[Significance of autopsy in patients with head and neck cancer]. / Stellenwert der Autopsie bei Patienten mit Kopf-Halstumoren.

BACKGROUND: Nowadays, the morphological assessment of samples obtained from living patients has a greater importance than the scientific knowledge which is gained by autopsy. Therefore, the aim of the study was a retrospective analysis of causes of death in patients with head and neck cancer. MATERIAL AND METHODS: The autopsy rate, clinical parameters of oncologic patients as well as autopsy findings like lethal complications, distant metastases and second primary tumors were retrospectively analyzed. RESULTS: From 1968 to 2007 in 91 patients with malignant tumors of the head and neck an autopsy was performed. In these 39 years an autopsy was performed in 45.9% of dead oncologic patients. Autopsy findings revealed distant metastases in 46.2% and second primary tumors in 17.6% of the patients. 49.5% of the patients died from pneumonia, 20.9% from tumor bleeding and 10% from progressive cachexia. CONCLUSION: The study confirms the global trend of a decline in autopsy numbers in the last 3 decades. However, as an important instrument of quality assurance autopsies continue to play an essential and indispensable role in medical research.

Lymphatic malformations involving the parotid gland.

INTRODUCTION: Cases of salivary gland involvement of lymphatic malformations have been occasionally reported in the literature. Of all the lymphatic malformations in the salivary glands, the parotid is the most common site. The present study aimed to analyze a series of lymphatic malformations of the parotid gland. MATERIALS AND METHODS: A retrospective analysis of the localization, symptoms, management and outcome was performed. RESULTS: Out of a total of 20 patients with lymphatic malformations of the parotid gland, 4 patients suffered from lymphatic malformations limited to the parotid gland (type I) and 16 patients from extensive cervicofacial lymphatic malformations involving the parotid gland (typeII). In 2 cases with type I disease and 4 cases with type II disease the malformations could be completely resected. In 3 patients with type II lymphatic malformations a partial resection was performed. The other patients were closely observed. 8 of them had already been treated elsewhere with surgery, sclerotherapy or laser therapy. One patient suffered from facial paralysis and 1 from transient facial nerve weakness immediately after surgery. In all, 11 patients suffered from persistent lymphatic malformations despite several attempts to reduce or resect the lymphatic malformation. CONCLUSION: The treatment of lymphatic malformations of the parotid gland remains challenging and persistent disease after therapy is common. Care should be taken to excise the entire malformation during initial surgery in order to avoid recurrence.

Analysis of clinically suspected orbital cavernomas.

BACKGROUND: Orbital cavernomas are low-flow vascular malformations that are the most common benign neoplasms of the orbit in adults, typically becoming symptomatic in the middle age. METHODS: The medical records of six patients with clinically suspected orbital cavernomas receiving elective surgical excision were analysed concerning symptoms, physical findings, treatment results and visual outcome. The pathologic slides were evaluated, and additional immunohistochemical stains were done if necessary to obtain diagnosis. RESULTS: Histologic evaluation revealed three of six cases not being cavernomas, although the clinical and macroscopic findings were consistent with orbital cavernomas. Two of them were haemorrhagic lymphangiomas, and one was a solitary fibrous tumour. CONCLUSIONS: Haemorrhagic lymphangiomas and other vascular tumours may mimic orbital cavernomas regarding anamnesis, radiologic and intraoperative findings and gross examination. Therefore, exact histologic evaluation is necessary to get the correct diagnosis.

Propranolol therapy for infantile haemangiomas: review of the literature.

OBJECTIVES: Haemangiomas are the most common tumors of infancy affecting approximately 1 in 10 children. Unlike other tumors, haemangiomas enter an involution phase, during which they usually regress over the next several months to years. Sometimes intervention is required due to proliferative growth which is complicated by ulceration, bleeding, persistent aesthetic deformity or infection. METHODS: Review of the literature. RESULTS: Propranolol, a nonselective beta-blocker, has recently been introduced as a novel modality for the treatment of proliferating haemangiomas. The exact mechanism of action of propranolol in the treatment of haemangiomas remains unclear, but vasoconstriction, down-regulation of angiogenic factors such as VEGF and bFGF and up-regulation of apoptosis of capillary endothelial cells may be responsible for the reduction of haemangiomas. Besides, an inhibition of MMP-9 and HBMEC expression by propanolol is discussed as possible mechanism influencing the growth of haemangiomas. However, there are different case reports of successfully treated infants in the current literature. CONCLUSION: There is the obtain that propranolol will detach steroids in the therapy for infantile haemangiomas.

Orbital lymphatic malformation showing the symptoms of orbital complications of acute rhinosinusitis in children: a report of 2 cases.

Orbital lymphatic malformations are benign cystic malformations of the lymphatic system. The present report shows two cases with symptoms of orbital complications of acute rhinosinusitis with proptosis, compressive optic neuropathy, loss of vision and cellulites in children. Magnetic resonance imaging (MRI) revealed a well-demarcated intraorbital mass with heterogeneous signal conformable with lymphatic malformation in both cases. A tumor extirpation was performed via lateral orbitotomy in both cases. Postoperatively the symptoms and especially the loss of vision improved completely. Histological analysis of the surgical specimens verified lymphatic malformations of the orbit. Orbital lymphatic malformations can mimic the symptoms of orbital complications of acute rhinosinusitis. The existence of lymphatic malformation should be considered in every orbital complication of rhinosinusitis in children.

Transfusion of washed and centrifuged shed RBCs during maxillofacial surgery affects cytokine concentrations.

BACKGROUND: In patients undergoing elective maxillofacial surgery, hyperthermic reactions have been observed after the transfusion of autologous washed and centrifuged shed blood. It was the aim of this study to correlate the clinical features with changes in cytokine levels. STUDY DESIGN AND METHODS: In 24 consecutive patients, TNFalpha, IL-1, and IL-6 levels were determined in washed and centrifuged shed RBCs (CS RBCs) and in the patient's serum before, as well as 15 and 120 minutes after transfusion. At the same time, blood was drawn for culture. Patients in whom whole blood was saved through the use of acute normovolemic hemodilution served as a control group (n = 6). RESULTS: After the transfusion of CS RBCs, patients had not only elevated cytokine levels but also transient bacteremia involving the pathogens previously detected in CS RBCs. No rise in body temperature occurred. CONCLUSION: In the light of these results, the use of CS RBCs in patients undergoing maxillofacial surgery should be restricted to those patients with no primary bacterial contamination.

Intravenous versus oral iron supplementation for preoperative stimulation of hemoglobin synthesis using recombinant human erythropoietin.

To compare two modalities of iron supplementation for the preoperative stimulation of erythropoiesis using recombinant human erythropoietin (rhEPO), 12 adults in normal hemoglobin and iron status due for elective surgery were randomized to rhEPO 200 U/kg body weight subcutaneously twice weekly combined with either iron sucrose 200 mg intravenously twice weekly or iron sulfate 160 mg/day orally, for 3 weeks preoperatively. Efficacy was measured by the increases over baseline in hemoglobin, reticulocyte count, and ferritin determined 3 days before surgery; preoperative reticulocyte count and ferritin were significantly higher with intravenous iron, whereas the only significant intragroup increases in hemoglobin between time points also occurred in this group. Intravenous iron significantly boosts the hematopoietic response to rhEPO and prevents iatrogenic iron depletion in otherwise healthy candidates for elective surgery.

Alternative methods for reduction of blood loss during elective orthognathic surgery.

Bimaxillary orthognathic surgery and genioplasty are frequently performed to correct dentoskeletal anomalies in otherwise healthy young patients. Until 1990 homologous blood transfusions were routinely necessary for these procedures. The present study describes a protocol of blood-saving measures that was adopted and tested on a continuous sample of 127 patients treated between 1994 and 1997. The protocol comprises acute normovolemic hemodilution, controlled moderate hypotension, positioning the surgical field above the heart level, cell saving, intraoperative homeostasis, preoperative autologous blood donation, administration of recombinant erythropoietin, and acceptance of a low hematocrit perioperatively. This study shows that homologous blood transfusions may be avoided intraoperatively by following the protocol described.

Multimodal strategy for reduction of homologous transfusions in cranio-maxillofacial surgery.

The transfusion of homologous blood carries well-known risks that have prompted efforts to develop alternative techniques. Such measures are of particular interest to patients undergoing elective procedures. A total of 204 patients, out of 1470 patients who consecutively underwent major craniomaxillofacial procedures under general anesthesia over a two-year period, were enrolled in a prospective protocol to reduce homologous transfusion requirements when a blood loss in excess of 500 ml was anticipated. The data were compared with the results of a retrospective control group (n=2890) covering major procedures during the previous four years, when blood-saving measures were applied occasionally, but not based on a global strategy. Techniques for the reduction of homologous transfusions were acute normovolemic hemodilution, controlled moderate hypotension, cell saver and predeposit autologous blood. In addition, preoperative administration of human recombinant erythropoietin was introduced during the last year of the study. These techniques were applied individually or in combination, depending on contraindications specific for each technique, using invasive monitoring in order to maintain intraoperative hemodynamic stability. The goal of this study was to examine the extent to which homologous transfusions may be reduced with the systematic application of transfusion-sparing techniques. Of 204 patients qualifying for the transfusion-sparing protocol, 30 received homologous transfusions. In comparison to the control group, utilization of transfusion-sparing techniques had doubled. The overall reduction in the use of homologous transfusions was highly significant. When acute normovolemic hemodilution, controlled moderate hypotension and the cell saver were used in combination, a greater reduction in homologous transfusions was achieved than with the use of either a single modality or combination of any two. No transfusions were required in patients pretreated with erythropoietin.

Histologic evidence of osseointegration in the irradiated and reconstructed mandible: a case report.

Osseointegrated implants are widely used in dental rehabilitation. They are particularly valuable if the structures supporting a denture had to be removed because of oral cancer. Additionally, many of these patients undergo radiotherapy, but cancer and radiotherapy are seen as relative contraindications for implant therapy. In the literature, there are few clinical studies documenting successful oral rehabilitation using implants in such patients. The authors report a clinical case in which histologic evidence of osseointegration can be demonstrated in an irradiated and reconstructed mandible. This observation should encourage the extended application of implants in rehabilitation following oral cancer surgery.

[Allo-transfusion saving measures in maxillofacial surgery]. / Fremdblutsparende Massnahmen in der Kiefer-und Gesichtschirurgie.

In terms of a prospective clinical study between June 1994 and May 1996, in 204 patients undergoing maxillo-facial surgeries with a expected blood loss of more than 500 ml a protocol of bloodsaving measures was followed. By means of an additional retrospective study, the consumption of homologous blood and the amount of bloodsaving measures between June 1990 and May 1994 was evaluated. Bloodsaving measures were consisting from acute normovolemic hemodilution, controlled moderate hypotension, cell saving, preoperative autologous blood donation, and administration of rh-erythropoetine. The methoda were applied isolated as well as in combination. Special concerns were given to a stable intraoperative homeostasis and to the acceptance of a low hematocrit perioperatively. Aim of the study was to investigate if, following the protocol, even in major maxillofacial procedures homologous blood transfusions almost completely can be avoided. Out of the 204 patients in the prospective study, only 30 received homologous blood. For the period June 94 to May 96, the reduction of the number of patients receiving homologous blood in relation to the period June 90 to May 94 was 83%. The results indicate that in the years 94 to 96 twice as much patients received bloodsaving measures. These led to a reduction of homologous blood consumption for 427 units in 1990 to 56 units 1996 (p < 0.001). If three measures, i.e. normovolemic hemodilution, cell saving, and hypotension were combined, the need of blood transfusion was at the minimum level. The effective reduction of homologous blood transfusion by consequent application of bloodsaving measures can with these data obviously be demonstrated.

Histological evidence of osseointegration 4 years after implantation. A case report.

Histological examinations of clinically successful dental implants are very rare in the literature. This article presents a clinical case where an ITI hollow-cylinder titanium implant type F (red mark, 16 mm) had to be removed simultaneously with the resection of a squamous cell carcinoma of the lower jaw. The duration of functional loading of the implant was 49 months. The fixture was situated at the margin of the tissue to be resected during tumor surgery and could therefore be prepared as a histological specimen independent of the tumorous tissue. In the sections obtained, close contact of alveolar bone to the implant surface was clearly visible. Together with the clinical success of the implant, criteria of osseointegration seems to have been matched. This observation represents the longest histological survey of a clinically successful fixture of this implant system.