SARS-CoV-2 RNA viability on high-touch surfaces and evaluation of a continuous-flow ozonation treatment.

Background: The COVID-19 emergency has highlighted the importance of prevention systems and environ-mental microbiological monitoring as fundamental elements in the response to epidemics and other such threats to individual and collective health. The use of automated "No-touch" room disinfection systems eliminates or reduces the dependence on operators, thus allowing an improvement in the effectiveness of terminal disinfection. Study design: In the present study, we focused on possible SARS-CoV-2 contamination of surfaces of com-mercial services, and the effectiveness of ozone treatment on the virus. Methods: Analyses were conducted on 4-7 October and 27-30 December 2021 in four supermarkets in an Apulian city; supermarkets A and B were equipped with an ozonisation system, while C and D were without any environmental remediation. Results: SARS-CoV-2 RNA was detected by real-time RT-PCR only in December, in 6% of the surfaces tested, and all examined samples were found to be negative after viral culture, since no cytopathic effect was observed. A statistically significant difference emerged from the comparison of October vs. December (p = 0.0289), but no statistically significant difference (p = 0.6777) emerged from the comparison between supermarkets with and without the ozonisation system. Conclusions: Although no important changes were observed by treating the environments with ozonisation systems, further studies are needed to validate the effectiveness of environmental treatments with airborne disinfectants.

Endometriosis: seeking optimal management in women approaching menopause.

The incidence of endometriosis in middle-aged women is not minimal compared to that in the reproductive age group. The treatment of affected women after childbearing age to the natural transition toward menopause has received considerably poor attention. Disease management is problematic for these women due to increased contraindications regarding hormonal treatment and the possibility for malignant transformation, considering the increased cancer risk in patients with a long-standing history of the disease. This state-of-the-art review aims for the first time to assess the benefits of the available therapies to help guide treatment decisions for the care of endometriosis in women approaching menopause. Progestins are proven effective in reducing pain and should be preferred in these women. According to the international guidelines that lack precise recommendations, hysterectomy with bilateral salpingo-oophorectomy should be the definitive therapy in women who have completed their reproductive arc, if medical therapy has failed. Strict surveillance or surgery with removal of affected gonads should be considered in cases of long-standing or recurrent endometriomas, especially in the presence of modifications of ultrasonographic cyst patterns. Although rare, malignant transformation of various tissues in endometriosis patients has been described, and management is herein discussed.

Official controls regarding artisanal ice cream shops: public health policies and consumer protection in the Italian and European legislative frameworks.

Ice cream is a widely enjoyed food that is especially popular during summer. To ensure it is safe and ready-to-eat for consumers, legislation imposes a series of obligations for food business operators, and for competent authorities that have to carry out official controls, including official sampling. This article reviews the general and specific requirements applicable to the premises where ice cream is produced, concerning aspects related to health notification obligations and to implementing and maintaining procedures based on the principles of the Hazard Analysis and Critical Control Point system. The review extends to results stemming from the most recent official control activities conducted in Italy, and to future perspectives on control methods that will have to be compliant with the provisions of the new EU Regulation 625/2017 applicable from 2019.

Effect of compost application on the dynamics of carbon in a nectarine orchard ecosystem.

The aim of the present study was to compare the quantity and the type of carbon (C) stored during the 14-year lifetime of a commercial nectarine orchard ecosystem fertilized with mineral or organic fertilizers. The study was carried out in the Po valley, Italy, in a nectarine orchard of the variety Stark RedGold, grafted on GF677 hybrid peach × almond. Since orchard planting in August 2001, the following treatments were applied in a randomized complete block design with four replicates per block and compared: 1. unfertilized control; 2. mineral fertilization (including P and K at planting and N applied as NO3NH4 yearly at the rate of 70-130 kg ha-1); 3. compost application at a rate of 5 Mg DW ha-1 yr-1; 4. compost application at a rate of 10 Mg DW ha-1 yr-1. Compost was obtained from domestic organic wastes mixed with pruning material from urban ornamental trees and garden management after a 3-month stabilization period. Application of compost at the highest rate increased C in the soil; the amount of C sequestered was approximately 60% from amendment source and 40% from the net primary production of trees and grasses with a net increase of C compared to mineral fertilization. Compost application was found to be a win-win strategy to increase C storage in soil and, at the same time, to promote plant growth and yield to levels similar to those obtained with mineral fertilization. The rate of C application is crucial, indicated by the fact that compost supply at the rate of 10 Mg ha-1 yr-1 was the only fertilization strategy of the ones tested that resulted in higher C sequestration. This shows that compost amendment may stimulate an increase in the net primary production of plants.

Isthmocele in a retroflexed uterus: a report of an unrecognized case.

The term "isthmocele" refers to a niche on the anterior wall of the uterine isthmus or of the cervical canal at the site of a previous cesarean delivery scar. Such anatomic defect can cause many gynecologic sequelae that only recently have being identified and described. Hysteroscopy is commonly considered the gold standard for the diagnosis and also for the treatment, at least in the case of defects of small size. The authors described the case of a 37-year-old woman who underwent a cesarean section (CS) seven years before, with a long lasting history of menstrual irregularities, and pelvic pain increasing during menstruation at the hypogastric level. Magnetic resonance imaging (MRI) showed an exceptionally large isthmocele on the anterior wall of a retroflexed uterus which was otherwise misinterpreted as the uterine cavity filled with menstrual blood during a previous hysteroscopy (HSC). Although exceptional, this case highlights the possibility that a large sized isthmocele in a retroflexed uterus could be misinterpreted as the uterine cavity filled by menstrual blood at HSC. In this case MRI definitely clarified the diagnosis.

MRI in the assessment of prolapsed pedunculated submucous leiomyomas: two case reports.

Uterine leiomyomas are the most common benign gynecological tumors affecting 20-30% of women in reproductive age. Despite their benignity, in some cases several symptoms may require surgical intervention. Submucosal leiomyomas are less frequent (5-10%), but are usually symptomatic. Approximately 2.5% of the myomas are pedunculated and can protrude in the cervical canal. Symptomatic leiomyomas can be treated either by hysterectomy or myomectomy, and these procedures can be performed with several techniques. Whenever possible, hysteroscopic myomectomy is better because it has many advantages, as it also preserves future fertility. Two interesting cases of prolapsed pedunculated submucous leiomyomas are reported in order to prove that magnetic resonance imaging (MRI) is essential to choose the most appropriate treatment and to perform an adequate presurgical planning, which must be based on an overall assessment of the leiomyoma's characteristics (number, location, size and presence or absence of a stalk) and the patient's characteristics.

Effect of myo-inositol and alpha-lipoic acid on oocyte quality in polycystic ovary syndrome non-obese women undergoing in vitro fertilization: a pilot study.

The aim of the present study was to evaluate the effectiveness of the combined administration of myo-inositol and α-lipoic acid in polycystic ovary syndrome (PCOS) patients with normal body mass index (BMI), who had previously undergone intracytoplasmic sperm injection (ICSI) and received myo-inositol alone. Thirty-six of 65 normal-weight patients affected by PCOS who did not achieve pregnancy and one patient who had a spontaneous abortion were re-enrolled and given a cycle of treatment with myo-inositol and α-lipoic acid. For all female partners of the treated couples, the endocrine-metabolic and ultrasound parameters, ovarian volume, oocyte and embryo quality, and pregnancy rates were assessed before and after three months of treatment and compared with those of previous in vitro fertilization (IVF) cycle(s). After supplementation of myo-inositol with α-lipoic acid, insulin levels, BMI and ovarian volume were significantly reduced compared with myo-inositol alone. No differences were found in the fertilization and cleavage rate or in the mean number of transferred embryos between the two different treatments, whereas the number of grade 1 embryos was significantly increased, with a significant reduction in the number of grade 2 embryos treated with myo-inositol plus α-lipoic acid. Clinical pregnancy was not significantly different with a trend for a higher percentage for of myo-inositol and α-lipoic acid compared to the myo-inositol alone group. Our preliminary data suggest that the supplementation of myo-inositol and α-lipoic acid in PCOS patients undergoing an IVF cycle can help to improve their reproductive outcome and also their metabolic profiles, opening potential for their use in long-term prevention of PCOS.

The impact of a multidisciplinary approach on response rate of mandibular advancing device therapy in patients with obstructive sleep apnoea syndrome.

The aim of the present study was to evaluate the importance of a multidisciplinary approach on increasing the response ratio expectation to mandibular advancing device (MAD) therapy in patients with obstructive sleep apnoea syndrome, especially in severe cases. Forty-two mild-to-severe OSAS patients were selected, after comprehensive evaluation by neurologists, otorhinolaryngologists and orthodontists, and treated with a Somnodent® device. Six months later, a polysomnographic exam with the MAD in situ was performed. The paired t-test evaluated the effectiveness of therapy and the results were compared with data from systematic reviews. The average treatment response was statistically significant for the apnoea/hypopnea index (AHI) and oxygen desaturation index and was higher than the outcomes presented in literature. An optimum therapy response (AHI < 5) was observed in 53% of patients (40% in severe OSAS) and a good response (AHI < 10) in 73% of patients (50% in severe OSAS). The Somnodent® device was effective and the multidisciplinary patient selection improved the response ratio compared to that reported by previous systematic reviews.

Biochar reduces short-term nitrate leaching from a horizon in an apple orchard.

Nitrogen leaching in croplands is a worldwide problem with implications both on human health and on the environment. Efforts should be taken to increase nutrient use efficiency and minimize N losses from terrestrial to water ecosystems. Soil-applied biochar has been reported to increase soil fertility and decrease nutrient leaching in tropical soils and under laboratory conditions. Our objective was to evaluate the effect of biochar addition on short-term N leaching from A soil horizon in a mature apple orchard growing on subalkaline soils located in the Po Valley (Italy). In spring 2009, 10 Mg of biochar per hectare was incorporated into the surface 20-cm soil layer by soil plowing. Cumulative nitrate (NO) and ammonium (NH) leaching was measured in treated and control plots 4 mo after the addition of biochar and the following year by using ion-exchange resin lysimeters installed below the plowed soil layer. Cumulative NO leaching was not affected by biochar after 4 mo, whereas in the following year it was significantly ( < 0.05) reduced by 75% over the control (from 5.5 to 1.4 kg ha). Conversely, NH leaching was very low and unaffected by soil biochar treatment. The present study shows that soil biochar addition can significantly decrease short-term nitrate leaching from the surface layer of a subalkaline soil under temperate climatic conditions.

Meta-analysis: the efficacy of proton pump inhibitors for laryngeal symptoms attributed to gastro-oesophageal reflux disease.

BACKGROUND: Many investigators have proposed an association between gastro-oesophageal reflux disease and laryngo-pharyngeal symptoms, suggesting that medical or surgical therapy for reflux may be useful. AIM: To perform a meta-analysis assessing the effectiveness of medical or surgical therapy for reflux disease in adult patients with laryngeal or pharyngeal symptoms presumed to be due to gastro-oesophageal reflux disease. METHODS: Randomized controlled trials comparing medical or surgical treatments for gastro-oesophageal reflux disease against placebo were identified by searching MEDLINE (1966-September 2005), EMBASE (1974-September 2005), the CCRCT (until September 2005) and abstracts from gastroenterology and ENT meetings. The relative risks of reporting symptomatic improvement or resolution of symptoms was evaluated using a random-effects model. RESULTS: Five studies using high-dose proton pump inhibitor as intervention met the inclusion criteria and were included in the meta-analysis. No surgical studies met inclusion criteria. The pooled relative risk was 1.18 (95% confidence interval: 0.81-1.74). There was no heterogeneity between studies but evidence of significant publication bias. Sub-group analysis performed evaluating Jadad scores and symptom type, did not change the relative risk. CONCLUSIONS: Therapy with a high-dose proton pump inhibitor is no more effective than placebo in producing symptomatic improvement or resolution of laryngo-pharyngeal symptoms. Further studies are necessary to identify the characteristics of patients that may respond to proton pump inhibitor therapy.

Directed laparoscopic cryomyolysis for symptomatic leiomyomata: one-year follow up.

STUDY OBJECTIVE: To evaluate the long-term effectiveness of laparoscopic cryomyolysis as a minimally invasive technique for the treatment of symptomatic uterine myomas in menstruating women. DESIGN: Open, one-arm pilot study (Canadian Task Force classification II). SETTING: University-affiliated public hospital. PATIENTS: Twenty patients with symptomatic uterine myomas were treated with directed cryomyolysis. All had reported abnormal bleeding and/or pelvic pain/pressure and/or urinary frequency. Myoma diameters varied from 4 to 10 cm. INTERVENTION: One-year follow-up after laparoscopic-directed cryomyolysis. MEASUREMENTS AND MAIN RESULTS: Laparoscopic cryomyolysis was performed using the Her Option Cryoablation Unit (American Medical Systems, Minneapolis, MN). Patients were evaluated 1, 3, 6, 9, and 12 months after surgery. Power color Doppler ultrasound was performed preoperatively and postoperatively to demonstrate the effectiveness of the technique in reducing or eliminating the primary blood supply to the myomas, as well documenting regression of the myomas. All patients reported a high rate of satisfaction with the treatment including absence of symptoms 12 months after surgery, with no bleeding and no myoma-related symptoms, comparable with patients who underwent hysterectomy. Mean shrinkage of myoma volume increased until 9 months after surgery (59.5% +/- 13.2%), reaching a steady mean-volume reduction of approximately 60% (61.9% +/- 11.9%) 12 months after surgery. CONCLUSIONS: Directed laparoscopic cryomyolysis appears to be an effective and safe technique for providing rapid symptom relief and at least 12 months' effectiveness in the treatment of symptomatic uterine leiomyomas.

Tongue base reduction with hyoepiglottoplasty for the treatment of severe OSA.

Surgical treatment for retro-lingual obstruction in patients suffering from obstructive sleep apnea syndrome remains a problem for which there is no simple solution. The techniques most in use (tongue suspension, genioglossal advancement with hyoid suspension) are effective primarily as stabilization methods modifying neither tongue position, nor volume and only produce appreciable results when performed on non-overweight patients with respiratory disturbance index <40. For patients suffering from severe obstructive sleep apnoea syndrome in whom the most obvious morphological alteration is the presence of hypo-pharyngeal obstruction due to tongue base hypertrophy, who are overweight or suffering from moderate obesity, a surgical procedure aimed at reducing tongue volume and at repositioning the hyoid bone, even if invasive, leads to a favourable outcome. Herein, personal experience is described in a group of 8 patients presenting severe obstructive sleep apnoea syndrome incompatible with normal quality of life and normal life expectancy (mean respiratory disturbance index = 55.1) who underwent surgical resection of the tongue base with hyoepiglottoplasty. This technique, first described by Chabolle, differs radically from others inasmuch as it guarantees enlargement of the hypo-pharyngeal lumen and remodelling of the hyolingual complex. Using a suprahyoid cervical approach, it is possible to effect ample reduction of the tongue base with amplification of the hypo-pharyngeal airway without inducing problems as far as concerns either swallowing or speech.

Tongue base suspension technique in obstructive sleep apnea: personal experience.

Tongue suspension with Kit Repose is a surgical mini-invasive end-oral technique used in treatment of rear tongue obstruction. The base of the tongue is anchored with a non-reabsorbable suture, held in place with a titanium screw, to the mandible in correspondence to the geni apophysis of the mandible: this loop should prevent the tongue, during sleep, from dropping backwards, favoured also by gravity and hypotonicity of the genioglossus muscle. Aim of this report is to focus on the results of our experience in 15 patients presenting obstructive sleep apnea submitted to uvulopalatopharyngoplasty associated with tongue suspension, using the Kit Response bone screw system (Influent Inc., San Francisco, CA, USA). Mean age of patients was 50.5 years (range 36-66), with mean RDI (apnoea/hypopnea index) of 44.47 (range 23-63) and mean body mass index of 28.27 (range 22.6-34.4). Scrupulous clinical evaluation, including endoscopy and cephalometry, revealed a pharyngeal obstruction both retro palatal and retro lingual. Clinical and polysonnographic examinations were carried out 4-6 months after surgery. Patients were considered responders if the RDI had decreased by 50% and below 20, with disappearance of subjective symptoms (snoring, daytime sleepiness). Polysonnographic examination showed, overall, good results with mean reduction of RDI from 44.5 to 24.2 (45% reduction); albeit, only 6 cases could be considered surgically successful; 4 cases (26.6%) showed improvement whereas the remaining 5 (33.4%) failed to present any significant change in RDI. Even if the technique was, indeed, mini-invasive, rapidly performed and lacked significant complications, the results were not, in our opinion, encouraging, bearing in mind the high cost of the kit and limited stability of the results over time. Better results can be obtained by advancement of the genioglossus associated with hyoid suspension, whereas, of the mini-invasive techniques, promising outcomes would appear feasible with reduction of volume at the base of the tongue, using radiofrequency.

Morphological characteristics by SEM observations and regulatory volume decrease (RVD) of tentacular nematocytes isolated by heat dissociation from Aiptasia diaphana (Cnidaria: Anthozoa).

This paper examines the morphological characteristics and response to hyposmotic shock of nematocytes isolated by heat dissociation at 45 degrees C for 20 min from the tentacles of Aiptasia diaphana, an anthozoan living in the brackish water of Lake Faro (Messina, Italy). Morphological characteristics were evaluated by scanning electron microscopy (SEM) observations and cytological test, functional characteristics by exposure to 35% hyposmotic stress. 81% of the population of isolated nematocytes had ciliary protrusions. Microbasic-mastigophore and amastigophore nematocytes had a hair bundle at the crown shaped apex composed of ciliary protrusions of different heights and diameters. In basitrichs, instead, a single ciliary protrusion was observed. Following exposure to 35% hyposmotic shock, nematocytes isolated by heat dissociation did not show RVD, while, following treatment with 1 microM and 2 microM gramicidin-S, activation of volume regulation in conditions of hyposmoticity was observed. The effect of gramicidin was concentration-dependent and confirmed the relevant role of conductance to K+ in volume regulation, as previously described (17) on nematocytes isolated by chemical methods.

Glycosaminoglycans as a possible tool for micro- and macroalbuminuria in diabetic patients. A pilot study.

The aim was to investigate sulodexide as a possible therapeutic tool for treating micro- and macroalbuminuria in diabetic patients. Fifteen patients (13 micro- and 2 macroalbuminuric) with Type II diabetes, were treated with 600 lipoprotein-lipase releasing units of sulodexide by the intramuscular route, daily for 28 days, and followed up for 2 months. The main evaluation parameter was the albumin excretion rate. At the end of treatment, six of the 13 microalbuminuric patients showed a decrease in the albumin excretion rate, which increased again in three of the six during follow-up. In the two macroalbuminuric patients the albumin excretion rate decreased at the end of treatment and remained unchanged after a further 2 months. Overall analysis (15 patients) showed a significant decrease (P < 0.05) in the albumin excretion rate compared with baseline. Metabolic control and blood pressure remained unchanged during the entire period of study. No adverse events were registered. It is concluded that sulodexide administration has a favourable effect in reducing the albumin excretion rate in Type II diabetic patients with micro- and macroalbuminuria.

[Fundus-oriented perimetry. Evaluation of a new visual field examination method for detecting angioscotoma]. / Fundus-orientierte Perimetrie. Evaluation eines neuen Gesichtsfeld-Untersuchungsverfahrens bezüglich der Detektion von Angioskotomen.

BACKGROUND: Conventional automated perimeters usually work with a given set of grids and thus are normally not adapted to individual conditions. This fact restricts efficiency of this method not only for any single examination but also for follow-up studies. MATERIALS AND METHODS: A new method (patent pending) is introduced which superimposes an individual perimetric grid--corrected in respect to orientation, position and size--onto a patient's fundus image. A recently developed software realizes this procedure in a comfortable manner: the digitized fundus image is loaded into the computer by e.g. photo-CD or disc, depicted on a control monitor and mirrored if necessary. Assuming a central fixation, the foveola is translationally shifted to the center of the perimetric grid by the help of a crosshair. The blind spot which has been previously determined with kinetic perimetry is then superimposed onto the optic disc of the fundus image using a rotation and zoom function. In this way, it is possible to adapt the perimetric grid directly to the underlying individual fundus findings: thus, stimuli can be spatially concentrated or more frequently tested in special regions of interest. Additionally, test points can be dragged away from delicate positions to avoid artifacts. Examinations were carried out on a high resolution colour VDU of the Tübingen Electronic Campimeter (TCC). Alternatively, suited bowl perimeters can be used. RESULTS: In order to test the precision of the superimposing procedure, fundus oriented perimetry was performed to detect angioscotomata in 13 ophthalmologically normal subjects. Using dark stimuli (12'), visual field defects in the expected region, caused by retinal vessels, could be detected in 7 cases (= 54%). The resulting attenuation of differential light sensitivity in this circumscribed region was up to 12 dB. CONCLUSIONS: By means of a morphologically adapted, individual arrangement of stimulus locations fundus-oriented perimetry enables detection of even minute (angio-) scotomata.

[Acute epiglottitis in adults: a rare cause of acute respiratory insufficiency]. / L'epiglottite acuta nell'adulto: una rara causa di insufficienza respiratoria acuta.

Acute epiglottitis is an infective disease which may have a rapid and aggressive course to total upper airway obstruction. Due to its rarity (mostly in adults) and aspecific initial clinical features, it may present diagnostic problems to less experienced medical personnel. This is the principal reason why the mortality rate is still unacceptably high. Indirect or direct laryngoscopy is mandatory for diagnosis: as this might be difficult for non-specialist physicians, their awareness of the potentially severe consequences of epiglottic infections is fundamental to minimizing diagnostic delay. In fact, early involvement of experienced ENT and anaesthesiological staff is essential for diagnosis, which must be as prompt as possible and followed by thorough clinical monitoring to avoid fatal outcome.

[External radiotherapy in early stage squamous cell carcinoma of the supraglottic larynx. Report of 28 cases]. / Il trattamento radiante nel carcinoma iniziale (T1-T2N0) sopraglottico. Revisione di una casistica di 28 casi.

The Authors reviewed a group of 28 pts with early-stage supraglottic carcinoma (T1-T2N0), classified according to UICC (1987), and treated exclusively with radiotherapy (RT) between 1980 and 1991. Until 1990 RT was employed for such tumors when surgery was refused or controindicated, while since 1991 primary irradiation (with surgery in reserve) has been considered the treatment of choice. The total dose ranged from 66 to 70 Gy on the larynx and up to 50 Gy on neck nodes. RT was applied in a daily fraction of 2 Gy five times a week. No significant early complications were observed. Only 1 pt showed residual cronical oedema in the arytenoid region. In none of the pts was tracheostomy necessary. The local control rate obtained after 30 months was 85.7% (24/28). Salvage surgery (horizontal supraglottic laringectomy, HSL) was performed in 3 out of 4 pts with local failure and achieved complete control of the disease. In the last pt the surgery was controindicated because of poor general health conditions. The actuarial survival rate after 5 years is 86.2%. The present series was compared to a group of 152 pts with T1-T2N0 supraglottic cancer treated surgically (HSL) at the same Istitution. In these pts local control and the actuarial survival rates are 85.6% and 89% respectively. According to recent Literature data, the present findings confirm that RT may be administered for the treatment of selected early stage (T1-T2N0) supraglottic squamous cell carcinoma of the larynx with oncologic results equivalent to those obtained with radical surgery. The importance of imaging techniques (TC, MRI) in the correct staging of the tumor is emphasised.

[Extramedullary plasmocytoma (EMP) of the head and neck: a series of 22 cases]. / Plasmocitoma extramidollare (P.E.M.) della testa e del collo: considerazioni su 22 casi.

Plasmacytoma is a rare neoplastic disorder arising from B-cell series lymphocytes. It can develop in three clinical variants: a) Multiple Myeloma (M.M.); b) Solitary Plasmacytoma of the bone; c) Extramedullary Plasmacytoma (EMP). EMP generally occurs in the submucosal tissue of the upper airways (80% of cases). This paper reports 22 cases of EMP of the head and neck observed in the last 20 years and reviews pertinent Literature. Four of our cases were located in the nasopharynx, four in the oropharynx and five in naso-sinusal sites. More rarely, the lesion occurred in the larynx (2 cases) or in the oral cavity (3 cases). In 4 patients multiple localizations in the upper airways were observed. Full evaluation was carried out in order to exclude disseminated disease. With the exception of 2 cases which were surgically treated, radiotherapy (RT) represented the treatment of choice in all patients, with doses ranging from 36 to 58 Gy. In 9 cases RT was administered after complete surgical resection. Follow-up time ranged from 13 to 167 months (mean 69.6). A partial response after treatment was observed in 4 cases. In only two of these cases neoplastic residue was observed (further RT allowed complete remission of the disease). In the other two cases, residual masses consisted in amyloid deposits. Three patients developed disseminated disease (MM) after a disease-free period ranging from 3 to 6 years. Five-year actuarial disease was 92%. Although surgery is generally considered a diagnostic tool, in our opinion local disease should always be removed surgically when surgery produces low morbidity. Surgical debulking of the lesion can increase the probability or local radiotherapeutic control.