surgical approach. Tumors with lateral extension into the pterygomaxillary fossa can be easily removed through a midface degloving; large involvement of the infratemporal fossa requires, also, a transzygomatic dissection. In JNAs with intracranial extension a combined intracranial-extracranial approach is advisable.

The rebirth of the cervical cap.

PIP: In an effort to dispel myths surrounding the cervical cap, the historical and political factors affecting the cap's use in the U.S. are described. Clinical aspects of cap fitting are also included. The cervical cap has found only limited acceptance in the U.S. Skepticisms on the part of physicians may be the result of 2 factors: confusion of the cervical cap with intracervical devices used for artificial insemination and confusion with stem pessaries; and the lack of clinical research and statistical evaluation of efficacy rates. The latter factor prompted Tietze et al. to conduct the only U.S. statistical study of the cap in 1953. Of the 143 women studied, the pregnancy rate was 7.6/100 years of use. Of the 28 unplanned pregnancies, 6 were related to faulty technique or omission of a spermicide and 10 were instances of admittedly irregular use. When these failures are omitted, the theoretical effectiveness rate is about 98%. Some practitioners are concerned about an increased incidence of cervical erosion with cap use. Possibly currently conducted studies will show that cap and spermicide users have a lower incidence of cervical erosion than women using no contraceptive method. Study findings suggest that the cervical cap may afford protection without any spermicidal supplement, but the use of spermicides continues to be recommended to clients. Advantages of the cervical cap include the following: it can be left in place longer than a diaphragm without additional applications of spermicide in the vagina; and the insertion of the cap is unrelated to the time of intercourse. Despite research on toleration of the cap for 3 weeks at a time, it is recommended that the cap be worn for only a few days at a time. At this time there are no manufacturers of cervical caps for contraceptive use in the U.S. The cap is now being imported from England and it costs $6.00. A factor that has made the cap unpopular with many physicians is the lengthy time required for fitting. An assessment guide that physicians can use to incorporate cervical caps in their practice is included. The guide covers medical/gynecological history; informed consent; pelvic examinations; assessment; fitting the cap; and instructing the client. Instructions for client use are also outlined.^ieng