[Differential diagnosis in fibro-osseous lesions of facial bones: report of a case of ossifying fibroma and review of literature]. / Diagnosi differenziale delle lesioni fibro-ossee delle ossa del massiccio facciale: descrizione di un caso clinico di fibroma ossificante e revisione della letteratura.

Ossifying fibroma is a relatively rare, benign neoplasm of non-odontogenic origin, affecting the facial bones, and prevalently localized in the mandible, but which can also appear in the maxilla, paranasal sinuses and peripheral bones. Its growth is generally very slow and it is usually asymptomatic, for which it often manages to reach a considerable size. An incidental diagnosis during orthopantography, on the other hand, is not infrequent. The diagnosis, which is fundamentally made by utilizing conventional x-rays and CT and NMR scans, may present several controversial aspects and is not to be disjointed from the clinical and anatomopathological aspects, for which close interdisciplinary collaboration is required in many cases. In effecting a differential diagnosis, the possibility of inflammatory lesions, other fibrous-osseous lesions (in particular, fibrous dysplasia) and benign or malignant neoplasms must be taken into consideration. The present work presents a case of ossifying fibroma of the maxilla that is emblematic in its clinical, radiological and histopathological aspects. It also discusses problems connected with classification and differential diagnosis, in particular with respect to fibrous dysplasia, which are important in determining the proper therapeutic approach.

Adjuvant radiotherapy influences the survival of patients with squamous carcinoma of the head and neck who have poor prognoses.

The treatment of carcinoma of the head and neck in recent years has improved significantly, chiefly thanks to progress in surgery and radiotherapy. Despite these advances, the survival statistics reported in the literature show no appreciable evidence of radical improvement. The aims of this study were to evaluate the impact on survival achieved with the combination of surgical and postoperative radiotherapy in patients with advanced head and neck carcinomas and to identify the prognostic value of several host- and tumor-related factors that can influence the results of combined treatment. We retrospectively reviewed the medical records of 394 patients with stage III and IV carcinoma of the head and neck, of whom 170 (43%) underwent surgery alone and 224 (57%) received combined surgery and postoperative radiotherapy. The 394 patients were stratified for a set of variables including the patient's condition, the characteristics of the tumor, and the modality of treatment. Univariate analysis revealed that coexistent medical diseases, the size and site of the primary lesion, the stage of the tumor, and certain pathologic features had a negative impact on survival. Multivariate analysis showed that the removal of lymph nodes and postoperative radiotherapy can have a positive influence and can improve the prognosis. We compared the survival rates of the patients treated with surgery alone with those of the patients who underwent combined treatment, and we observed that the two survival curves were comparable, even if there was a bias because the combined treatment group consisted of patients with negative prognostic factors. The meaning of these results, compared with data from the literature, has been discussed.

A physical-based model for the simulation of neoplastic growth and metastasis.

BACKGROUND AND OBJECTIVES: It is possible to formulate models capable of reproducing the main details of the physical processes involved in the evolution of biological systems. The complexity of the problem requires to begin with a simple and universal model for the description of the cellular growth, to be adapted successively to the local conditions found in clinically observed neoplastic growths. METHODS: A model based on the Local Interaction Simulation Approach (LISA) has been formulated for the simulation of growth, diffusion, and metastasis of neoplasms. The vascularization is described by a blood vessel located on one edge of the specimen in which a constant and homogeneous flow is assumed. A nutrient density is defined to mimic the blood flow within the tissue. RESULTS: Photograms taken at proper times may identify the main characteristics of the tumor evolution and describe its volume variations in a transversal section. Furthermore, it is possible to monitor constantly the volume of the neoplasm and of the necrotic tissue as a function of time, as well as the portion of cells that have migrated in the blood vessel. CONCLUSIONS: In spite of strong simplifying assumptions, the model presents good qualitative agreement with clinical data, which may be further improved by more detailed information about cancer cells properties or local vascular system patterns.

Treatment of malignant neoplasms of the parotid gland.

In this study we evaluated the effects of surgical and radiotherapy treatment on local control in 126 patients with malignant tumors of the parotid gland. The most frequently observed malignant tumors were high-grade tumors (68%). Surgical treatment was performed in 81 patients (83.5%). Total conservative parotidectomy was the most frequent procedure (74%), and radiotherapy was performed in 81 patients (83.5%). The global survival rate was approximately 54% at 5 years, whereas disease-free survival was 47% at 5 years. No statistically significant difference in survival rate was found between conservative (52% at 5 years) and radical treatment of the seventh cranial nerve (43% at 5 years). The incidence of recurrent cancer was 25.7% (25 of 97), of which 88% developed during the first 2 years. We report some of the clinical and histologic factors that can influence the prognosis of the disease.

Surgery or radiotherapy for early stages carcinomas of the glottic larynx.

AIMS AND BACKGROUND: The choice of treatment in limited squamous cell carcinoma of the glottic larynx often depends on individual and tumor factors. Data of the literature clearly show that surgery and radiotherapy tend to give identical results in terms of survival. We examined 196 cases of T1-T2/N0 cancers of the glottic larynx. We review the literature and discuss the indications and the efficacy of the various available treatments. METHODS AND STUDY DESIGN: 196 consecutive cases of T1-T2/N0 cancers of the glottic larynx were examined. In 54.5% the tumor was confined to the vocal cord; in 38.2% it extended to the anterior commissure, in 4.6% to the arytenoid cartilage and in 2.5% to the floor of the ventricle. We performed partial laryngeal surgery in 41.3% (81 cases). Radiotherapy alone was employed in 58.6% (115 cases). RESULTS: In T1a and T1b cases there was no statistically significant difference in 5-year disease-free survival. In T2 cases the NED survival of patients who underwent partial laryngectomies (90% of cases) was significantly better (P <0.05) than among patients given radiotherapy (73%). NED survival at 5 years in patients with the primary tumor on a vocal cord, ventricle or anterior commissure was 78%, 80% and 81%, respectively, with no statistically significant difference among the various sites. It is possible that involvement of the anterior commissure exposes patients to greater risk of recurrence when radiotherapy alone is used (5 out of 23 cases, 21.7%, compared to 3 out of 52 cases, 5.7%, among our surgically treated patients). CONCLUSIONS: When the tumor is confined to the vocal cord and mobility is not impaired (T1a), surgery and radiotherapy give comparable results, and the latter yields a better functional outcome. When the anterior commissure is involved, recurrences appear to be less likely after surgery. In T2 glottic carcinoma, surgery gives better results than radiotherapy alone. In any event, the choice of treatment should be patient-specific and based on a careful analysis of the factors involved in each case.

Lymphnode metastasis in head and neck squamous cells carcinoma: multivariate analysis of prognostic variables.

Cervical lymphnodes metastatization by the squamous cell carcinoma of the head and neck is well known as a prognostic negative factor as far as survival is concerned. Multivariate analysis has been used on 207 cases of head and neck squamous cell carcinomas (HNSCC) in order to identify the possible prognostic significance of a group of clinical and histopathological characteristics, aiming to find a correlation with the possible occurrence of cervical lymphnodes. Two hundred and seven patients (168 males and 39 females, mean age: 62 years) with SCCHN were studied. They underwent surgery alone and radiotherapeutic associated treatment. Variables regarding the patient, carcinoma and histology were analysed: age, sex, smoking and alcohol consumption, performance status, concomitant internal pathologies (cardiopathies, hepatopathies, broncho-pneumopathies, metabolic disorders), site and size of primary tumor (T stage), number and size of laterocervical lymph node localization (clinical N stage), grading, vascular permeation, perineural infiltration. Multivariate analysis of prognostic factors was performed using BMDP's PLR programme. Some variables showed a great risk of lymphnode metastasis; among sites: supraglottic larynx (p = 0.05), base of the tongue (p = 0.04), hypopharynx (p = 0.05); some histological parameters as lower degree of histological differentiation (p = 0.02), the presence of vascular permeation (p = 0.06) and perineural invasion (p = 0.07) appear to represent predisposing factors for the onset of adenopathies. By considering prognostic factors as shown, it is possible to better identify metastasis risk cases, that leads to improved therapeutical strategies.

[Tumors of the parapharyngeal space: case report of clear cell myoepithelioma of the parotid gland and review of literature]. / Tumori dello spazio parafaringeo. Presentazione di un caso clinico di mioepitelioma a cellule chiare del lobo profondo della ghiandola parotide e revisione della letteratura.

The parapharyngeal space is a deep neck region and can be the site of a wide range of neoplasms, including primary benign or malignant tumors, metastatic tumors, neoplasms invading the parapharyngeal space from the adjacent regions and neoformations stemming from systemic processes. Tumors of the parapharyngeal space are, nevertheless, relatively rare and account for 0.5-0.8% of all head and neck tumors. Most are benign tumors originating in the deep lobe of the parotid gland and the minor salivary glands. The most frequent tumor is pleomorphic adenoma while myoepithelioma accounts for just 1% of all salivary gland tumors. The present case report involves a case of myoepithelioma of the deep parotid gland lobe, arising in the parapharyngeal space. Together with a review of the literature, considerations are presented on the clinical and radiological evaluation, differential diagnosis and treatment of these lesions.

Carcinoma of the larynx in the elderly: analysis of potentially significant prognostic variables.

The incidence reported for carcinomas of the head and neck currently peaks between the sixth and seventh decades of life. In this retrospective study we were interested in learning whether age is a potentially significant prognostic factor for survival. We considered a set of variables in a series of 134 patients, divided into two groups; between 65 and 70 years of age, and older than 70. Stage I-II tumors were present in 44 patients, while locally advanced lesions (stages III-IV) were present in 90. Statistical analysis of survival was performed using the actuarial survival rates according to Kaplan-Meier; significance was evaluated using the log-rank test. Multivariate analysis was performed according to the Cox logistic regression model to determine the prognostic significance of any of the variables. Univariate analysis was performed on a series of variables regarding the patient, tumor and treatment. In the younger group, age appeared to be a favorable prognostic factor. Tumor size had a significant effect on disease-free survival, both globally and between the two groups (p < 0.05). Lymph node status substantially influenced the five-year survival rate (p = 0.001). Tumor invasion of the lymph nodes led to a difference between the two groups. Survival was lower in the younger than in the older group. There was a significant difference (p < 0.01) in survival between patients who had undergone surgery (75%) and those who received radiotherapy alone (33%). Multivariate analysis of these variables showed that disease stage, and treatment of lymph nodes were both significant (p = 0.0016 and p = 0.0002, respectively). Survival rates for the so-called "young elderly" (65-70 years) are generally higher than that for those aged 70 and over. Following accurate and comprehensive assessment by the anesthesiologist and the internist, and appropriate adjustment of the patient's nutritional and metabolic status, combined radical surgery and radiotherapy can and must be performed. Minimal palliative interventions, in the belief that tumor growth is biologically less aggressive in the elderly patient, should be avoided.

Squamous cell carcinoma of the lacrimal drainage system: case report and literature review.

AIMS AND BACKGROUND: Epithelial malignant tumors of the lacrimal drainage system are rare. The most prevalent type is squamous cell carcinoma. These tumors generally present with aspecific symptoms suggestive of chronic dacryocystitis, with the result that diagnosis and treatment are often delayed. METHODS AND STUDY DESIGN: We present the case of a patient with a squamous cell carcinoma of the lacrimal ducts and discuss the clinical and pathological features of these neoplasms, together with diagnostic and therapeutic strategies according to the data available in the literature. RESULTS AND CONCLUSIONS: The diagnostic and therapeutic approach to this kind of rare tumors has to be planned carefully. Radiographic examination of all masses arising in the medial canthus is essential. Dacryocystography allows the identification of space-occupying tumors in the lacrimal sac. Computed tomography and magnetic resonance imaging provide the most useful information about the extent of the neoplasm and its relationship with surrounding bone structures and soft tissues. Histological examination of a biopsy sample obtained by standard dacryocystectomy is essential to confirm the diagnosis. The treatment of choice is primarily surgical, consisting of complete resection with long-term follow-up. A number of surgical procedures have been described, which are more or less aggressive depending on the extension of the tumor. Radiotherapy is indicated when bone or lymphatic invasion is evident, and when neoplastic cells are present in the resection margins. Radiotherapy alone is not considered a treatment of choice, but only a palliative option in selected cases. The follow-up data available in the literature are incomplete. In most of the literature reports, relapse occurs in 50% of patients within 5 years.

[Therapeutic strategies for the treatment of parotid gland malignancies]. / Strategie terapeutiche per il trattamento dei tumori maligni della ghiandola parotide.

Parotid gland neoplasms include a quite heterogeneous group of histotypes with markedly different biological characteristics and evolution, thus requiring different forms of treatment. The present study evaluated the effects surgery and radiotherapy have on local disease control, survival rates and onset of locoregional recurrences. 126 malignant parotid tumors were examined (59 males, 67 females; age range 11 to 88 years; mean age 62 years) with a minimum of 1 year follow-up. The most malignant tumors were those most frequently seen in this case study (68%). Surgery was performed in 81 subjects (83.5%). Conservative total parotidectomy was the procedure most frequently performed (60/81, 74%). The overall 5-year survival rate was around 54% while 47% were "disease-free" patients at 5 years. When the subjects were broken down into 2 groups according to the degree of malignancy (high or low), the survival curve for disease-free subjects showed some differences (respectively 52% and 42%). The choice of treatment for the primary T significantly affect survival. Radiotherapy alone proved much less satisfactory than surgery (p < 0.01). The 5-year survival rate following a combination of surgery and subsequent radiotherapy was 52%, while it was 47% for those treated by surgery alone. An examination of the type of surgery performed revealed a difference in survival between those treated with preservation of the VII cranial nerve (52% at 5 years) and the more radical surgery (43% at 5 years) although this difference was not statistically significant. The incidence of recurrence was 25.7% (25 cases out of 97), of which 88% arose within the first 2 years. In conclusion, it has been seen that malignant parotid gland neoplasms are highly aggressive and the treatment of choice appears to be surgery plus radiotherapy whenever the clinical-biological features of the neoplasm warrant it. The surgical approach to the facial nerve should be as conservative as possible, reserving utmost radicality for the most advanced cases compromising the adjacent structures.

[Laryngeal myoblastoma in childhood]. / Mioblastoma della laringe nell'infanzia.

Laryngeal tumors originating in the nerves are extremely rare, particularly in infants. Indeed, this type of neoplasm normally arises in adult males. Only 10 cases have been described in the 5 to 17 year age range. The present work reports a clinical case of granulous tumor of the larynx in an 11-year-old boy. Histologically this tumor showed cells which preserved their original structure and were in close relation with the nerve fibers, but not with the myocytes. Their metabolic activity was similar to that of the nerve cells. The neurogenic origin of the neoplastic granulous cells shows the presence of neuroectodermic cytoplasmic S-100 specific for cells derived from the neural crest. The boy manifested ingravescent dyspnea due to the presence of a myoblastoma in the right laryngeal ventricle. A thyrotomic approach was adopted because of the significant size of the neoplasm although it was possible to perform conservative surgery given that the lesion was benign. The authors underline the polymorphic histology of this neoplasm and the importance of the type of surgery which should both avoid widespread demolition since the neoplasm is benign and, at the same time, prevent recurrences.

[Identification of clinical, biological and prognostic factors in recurring squamous cell carcinoma of the head and neck]. / Individuazione di fattori prognostici clinici e biologici in caso di recidive dei carcinomi squamosi della testa e del collo.

Many studies have been performed to determine some prognostic factors for malignant head and neck tumors. Defining the clinical and biological features would enable one to predict the progression of the disease and plan treatment. The aim of the present study has been to identify what host and neoplasm characteristics provide prognostic indication of possible recurrences. A group of 380 patients with squamous cell carcinoma of the head and neck was studied. The neoplasm was located in the following sites: 257 larynx-hypopharynx, 69 oropharynx, 54 oral cavity. At the present time 309 of these subjects are still alive and disease free while 71 have had recurrences. Analyses were performed on various variables regarding the patient, neoplasm and histology. Multivariante analysis of these prognostic factors was performed using the PLR-BMDP program. The time of recurrence in the primary tumor site and at the lymph node level was evaluated using the Kaplan-Meier method. Of the 28 variables analyzed 16 had no effect on the probability of recurrence. Two variables reduced the risk of recurrence: age over 61 years (p < 0.05) and primarily intra and peritumoral lymphocyte infiltration (p = 0.06). Of the data regarding the patient, age lower than 61 years and presence of associated internal pathologies (i.e. bronchial pneumonia and hepatitis) appeared to significantly facilitate the appearance of recurrence. The characteristics of the neoplasm which appear to effect recurrences are: tumor site (hypopharynx), presence of lymph node metastases, morphological elements of tissue spread (vascular invasion, plasmocyte infiltration), capsular breakdown, positive margins and post-operative infection. In conclusion, it can be asserted that technical development of multifactorial analysis has made it possible to identify important prognostic factors and quantify their impact on the evolution of a neoplasm.

[Evaluation of the cochlear aqueduct patency: comparison of 2 noninvasive techniques]. / Valutazione della pervietà dell'acquedotto cocleare: comparazione tra due tecniche non invasive.

Variations in cephalo-rachidian fluid pressure can be transmitted to the middle ear through the cochlear aqueduct (CA). This gives us a non-invasive manner to evaluate any changes in fluid pressure by measuring middle ear impedance (impedancemetry). The present study compared two indirect methods for measuring intracranial pressure: a) impedancemetry during evoked jugulo-tympanic reflex (JTR) and b) study of the tympanic membrane (TM) fine motility using a MMS-10 analyzer. The latter is a new procedure involving the indirect evaluation of the fluid pressure. In fact, when the CA is open the labyrinthine fluid pressure is transmitted to the oval window, the stapes platina and, finally, to the tympanic membrane where it can be measured with an MMS-10 unit. This equipment can measure nanoliter shifts in the TM. In particular, comparison between the clinostatic and orthostatic tympanic motility measurements enable one to establish whether the CA is patent or not. In the present study 15 subjects were examined using both a) impedancemetry during jugular compression and b) analysis of the TM shift using an MMS-10 unit. In 14 of the 15 cases there was good correlation between the data obtained using both methods: in all but one case it proved possible to record a JTR-induced variation in impedance whenever the MMS-10 indicated that the CA was open. The results suggest that, in clinical practice, the two methods can be used in parallel for non-invasive monitoring of variations in intracranial pressure in patients with neurological involvement. On the other hand, in the E.N.T. field these techniques could be used to study inner ear pathologies causing dynamic alterations of the endolabyrinth fluids (endolymphatic hydrops, labyrinthine fistula).

Prognostic factors of cervical lymph node metastasis in head and neck squamous cell carcinoma.

AIMS AND BACKGROUND: The metastatic spread of squamous cell carcinoma of the head and neck (SCCHN) to the cervical lymph nodes is a negative prognostic factor in terms of survival. We have used multivariate analysis to identify the possible prognostic significance of a number of clinical and pathological characteristics in relation to possible involvement of the cervical lymph nodes in a series of 396 patients. METHOD: 396 patients with SCCHN were studied. Variables regarding the patient, the carcinoma and histology were analysed by multivariate analysis using BMDP's PLR programme. RESULTS: Some variables appear to represent predisposing factors for tumor spread to the lymph nodes: tumor site (supraglottic larynx: P = 0.005; base of the tongue: P = 0.02; hypopharynx: P = 0.02), grading (P = 0.001), and a number of histological parameters (lower degree of histological differentiation: P = 0.001; vascular permeation: P = 0.04; perineural invasion: P < 0.05; prevalently plasmocytic infiltrate: P < 0.05). CONCLUSION: The identification of cases at risk for metastasis can be improved by the assessment of prognostic factors, with a consequent improvement in treatment strategies.

Treatment of oral cavity and oropharynx squamous cell carcinoma with perilymphatic interleukin-2: clinical and pathologic correlations.

We describe the correlations between the clinical and histologic findings in an initial series of 60 patients with T2-4, N0-3, M0 squamous cell carcinoma (SCC) of the oral cavity or oropharynx enrolled in a randomized trial set up to evaluate whether the disease-free interval and survival are extended when perilymphatic injections of recombinant interleukin-2 (rIL-2) are combined with routine surgery and radiotherapy. Twenty-nine patients were operated on only (controls). The other 31 received two daily injections of 2,500 U rIL-2, one near the mastoid process on the same side as the tumor and the other under the chin, for 10 days before surgery, and further injections on the nonoperated-on side on a monthly basis for 1 year starting 4 weeks after surgery (or radiotherapy, where necessary) in an effort to upregulate the immune system and delay recurrence. Their surgical specimens displayed a significantly greater inflammatory reaction, larger areas of necrosis, and more intense sclerosis. The inflammatory tumor infiltration consisted of eosinophils, plasma cells, and CD25+ and human leukocyte antigen (HLA)-DR+ lymphocytes. However, no correlations were apparent with regard to the intensity of necrosis, eosinophil infiltration, and the number of DR+ cells and the clinical outcome. By contrast, the correlation between CD25+ cells and a significantly longer disease-free survival suggests that induction of T-cell reactivity, and perhaps specific immunity, is the only important aspect of rIL-2-induced antitumor reactivity.

Prognostic factors for head and neck tumor recurrence.

The introduction of new treatment methods has stimulated the identification of further prognostic factors capable of defining the clinical and biological characteristics of the tumor type in question and improving treatment programming. The aim of this study was to identify which characteristics of the host and tumor are of prognostic value in relation to the onset of locoregional tumor recurrence. A total of 396 patients were studied. The tumor site distribution can be summarized as follows: 267 laryngohypopharyngeal, 74 oropharyngeal, 55 oral cavity. Variables regarding patient, tumor and histology were evaluated for the purpose of analysis. Multivariate analysis of these prognostic factors was performed using PLR software by BMDP. Mean tumor recurrence time was 19 months. Seventeen of the 29 variables analysed did not influence the probability of tumor recurrence. Two variables reduced the risk of tumor recurrence: age > 61 years and abundant and prevalently lymphocytic intra-and peritumoral infiltrate. The study of tumor recurrence onset mechanisms is justified by its impact on the evolution of disease. The use of multivariate analysis in this study showed that some clinical and pathological characteristics of squamous cell carcinoma of the head and neck have a statistically significant impact on tumor recurrence.

[Autonomic nervous system disturbance as a possible cause of vertigo or dizziness]. / Alterazioni del sistema nervoso autonomo come possibile causa di vertigine od instabilità.

In the present study possible interactions between dizziness, or vertigo, and eventual malfunctioning of the Autonomic Nervous System were evaluated. Two groups of ten patients each were patients each were tested. All the patients had vertigo or dizziness of uncertain etiology and ten had arterious hypotension. A careful anamnestic research was carried out in order to individualize symptoms or elements which could induce dysautonomia. A series of 6 tests aimed at evaluating cardiovascular responses was performed in all the patients. Alterations were present in 65% of the test responses. In particular, results were altered in patients with arterious hypotension. The Authors, underline the effectiveness of an adequate anamnesis in identifying patients with possible dysautonomia and affirm the validity of cardiovascular tests (non-invasive, specific and sensitive in obtaining information concerning the etiology of particular forms of dizziness.