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The objective of this study was to assess adherence of childhood cancer survivors in comparison to cancer-free adults of comparable age and sex (or "controls") to the 2012 American Cancer Society (ACS) Guidelines on Nutrition and Physical Activity.As part of the Chicago Healthy Living Study, 431 childhood cancer survivors (18.5 ± 8.1 years from diagnosis) and 361 controls completed a structured, health-focused interview including the Block Brief Food Frequency Questionnaire and Modifiable Activity Questionnaire. From these data, modified adherence scores were computed based on ACS guidelines (maximum score of 8 reflecting complete adherence). Comparisons were made between survivors and controls and among racial-ethnic groups of survivors and controls.There was no difference in overall ACS adherence scores between survivors and controls (4.3 ± 1.5 vs. 4.2 ± 1.5, p = 0.54). As compared to controls, survivors, on average, had a lower body mass index or BMI (27.9 ± 7.0 vs. 29.3 ± 7.8 kg/m(2), p = 0.01) and consumed less fiber (9.2 ± 3.5 vs. 9.7 ± 3.8 g/1,000 kcal, p = 0.05). Within the survivor group, ACS adherence scores did not differ across racial-ethnic groups, but differences were observed with respect to component behaviors. Hispanic survivors had a higher BMI when compared to those of whites (29.2 ± 7.4 vs. 26.2 ± 5.3 kg/m(2), p = 0.001). Daily alcohol consumption was greater for whites among both survivors and controls as compared to other racial-ethnic groups (p 0.017 for all comparisons).Compared to controls, survivors were not practicing healthier behaviors. Among minority survivors, excess body weight, particularly among Hispanics, is a major concern. Assessment of these behaviors should be incorporated into survivor follow-up care.There is much room for improvement in educating and encouraging survivors to follow healthier diet and lifestyle routines to prevent obesity and further morbidity.

Owing to a rise in necrotizing enterocolitis (NEC, stage ⩾ 2) among very low birth weight (VLBW, birth weight1500 g) infants from 4% in 2005 to 2006 to 10% in 2007 to 2008, we developed and implemented quality improvement (QI) initiatives. The objective was to evaluate the impact of QI initiatives on NEC incidence in VLBW infants.In September 2009, we developed an NEC QI multidisciplinary team that conducted literature reviews and reviewed practices from other institutions to develop a feeding protocol, which was implemented in December 2009. The team tracked intervention compliance and occurrence of NEC stage ⩾ 2. In May 2010, we reviewed our nasogastric tube practice and relevant literature to develop a second intervention that reduced nasogastric tube indwelling time. The infants were divided into three groups: baseline (January 2008 to Novovember 2009, n219), QI phase 1 (December 2009 to May 2010, n62) and QI phase 2 (June 2010 to November 2011, n170).The NEC incidence did not decrease after implementation of the feeding protocol in QI phase 1 (19.4%) but did decline significantly after changing nasogastric tube management in QI phase 2 (2.9%). Multivariable logistic regression analysis demonstrated a significant relationship between QI phase and the incidence of NEC.QI initiatives were effective in decreasing NEC incidence in our high human milk-feeding NICU. Nasogastric tube bacterial contamination may have contributed to our peak in NEC incidence.

Purpose Stereotactic body radiotherapy (SBRT) is being used with increasing frequency as definitive treatment of early stage prostate cancer. Much of the justification for its adoption was derived from earlier clinical results using high-dose-rate (HDR) brachytherapy. We determine whether HDR's dosimetry can be achieved by virtual SBRT. Methods and Materials Patients with intermediate-risk prostate cancer on a prospective trial evaluating the efficacy of HDR monotherapy treated to dose of 9.5 Gy × 4 fractions were used for this study. A total of 5 patients were used in this analysis. Virtual SBRT plans were developed to reproduce the planning target volume (PTV) HDR dose distributions. Both normal tissue– and PTV-prioritized plans were generated. Results From the normal tissue–prioritized plan, HDR and virtual SBRT achieved similar PTV V 100 (93.8% vs. 93.1%, p = 0.20) and V 150 (40.3% vs. 42.9%, p = 0.69) coverage. However, the PTV V 200 was not attainable with SBRT (15.2% vs. 0.0%, p D max was significantly lower with HDR (94.2% vs. 99.42%, p = 0.05). The rectal D 2 cc was also lower (60.8% vs. 71.1%, p = 0.07). Difference in D 1 cc urethral dose was not significantly different (87.7% vs. 75.2%, p = 0.33). Comparing the PTV-prioritized plans, the rectal D max (94.2% vs. 111.1%, p = 0.05) and mean dose (27.1% vs. 33.3%, p = 0.03) were significantly higher using SBRT, and the rectal D 2 cc was higher using SBRT (60.8% vs. 81.8%, p = 0.07). Conclusions HDR achieves significantly higher intraprostatic doses while achieving a lower maximum rectal dose compared with our virtual SBRT treatment planning. Future studies should compare clinical outcomes and toxicity between these modalities.

Hospital malnutrition is associated with increased morbidity and mortality, particularly among patients admitted to intensive care units (ICUs). The purpose of this observational study (August to November 2007) was to examine the adequacy of oral intake and to identify predictors of oral intake after ICU patients were removed from invasive mechanical ventilation. Patients aged > or = 18 years who required mechanical ventilation for at least 24 hours, advanced to an oral diet postextubation, and did not require supplemental enteral or parenteral nutrition were included. The first 7 days of oral intake after extubation were assessed via modified multiple-pass 24-hour recall and the numbers of days on therapeutic diets and reasons for decreased intake were collected. Oral intake

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.

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.

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.

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.

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.

The impact of major risk factors for stroke on EEG mapping and routine EEG findings was evaluated in volunteers with no clinical signs of cerebrovascular or other neuropsychiatric disease. Focal changes were seen in 22 subjects (30%) by means of EEG mapping, but in only 12 cases (16%) when routine-EEG was used (p

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.

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.

Malignant lymphomas account for 3% of all malignant disease in the head and neck area. Twenty-five to fifty percent of all lymphomas arising in this region develop in extra-nodal structures, mostly in the Waldeyer ring. Lymphomas of the Waldeyer ring are comparable to any other lymphomas and prognosis is strictly related to stage and histology. The present paper reports 51 patients with malignant lymphomas arising in the head and neck (25 patients with Waldeyer ring involvement) recorded at the National Institute for Cancer Research, Genoa, Italy, from 1985 to the present. The characteristics of patients with Waldeyer ring involvement are comparable to those reported in the literature. Differences can be found in the median age (older in the present series) and in the incidence of Hodgkin's disease (8%). Patients were treated according to stage: stage I and II received radiation therapy and, in a few selected patients, this was combined with chemotherapy; stage III-IV received chemotherapy followed, in a few selected patients, by radiation therapy. In the present series, survival was related to the involvement of the Waldeyer ring: analysis has shown that survival is better in those patients with only nodal involvement. Nevertheless, these patients usually have a more advanced stage (p = less than 0.03). This finding is quite surprising since all the known prognostic factors are better in the Waldeyer group.

Candidal endocarditis can develop if candidemia occurs during Swan-Ganz catheterization. Candida endocarditis may persist for many months and is fatal unless the infected valve is resected. Herein is reported the first case of rupture of a mycotic pulmonary artery aneurysm caused by chronic candidal endocarditis. The endocarditis followed Swan-Ganz catheterization and aneurysm progressed despite appropriate medical and surgical therapy.

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.

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).

A case of retroperitoneal infectious myositis is described. The symptoms of infectious myositis may be confused with those of other more frequent soft tissue pathologies (haematoma and sarcomata). This infection is more frequent in countries with a tropical climate. The most frequent aetiological agent is Staphylococcus aureus. This paper reports on the diagnostic and therapeutic problems of this disease as recently observed at the Division of Surgical Oncology of the National Cancer Institute in Genoa.

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.