The clinical efficacy of L-DOPA and STN-DBS share a common marker: reduced GABA content in the motor thalamus.

At odd with traditional views, effective sub-thalamic nucleus (STN) deep brain stimulation (DBS), in Parkinson's disease (PD) patients, may increase the discharge rate of the substantia nigra pars reticulata and the internal globus pallidus (GPi), in combination with increased cyclic guanosine monophosphate (cGMP) levels. How these changes affect the basal ganglia (BG) output to the motor thalamus, the crucial structure conveying motor information to cortex, is critical. Here, we determined the extracellular GABA concentration in the ventral anterior nucleus (VA) during the first delivery of STN-DBS (n=10) or following levodopa (LD) (n=8). Both DBS and subdyskinetic LD reversibly reduced (-30%) VA GABA levels. A significant correlation occurred between clinical score and GABA concentration. By contrast, only STN-DBS increased GPi cGMP levels. Hence, STN-ON and MED-ON involve partially different action mechanisms but share a common target in the VA. These findings suggest that the standard BG circuitry, in PD, needs revision as relief from akinesia may take place, during DBS, even in absence of reduced GPi excitability. However, clinical amelioration requires fast change of thalamic GABA, confirming, in line with the old model, that VA is the core player in determining thalamo-cortical transmission.

Surgical management of parapharyngeal space tumours: results of 10-year follow-up.

Although primary tumours of the parapharyngeal space are rare and account for only 0.5% of head and neck neoplasms, they represent a formidable challenge to the surgeon both in the assessment of the preoperative condition and the appropriate surgical approach. This study is a retrospective review of the clinical records of 12 patients (8 male, 4 female, mean age 49 years), treated for parapharyngeal space tumours by the same surgical team from 1992 to 1998 and observed at follow-up for at least 10 years. Of these, 8 (66.6%) were benign and 4 (33.4%) malignant. Magnetic resonance imaging and fine-needle aspiration biopsy were performed as the preoperative evaluation in 8/12 cases. The positive predictive value of our fine-needle aspiration biopsy was 75% for benign tumours (3/4) and 100% (4/4) for malignant tumours. Different surgical approaches were used: transcervical-transmandibular in 5 cases (41.6%); transparotid-transcervical in 4 patients (33.4%); transoral in 2 patients (16.6%) with a small pleomorphic adenoma of the deep lobe of parotid, and in the last case (8.4%), transcervical surgery was performed for papillary thyroid carcinoma metastasis. Post-operative complications occurred in 3/12 patients: two developed Horner's syndrome and one patient presented a temporary marginal mandibular of facial nerve dysfunction. Post-operative radiotherapy was performed in 3/4 patients on account of malignancy. Each patient underwent a follow-up protocol of clinical controls and ultrasonography every 6 months, computed tomography and/or magnetic resonance imaging once a year for 10 years. Eleven patients (91.4%) were still disease free after 10-year follow-up. One patient with a recurrent parotid gland adenocarcinoma died of distant metastasis 4 years after parapharyngeal space surgery. These 12 parapharyngeal space tumours were treated with use of one of the various surgical approaches described in relation to the histopathological diagnosis (benign or malignant), to the side (prestyloid or poststyloid) and to the size (+/-4 cm) of the neoplasia and, moreover, were observed at long-term follow-up. Results of personal experience in the treatment of the tumours of the parapharyngeal space confirm the necessity to follow a careful preoperative diagnostic outline that must be taken advantage of the study for imaging (computed tomography, magnetic resonance imaging) and of cytology, in order to plan surgical treatment with a safe approach and that reduces complications, aesthetic-functional damages and risk of recurrence.

Overexpression of p53 and bcl-2 proteins and the presence of HPV infection are independent events in head and neck cancer.

The expression of p53 and bcl-2 proteins by immunohistochemistry and the identification of human papillomavirus (HPV) infection by a non-isotopic polymerase chain reaction (PCR)based method were investigated in 30 patients with head and neck cancer. Ten cases were HPV-positive (33%), mostly as double or multiple infections by high- or intermediate-risk types. Twenty-one patients were p53-positive (70%), 9/10 with HPV-positive tumours and 12/20 with HPV-negative tumours; this difference was not statistically significant. Only four cases were bcl-2-positive, irrespective of the presence of either HPV or p53. No correlation was found between these biological factors and tumour stage, differentiation grade, and alcohol or tobacco use. Our findings indicate that p53 is involved in the majority of cases, bcl-2 is rare, and high-risk HPV could play a key role, especially in tumours of tongue and tonsil. In conclusion p53 and bcl-2 protein expression and the presence of HPV infection are independent events in these malignancies.

Physical state and expression of human papillomavirus in laryngeal carcinoma and surrounding normal mucosa.

Epidemiologic and biomolecular evidence suggests that human papillomavirus (HPV) infection may be associated with the development of head and neck cancers. To clarify the role of HPV in larynx carcinoma, 25 patients were studied for the presence of viral DNA, possible virus integration into the cellular genome, and viral expression both in neoplastic tissues and in neighbouring normal mucosa. Twelve of 25 patients with neoplasia (48%) showed negative results for HPV sequences, and 13 (52%) showed positive results. Among the latter group of patients, seven were HPV-16 positive, five were HPV-6, and one was HPV-45. No multiple infections were detected. The physical status of the HPV genome was analysed by three methods: polymerase chain reaction (PCR), bidimensional agarose gel electrophoresis, and in situ hybridisation. Viral integration into the host genome occurred in 43% of cases of HPV-16 and in 20% of cases of HPV-6. Viral RNA expression was detected by reverse transcription-PCR only in HPV-16-positive tumours. The pattern of expression was consistent with an active role of HPV in cellular transformation. In conclusion, the present work suggests that HPV infection may be involved in some cases of laryngeal carcinoma. However, the transformation mechanisms might be different from those currently accepted for anogenital cancers.

Age as a risk factor in cervicofacial reconstruction.

The Authors report their experience from January 1980 to January 1998 with 392 reconstructive flaps for the oncological reconstruction of the cervicofacial district. One hundred and forty-two were conventional flaps, 187 were myocutaneous or pedicled muscular ones and 63 were microvascular. Ninety percent of the patients had Stage IV disease, 80% were tumors involving the oral cavity structures, 40% of the patients had received preoperative radiotherapy; 35% of the cases were recurrences. The complications related to the surgery were evaluated for each type of flap, comparing them to the same flaps employed in patients > 70. Complications were divided into major and minor that were observed at an overall rate of 22%. With the use of conventional flaps, there was an 11.3% rate of minor complications and a 5.6% rate of major ones. Examining the 187 myocutaneous or pedicled muscular flaps, 21% of the overall 27% were minor and 6% were major complications. Of the remaining 63 free flaps, minor complications were observed in 4.7% and major complications in 14.2% of cases. Thirty-four of the 392 flaps, 24 of which were myocutaneous or pedicled muscular and 10 free flaps, were utilized in elderly patients and compared with the 216 of the same type, in patients < 70. A comparative analysis shows that there was a major complication rate of 11.7% in the flaps employed on the elderly patients as opposed to 7.9% for those employed in the younger patients. In terms of minor complications, a 20.5% complication rate was observed for those > 70 as opposed to 16.7% for patients < 70. A more detailed analysis of these data, enabled to postulate that the smaller group of flaps used in elderly patients is statistically influenced by the "dilution" of the complication rate in favour of the larger group of younger patients. Furthermore, by appropriately correcting the risk factors due to concomitant diseases that were not related to surgery in the older patients, a realignment of the results may be seen. Therefore, a careful preoperative study must be carried out in the elderly patients with cervicofacial tumors who are eligible for surgery to establish and possibly treat the concomitant disease responsible for the increased peri- and postoperative morbidity. In conclusion, complications in elderly patients are correlated to the state of co-morbidity and neither to age nor to the duration of the operation. Responsiveness may therefore be obtained also in elderly patients employing sophisticated techniques such as microvascular flaps.

[Carcinoma of the hypopharynx: reconstruction of the pharyngo-esophageal tract after circular pharyngectomy by the transplantation of a U-shaped jejunal loop to the neck]. / Carcinoma dell'ipofaringe: ricostruzione del tratto faringo-esofageo dopo faringo-laringectomia circolare mediante trapianto di ansa digiunale ad U al collo.

Reconstruction of the oro- and hypopharynx has specific difficulties duo to their wide diameters. Thirteen patients underwent reconstruction with a free U-shaped jejunal transplant, after circular pharyngo-laryngectomy for hypopharyngeal cancer invading the oropharynx. This transplant included a side-to-side anastomosis between the two limbs of the jejunal loop and allowed reconstruction of the upper digestive tract after wide carcinologic resection of the pharynx. The U-shaped jejunal transplant facilitated the upper anastomosis, especially the upper part where the resection involved the oropharynx. It formed a reservoir behind the tongue and avoided nasal reflux. Best indication are large resections involving the oropharynx.

[Free radial forearm flap and myocutaneous flaps in oncological reconstructive surgery of the oral cavity, Comparison of functional results]. / Il lembo libero radiale di avambraccio ed i lembi miocutanei nella chirurgia ricostruttiva oncologica del cavo orale. Implicazioni funzionali a confronto.

In modern multi-disciplinary cancer treatment, rehabilitation and functional results represent utmost intent in reconstructive surgery of the oral cavity. Even in cases where the stage of disease is advanced) and the perspective of survival is limited, it is possible to achieve an acceptable quality of life. The authors report, in this study, the morpho-functional results and the morbidity observed in glossectomies in which the reconstruction was performed using three different methods. In a total of 264 reconstructive flaps of the head and neck regions, the authors considered three groups of 15 patients that had had reconstruction after the demolitive procedure. Respectively these groups were divided by the followed methods: free forearm flap, pectoralis major myocutaneous flap and nasolabial flap. The morbidity showed an extremely low rate of flap loss in all the groups, but "minor" complications, such as fistulas and leakages, were significantly more frequent in the myocutaneous flaps group. Functional evaluation for speech and deglutition showed good results in most patients. Extremely severe postoperative conditions as a permanent NG tube or incomprehensible speech had been observed in less than 15% of the cases. Particularly, the pectoralis major flap, showed its best functional performances in the total or subtotal glossectomies with a sacrifice of the muscles of the oral floor. The free forearm flap is reliable and safe with its low thickness and pliability, especially for partial glossectomies. The nasolabial flap was confirmed to be the first reconstructive choice for selected limited resections of the tongue and of the antero-lateral floor. With this experience it is possible, even in more complex free flaps, to reduce the time consumption and the complication rate. Free flaps do not substitute routinely myocutaneous and conventional flaps, but they represent the "ideal" reconstructive alternatives for specific and selected indications.

[U-shaped free jejunum transplant]. / Le transplant libre de jéjunum en U.

Reconstruction of the oro and hypopharynx has specific difficulties due to their wide diameters. Seven patients underwent reconstruction with a free U-shaped jejunal transplant, after circular pharyngolaryngectomy for hypopharyngeal cancer invading the oropharynx. This transplant included a side-to-side anastomosis between the two limbs of the jejunal loop. This transplant allowed reconstruction of the upper digestive tract after wide carcinologic resection of the pharynx. The U-shaped jejunal transplant facilitated the upper anastomosis, especially at the upper part where the resection involved the oropharynx. It formed a reservoir behind the tongue, and avoided nasal reflux. The best indications are large resections involving the oropharynx.

[Multiple stage cervical laryngotracheal reconstruction after trauma with extensive tissue loss]. / La ricostruzione per stadi della laringe e della trachea cervicale dopo traumi con estesa perdita di sostanza.

Laryngotracheal reconstruction after trauma with extensive tissue loss is one of the most controversial issues in head and neck surgery today. The main goal is to provide a durable supportive framework over which endolaryngeal mucosa can regenerate. Although a variety of single-stage and multiple-stage reconstructive techniques are available, all have limitations. As there is no single universally applicable technique, it is necessary to know most of them and to realize the advantages and limitations of each procedure. On the basis of 18 years' experience we show the results from a series of 18 patients who underwent multiple-stage laryngotracheal reconstruction done with almost all available procedures (Laser surgery, Aubry technique, laryngotracheoplasty with cartilage grafting, subtotal laryngectomy, tracheal and laryngo-tracheal anastomosis, sternocleidomastoid myoperiosteal flap, composite hyoid sternohyoid muscle flap). Fourteen of the 18 patients were successfully decannulated. All of the mentioned procedures have been previously reported to be successful by their proponents, with variable complication rates. Subsequently, every case requires individual evaluation to determine which reconstructive technique is most appropriate for the patient's particular disease process.

[Reconstructive oncologic surgery of the head and neck. Morbidity and comparative results of conventional and myocutaneous flaps]. / Chirurgia ricostruttiva oncologica cervico-facciale. Morbilità e risultati comparativi tra lembi convenzionali e miocutanei.

The authors analyzed the data obtained from their experiences in extensive head and neck resections, and, reconstructive treatments using myocutaneous and conventional flaps. They tried to evaluate comparatively the reconstructive approach, in terms of morbidity and functional results. The 145 cases of advanced had and neck cancer, treated from January 1990 to January 1994, were considered in this study. The reconstructive procedures consisted of 193 flaps. In this study, 106 were myocutaneous flaps (pectoralis major or trapezius flap); 72 were conventional flaps (fasciocutaneous, cutaneous or muscular only) and the remainder were 15 free flaps. The morbidity related to both flap procedures had been low: 33% in myocutaneous flaps versus 11% in conventional flaps. This report demonstrated the versatility, usefulness, and reliability of both kinds of these reconstructive procedures, especially in intra-oral reconstruction. The expected morphological and functional results were quite encouraging in terms of swallowing and speech.

[The rectus abdominis free flap in reconstructive surgery of the head and neck]. / Il lembo libero di muscolo retto addominale nella chirurgia ricostruttiva cervico-facciale.

The Authors describe their preliminary experience with rectus abdominis free flap in reconstructive surgery of the head and neck. Out of the 29 cases of microsurgery in treating head and neck tumours, four inferior rectus abdominis free tissue transfers were used: two for complex intraoral reconstruction and two for composite facial defects. There was one flap loss due to late infection in the region of anastomosis, while there were two complications in the remaining three cases. The morphological and functional results have proved to be highly satisfactory. The flap, based on the deep inferior epigastric vessels, appears to be versatile in terms of skin island design, thickness and length of the pedicle. As with the forearm free flap, the inferior rectus abdominis has the advantage of offering the possibility of simultaneous demolition and reconstruction in one surgical session. The Authors conclude that the low morbidity concerned with this microvascular flap, also reported in international literature, confirm its validity as a soft tissue transfer in the in the treatment of advanced head and neck cancer.

T stages of tumors of the tongue and floor of the mouth: correlation between MR with gadopentetate dimeglumine and pathologic data.

PURPOSE: To define MR accuracy in the evaluation of the T stages of tumors of the tongue and floor of the mouth. METHODS: Fifty-two patients affected by squamous cell carcinoma were studied with a superconductive system at 1.5 T. The study was performed with spin-echo T1- and T2-weighted images before contrast and short spin-echo T1-weighted and gradient-echo sequences after gadopentetate dimeglumine administration. The results obtained with MR were compared with pathologic data. RESULTS: Good correlation of T stages (TNM system) was obtained in 45 of 52 cases. MR did not show four superficial lesions. In one case, infiltration of the cortical bone of the mandible was not demonstrated (MR, T2; pathologic, T4), and in another the lesion was classified as T2 instead of T3, as it was pathologically. One lesion was classified as T4 on MR because of infiltration of the alveolar ridge but was classified as T2 at surgery. In 46 patients who underwent surgery, the accuracy of MR was excellent for predicting the relationship of tumor to midline and oral floor musculature. The results obtained with gadopentetate dimeglumine were better than those obtained in noncontrast studies in 32 (62%) of 53 cases. CONCLUSION: MR showed high accuracy in the study of tumors of the tongue and floor of the mouth.

[Total/near-total glossectomy for advanced carcinoma of the tongue]. / La glossectoma totale/subtotale nel trattamento dei tumori avanzati della lingua.

Poor survival rates and the limited palliation afforded by radiotherapy alone, together with progress made in reconstructive surgery in restoring mucosal continuity after large resections, make total glossectomy reasonably indicated for treatment of advanced carcinoma of the tongue. The Authors reviewed 19 cases (17 males, 2 females, mean age 58.4 years) of total and near total glossectomy without laryngectomy treated at National Cancer Institute "Regina Elena" of Rome from 1990 to 1993 in order to evaluate oncological and functional results. All patients were reconstructed immediately, 16 with a pectoralis major flap, 2 with a nasolabial flap and 1 with a radial forearm free flap and were available for follow-up from 6 to 45 months (mean 29 months). There was no operative mortality and no patient needed total laryngectomy for aspiration. The rate of local recurrencies was 52.6%, most of them (75%) in patients who had undergone total/near total glossectomy for recurrence. Survival rate was 61.5% after 1 year and 20% after 2 years. 94% of patients resumed swallowing and independent oral alimentation (48% of them without any dysphagia); 84%; of the patients were decannulated and 48% produced easily intellegible speech. Data from our experience let us conclude that, in the light of the acceptable functional results obtained with reconstructive flaps, total glossectomy should be considered as the primary treatment modality in advanced carcinoma of the tongue (including T2 > 3 cm exceeding midline), and should not be reserved only for salvaging hopeless situations.

A randomized phase II study comparing sequential versus simultaneous chemo-radiotherapy in patients with unresectable locally advanced squamous cell cancer of the head and neck.

BACKGROUND: Single-modality radiotherapy is still considered standard treatment for patients with locally advanced unresectable cancer of the head and neck. As treatment outcome is poor, attempts to integrate chemotherapy into the overall management of these patients are ongoing. PATIENTS AND METHODS: A randomized study was undertaken to compare a sequential with a simultaneous chemoradiotherapy program. Between February 1986 and February 1991, 93 eligible patients with locally advanced unresectable cancer of the head and neck were stratified by WHO PS, T and N class and primary site and then randomized to receive either three courses of neoadjuvant chemotherapy with cisplatin (100 mg/m2 i.v. d 1) and 5-fluorouracil 1000 mg/m2/days 1-5 by continuous i.v. infusion every 3 weeks prior to definitive conventional radiotherapy of 65-70 Gy (sequential treatment), or cisplatin 100 mg/m2 on days 1, 22, 43 given simultaneously for the duration of the same conventional radiotherapy (simultaneous treatment). RESULTS: At the end of the entire treatment 18 complete responses (47%) in the sequential-treatment arm and 18 (41%) in the simultaneous treatment arm were obtained. No statistically significant differences in the 5-yr progression-free survival, in the median time to loco-regional and distant progression and in the 5-yr overall survival were observed. Leukopenia was more frequent in the simultaneous than in the sequential arm (p = 0.03), whereas alopecia (p = 0.008) and phlebitis (p < 0.0001) were more frequent in the sequential-treatment arm. A better compliance was associated with the concomitant treatment, with 87% of the patients completing the entire radiotherapy program versus 63% of those in the sequential arm (p = 0.01). CONCLUSIONS: In the present study, the two treatment arms showed similar activity (complete response, progression-free and overall survival rates). Compliance to treatment was better in the concomitant arm. These data suggest that concomitant chemo-radiation therapy might be considered an option in unresectable locally advanced cancer of the head and neck. Phase III studies are needed in order to establish the superiority of this combination of cisplatin and radiotherapy versus radiotherapy alone.

[The magnetic resonance estimation of the T parameter in the staging of tumors of the oral cavity and tongue. A correlation with postoperative data and preliminary echotomographic experience]. / Valutazione con risonanza magnetica del parametro "T" nella stadiazione dei tumori della cavità orale e della lingua. Correlazione con i dati post-operatori e preliminare esperienza con ecotomografia.

Fifty-three patients with oral cavity and tongue tumors were studied with MRI, 18 with CT and 10 with US. MR results were compared with postoperative and clinical results relative to the T variable of the TNM classification of oral cavity tumors. MRI demonstrated 51 of 53 tumors; it was in agreement with surgery, relative to T, in 43 of 48 cases and with clinics in 5 of 5 cases. In 5 patients MRI understaged: two lesions were classified as T0 because the tumors developed on the surface (p T4, for alveolar ridge infiltration). Moreover, MRI staged another lesion as T2 instead of T3 because of its superficial component, while in 2 cases the infiltration of the cortical bone of the jaw was not demonstrated (T1 at MRI, T4 at p; T2 at MRI, T4 at p). MRI was reliable enough to evaluate the relationships between the lesions and the surrounding structures but it was limited in demonstrating superficial lesions and in evaluating the infiltration of the alveolar ridge and of the cortical bone of the jaw in the early stage. The use of gadolinium proved to be especially useful for the exact definition of the size of the lesions and of their relationships with the surrounding structures. CT proved better than MRI to evaluate bone involvement in one case, even though neither technique could identify bone involvement in another patient. US yielded accurate information on the presence of lesions, their size and relationships with midline and floor of the mouth muscles, while its demonstration of the relationships between tumors and bone structures was poor, especially relative to tumor spread outside the oral cavity.

[Overtreatment in advanced tumors of the head and neck]. / L'accanimento terapeutico nei tumori avanzati della testa e del collo.

So-called "over-treatment" in the practical management of advanced head and neck tumors is a very important problem in terms of its professional, ethical, moral and legal implications, that involve the physician in the therapeutic decision he must make. After presenting the general aspects of the subject, the chairman, together with all those participating in the Round Table, deals with the most important points of the problem: the definition of overtreatment, the limits of treatment, nontreatment, passive euthanasia, informed consent and quality of life. The various aspects of the problem have been dealt with and discussed from the point of view of the surgeon, the expert in bio-ethics and the magistrate. After comparing the different opinions, the most important point, in terms of a therapeutic choice, should be the patient's quality of life, whose improvement justifies every therapeutic strategy. Given that the advances in surgery, either demolitive or above all reconstructive, have made almost every operation technically possible, attention has been concentrated on overtreatment in nonsurgical therapies. In extremely advanced tumors, radio- and chemotherapy are often burdened by side effects and sequelae that lead to a quality of life at the limits of biological supportability. The Round Table ends with the presentation of emblematic case reports, followed by a vivacious discussion, also with those in the audience, that was basically in agreement with the therapeutic choices made.

[Morbidity and the morphofunctional aspects of myocutaneous flaps used in the head and neck area]. / Morbilità e aspetti morfo-funzionali in 73 lembi mio-cutanei utilizzati nel distretto cervico-facciale.

The authors analysed the data obtained from their experiences in extensive head and neck resections as well as reconstructive treatments using myocutaneous flaps. They tried to evaluate the reconstructive approach in terms of morbidity and functional results. Sixty-nine patients, treated from January 90 to November 92 for advances intra-oral cancer, were considered in this study. The reconstructive procedure in 68 cases was the pectoralis major myocutaneous flap while in 5 cases the trapezius flap was utilized. Even though the oncological results were poor, the functional ones were quite encouraging. In fact, the assessment of speech and swallowing was extremely satisfactory in 83% of the cases. The morbidity related to both flap procedures was low and the patients' life quality was good. Indeed, the use of a free flap offers additional advantages, without necessarily compromising safety of the reconstruction. Free flaps in general allow greater leeway in flap design and donor-site choice than pedicled flaps. Several reports have already demonstrated the versatility, usefulness and reliability of these flaps, especially in intra-oral reconstruction. The intricate nature of microsurgery and the expense of microsurgical equipment inhibit this kind surgery in many institutions around the world where the standard myocutaneous flaps would be a more practical procedure. In conclusion, even those patients with a poor prognosis may be considered potential candidates for demolitive and reconstructive treatment with which satisfactory results may be obtained.

[The recurrent multifocal pleomorphic adenoma]. / Le recidive multifocali di adenoma pleomorfo.

Pleomorphic adenoma (P.A.), the most common tumor of the salivary gland, demonstrates a peculiar clinicopathological behaviour for numerous reasons: the high recurrence rate following primary surgery (up to 50%), the appearance of malignancy (2-9%), the reported number of distant metastases histologically identical to the primary P.A. From among 71 cases of benign parotid tumors treated from Nov. 89 to Nov. 92 in the ENT Department of "Regina Elena", the National Cancer Institute in Rome, six particular cases showed multiple force of P.A. recurring after primary surgery performed from 3 to 32 years previously and are object of discussion in this study. All of these six cases had multiple recurrences, usually manifest as nodular clusters in the parotid area, while in three cases appeared as well a recurrence in the soft tissue of the neck, far removed from the parotid space, with no involvement of neck nodes as was revealed through histological examination following neck dissection. A hypothetical mechanism of diffusion is discussed. The Authors agree with the opinion which holds the surgeon's inability to successfully eradicate primary tumors responsible for the high frequency of recurrences. The surgical technique of "enucleation" is, in fact, inadequate in P.A. excision owing the high risk of mishandling or rupturing the tumor capsule with a consequent seeding of the tumor onto the surgical bed. Lateral lobectomy, with identification of the facial nerve, or total conservative parotidectomy (for deep lobe adenoma) are correct techniques in treating primary P.A.. The Authors also discuss management of recurrent P.A. in relation to facial nerve involvement. Preservation of the seventh nerve with eventual post-operative radiation should be considered an alternative to nerve sacrifice in selected cases of recurrent pleomorphic adenoma.

[Excisional and reconstructive treatment of stage IV tumors in the oral cavity. Results and limits]. / Trattamento exeretico e ricostruttivo dei tumori del cavo orale al IV stadio. Risultati e limiti.

The patients with advanced stages of intraoral cancer, having a limited life expectancy, are often considered non-surgical cases. Radiochemotherapy does not warrant an acceptable quality of life. The authors analysed the data obtained from their experiences in resections that had been extensive, as well as, reconstructive treatment of these kinds of neoplasms. They tried to evaluate the demolitive and reconstructive approach, in terms of morbidity, functional results and survival rate. Thirty-six patients, treated from January 1990 to August 1991 for advanced intraoral cancer, were considered in this study; 58% of the cases had primary tumors and 42% had recurrences. The reconstructive procedure used in all cases, was the pectoralis major myocutaneous flap. Even though the expected oncological results had been poor, the functional ones, had been quite encouraging. In fact, the assessment of speech and swallowing was extremely satisfactory, respectively in 82% and 89% of cases. The morbidity related to the flap procedure had been low. The quality of the residual life of the patients was good, especially if compared with the life of those patients who had not been treated. In conclusion, the authors maintain that even patients with limited prognosis may be considered as potential candidates for demolitive and reconstructive treatment.