Transoral versus transfacial surgical approach to maxillary tumors: evaluation of outcomes and perspectives.

Neoplasms of the maxilla have multiple different origins and histology, and often extend towards the infratemporal fossa, orbit, or skull base. Extensive resection may be required, often leading to poor esthetic and functional results. Usually, these lesions are removed via a transfacial approach. The aim of this study was to compare the outcomes of the transoral versus transfacial approach for maxillary tumors. A single-institution retrospective study was conducted on patients with maxillary-midface tumors, treated between January 2009 and December 2019. The patients were divided into two groups according to the surgical approach, transfacial or transoral, and the following outcomes were assessed: extent of the resection based on Brown's classification; postoperative pathology margin assessment; reconstruction technique; esthetic/functional results. A total of 178 patients were included. A satisfactory resection was obtained in both groups, with the transoral cohort achieving a higher rate of clear oncological margins (positive margins: transoral group 3.7% versus transfacial group 6.8%, P = 0.389) and a significantly higher University of Washington Quality of Life score (mean 72.2 versus 67.8, P < 0.001). Even large and invasive tumors can be treated successfully with the transoral approach, avoiding unesthetic facial scars while still providing complete resection of the tumor.

Contrasting opioid use for pain management in microvascular head and neck reconstruction: an international study.

Opioids are often the mainstay of postoperative pain management, despite strong evidence of their ill effects and potential for long-term addiction. The goal of this study was to quantify opioid use and contrast pain management strategies of multiple international institutions performing fibula free flap reconstruction. A retrospective multicenter cohort study was designed, including five international centers. For inclusion, the patients had to have undergone a primary fibula free flap reconstruction of the mandible. A total of 185 patients were included. The median opioid use across all centers at 72 hours was 133 oral morphine equivalents. The highest utilization was in the USA (P < 0.001), which was approximately six times that of Italy, four times that of Argentina, and twice that of India, despite all centers performing a similar procedure. Based on this study there are clear differences in prescribing practices and ideologies among surgeons from different countries.

Implant placement in oral squamous cells carcinoma patients treated with chemoradiotherapy: "Sapienza Head and Neck Unit" clinical recommendations.

OBJECTIVE: To date, the treatment of patients affected by head and neck squamous cell carcinoma (HNSCC) is highly challenging for clinicians. Possible therapies are surgical resection of the tumor mass, radiotherapy, chemotherapy or, more often, a combined treatment that inevitably affects both normal and tumor cells. Consequently, patients' anatomy and functions become reduced or altered. Nowadays the functional restoration is significantly improved thanks to the innovation in prosthetic rehabilitation and in radiotherapy. The current IMRT (Intensity Modulated Radiation Therapy) allows planning adequate treatments evaluating different tissues' involvement and radiation dosage. It is possible to define the most suitable sites for implant insertion, using data provided by dose-volume histogram (DVH). This study aims to illustrate the idea of obtaining a unique CT image by blending radiation-planning CT and Cone Beam CT. PATIENTS AND METHODS: Five patients among 54 candidates were selected for this study. Selection criteria were: good general health (PS0-1), age between 18 and 72 years, absence of metastatic disease or local recurrence, disease-free interval of at least 18 months. Radiation planning CT scan and maxillo-facial CT Cone Beam of every patient were overlapped and merged. Only one CT for every evaluated patient was obtained in order to plan the most suitable areas for implant placement. RESULTS: The placement of 10 implants in 5 patients was programmed using the explained method. Patients (all male) were aged between 48 and 72 years old, with a median age of 64.4 years. In every case of this study, a modification of the initial program of implant placement was necessary. The new imaging method we are proposing was able to provide information about radiation isodoses received in the planned osseointegrated implants' positions. CONCLUSIONS: This new method allows operators to correct their own therapy plans and choices, customizing the treatment plan on the actual condition of the patient. Moreover, it makes all the rehabilitation process safer and can reduce the risk of failure, side effects and inconveniences for the patients.

Laparoscopic Ovarian Transposition and Ovariopexy for Fertility Preservation in Patients Treated with Pelvic Radiotherapy with or without Chemotherapy.

BACKGROUND: Preservation of fertility in cancer patients of reproductive age is a concern for both the patient and the clinician. In this study, we aimed to study the effectiveness of laparoscopic ovarian transposition or ovariopexy in preserving ovarian function in women undergoing pelvic radiotherapy with or without chemotherapy for pelvic tumours. METHODS: The records of patients who underwent laparoscopic ovarian transposition or ovariopexy prior to pelvic radiation therapy between 2002 and 2018 were reviewed retrospectively. RESULTS: Thirty-nine women or adolescent girls with a diagnosis of cervical cancer (n=15), Hodgkin's lymphoma (n=6) or other types of pelvic tumours (n=18) were included in the study. The majority of patients had bilateral (n=25) or unilateral (n=8) ovarian transposition prior to radiotherapy. Nine out of 10 (90%) patients with soft tissue tumors, Ewing sarcoma or ependymoma, five out of seven (71.4%) patients with Hodgkin's lymphoma, two patients (100%) with rectal and anal cancer, and six out of 15 (40%) with cervical cancer retained ovarian function. Patients with cervical cancer, those who received concomitant chemotherapy and those older than 30 years were more likely to experience ovarian failure. Five patients conceived spontaneously and two women had four live births. CONCLUSION: Laparoscopic repositioning of the ovaries out of the radiation field in order to protect ovarian function in patients receiving radiotherapy appears to be effective in the majority of patients. The procedure seems safe and should be considered either as a sole procedure or in association with other fertility preservation methods prior to pelvic radiotherapy.

Effect of Different Adhesive Systems Used for Immediate Dentin Sealing on Bond Strength of a Self-Adhesive Resin Cement to Dentin.

OBJECTIVE: The purpose of this study was to investigate the immediate and three-month water storage behavior of adhesives when used for immediate dentin sealing (IDS). METHODS AND MATERIALS: Four adhesive systems were used to perform IDS: a one-step self-etch (Xeno V), a two-step self-etch (Clearfil SE Bond), a two-step etch-and-rinse (XP Bond), and a three-step etch-and-rinse (Optibond FL). For the control group, IDS was not performed. The self-adhesive resin cement RelyX Unicem was used for the luting procedures. After seven days of water storage, specimens (n=6) were sectioned into beams (n=5) with an approximately 1-mm2 cross-sectional area. Half of the specimens were tested in tension after seven days of water storage at 37°C, while the other half was stored for three months prior to testing in tension using a universal testing machine (1 mm/min). The failure pattern was determined using a stereomicroscope and scanning electron microscopy. Microtensile bond strength (µTBS) data were statistically analyzed by two-way analysis of variance and Tukey post hoc test (α=0.05). RESULTS: After seven days, the control group presented the lowest µTBS but did not differ from XP Bond and Clearfil SE Bond. After three months, there was no µTBS difference between the IDS groups and the control. CONCLUSIONS: After seven days of water storage, the groups with IDS presented higher µTBS values than the control group, although XP Bond and Clearfil SE Bond did not present significant differences. However, after three months of storage in water, IDS groups did not differ significantly from control group, which did not receive IDS.

Our experience in the surgical management of craniofacial fibrous dysplasia: what has changed in the last 10 years?

The mainstay of treatment of craniofacial dysplasia (CFD) remains surgery once clinical observation has been excluded. Nevertheless, disagreement remains about the type of surgical intervention (remodelling versus radical resection). The aim of this paper is to present our experience until 2013 comparing CFD management between 1980 and 2002 and between 2003 and 2013 and to propose our surgical algorithm. From January 2003 to December 2013, 41 new patients (18 males and 23 females) with histologically demonstrated CFD presented to our Department. Data were compared with those of 95 patients observed and/or treated between 1980 and 2002. Considering the last period, we noted that observation (26/41 patients) was the most used method; radical resection was performed in most cases (8/15 patients), but in proportion the numbers of patients undergoing bone shaving has increased (6% between 1980 and 2002 vs 15% between 2003 and 2013), while a decrease in the number of patients undergoing excision was seen (63% between 1980 and 2002 vs. 19% between 2003 and 2013). On this basis, we believe that radical resection is the only technique to obtain resolution of fibrous dysplasia. Wait-and-see is indicated in case of stable lesions. Reconstructive techniques allow obtaining adequate aesthetical and functional results; nevertheless, in most cases adjunctive surgical refinements are required and recovery time is higher than with surgical shaving, so that most patients prefer to perform remodelling. Nevertheless, in case of aggressive lesions radical resection is mandatory, except in paediatric patients with residual large defects in which it can be acceptable to try to resolve symptoms via bone shaving, reserving more aggressive treatments in case of relapse or after skeletal maturity.

Role of three different plants on simultaneous salt and nutrient reduction from saline synthetic wastewater in lab-scale constructed wetlands.

Constructed Wetlands (CWs) can be a valuable technology to treat high salinity wastewaters but it is not known their potential for removal of both nutrients and salt, and the type of plants to use. This study evaluated the effect of three plants on salt reduction and simultaneous nutrient removal in CWs microcosms with expanded clay and in hydroponic conditions. Initial values of the synthetic wastewater tested were EC=15dSm-1, SAR=151; NH4+-N=24mgL-1; PO43--P=30mgL-1 and NO3--N=34mgL-1. With expanded clay CW removal efficiency for NH4+-N was 21, 88 and 85%, while for NO3--N, it was 4, 56 and 68% for Spartina maritima, Juncus maritimus and Arundo donax, respectively. PO43--P was adsorbed completely in the expanded clay. However, in hydroponic system, removal efficiencies for NH4+-N were 53 and 50%, while PO43--P removal was 89 and -14% for Spartina maritima and Juncus maritimus, respectively. Nutrient removal in planted microcosms was statistically higher than unplanted controls for NH4+-N and PO43--P. However, salt removal was apparent in the hydroponic system only after 23days of HRT, despite clear salt excretion visible in both Spartina maritima and Juncus maritimus. This study demonstrates the potential of two halophytic plants for saline wastewater treatment. However, salt removal in such a scenario could not be well documented and might prove to be impractical in future work.

The role of time-resolved imaging of contrast kinetics (TRICKS) magnetic resonance angiography (MRA) in the evaluation of head-neck vascular anomalies: a preliminary experience.

OBJECTIVES: In this preliminary report, we describe our experience with time-resolved imaging of contrast kinetics-MR angiography (TRICKS-MRA) in the assessment of head-neck vascular anomalies (HNVAs). METHODS: We prospectively studied six consecutive patients with clinically suspected or diagnosed HNVAs. All of them underwent TRICKS-MRA of the head and neck as part of the routine for treatment planning. A digital subtraction angiography (DSA) was also performed. RESULTS: TRICKS-MRA could be achieved in all cases. Three subjects were treated based on TRICKS-MRA imaging findings and subsequent DSA examination. In all of them, DSA confirmed the vascular architecture of HNVAs shown by TRICKS-MRA. In the other three patients, a close follow up to assess the evolution of the suspected haemangioma was preferred. CONCLUSIONS: TRICKS sequences add important diagnostic information in cases of HNVAs, helpful for therapeutic decisions and post-treatment follow up. We recommend TRICKS-MRA use (if technically possible) as part of routine MRI protocol for HNVAs, representing a possible alternative imaging tool to conventional DSA.

Tumour volume changes following pre-operative radiotherapy in borderline resectable limb and trunk soft tissue sarcoma.

AIMS: To evaluate tumour volume changes after preoperative radiotherapy (PRT) for borderline operable soft tissue sarcomas (STS). MATERIALS AND METHODS: A retrospective review was performed of 68 patients who received PRT between December 2004 and July 2011. Endpoints were radiological response, surgical margins, local control and survival. RESULTS: Median tumour size was 12.5 cm. Tumour location was extremity (87%), trunk (12%), and neck (1%). Commonest histological subtypes were myxoid liposarcoma (32%) and myxofibrosarcoma (16%). The majority of patients (88%) received 50 Gy in 25 fractions. Post-radiotherapy imaging was available in 55 cases. By RECIST there was stable disease in 89%, partial response in 7% and progressive disease in 4%. Tumour volumes reduced in 80%. Median change in maximal tumour dimension was -13.6%; median change in volume was greater, at -33.3%. Tumour volumes increased in 11 cases (20%). However, surgical margins were clear in all 11 cases, with no local recurrences in this group. For the entire group, surgical margins were clear in 93%, and microscopically positive in 7%. Eight patients (12%) had local relapse at 2-24.8 months after surgery. Two year local relapse free survival was 87.5%; 2 year overall survival was 74.7%. CONCLUSION: The majority of tumours showed reduction in volume. A small number of tumours increased in volume, but there was no definite relationship between volume increase and poor surgical outcomes or lower local control rates. Local control was equivalent to published series' of PRT. PRT is a reasonable approach in patients with borderline resectable tumours.

Two clinical cases of prosthetical rehabilitation after a tumor of the upper maxilla.

The most frequent type of treatment for patients diagnosed with a malignant neoplasia of the oral cavity is surgical removal of the tumor. As a result of the resection performed, it is difficult to obtain satisfactory results in the oral rehabilitation of these patients. When possible, fixed prostheses are the best option, because they guarantee stability, but they should be made so that the operator can remove them periodically to check the health of the oral tissues underneath and to intercept any relapse of the tumor. This study analyses two cases of patients surgically treated for a tumor of the upper maxilla at the Oral and Maxillo-Facial Surgery of Sapienza University, in Rome. In the first case the surgical site was covered with local flaps, and the patient was rehabilitated with an implant-supported removable prosthesis. In the second case the maxilla was reconstructed with a fibula vascularized free flap, and the patient was rehabilitated with an implant-supported prosthesis screwed to a titanium bar solidarizing the implants. Therefore, this prosthesis was fixed, but could be removed by the dentist. The different approach to these two cases was influenced by the different anatomic situations after the reconstruction. It is important for the dentist to approach these patients knowing the kind of surgery they received because this aspect will influence rehabilitative choices. Rehabilitation should be planned, when possible, before surgical treatment, in order to cooperate with the maxillo-facial surgeon in choosing the most appropriate restorative treatment.

Prophylactic breast bud radiotherapy for patients taking bicalutamide: should this still be practised for patients with prostate cancer?

Prophylactic breast bud radiotherapy is used to prevent gynaecomastia and mastalgia in patients with prostate cancer who are being treated with antiandrogen and oestrogen therapy. Here a case is presented of a patient who developed soft-tissue sarcoma of the breast subsequent to breast bud radiotherapy prior to bicalutamide hormone treatment. Bicalutamide is often prescribed for younger men in the adjuvant setting or as monotherapy for locally advanced disease. The data regarding the efficacy of prophylactic breast bud radiotherapy is reviewed, and it is proposed that alternative therapies should be considered such as tamoxifen.

(Stereotactic) radiosurgery XIX: spinal radiosurgery--two year experience in a UK centre.

INTRODUCTION: Modern radiotherapy image guidance enables the treatment of extracranial targets with the required accuracy for safe delivery of radiosurgical treatments. The first two years' experience of spinal radiosurgery in a UK radiotherapy centre is reported. MATERIALS AND METHODS: Patients with primary or metastatic spinal lesions were treated using the CyberKnife stereotactic radiotherapy system. Xsight Spine (fiducial-free) tumour tracking software was used in all cases. Treatment was delivered using either a single or a three-fraction schedule, between February 2009 and March 2011. RESULTS: Fifty-three spinal lesions were treated, comprising 14 primary lesions in 12 patients, and 39 metastases in 29 patients. The prescription dose ranged from 8 to 30 Gy in 1-3 fractions. Fifty-nine percent of patients experienced no acute side effects from treatment. There were three cases of acute grade 3 back or nerve root pain, all of which responded to a short course of oral corticosteroids. At a median follow-up of 11.1 months, local control and overall survival were 91 and 65%, respectively. Pain improvement was seen in 75% of symptomatic metastases at 6 months post treatment. CONCLUSIONS: Early UK experience confirms that radiosurgery is well tolerated with excellent local control rates. Longer-term prospective data are needed to clarify the role of spinal radiosurgery for patients in this country.

Halogen lamp and LED activation of resin-modified glass ionomer restorative material. In vitro microhardness after long-term storage.

AIM: The purpose of this study was to evaluate the activation of resin-modified glass ionomer restorative material (RMGI, Vitremer-3M-ESPE, A3) by halogen lamp (QTH) or light-emitting diode (LED) by Knoop microhardness (KHN) in two storage conditions: 24 hrs and 6 months and in two depths (0 and 2 mm). MATERIALS AND METHODS: The specimens were randomly divided into 3 experimental groups (n = 10) according to activation form and evaluated in depth after 24 h and after 6 months of storage. Activation was performed with QTH for 40s (700 mW/cm) and for 40 or 20 s with LED (1,200 mW/cm2). After 24 hrs and 6 months of storage at 37 degrees C in relative humidity in light-proof container, the Knoop microhardness test was performed. Statistics Data were analysed by three-way ANOVA and Tukey post-tests (p < 0.05). RESULTS: All evaluated factors showed significant differences (p < 0.05). After 24 hrs there were no differences within the experimental groups. KHN at 0 mm was significantly higher than 2 mm. After 6 months, there was an increase of microhardness values for all groups, being the ones activated by LED higher than the ones activated by QTH. CONCLUSION: Light-activation with LED positively influenced the KHN for RMGI evaluated after 6 months.

Fatal radiation myelopathy after high-dose busulfan and melphalan chemotherapy and radiotherapy for Ewing's sarcoma: a review of the literature and implications for practice.

Radiation myelopathy is a rare, devastating, late effect of radiotherapy to the spinal cord. Spinal cord tolerance is currently accepted as about 50 Gy in 1.8-2 Gy fractions. However, the effect of chemotherapy on cord tolerance is unclear. This issue is important, given the increasing use of chemotherapy in combination with radiotherapy. We describe the case of a 17-year-old boy with a right apical paraspinal Ewing's tumour in the neck treated with induction chemotherapy, high-dose chemotherapy (busulfan and melphalan) with peripheral stem-cell rescue and, 4 months later, radiotherapy to the primary tumour site (cervical cord received 50 Gy in 30 fractions). After a latent period of 4 months, he developed a progressive, severe and ultimately fatal radiation myelopathy, which we suggest was due to a synergistic interaction between the high-dose chemotherapy and the radiotherapy. The use of such chemotherapy regimens in Ewing's tumours should be carefully considered, particularly when radiotherapy encompassing the spinal cord is an essential component of management.

Radiofrequency ablation of neuroendocrine liver metastases: the Middlesex experience.

BACKGROUND: Current treatment options for neuroendocrine liver metastases are not widely applicable or not that effective. Image-guided thermal ablation offers the possibility of a minimally invasive, albeit palliative, treatment that decreases tumor volume, preserves most of the normal liver, and can be repeated several times. We report our experience with image-guided thermal ablation in 25 patients with unresectable liver metastases. METHODS: Since 1990 we have treated 189 tumors at 66 treatment sessions in 25 patients (12 female, 13 male; median age, 56 years; age range, 26--78 years). Thirty treatments were performed with a solid-state laser, and 36 treatments were performed with radiofrequency ablation. All but one treatment was performed percutaneously under image guidance. Sixteen patients had metastases from carcinoid primaries, three from gastrinoma, two from insulinoma, and four from miscellaneous causes. Fourteen of 25 had symptoms from hormone secretion. RESULTS: Imaging follow-up was available in 19 patients at a median of 21 months (range, 4--75 months). There was a complete response in six patients, a partial response in seven, and stable disease in one; hence, tumor load was controlled in 14 of 19 patients (74%). Relief of hormone-related symptoms was achieved in nine of 14 patients (69%). The median survival period from the diagnosis of liver metastases was 53 months. One patient with end-stage cardiac disease died after a carcinoid crisis. There were eight (12%) complications: five local and three distant, four major and four minor. CONCLUSIONS: As a minimally invasive, readily repeatable procedure that can be used to ablate small tumors, preferably before patients become severely symptomatic, radiofrequency ablation can provide effective control of liver tumor volume in most patients over many years.

Treatment of neuroendocrine tumours in adults with 131I-MIBG therapy.

This is a retrospective review of 131I-MIBG therapy for metastatic neuroendocrine tumours in 25 adult patients. The tumours comprised 17 carcinoids, six paragangliomas, one somatostatinoma and one intestinal smooth muscle sarcoma. All patients (age range 28-84 years) had stage IV disease and a positive diagnostic 123I-MIBG scan. Patients received 11.1 GBq (300 mCi) of 131I-MIBG given in three cycles at 3-monthly intervals. The mean cumulative dose was 27.7 GBq (751 mCi). Symptomatic response was observed in 80%, hormonal response in 55% and tumour response in 48% (WHO criteria). Of the 25 patients, 40% are still under follow-up. Death was due to disease progression in all except one. The median survival time was 48 months from diagnosis of metastatic disease, and 17 months from the last 131I-MIBG therapy. The 5-year survival rate was 59% (95% confidence interval, 34%-78%). There was no statistical difference in survival between previously treated (chemo/radiotherapy) and treatment-naive patients. Side-effects were minimal and commonly include nausea (in the first 24 h) and a transient fall in platelet count. 131I-MIBG provides a good therapeutic response in patients with metastatic neuro-endocrine tumours.

Single center experience of a new intensive induction therapy for ewing's family of tumors: feasibility, toxicity, and stem cell mobilization properties.

PURPOSE: To examine the feasibility, tolerability, and toxicity of an intensified induction regimen (vincristine, ifosfamide, doxorubicin, and etoposide [VIDE]) in patients with newly diagnosed Ewing's family of tumors (EFT); to assess ability to maintain dose-intensity, and predictability of peripheral-blood stem cell mobilization. PATIENTS AND METHODS: Thirty patients were treated with vincristine 1.4 mg/m2 (maximum 2 mg) on day 1, doxorubicin 20 mg/m2, ifosfamide 3 g/m2 plus mesna and etoposide 150 mg/m2 on days 1 to 3. Cycles were given every 21 days for up to six cycles. RESULTS: One-hundred and seventy cycles of VIDE were given. The median treatment interval was 21 days (21 to 42) and nadir count: hemoglobin 8.3 (6.3 to 11.9), neutrophils 0.045 (0.0 to 2.1), and platelets 45 (3 to 343). There were 96 episodes of infection requiring hospitalization (56%). Growth factor support reduced infectious complications by 34%. Etoposide dose was reduced, or omitted, in 24% of cycles. Four patients did not complete six cycles due to unacceptable toxicity and one patient progressed on treatment. Twenty patients underwent peripheral-blood stem cell harvesting, 15 after cycle 3, and five after cycle 4. Median CD34+ yield was 4.6 x 106/kg per patient (1.8 to 14.5). Overall response to treatment, measured in 24 patients, was 88%. Seven of 11 patients undergoing surgery achieved greater than 90% necrosis of tumor (64%). CONCLUSION: VIDE is an effective induction regimen with substantial but acceptable toxicity that allows predictable mobilization of stem cells. Maintenance of dose-intensity is feasible in the majority of patients. Growth factors play a role in maintaining dose-intensity and reduce infectious complications.

A pilot study of short-course intensive multiagent chemotherapy in metastatic and axial skeletal osteosarcoma.

BACKGROUND: This pilot study was undertaken to assess the feasibility, toxicity and response to short-course multiagent chemotherapy followed by high-dose chemotherapy (HDC) in patients with poor prognosis osteosarcoma. PATIENTS AND METHODS: A total of 30 patients entered the study. Chemotherapy consisted of four blocks of multiagent chemotherapy administered sequentially over a short period in a dose-intensive manner. This therapy was followed by HDC which consisted of carboplatin at an AUC8 x 3 days, etoposide 400 mg/m(2) x 3 days and cyclophosphamide 60 mg/kg x 2 days. RESULTS: A total of 227 cycles of chemotherapy were administered. The main toxicity (for blocks 1-4) was haematological. There were two treatment-related deaths: one post HDC due to sepsis and one during surgery. High-dose chemotherapy was administered to 11 patients (10 with extremity tumours and only one with a pelvic tumour). Twenty-seven patients underwent surgery to the primary. Histological response was assessed in 23 patients. Seven patients (30%) had >90% necrosis. Eight patients underwent pulmonary metastatectomy. The median survival time for the whole group was 16 months. The 2- and 3-year survival rates were 50% and 21% for those with extremity tumours and 19% and 13% for those with axial skeletal tumours. CONCLUSIONS: Dose-intensive multiagent chemotherapy though feasible in the group of patients with extremity tumours did not significantly improve the treatment outcome compared with conventional relapse therapy. Inferior survival rates in the axial skeletal group are attributed to less intensive treatment and poor local tumour control.