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The authors report their experience on six male patients and one female patient (age range: 58–76 years, median: 67) with facial tumours involving the anterior skull base, undergoing craniofacial resection between January 1992 and May 1994 at the Division of Surgical Oncology in the Tumor Institute, Genoa. Three patients had squamous carcinom and adenocarcinoma of the nasal fossa; two patients had squamous carcinoma rT4NO and adenocarcinoma rT4NO 1 of the maxillary sinus; one patient had squamous carcinoma of the eyelid, and another had squamous carcinoma of the internal chantus. Four patients had had previous radiotherapy, another underwent pre-operative chemoradiotherapy, and only two patients had not been treated before. A proper craniofacial tumour resection was performed in three patients; one patient had a left maxillectomy with ethmoidectomy and orbital exenteration; one patient underwent maxillectomy, resection of the medial and inferior wall of the orbit, ethmoidectomy, and orbital exenteration; one patient underwent maxillectomy, ethmoidectomy, and mucosectomy of the sphenoidal sinus, and one patient had total ethmoidectomy. As for reconstruction procedures of the anterior skull base, lyophilized dura with galeal pericranial flap was commonly used. A myocutaneous flap transposition (transverse rectus abdominis and latissimus dorsi myocutaneous flap) was used in two patients for the reconstruction of the resected tissues and bones of maxillary and orbital regions. Post-operative complications included intraoperative liquorrhea in one patient; one case of early and serious pneumocephalus; flap necrosis occurred following transposition of latissimus dorsi. Median hospital stay was 34 days. After a median follow-up of 18 months (range: 3 to 34 months) five of seven patients (71.4%) are alive and disease-free at 15, 17, 18, 30 and 34 months from surgery.

PURPOSE To determine whether pretherapy cell kinetics can predict local control for patients affected by head and neck squamous cell carcinomas (HN-SCCs) to be treated by primary radiotherapy and, moreover, guide to a choice between conventional and accelerated radiotherapy. PATIENTS AND METHODS Between 1989 and 1993, 83 patients with stage II to IV HN-SCC entered the study. Multiple primary tumor biopsies were obtained 6 hours after in vivo infusion of bromodeoxyuridine (BrdUrd). In vivo S-phase fraction labeling index (LI), duration of S phase (Ts), and potential doubling time (Tpot) were obtained by analysis of multivariate flow-cytometric data. Between April 1989 and January 1991, 49 patients were treated by conventional radiotherapy (70 Gy in 35 fractions over 7 weeks), whereas, afterwards, 34 patients entered an accelerated radiotherapy regimen with the concomitant boost technique (75 Gy in 40 fractions over 6 weeks). RESULTS Univariate analysis showed that, among patients treated by conventional radiotherapy, local control probability was affected by tumor stage (P = .02), Tpot (P < .001), and LI (P = .04). Similarly, among patients treated with accelerated radiotherapy, we found that local control probability was related to tumor stage (P = .03) and primary tumor site (P = .05). For the subgroup of patients with tumors characterized by fast growth (Tpot < or = 5 days), accelerated radiotherapy gave a better local control rate than conventional radiotherapy (P = .02). Cox multivariate analysis of the total number of patients showed that the only significant independent prognostic factors related to local control were tumor stage (P = .002) and Tpot (P = .004). Moreover, when the Cox analysis was restricted to the subgroup of patients treated with conventional radiotherapy, Tpot was the most significant factor to predict local outcome (P < .01). CONCLUSION Pretreatment tumor Tpot appears to be an important independent prognostic factor for local control of HN-SCC treated by primary radiotherapy.

The efficacy of ten daily injections of 500 or 500,000 U of recombinant interleukin 2 (IL-2) day-1 given 1.5 cm from the insertion of the sternocleidomastoid muscle on the mastoid was evaluated in 31 patients with recurrent head and neck squamous cell carcinoma. No toxic effects were noted. One complete response (CR) and three partial responses (PRs) were observed in the 16 patients who received 500 U of IL-2, whereas the higher dose was not effective. The CR was recorded in one of the seven patients with a oropharyngeal recurrence. Partial responses were obtained in 1/5 patients with hypopharyngeal recurrences, in 1/5 patients with oral cavity recurrences and 1/7 patients with laryngeal recurrences. The duration of the responses was 3-5 months and additional courses of ten injections of IL-2 had no further effect. Images Figure 1 Figure 2

Patients with advanced head and neck squamous cell carcinoma (HNSCC) are severely immunocompromised. In virtually all such patients who have been studied, reduced numbers of circulating CD3+ T-cell-receptor (TCR)α/β + T lymphocytes, a reduction of natural killer (NK) activity, and a poor induction of lymphokine-activated killer (LAK) cell activity (following in vitro treatment with recombinant interleukin-2 [rIL-2]) have been detected. Recently, however, it has been demonstrated that perilymphatic injections of low doses of rIL-2 may induce a local reduction of tumor masses in these patients. The present study, a cooperative pilot effort on the clinical effects of this route of administration, showed an activation of the lytic machinery in lymphocytes belonging to the T-cell lineage, as well as a potentiation of NK activity in the peripheral blood. These findings demonstrated that the severe immunodeficiency of HNSCC patients may be at least partially corrected by in vivo administration of rIL-2.

Background The addition of gemcitabine may be a reasonable way to enhance the activity of the alternating cisplatin/5-fluorouracil and radiation regimen considered the referring approach for patients with advanced squamous cell carcinoma (SCC) of the head and neck at the National Institute for Cancer Research of Genoa. Methods Three courses of cisplatin, 20mg/m 2 /day and 5-fluorouracil, 200mg/m 2 /day, days 1–5 (weeks 1, 4, and 7) alternated to 3 courses of radiotherapy at standard fractionation (weeks 2–3, 5–6, 8–9) up to 60Gy, and gemcitabine, 50mg/m 2 on monday of each week of radiation, were administered to 47 patients with stage IV (42 patients) or relapsed after surgery (5 patients), SCC of the oral cavity, pharynx or larynx. Results Eighty-five percent of the patients completed the planned treatment. Main grade 3–4 acute toxicities were: mucositis (40%), neutropenia (26%) and thrombocytopenia (30%). Twenty-seven patients reached a complete response (57%). Seven partial responders were rendered disease-free by surgery (final complete response rate: 72%). At a median follow-up of 37 months, 3-year overall survival, progression-free survival and loco-regional control are 50%, 43% and 54%, respectively. Conclusions The addition of gemcitabine at low dose to our referring alternating regimen is feasible and very active. It may improve the long-term outcomes despite an acceptable increase of acute mucoseal toxicity.

Patients with squamous cell carcinoma of the head and neck (HNSCC) after being treated radically remain at high risk for both recurrent and second primary tumours. 13-cis retinoic acid (13-cRA) was demonstrated to reverse pre-malignant lesions of the oral cavity and to reduce the incidence of second primary tumours in patients treated radically for HNSCC. Synergism between retinoids and interferon in tumoural cell lines have been demonstrated. Based on these data, the Italian Head and Neck Chemoprevention Study Group started a randomized chemoprevention study in patients radically treated for stage III and IV HNSCC. From February 1992 to January 1996, 267 patients were randomized: 126 were allocated to the control group, 126 were randomized to receive 13-cRA at a dose of 0.5 mg/kg per day per os and 15 patients have been assigned to the group of 13-cRA plus interferon alpha2a (IFN-alpha2a) at a dose of 3,000,000 UI 3 times a week (randomization in this arm interrupted due to administrative financial problems). The mean follow-up was 39 months. The 5-year actuarial survival was 58.9% for patients of the 13-cRA group and 57.2% for those of the control group (P=0.94). Among evaluable patients, disease progression was observed in 45 of 123 patients (36.6%) of the 13-cRA group and in 42 of 124 (33.9%) of the control group. The 5-year actuarial relapse-free survival was 48.9% for the 13-cRA group and 55.6% for the control group (P=0.62). Adverse effects, mostly of grade I were reported in 69.4% of treated patients (haematologic disorders, mucositis, conjunctivitis, cutaneous toxicity, hypertriglyceridemia and hypercholesterolemia). Only 5 patients (4.1%) reported grade III-IV toxicity. Low-dose of 13-cRA given for 1 year is ineffective as chemoprevention in patients with radically treated HNSCC.

The authors report their experience in patients with adjuvant systemic 2-interferon with the aim of defining the effectiveness, side-effects, indications and limitations of this treatment.From January 1989 to December 1996, 123 patients with genital, anorectal and perineal HPV lesions were treated with cryosurgery; adjuvant systemic a2-interferon was administered to 38 of them. There were 76 female and 47 male patients (median age of 29 years, range; 15-56 years). Clinical examinations included: digital rectal examination, head and neck examination, urethral meatus inspection and, in female patients, gynaecological examination; they underwent colposcopylurethroscopy, proctosigmoidoscopy, cystoscopy (in advanced disease); scraping for cytology and PCR analysis, and biopsy for histology. Twenty-three percent of patients had more than one site involved; upper digestive tract involvement was observed in 6.6% and 47% had lesions larger than 6 sqcm. Twenty-five females with genital lesions had esocervical lesions only; ten of them had SIL1, while seven a SIL3.Ninety-eight out of 123 patients (79.7%) were recurrence-free after a median follow-up of 32 months. A recurrence was observed in 25 patients: in univariate analysis, recurrence of disease occurred more frequently in females (p = 0.04), in patients with longer duration of symptoms (p = 0.0002),with wider lesions (p = 0.00015), with head and neck involvement (p0.01), and in HIV-positive patients (p = 0.03). In multivariate analysis, duration of symptoms (p = 0.005), head and neck involvement (p = 0.01), and width of lesion3 sq cm (p = 0.025) were associated with increased riskOur findings confirm the value of cryosurgery in the treatment HPV lesions; it is less traumatic, and gives good aesthetic and functional results; moreover, large lesions may be treated and the depth of cryonecrosis is more suitably adapted. Patients amenable to adjuvant treatment with a2-interferon should have multiorgan involvement, HPV type 16 or 18, lesions3 sqcm, long lasting symptoms (6 months) and presence of SIL.

To assess the value of micronuclei in the characterization of precancerous lesions of the oral cavity with reference to their likelihood of progressing to malignant lesions.The frequency of micronuclei was determined in exfoliated cells from normal oral mucosa, a preneoplastic condition (leukoplakia) and precancerous lesions with and without dysplasia, squamous cell carcinomas and sites of previous carcinomas that had been removed.Average micronucleus frequencies were increased in precancerous lesions as compared to normal mucosa and further increased in carcinomas, suggesting that micronuclei are a biomarker of neoplastic progression in this type of cancer. With all samples, micronucleus frequencies were systematically higher when cells were collected by vigorous than by light scraping, suggesting a decreasing gradient from basal to superficial layers of mucosa. The micronucleus frequency did not vary with the sex or age of patients, while it did vary with the anatomic site of the lesions.Although the gradual increase in micronucleus counts from normal mucosa to precancerous lesions to carcinomas suggests a link of this biomarker with neoplastic progression, the large overlapping of data prevents its use as a predictor of progression of precancerous lesions to malignancy in individual patients.

16 patients with oral leukoplakia were treated with oral 13-cis-retinoic acid. The initial dose, given for 3 months, was 0.2 mg/kg/day, increasing by a further 0.2 mg/kg/day in successive 3 month cycles. The maximum dosage reached at 1.0 mg/kg/day, was given to only 2 patients (who received a total of 15 months treatment). However, 10 patients completed the cycle at 0.8 mg/kg/day (12 months treatment in total), but treatment could not continue due to toxicity (grade I and II), which was cutaneous, mucosal, and haematological (hypertriglyceridemia and hypercholesterolemia). There was grade III toxicity in the skin and mucosa in only 1 case, a patient treated at a dose of 1.0 mg/kg/day. The toxicity was reversible in all cases. 14 of the patients completed the trial. In 4 there were improvements graded as partial responses (PR) obtained at 0.2 mg/kg/day (3PR) and 0.6 (1PR) and there was one complete response (CR) obtained at 0.4 mg/kg/day. Overall there was thus an objective response rate of 36% who showed 50% or more reduction in lesion size. After the retinoic acid treatment was stopped, patients were followed-up for 12 months; 2 patients showed regression of the responses obtained after 6 and 9 months. This study shows that oral treatment with 13-cis-retinoic acid at low dosages is efficacious and with minimal toxicity. It also shows that it is not feasible to treat these patients at doses above 0.8 mg/kg/day for long periods--mainly due to poor compliance.

The introduction of ultrasonography and fine needle biopsy (FNB) has changed the approach towards thyroid pathology. At the Division of Surgical Oncology of the National Institute for Cancer Research in Genoa we use a complex diagnostic system for the selection of patients affected by thyroid pathologies. Our aim is to analyze this methodology and find the best diagnostic procedure for the individual patient.Between January 1982 and June 1997, 2500 patients (pts) were found to be affected by thyroid pathologies. The diagnostic procedures for thyroid pathologies are: physical examination and anamnesis, scintigraphy, ultrasonography, fine needle biopsy, blood dosages, radiography of trachea and aesophagus; some cases require Computerized Tomography of the neck and Magnetic Nuclear Resonance. At the end of the examinations 409 pts underwent surgery; we will be evaluating the diagnostic system of these patients.We found from our data, that the group with the highest incidence of malignant tumors is characterized by a large number of instrumental examinations. In fact, 55/73 pts underwent all the instrumental exams, and in 21.1% a malignant tumor was found. These data are interesting, but more important is that only 409 patients out of 2500 underwent surgery 16.3%.We believe that one single instrumental examination is not enough to detect the characteristic of a thyroid nodule; the three most important examinations, scintigraphy, ultrasonography and cytology, would make it possible to select those cases which need a surgical approach. We believe that the 20% incidence in these cases can be considered good result, considering that the incidence of malignant tumors in thyroid pathologies is about 5% and that in these cases although the tumors were not malignant, they were operated on for functional or mechanical disorder.

Purpose: The aim of this study was to investigate the potential clinical relevance of cell kinetics parameters to the locoregional control (LRC) and overall survival of patients affected by head and neck squamous cell carcinoma (HN-SCC) treated by conventional radiotherapy, partly accelerated radiotherapy, or alternating chemoradiotherapy. Methods and Materials: Between January 1993 and June 1996,115 patients with HN-SCC at Stage III and IV entered the study. Multiple primary tumor biopsies were obtained 6 h after in vivo infusion of bromodeoxyuridine (BrdUrd), an analogue of thymidine that is incorporated in DNA-synthesizing cells. In vivo S-phase fraction labeling index (LI), duration of S-phase (Ts), and potential doubling time (Tpot) were obtained by analysis of the flow cytometric content of BrdUrd and DNA. Eighty-two patients were randomly assigned to receive either alternating chemoradiotherapy or partly accelerated radiotherapy, whereas 33 other matching patients received conventional radiotherapy. Results: Univariate LRC analysis showed that LI value was a prognostically significant factor, independent of type of therapy. Multivariate analysis failed to show cell kinetics parameters as statistically significant factors affecting LRC probability and overall survival. However, subgroup analysis showed that LRC probability at 4 years for fast proliferating tumors characterized by a LI ≥ 8% was significantly better for patients treated either with alternating chemoradiotherapy or partly accelerated radiotherapy than it was for those treated with conventional radiotherapy. Conversely, LRC probability for slow proliferating tumors (LI < 8%) treated with the three treatment modalities was similar. Conclusions: These results showed that, independent of type of treatment, pretreatment cell kinetics provided only a weak prognostic role of outcome in HN-SCC. However, this report raises the hypothesis that fast growing HN-SCC may be more likely to benefit from intensified therapy, as given in this series. Cell kinetics parameters studied by the in vivo BrdUrd/flow cytometry method might be considered predictive factors of response, providing information on which type of treatment may be selected according to tumor proliferation rate.

To investigate neck control probability and the value of nodal response at completion of alternating chemoradiotherapy, a group of 43 patients was reviewed.Patients were treated with 60 Gy alternated with four cycles of cisplatin and fluorouracil. All patients had lymph nodes positive for squamous cell carcinoma from various primary sites, underwent computed tomography (CT) for staging and evaluation of response, and were treated at a single institution. Patients with bilateral lymph nodes (N2c) were further staged according to the side of dominant neck disease.After chemoradiotherapy alone, 2-year neck control probabilities (NCP) are 86+/-13%, 58+/-10%, and 0 for N1, N2a/b, and N3 neck stages, respectively (p = .038). Two-year NCP for 25 complete responders is 85+/-8%, whereas, at the same time interval, it is 17+/-9% for 18 partial responses (p.0001). Within patients with N1-2a/b neck disease, 21 complete responders had a 2-year NCP of 92+/-8%. Five (11%) heminecks in four patients developed severe (Radiation Therapy Oncology Group [RTOG] grade2) subcutaneous late reactions.For patients with N1-2a/b neck disease, response at the end of treatment as evaluated by both physical exam and CT is a reliable criterion to select patients for complementary surgery even after chemoradiotherapy. For N3 disease, planned neck dissection regardless of response seems warranted.

The aim of this pilot study was to explore the prognostic relevance of cell kinetics parameters on the local control of patients affected by head and neck squamous cell carcinoma (HN-SCC), randomly assigned to receive either alternating chemoradiotherapy or partly accelerated radiotherapy. Between 1992 and 1995, 40 patients with HN-SCC at stages III and IV entered the study. Multiple primary tumor biopsies were obtained 6 h after in vivo infusion of bromodeoxyuridine, an analogue of thymidine that is incorporated in DNA-synthesizing cells. In vivo S-phase fraction labeling index (LI), duration of S-phase (TS), and potential doubling time (Tpot) were obtained by analysis of the flow cytometric content of bromodeoxyuridine and DNA. Twenty patients were treated by alternating chemotherapy and conventional radiotherapy (arm A), whereas 20 other matching patients received partly accelerated radiotherapy alone (arm B). Univariate local control analysis showed that LI, TS, and Tpot were not prognostically significant in either arm. However, local control probability at 2 years for fast growing tumors, characterized by a LI of 9%, was higher for patients treated with alternating chemoradiotherapy than it was for those treated with partly accelerated radiotherapy alone (68 versus 39%). Conversely, local control probabilities for slow proliferating tumors (LI,9%) treated in the two arms were similar. These results suggest a potential role for alternating chemotherapy and radiotherapy in HN-SCC patients with fast growing tumors.

146 patients with precancerous lesions of the oral cavity were observed in our institute between 1988 and 1995. Out of a total of 188 lesions, 110 were single and 36 were multifocal. Histologically 164 lesions were classified as keratosis, 14 as dysplasia, and 10 as lichen ruber planus. 76 patients were treated by cryosurgery, 20 received medical treatment and 3 underwent surgery. Only 47 patients eliminated such risk factors as smoking and alcohol consumption from their daily life-styles. Complete response was 99%, 20.8% and 29.8%, respectively, for cryosurgery, medical treatment and preventive measures. Only 2 patients (1.4%) developed squamous cell carcinoma of the oral cavity. Of these, 1 had had keratosis of the tongue, treated with cryosurgery, while the other had had a medically treated dysplasia of the floor of the mouth. There were 8 precancerous lesion recurrences after cryosurgery and 2 after medical treatment. After cryosurgery 18 new lesions appeared in a site other than the primary site, 4 occurred after medical treatment, 1 after surgery and 2 in patients who had eliminated tobacco and alcohol consumption. Since precancerous lesions constitute a general apparatus disease, a systemic treatment is required which can stimulate cell differentiation and/or suppress the mechanisms inducing carcinogenesis. This may prevent the occurrence of new lesions. For this reason the authors believe that the initial treatment for patients with precancerous lesions should be medical. Loco-regional therapy should be reserved for those cases which do not respond to medical treatment.

The purpose of the study was to determine whether pretreatment tumor cell kinetics can predict local control in elderly patients affected by squamous cell carcinoma of the head and neck (SCC-HN) and help guide different therapeutic modalities. Over a 6-year period, 52 patients with stage II to IV SCC-HN and aged more than 70 years were given an infusion of bromodeoxyuridine (BrdUrd) 6 hours prior to tumor biopsy sampling. The simultaneous labeling S phase fraction (LI) and duration (Ts) as well as potential doubling time (Tpot) were measured with flow cytometric analysis of BrdUrd and DNA content. Patients were then treated as follows: 14 with conventional radiotherapy; 13 with partly accelerated radiotherapy; 11 with chemoradiotherapy; 14 with surgery plus adjuvant radiotherapy. Univariate analysis showed that, independently of treatment type, patients with fast growing SCCs-HN characterized by Tpot valueor = 5 days had a lower three-year local control than patients with slow growing tumors with Tpot value5 days. Our results also demonstrated that surgery or chemoradiotherapy were effective treatments for fast growing tumors. Radiotherapy alone, instead, was more effective for slow growing tumors. Our data suggest that in vivo cell kinetics may play a role as additional prognostic factor for elderly patients with SCC-HN and predict the outcome of different treatments.

Background : In 1992, we reported the first analysis of a randomized trial comparing alternating radiotherapy and chemotherapy with radiotherapy alone in the treatment of squamous cell carcinoma of the head and neck. The results of that 3-year analysis indicated that the combined treatment had superior efficacy. Purpose : After an additional 2 years of follow-up, we again compared the efficacy of the two treatment regimens, with attention paid to differences in overall survival, progression-free survival, and locoregional relapse-free survival. Methods : One hundred fifty-seven patients with untreated, unresectable squamous cell carcinoma of the head and neck were randomly assigned to receive either chemotherapy (four courses of cisplatin [20 mg/m 2 ] and fluorouracil [200 mg/m 2 ], given daily for 5 consecutive days during weeks 1, 4, 7, and 10) plus radiotherapy (three courses of 20 Gy each, given in fractions of 2 Gy per day during weeks 2-3, 5-6, and 8-9) or radiotherapy alone (70 Gy total dose, given in fractions of 2 Gy per day, 5 days per week). Eighty patients received the combined therapy, and 77 were treated with radiotherapy alone. Responses, failures, and toxic effects associated with the two treatment regimens were compared. Overall survival, progression-free survival, and locoregional relapse-free survival were calculated according to the Kaplan-Meier method ; the logrank test was used to compare survival parameters between the two patient groups. Reported P values are two-sided. Results : As reported previously, toxic effects associated with the combined therapy included both chemotherapy- and radiotherapy-related effects ; however, the incidence and severity of mucositis were nearly identical among patients in the two treatment arms. The combined treatment was associated with a statistically significant increase in the frequency of complete response (i.e., the disappearance of clinically detectable disease for at least 4 weeks) (43% for the combined-treatment group compared with 22% for the radiotherapy-only group ; P =.037, chi-squared test). Five-year estimates of overall survival in the combined-treatment group compared with the radiotherapy-only group were 24% (95% confidence interval [CI] = 14%-40%) and 10% (95% CI = 4%-24%), respectively (P = .01, logrank test). The estimates of progression-free survival at 5 years in the combined-treatment group compared with the radiotherapy-only group were 21% (95% CI = 11%-37%) and 9% (95% CI = 3%-22%), respectively (P =.008, logrank test). Finally, the 5-year estimates of locoregional relapse-free survival were 64% (95% CI = 36%-84%) in the combined-treatment group and 32% (95% CI = 10%-65%) in the radiotherapy-only group (P =.038, logrank test). Conclusions and Implications : The superiority of alternating chemotherapy and radiotherapy over radiotherapy alone in treating unresectable squamous cell carcinoma of the head and neck seen at 3 years was confirmed at 5 years. However, additional trials must be conducted before considering the combined approach as standard therapy.

Between 1987 and 1993, 36 patients with early squamous cell carcinoma of the larynx (I-II stage) were treated with radiotherapy, at the National Institute for Cancer Research of Genoa; 25 patients were stage I (5 T1N0 of supraglottic larynx, 15 T1aN0 and 5 T1bN0 of glottic larynx) and 11 patients stage II (7 T2N0 of supraglottic larynx and 4 T2N0 of glottic larynx); there were 32 males (89%) and 4 females (11%), ages ranging from 34 to 83 years (mean age 61 years). The radiotherapy was performed utilizing the X-ray of a 6 MV linear accelerator, with a daily conventional fractionation and a dose of 66-70 Gy/33-35 fr./7 weeks, with co-axial latero-lateral beams including cervical lymph-nodes, except for T1N0 glottic cancer. The median follow-up was 51 months (range 8-84 months). The local control rate of all the patients was 80.5% at 51 months. According to the stage and tumor subsite, it was 80% for stage I a-b of the glottic site, 60% for the stage I of supraglottic site, 91% for stage II of supraglottic and glottic site. Only 6 patients (18%) underwent the salvage surgery and in all the patients the illness was under control. The overall survival rate was 83.3% at 51 months (4 patients died of a second tumor (11%) and 2 from heart disease (5.5%)). The only complication we observed was a glottic edema. The analysis of our results demonstrates that radiotherapy seems to be more appropriate in the T1a-b glottic cancer. These results are in agreement with those obtained by other studies. On the contrary, the results obtained with radiotherapy, in the T2N0 glottic cancer, are not satisfactory, with regard to local control, as those obtained with surgery, but offers best functional results. In most T2N0 tumors, after the failure of radiotherapy, a reconstructive laryngectomy is still possible. We also obtained good results with the supraglottic lesions. The small number of cases we treated does not allow us to achieve final conclusions and other studies are necessary to confirm our results.

Between 1982 and 1993, 224 patients (196 females and 28 males) with benign lesion of the thyroid underwent surgery. This group included: 1) 210 pts with p multinodular goiter or solitary nodule with normal serum levels of T3, T4, FT3, FT4, TSH (Thyroid stimulating hormone; 2) 14 pts with a hyper-functioning goiter; 3) 12 pts with recurrent nodules following surgery which had been carried out in another hospital. In this study only those pts with solid cold (hypofunctioning) nodules which had not been treated previously were evaluated. The minimal follow-up was 18 months. It consisted of serologic studies (86 cases), ultrasonography (70 cases) and ultrasonography and scintigraphy (5 cases). We performed isthmusectomy in 2 cases, total lobectomy in 42 cases and subtotal thyroidectomy in 42 cases. Out of the 86 pts evaluated, 70 (81.3%) were treated with post-surgical hormone suppressive therapy (Levothyroxin 100 gamma daily). The endogenous thyroid stimulating hormone (TSH) was suppressed in 50 cases (71%), while 20 pts (28.5%) remained within the norm. Thyroid ultrasonography demonstrated recurrent nodules in 14 out of the 86 evaluated (16.2%). All these pts received thyroxine therapy. Among the 50 pts who had been treated with an adequate dose of thyroid hormone, 5 had recurrences (10%), as compared to 3 out of the 20 cases (15%) who had been administered thyroxine dosage not high enough to suppress THS and to 6 pts out of the 16 (33.5%) who had not been administered thyroid hormone. One out of the 20 pts (5%) who had undergone total lobectomy and post-surgical suppressive hormone therapy developed recurrence as compared to 6 out of the 24 pts (25%) who had under gone lobectomy and had been administered a hormone dosage which was not high enough to suppress TSH. Four out of the cases (13.3%) who had under gone subtotal thyroidectomy and post-surgical suppressive hormone therapy had recurrence as compared to 3 out of the 12 (25%) who had undergone subtotal thyroidectomy without TSH suppression. We conclude that treatment with thyroid hormone decreases the risk of benign recurrences only when undergone a long thyroxine therapy in doses high enough to suppress endogenous TSH.

Purpose: The aim of the study was to determine preliminarily whether cell kinetic parameters evaluated using in vivo infusion of bromodeoxyuridine (BrdUrd) and flow cytometry, play a role as prognostic factors of loco-regional control in squamous cell head and neck carcinoma treated with radiotherapy. Methods and Materials: Between April 1989 and December 1991, 42 patients with unresectable Stage II–IV squamous cell carcinoma of the oral cavity, pharynx or larynx were given an infusion of BrdUrd solution prior to primary tumor biopsy sampling at 4–6 hr later. The simultaneous labeling S-phase fraction (LI) and duration (Ts) as well as the estimated potential doubling time (Tpot) were measured using flow cytometric analysis of BrdUrd and DNA content. Twenty-six patients received standard radiotherapy (70 Gy/35 fractions/7 weeks) whereas 15 patients were treated with the concomitant boost technique (75 Gy/40 fractions/6 weeks). Results: A complete set of flow cytometric data was available for 31 patients. The median value of LI, Ts, and Tpot were 9%, 9 hr and 5 days, respectively. Univariate analysis among the patients treated homogeneously by standard radiotherapy, indicated that local control was affected by Tpot value ( p = 0.02). When the same analysis was performed for the patients treated with either standard radiotherapy or concomitant boost regimen, we found a p = 0.04. Thus, patients with a tumor Tpot value ⩽ 5 days had a significantly lower three-year local control than patients with Tpot > 5 days. Log-rank test univariate analysis showed, in addition, that nodal status was the strongest prognostic factor of local control ( p = 0.005). Age, tumor stage, tumor site, performance status, grading, radiotherapy regimen, DNA ploidy and LI value were, instead, not significantly related to loco-regional control. Finally, when comparing the type of radiotherapy for tumors with Tpot ⩽ 5 days, we found a trend toward a better local control after concomitant boost regimen, with respect to standard regimen ( p = 0.06). Conclusion: The present preliminary results suggest that Tpot could play a role as additional prognostic factor influencing the disease outcome in head and neck carcinoma treated by radiotherapy

Invasion of the mandible is found in 22% to 29% of advanced (Stage III-IV) head and neck cancers; only an aggressive surgical technique, such as Commando's operation with subsequent reconstruction of tissue defects, can give a chance of cure to these patients. The reconstruction is feasible both by means of microsurgical free-tissue transfers or with alloplastic materials and myocutaneous flaps. Between 1982 and 1991, 34 patients in Stage III (n = 6; 17.7%) and IV (n = 28; 82.3%) head and neck cancers underwent Commando's operation with different types of reconstruction in 30 patients: pectoralis myocutaneous flap (n = 9), osteo-myocutaneous flap with the underlying segment of the fifth rib (n = 2), myocutaneous flap plus prosthesis (n = 17), or prosthesis alone (n = 2). Two different prostheses were implanted: the linear A-O mandibular reconstruction plate (n = 13), and the Dumbach titanium cage (n = 6). In the group of patients in which the linear A-O mandibular reconstruction plate was used there were four cases of prosthesis dislodgement and major exposure and one case of prosthesis breakage while in patients who were given the Dumbach titanium cage there were four cases of major exposure. Prosthesis removal was required in five and two patients with linear A-O and Dumbach titanium cage prosthesis, respectively. Median survival was 14 months with 28% five-year survival. In our experience, metallic prostheses with a shape and arrangement that allow a distribution of traction forces on a wider surface, with screws drilled in nonaligned points of the mandible, seem to be more reliable as they reduce the risk of dislodgement and breakage.

For patients with advanced, unresectable squamous-cell carcinoma of the head and neck, radiotherapy is the standard treatment but has poor results. We therefore designed a randomized trial to determine whether alternating chemotherapy with radiotherapy would improve the survival of such patients.Patients in the trial had biopsy-confirmed unresectable, previously untreated Stage III or IV, squamous-cell carcinoma of the oral cavity, pharynx, or larynx. They were randomly assigned to chemotherapy consisting of four cycles of intravenous cisplatin (20 mg per square meter of body-surface area per day for five consecutive days) and fluorouracil (200 mg per square meter per day for five consecutive days) alternating with radiotherapy in three two-week courses (20 Gy per course; 2 Gy per day, five days per week), or to radiotherapy alone (up to 70 Gy; 2 Gy per day, five days per week).The 80 patients given chemotherapy alternating with radiotherapy and the 77 given radiotherapy alone were comparable in terms of age, sex, performance status, disease stage, and site of the primary tumor. Complete responses were obtained in 42 percent of the patients in the combined-therapy group and 22 percent of those in the radiotherapy group (P = 0.037). The median survival was 16.5 months in the combined-therapy group and 11.7 months in the radiotherapy group (P less than 0.05); the 3-year survival was 41 percent and 23 percent, respectively. Severe mucositis occurred in 19 percent of the patients in the combined-therapy group and 18 percent of those in the radiotherapy group.In patients with advanced unresectable squamous-cell carcinoma of the head and neck, chemotherapy alternating with radiotherapy increases the median survival and doubles the probability of survival for three years as compared with radiotherapy alone. However, since local disease cannot be controlled in over half the patients who receive the combined treatment and since almost two thirds die within three years, further improvements in management are necessary.

Cell kinetic parameters were evaluated using the method based on in vivo incorporation of Bromodeoxyuridine (BrdU) and flow cytometric (FCM) analysis in 30 human epidermoid head and neck tumors from oropharynx, oral cavity, rhinopharynx, larynx and lips. BrdU was injected four/six hours before the obtainment of multiple bioptic samples from the tumor tissues. The flow cytometric method was carried out on 70% ethanol fixed cell suspensions based on established protocol for the simultaneous evaluation of DNA content and BrdU uptake using anti-BrdU monoclonal antibodies. We have evaluated the following FCM parameters: DNA ploidy, the degree of DNA aneuploidy (DNA index), Labelling Index (LI), duration of s-phase (Ts) and tumor potential doubling time (Tpot). LI values ranged from 1.5 to 20% with a median value of 10%. The median LI of DNA diploid tumors was 5.4% compared to 14% in DNA aneuploid tumors. Ts values ranged from 8 to 11, the median value being 10 hours. Tpot values ranged from 2 days to 16 days, the median Tpot being 5 days. The large heterogeneity of all these parameters indicates that these tumors may have a different degree of biologic aggressiveness (9). Tpot values did not correlate with DNA ploidy nor with lymph node metastasis status. Tpot values did not correlate in a statistically significant manner with degree of differentiation although shorter Tpot were more frequently observed in moderate or poorly differentiated tumors. Our study shows that the FCM-BrdU technique in vivo is feasible in a clinical setting to evaluate the proliferative behaviour of head and neck tumors, before any specific therapeutic decision is taken after surgery is performed. It is likely that tumors with more aggressive biological behavior, as indicated by LI15%, DNA aneuploidy and Tpot5 days, may benefit from more aggressive therapies such as accelerated regimeus of radiotherapy and/or other multimodal therapies in respect to tumors with slow growth rate (LI15%), DNA diploidy and Tpot5 days. So far, however, it still remains to be demonstrated from randomized clinical trials if the knowledge of such individualized cell Kinetic parameters really can help to choose the most effective therapy for every individual patient.

Lipoma is a benign tumor of the adipose tissue. It is a common neoplasm but very rarely involves the tongue. Only 0.3% of all tumors involving the tongue are lipomas. A case of lipoma originating in the tongue is described. The tumor was removed and did not recur one year after excision.

Between January 1982 and December 1988, 37 patients with neoplasm of salivary glands have been treated in our Division of Surgical Oncology. The sites of tumors were: parotid 26, submandibular gland 4, minor salivary gland 7. The preoperative diagnostic procedures were: sialogram, ultrasonogram, fine needle aspiration. Malignant tumors were 16:5 adenoca., 4 metastases, 3 adenoid cystic, 2 mucoepidermoid, 1 acinic cells, 1 lymphoma. Twenty-one patients affected by neoplasms and 5 by malignant tumors were treated with surgery only. Nine patients affected by malignant tumors were treated with surgery and RT. Two patients were treated with RT only. The first therapeutic step is surgery; in order to control local evolution of tumor, postoperative irradiation is recommended. Possible indications of preoperative diagnostic procedures and the therapeutic choices are discussed.

Between 1983 and 1986, the National Institute for Cancer Research in Genoa and affiliated institutions conducted a randomized study to compare two different ways of combining chemotherapy (CT) and radiation therapy (RT). One hundred sixteen patients were randomized to receive neoadjuvant CT followed by definitive RT (treatment arm A) or alternating CT and RT. In treatment arm A, RT consisted of 70 Gy to the involved areas and 50 Gy to the uninvolved neck at 2 Gy/fraction, five fractions per week. In treatment arm B, RT consisted of 60 Gy to involved areas and 50 Gy to the uninvolved neck in three courses of 20 Gy each, 2 Gy/fraction, ten fractions/2 weeks alternated with four courses of CT. CT consisted of vinblastine 6 mg/m2 intravenously followed 6 hours later by bleomycin 30 IU intramuscularly, day 1; methotrexate 200 mg intravenously, day 2; leucovorin rescue, day 3. CT was repeated every 2 weeks up to four courses. The same CT was used in both treatment arms of the study. Fifty-five patients were entered in treatment arm A and 61 in treatment arm B. Complete responses were 7/48 and 19/57 in treatment arms A and B, respectively (P less than 0.03). Four-year progression-free survival was 4% in treatment arm A and 12% in treatment arm B (P less than 0.02), and four-year survival was 10% in A and 22% in B (P less than 0.02). Mucosal tolerance was significantly worse in treatment arm B (P less than 0.00004). The subgroup analysis shows the major improvement of alternating CT and RT in patients with the worst prognostic characteristics.

Surgery is the treatment of choice for thyroid cancer, often followed by I131 and thyroid hormone to control the local residual tumor and distant metastasis. Hundred and sixty-two patients with thyroid disease underwent surgery at the Division of Surgical Oncology of the Cancer Institute in Genoa. Thirty cases presented no malignant hot thyroid nodules, 37 of the other 132 cases were cancers (28%). In 23 cases (62%), the pathological diagnosis was papillary carcinoma, in ten cases (27%) follicular carcinoma, in four (11%) medullary carcinoma. In 13 cases (35%) (ten papillary carcinoma, two follicular carcinoma, one medullary carcinoma) the lesion was multicentric. Our data suggest that total thyroidectomy, performed in two steps, in most cases does not carry important post-operative morbidity but offers the greatest potential for cure. In our cases only one patient died (of the cancer). After radical surgery it is possible to detect and treat metastases by I131.

The role of surgery in head and neck cancer treatment is now well established, as it appears the most effective approach to such patients, while other therapies (i.e. chemotherapy, radiotherapy) can be of some help as second choice procedures. Surgery demonstrates however its own pitfalls, as it can often cause secondary anatomo-functional defects. The main problems appear to be related to the impossibility of physiological feeding following composite resection for oral cancer. An immediate reconstruction by transposition of myocutaneous flaps is of the utmost importance, as it reestablishes the preoperative condition lessening hospitalization time and postoperative disabilities. Neurological lesions, an unfrequent major complication of cervical lymphadenectomy, can cover a wide range of seriousness, from hardly detectable sensorial deficits to the impossibility of spontaneous ventilation. In this paper the Authors, on the basis of their experience, describe the measures to be taken in order to avoid secondary lesions (or to minimize their effects) in head and neck cancer surgery.

From January 1987 to May 1988, 16 patients with advanced squamous cell carcinoma of the head and neck received combined treatment, based on an alternating schedule of chemotherapy and multiple fractions per day (MFD)-radiotherapy. The chemotherapy regimen consisted of cisplatin, 20 mg/m2, followed by 5-fluorouracil (5-FU), 200 mg/m2 i.v. push, from days 1 to 5 during weeks 1, 5, and 9. Radiotherapy was administered in two courses of 32 Gy each (total dose, 64 Gy) during weeks 2 and 3 and 6 and 7. Each course was given in two fractions per day, 5 days per week. The 16 patients were evaluated for toxicity and response. We observed 7 complete responders, 6 partial responders, and 3 nonresponders. The overall response rate was 81%. Toxicity was heavy: 44% of the patients developed grade III-IV mucositis. Our results suggest that cisplatin and 5-fluorouracil alternating with MFD-radiotherapy is effective; however, a new less toxic scheduling must be determinated.

A cooperative randomized study was begun in August 1983 to compare a sequential program of induction chemotherapy followed by definitive treatment, arm A, with an alternation of chemotherapy and radiotherapy (three courses of 20 Gy in ten daily fractions), arm B. The same chemotherapy was used in both arms: 6 mg/m2, vinblastine, hour 0; 30 mg, bleomycin, hour 6; 200 mg, methotrexate, hours 24 to 26; 45 mg, leucovorin, hour 48. One hundred sixteen patients entered the study, 55 in arm A and 61 in arm B. The patients all had previously untreated squamous cell carcinoma of the head and neck (SCCHN). Forty-five patients had stage III and 71 had stage IV disease. The two arms were fully comparable. As of April 1986, 116 patients were evaluable for survival, while 112 were evaluable for toxicity and 105 for response. Response analysis shows that there were 14 complete responses (CR) and 11 partial responses (PR), for an overall response rate (ORR) of 52% in arm A, and 30 CRs and seven PRs, for an ORR of 64.9% in arm B. The difference in terms of CR between the two arms was statistically significant (P less than .03). Progression-free survival (PFS) was also statistically different, with an advantage for arm B (P less than .05), but without differences in overall survival. Arm B correlates with a significant increase in mucositis compared with arm A (P less than .001).

In a patient with recurrent head and neck squamous cell carcinoma, reconstruction of the floor of the mouth was carried out by transposition of a pectoralis major myocutaneous flap after composite resection. Twelve months after surgery, a chest wall metastasis corresponding to the site of the vascular pedicle was observed. It appears that the lymphatic and hematogenous tumor spread can occur along the vascular pathways of a transposed myocutaneous flap.

Vaginal elimination of stool due to sigmoid-uterine fistula was the first symptom in a case of neoplasia of the sigma. Few instances of a similar fistula appear in the literature. Bouskela, Chérisié, Yourde and Taieb observed one case starting from the uterus. McGregorBacon have described a fistula starting from the colon due to diverticulitis, as have ColceckStaumann, Smalley et al., and JohnstonStubbs. No previous example of tumour of the large intestine as the cause of a fistula with the corpus uteri could be found. On examination, the patient presented losss of stool via the vagina and a sigmoid-uterine fistula. Her condition was poor. Blood glucose was high, the protein picture was altered with a los of albumin, and infection was present. Radical management was impossible. Left colostomy reduce the causes of infection and permitted devitalisation of the fistula. Subjective and objective improvement followed, though further enlargement of the tumour engulfing the sigma and uterus led to death some months later due to the onset of renal block.

The immunological status of 20 patients with chronic pharyngitis was studied. In 55% an increase of the T suppressor population was present while an inversion of T4/T8 ratio have a statistical significance compared with the control group (p = 0.029 and p = 0.003 respectively). The conclusion is drawn that an immunodeficiency is present in such patients and that treatment with immunostimulation drugs is justified.

Twenty-two patients undergoing major head and neck surgery were included in a randomized trial to value the efficacy and side effects of parenteral short-term antibiotic prophylaxis of post-operative infections. Two different antibiotic regimens were compared: group A, ceftazidime i.v. (2 g) in three doses (half an hour before surgery, 8 and 16 hours, from the first dose); group B, netilmicin (100 mg) plus clindamycin (600 mg i.v.), following the same chronological schedule. Overall infection rate was 18% (4/22): all post-operative infections occurred in group A patients, including one case of wound infection and 3 mixed infections (wound infection associated with lung infection), with a significant reduction of post-operative infection rate in group B patients (p = 0.045; Fisher's exact test).

Apart from the skin on the extremities, the skin of the head, face and neck is more subject to melanomas than any other part of the body. The most favourable prognosis is for melanomas of the cheek and neck cutis. Melanomas of the upper respiratory tract are much less common. The diagnosis of mouth is astonishingly tardive. Malignant melanomas very rarely occur on the salivary glands. In all the above cases surgery is the treatment of choice for all primary tumours. In the cases of local lymph node melanomas, elective dissection appears to give the best long-term results, especially in the case of cutaneous melanomas of the head, neck and upper respiratory tract.

The literature on carcinomas of the oral cavity shows general agreement that alcohol and smoking are risk factors. Only a few authors blame poor hygiene. The retrospective survey conducted in Genoa aimed to evaluate the relative importance of these risk factors, by means of a case-controlled study linking a specific risk factor to a specific condition. 98 histologically confirmed cases were hospitalised in 1979-80. A similar survey was conducted on a control group. Smoking and alcohol, often both together, were found to be the most significant aetiopathogenetic risk factors in the oncological pathology of the oral cavity.

Resection of locoregional recurrences was performed after mastectomy in 50 cases in the period 1961-1974. An incidence of 2% to 35% is reported for such recurrences, which are due to a variety of factors. In the present series, attention was directed to age at mastectomy and at recurrence, size of primary tumour, presence of axillary metastases, and details of menarche, menopause and pregnancy. Mean age at mastectomy was 50 yr and at recurrence 53 yr. Tumour diameter ranged from 2 to 5 cm in 73% of cases. Lympho node metastases were present in 42%. In 80%, the recurrence was paracicatricial, in 13% parasternal, and in 7% axillary. Treatment consisted of resection, radiochemotherapy or endocrino-ablative management.