Reconstruction of frontal defects with calvarial grafts.

BACKGROUND: There are many options for the reconstruction of frontal sinus wall defect resulting from injury, neoplastic lesions and aesthetic deformities. These mainly include autogenous grafts, allogenous grafts, and alloplastic materials. The aim of the present study is to report the advantages of using autogenous calvarial bone grafts over other reconstruction techniques, in the reconstruction of frontal defects. METHODS: We describe 16 consecutive cases of anterior frontal sinus defects between 2004 and 2015, in which calvarial bone grafts were used. Medical records were retrospectively analysed to evaluate graft survival. RESULTS: Bone defects were caused by injury (3), aesthetic deformities (2), external frontal sinus surgeries (2), tumours (6: three osteomas, two fibrous dysplasias, one squamous cell carcinoma), and osteomyelitis (3). There were no significant complications during harvesting, and morbidity was minimal. Furthermore, at one and five-year follow-up, no graft resorption or rejection was noted, and cosmetic results were satisfactory. CONCLUSIONS: Our results indicate that calvarial bone graft is an appropriate material to use in anterior frontal sinus reconstruction.

Double primary malignant fibrous histiocytoma and squamous cell carcinoma of the larynx treated with laser laryngeal conservation surgery.

ΒACKGROUND: Synchronous multiple malignancies of the larynx are rare. We present a case here of synchronous primary laryngeal squamous cell carcinoma (SCC) and malignant fibrous histiocytoma (MFH) in a patient with hoarseness though with no history of exposure to radiation. Clinical, intraoperative, and histopathological findings in this patient are discussed. METHODS: Wide laser excision of the left supraglottic lesion and laser cordectomy of the right true vocal cord were performed. RESULTS: The patient presented with a recurrence of the ΜFH alone (with no recurrence of the SCC) two months after the first operation and was managed with an extended second look laser cordectomy. The patient is under regular follow-up and remained disease-free nine months from diagnosis. CONCLUSIONS: Our results show that early-stage simultaneous tumours of the larynx and particularly MFH and SCC can be treated efficiently with endoscopic laryngeal surgery alone. Close follow-up is of paramount importance because of the aggressive nature of MFH.

Comparative pharmacokinetics of an injectable cephalexin suspension in beef cattle.

This study describes and compares the pharmacokinetics of a single 7.5mg/kg dose of cephalexin monohydrate oil-based 20% suspension after its administrations to six cows by the intramuscular (i.m.) and subcutaneous (s.c.) routes, and to five calves by the i.m. route. Significantly (P<0.05) higher peak plasma concentrations (5.6+/-0.79microg/ml versus 3.93+/-1.24microg/ml) and lower half-life (1.81+/-0.56h versus 4.21+/-0.82h) and mean residence time (4.12+/-1.07h versus 6.63+/-0.85h) were obtained after i.m. administration when compared to the s.c. administration to cows. No differences were found between pharmacokinetic parameters calculated for cows and calves. Cephalexin plasma concentrations remained above 0.5-0.75microg/ml for 11-14h and 8-9h after the s.c. and i.m. administrations, respectively. Thus, route of administration may be an important issue to be considered when calculating dosage schedules for successful treatments and safe withdrawal times for veterinary medicines.

[Study of the liver and the portal venous system with digital rotational angiography]. / Studio del fegato e del sistema venoso portale con angiografia digitale con rotazione.

PURPOSE: Digital subtraction angiography is of common clinical use for the evaluation of vascular disease. The rotation of the X-ray tube around the patient's body during contrast medium injection was first proposed in the early seventies in the neuroradiologic field; only recently it has been applied to the evaluation of vascular structures and abdominal parenchymatous organs. We investigated the potential clinical value of digital rotational subtraction angiography in the evaluation of the hepatic arteries and of the portal venous system. MATERIALS AND METHODS: Digital rotational subtraction angiography was performed in 46 patients (34 males and 12 females), mean age 59.3 years (range: 43-72). All the patients underwent digital rotational subtraction angiography after ultrasonographic, CT and/or MRI imaging for evaluation of hepatocellular carcinoma (31 patients) prior to trans-arterial chemoembolization, hepatic metastases from gastrointestinal cancer (9 patients) and pre-surgical study in portal hypertension (6 patients). Digital rotational subtraction angiography was performed using the following technical parameters: a maximum frame rate of 10 views per second, a 1024 x 1024 matrix, a rotation time of 5 seconds, a rotational arch of 90 degrees with a speed of 30 degrees/second. Digital rotational subtraction angiography of the liver was carried out after positioning of a Cobra angiographic catheter in the proper hepatic artery or in the left or right hepatic artery, and subsequent injection of 20-30 ml on contrast medium at a flow rate of 4-7 ml/sec. Conversely, in the portal study the catheter was placed in the splenic or superior mesenteric artery and contrast was administered at 10 ml/sec for an amount of 40-60 ml. Conventional, non-rotational angiography was always obtained with the same catheter and less contrast medium (15-25 at 4-7 ml/sec in the hepatic study, 25-40 ml at 5-7 ml/sec in the portal study). We have evaluated the diagnostic quality (rated as equal, superior or inferior) and the presence of image noise of digital rotational subtraction angiography when compared to digital non-rotational subtraction angiography. We also evaluated the tolerability and the mean time to perform the examination. RESULTS: Compared to non-rotational digital subtraction angiography, the diagnostic quality of digital rotational subtraction angiography was superior in 26 cases, equal in 20 and never inferior: these results are particularly evident in cine-mode. Diagnostic efficacy was similar in the arterial phase and generally better in the venous phase. Image noise was always perceptible, mostly in lateral and oblique views and is related to the patient's size. Noise especially hindered evaluation of the portal venous phase. Digital rotational subtraction angiography was well tolerated by all patients, although its most significative drawback was the prolonged apnea time required (about 8 seconds per single rotation) which can sometimes be difficult for elderly patients. Examination duration is about 5 to 10 minutes. Contrast medium doses required never exceeded 20-60 ml. DISCUSSION: Current evaluation of an hepatic lesion requires injections and multiple views to fully delineate arterial anatomy. This requires the radiologist to create a mental 3-D rendering based upon a 2-D view, obtained on the basis of the radiologist's experience. Rotational angiography, when reviewed in cine-loop, allows a better 3-D rendering than conventional angiography, increasing the advantages of the multiple views obtained from a single angiographic run and allowing an exact imaging of the course and direction of the hepatic arterial branching, making selective catheterization during trans-arterial chemoembolization or other interventional procedures easier. Magnification further improves the evaluation of a mass and of the arterial tree. In hepatic surgery, the most important problem is the precise knowledge of the segment involved and the position of the lesion inside the segment, since a mass in the middle of the segment requires a segmentectomy while a mass near the borders is treated by a larger resection. Digital rotational subtraction angiography improves the visibility of vascular anatomy, allows a better knowledge of hepatic artery branches and improves the angiographic investigation of the liver, permitting a correct spatial assessment. CONCLUSION: Digital rotational subtraction angiography is a useful tool for the evaluation of the liver as well as for transarterial chemoembolization or other interventional procedures. Images are obtained during a single contrast injection, with a better 3-D rendering of the hepatic artery and the portal venous system: no other method provides as complete a visualization of liver vascular anatomy after a single injection of contrast medium in one examination series. (ABSTRACT TRUNCATED)

Three-year follow-up of 62 cirrhotic patients with hepatocellular carcinoma treated with chemoembolization.

BACKGROUND: The aim of this study is to present our experience in 62 patients suffering from hepatocellular carcinoma (HCC) treated with transcatheter arterial chemoembolization (TACE) in two years. METHODS: TACE was performed with injection of doxorubicin mixed with lipiodol before embolization with spongostan. This procedure was repeated for 3 cycles almost. Follow-up was performed by US and CT and by assessment of clinical status and biochemical tests. TACE results were assessed comparing size, local spread and TACE technique with patients' survival. The lesion was single in 51 while multiple in 11. In 6 patients the lesion was greater than 5 cm while in 56 less than 5 cm. RESULTS: Overall survival rates were 95.7% at 6 months, 78.3% at 1 year, 46% at 2 years, 40% at 3 years. The best responses were obtained with single lesions smaller than 5 cm and treated with at least 3 cycles of TACE. CONCLUSIONS: We can conclude that TACE is an efficacious therapeutic choice in the HCC patients who cannot undergo surgery.

[Survival of 184 patients with hepatocellular carcinoma in cirrhotic liver treated with chemoembolization. A multicenter study]. / La sopravvivenza di 184 pazienti con carcinoma epatocellulare nel fegato cirrotico trattati con chemioembolizzazione. Studio multicentrico.

INTRODUCTION: We report the results of a multicenter study of 184 cirrhotic patients with hepatocellular carcinoma (HCC) treated with transcatheter arterial chemoembolization (TACE) and compare our results with those reported in the literature. MATERIAL AND METHODS: We treated 184 cirrhotic FNB-proved HCC patients with TACE in a 2 years' period; 159 were men and 25 women and their mean age was 59 years (range: 46-75 years). TACE was performed with selective or superselective injection of Doxorubicin chlorhydrate (20-50 mg) mixed with Lipiodol Ultrafluid before embolization with Spongostan. This procedure was repeated after 4-6 weeks for at least 3 cycles. Follow-up was performed by means of periodic US, CT and MR scans and by assessment of the clinical status and serum biochemical tests--alpha-fetoprotein, platelet and blood cell counts, protein electrophoresis, bilirubin and other standard liver and renal function tests. TACE results were assessed comparing site, size and local spread of tumor and TACE technique (lobar or segmental, number of performed procedures) with survival in each patient. The lesion was single in 85 (46.2%) and multiple in 99 (53.8%) patients. It exceeded 5 cm in 128 patients (69.5%) and was < 5 cm in 57 (30.5%). RESULTS: Angiography, CT and MRI showed complete necrosis in 148 patients (80.4%) and an unchanged pattern in 36 (19.6%). Overall survival rates were 95.7% at 6 months, 78.3% at 1 year, 46.0% at 2 years, 40.0% at 3 years. The best responses were obtained with lesions < 5 cm--with 100% survival at 6 months, 94.8% at 12 months, 71.4% at 18 months, 54.7% at 24 months and 50.0% at 36 months. Other factors affecting treatment response were singleness of lesion (96.4% at 6 months, 93.9% at 12 months, 71.4% at 18 months, 58.9% at 24 months, and 50.0% at 36 months) and at least 3 cycles of TACE (100% at 6 months, 87.8% at 12 months, 70.1% at 18 months, 48.7% at 24 months and 37.5% at 36 months). Abdominal pain and fever were the most frequent complications, particularly in the first TACE procedure, but both were mild and transient. Lipiodol cholecystitis was found in 3 patients but they were asymptomatic. No patients had evidence of cardiac toxicity or experienced significant leukopenia or thrombocytopenia as a result of systemic toxicity from Doxorubicin. CONCLUSIONS: We can conclude that TACE proves to be an efficacious treatment in the HCC patients who cannot undergo surgery.

[Computerized tomography with lipiodol in the assessment of hepatocellular carcinoma]. / La Tomografia Computerizzata con Lipiodol ella valutazione del carcinoma epatocellulare.

In this paper we report the results obtained with Lipiodol CT in 39 patients with hepatocellular carcinoma (HCC). All patients had focal or multifocal nodular HCC with FNB confirmation and were all submitted to CT 15-20 days after the injection of Lipiodol in common or proper hepatic arteries during an angiographic maneuver. Lipiodol CT showed all the lesions US had demonstrated and depicted more lesions in 12 patients (30.7%)--67 lesions in all. The lesions demonstrated by Lipiodol CT were always smaller than 2 cm: 9/12 had been missed by US, 6/12 by CT and 7/12 by arteriography. In 34/67 lesions (50.7%) enhancement was homogeneous, in 29/67 (43.2%) inhomogeneous and in 4/67 cases (5.9%) Lipiodol was not retained. Lipiodol uptake depended on lesion size: if the lesion was 1-2 cm, uptake was homogeneous, while bigger lesions exhibited inhomogeneous uptake. Lesions bigger than 4 cm exhibited no Lipiodol uptake and were necrotic. A surgical resection was performed in 21/39 patients (53.8%). To conclude, Lipiodol CT is a valuable technique in the preoperative screening of HCC, particularly in the detection of additional lesions: in our series they were demonstrated in 30.7% of patients.

[Comparison between portography-CT and lipiodol-CT in the staging of hepatocellular carcinoma]. / Confronto tra porto-TC e lipiodol-TC nella stadiazione del carcinoma epatocellulare.

Eighteen patients (13 men and 5 women) with uni- and multifocal hepatocellular carcinomas (HCC) were examined. Mean patients age was 63.3 years (range: 47-74 years). All patients had alcoholic or posthepatitis cirrhosis; they were submitted to both CT during arterial portography (APCT) and Lipiodol-CT. The diagnosis of HCC was confirmed by fine-needle biopsy (FNB) in all cases. APCT and Lipiodol-CT results were compared for number, size and site of lesions-32 lesions in all. APCT demonstrated all the lesions: 9 of them were smaller than 2 cm, 14 ranged 2-5 cm and 9 were bigger than 5 cm; moreover, APCT demonstrated other lesions in 3/18 patients (16.6%) which had been missed by US, CT and angiography. Also Lipiodol-CT demonstrated all the 32 lesions and showed smaller lesions in 4/18 patients (22.2%); these nodules were smaller than 2 cm. Based on APCT results 11/18 patients (61.1%) were considered operable, vs. 7/18 patients (38.8%) based on Lipiodol-CT results. To conclude, both APCT and Lipiodol-CT are useful in the preoperative staging of HCC; Lipiodol-CT is preferable to APCT in the study of lesions smaller than 2 cm.

[Survival in 46 patients with hepatocarcinoma treated by chemoembolization]. / La sopravvivenza in 46 pazienti affetti da epatocarcinoma trattati con chemioembolizzazione.

In this paper we report the results we obtained after chemoembolization in 46 patients with HCC in cirrhosis. Chemoembolization is performed by introducing, through an angiographic catheter placed after the origin of the gastroduodenal artery, 20 mg of Doxorubicin Chlorhydrate mixed with 20 ml of Lipiodol and with 10 ml of contrast agent followed by embolization with Spongostan. Chemoembolization results were assessed comparing site, size and local spread of the tumor, hepatic compromission (according to Child's classification) and number of chemoembolization maneuvers with survival in each patient. Overall survival rates are 95.7% at 6 months, 88.5% at 12 months, 60% at 18 months, 36.4% at 24 and 31.8% at 30 months. The best responses were obtained with lesions smaller than 5 cm (100% survival at 6 months, 91.7% at 12 months, 71.4% at 18 and 42.8% at 24 months). Other factors favoring good treatment response were a single lesion (92.9% at 6 months, 91.7% at 12 months, 71.4% at 18 and 42.8% at 24 months), at least 3 cycles of chemoembolization (100% at 6 months, 90% at 12 months, 85.7% at 18 and 42.8% at 24 months) and a low degree of hepatic compromission (Child A and B rather than Child C; in the latter group the survival rates were 75% a 6 months and 0% at 12 months). In conclusion, chemoembolization proves to be the treatment of choice in the HCC patients who cannot undergo surgery.