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The aim of our study was to compare three different anesthesiological techniques with regard to hemodynamics, recovery, and postoperative morbidity, for craniofacial surgery. One hundred twenty patients with American Society of Anesthesiologists (ASA) classification of I or II patients, 18 to 32 years old, and undergoing maxillary and mandibular osteotomies were randomly assigned to receive anesthesia with propofol-remifentanil (group P), desflurane-remifentanil (group D), or sevoflurane-remifentanil (group S). All patients were given premedication: midazolam 0.03 mg/kg, atropine 0.007 mg/kg, desametasone 0.1 mg/kg, NaCl 0.9% 100 mL + 2 mg/kg ketoprofene + 1.5 mg/kg ranitidine + 1 μg/kg clonidine. Anesthesia was induced by O2/air (FiO20.5), remifentanil 0.5 μg/kg/min, propofol 2 mg/kg, rocuronium 0.6 mg/kg. Maintenance group P received O2/air (FiO20.5), remifentanil 0.25 to 1.5 μg/kg/min, propofol 6 to 10 mg/kg/h; groups D and S received O2/air (FiO20.5), remifentanil 0.25 to 1.5 μg/kg/min, and respectively, sevoflurane or desflurane 0.5 minimum alveolar anesthetic concentration. The dosage of propofol, desflurane, and sevoflurane, obtained with a value of bispectral index (BIS) 40, was kept unchanged throughout the course, and remifentanil was titrated to maintain controlled hypotension: systolic arterial blood pressure 70 to 90 mmHg and mean arterial blood pressure 50 to 65 mmHg. A 24-hour elastomeric infusion system (ketoprofene 320 mg) was started 60 minutes before induction and cloridrat ondansetron 0.1 mg/kg was administered 30 minutes before the end of surgery. Hypotension was successfully obtained in all three groups with a bloodless surgical field, and there was no need for additional use of a potent hypotensive agent. Early and late recovery were faster and more complete in the D group; P< 0.05. Postoperative morbidity (nausea, vomiting, shivering, pain, and edema) was slight and did not significantly differ among the groups.

Aims and background To report results of hyperfractionated radiotherapy for T2N0 glottic carcinoma at a single institution after extended follow-up.Methods Between 1980 and 1988 at Varese University Hospital, 60 consecutive patients with T2N0 glottic carcinoma received exclusive radiotherapy consisting of 1.5 Gy/fraction twice a day. Treatment gaps during the radiotherapy course were allowed according to individual tolerance. This policy resulted in a wide range of elapsed treatment time: median, 5.7 weeks; range, 3.7-8.9. Median follow-up is 9.8 years.Results As a result of dose/time distribution, 16, 20 and 24 patients received an average weekly dose rate of <10 Gy/week, equal to 10 Gy/week or >10 Gy/week, respectively. Mean total dose for each group was 62.8 Gy, 63.7 Gy and 63.8 Gy, respectively. Five-year local-regional control was 69 ± 6% (95% Cl); ultimate local-regional control, including salvage surgery, was 78 ± 5%. All failures were at the primary site, and no patient developed neck recurrence as first site of failure. The actuarial incidence of grade 2-3 late reactions at 5 years was 42 ± 6%. Most late toxicity events were grade 2: only 2 patients developed grade 3 reactions and none grade 4. None of the several clinical and treatment-related variables showed any statistically significant impact on local-regional control or late toxicity at univariate and multivariate analysis. In particular, 3-year local-regional control rates were 73 ± 11%, 84 ± 8% and 69 ± 10% for an average weekly dose rate of <10 Gy/week, equal to 10 Gy/week and >10 Gy/week, respectively (not significantly different).Conclusions At a very long follow-up, the hyperfractionated regimen tested in the study was shown to be effective and devoid of major complications, provided individual patient acute tolerance is carefully taken into account. Also, time factor did not affect outcome in this series.

Purpose:: This study was performed to investigate factors associated with laryngeal morbidity when postoperative radiation therapy (RT) is added to supraglottic laryngectomy. Materials and Methods:: From 1980 to 1994, 56 patients affected with T1 to 4 N0 to 2c supraglottic squamous cell carcinoma selected for standard (59%) or extended (41%) supraglottic laryngectomy at 2 different institutions were retrospectively analyzed. Most of the patients (91%) also underwent neck dissection. Approximately 80% of the patients had stage T4 primary lesions or N2 neck disease. Postoperative RT was added for presumed microscopic disease at the primary site (13 patients), regional nodes (23 patients), or both (20 patients). Median delivered doses to the larynx and to the neck were 50 Gy (range, 40 to 64 Gy) and 46 Gy (range, 40 to 64 Gy), respectively. Median follow-up for living patients is 11 years (range, 2.8 to 16.9 years). Laryngeal complication was defined as the appearance of grade 2 or higher toxicity according to the European Organization for Research and Treatment of Cancer (EORTC) and the Radiation Therapy Oncology Group (RTOG) scoring systems. Results:: Two- and 5-year actuarial locoregional control rates were 85 +/- 5% and 83 +/- 5%, respectively. Thirty patients (54%) developed laryngeal complications. However, just one patient experienced grade 4 laryngeal oedema requiring permanent tracheostomy. Estimated actuarial survival without laryngeal complications were 50 +/- 7%, 43 +/- 7%, and 39 +/- 7% at 2, 5, and 10 years, respectively. At univariate analysis, treated volumes (P = .03) and total dose to the larynx (P = .03) were significantly associated with local toxicity. A trend was observed also for the maximum dose to the neck (P = .06) and dose per fraction (P = .09). A multivariate Cox proportional hazards model showed total dose to the larynx to be the only independent predictor of toxicity (P = .03). The hazard ratio of laryngeal toxicity was 2.2 (95% confidence interval: 1.1 @?; 4.6), for a total dose to the larynx greater than 50 Gy. Conclusion:: After supraglottic laryngectomy, postoperative RT to the neck does not affect local morbidity, but careful RT treatment planning is necessary to avoid delivering a total dose to the larynx greater than 50 Gy.

In order to evaluate survival of non-oat-cell lung carcinoma patients treated exclusively with radiotherapy, the authors analyzed a series of 791 cases irradiated at the Istituto del Radio « O. Alberti » from 1978 to 1982. The authors selected a homogeneous group of 131 patients, treated with high energy photons and with a fractionation course of a dose ranging from 1.75 to 2.00 Gy per fraction, 5 fractions per week, total dose ranging from 40 to 65 Gy within 4 to 8 weeks and with a time dose factor (TDF) ranging from 60 to 108. The survival curve was computed according to several prognostic factors by means of the Kaplan and Meier approach; a multifactorial analysis was carried out according to Cox's model. No factor significantly affected survival at the level P < 0.05, except complications: anyway, TDF and tumor size seem to play a particular role. The non-oat-cell lung carcinoma patient who can profit from radiotherapy may be only partially featured: an improved survival and quality of life may be achieved if there are correct criteria to include the patient in the radiotherapy program, if the tumor is small, heavy complications are absent and treatment TDF ranges from 82 to 92.

We have performed a review of recent literature about combined modality therapy in esophageal cancer. Radiobiological principles and radio-chemotherapy interactions modalities in clinical experiences have been considered. Therapeutic schedules, modalities of implementation, and the most relevant clinical results obtained by the major clinical research groups have been emphasized. We also comment on the current role of surgery and on the clinical questions arising in combined radio-chemotherapy treatment.

Background Clinical approaches to early primary gastric non-Hodgkin's lymphomas have not yet been clearly defined, and the role of postoperative radiotherapy remains a matter of discussion.Methods Twenty-seven patients with early primary gastric non-Hodgkin's lymphoma were observed from December 1978 to December 1990 at our Institution. They were staged according to Musshoff and Schmidt-Volmer (19) as I E (n = 16), II E 1 (n = 7) and II E 2 (n = 4). All of them underwent local combined treatment, consisting of surgery and postoperative radiotherapy; chemotherapy was also administered to 10 patients, mainly with the CHOP regimen, for 4-6 cycles before radiotherapy. Irradiation was delivered using 10 MV photons from a linear accelerator. Large abdominal fields were employed in 21 cases with daily fractions of 1.5-2 Gy up to a median total dose of 30 Gy (range: 27-36 Gy). Six patients were irradiated only on the surgical bed up to 40.5 Gy (range: 39-40.5 Gy).Results The 5-year overall and disease-free survivals were respectively 92.4% and 89.8%. The main known prognostic indicators, stage of disease, type of surgery as well as age and sex, were not found to be statistically significant in our series. No clear difference emerged between patients sequentially treated with the combination surgery-chemotherapy-radiotherapy and those who did not receive adjuvant chemotherapy. Two patients recurred at distant sites, but no local failure was seen during the follow-up.Conclusions Although no firm conclusion can be drawn, our experience, in agreement with recent published reports, points out that the use of postoperative radiotherapy is associated not only to favorable results in terms of local control and survival, but also, and moreover, to a negligible incidence of side effects and sequelae. However, in the absence of multi-institutional prospective randomized studies, whose activation is nowadays strongly warranted, the exact role of adjuvant therapies remains a matter of discussion, and the optimal treatment of early primary gastric non-Hodgkin's lymphoma still depends on individual experience and the physician's philosophy.

Central venous catheter (CVC) placement is a routine procedure in the management of critically ill patients. It is important to ensure correct positioning of the catheter tip just above the junction of the superior vena cava and the right atrium, to reduce associated complications and to optimize catheter function. The incidence of catheter misplacement is approximately 3–4 for both subclavian and internal jugular vein access procedures. CVC placement in the right subclavian vein is associated with a higher risk of malposition.1We report an unexpected secondary malposition of a right subclavian CVC in the anterior mediastinum, with resultant vena caval perforation in a patient admitted to the neuro-critical care unit after undergoing a craniotomy procedure.