Orbital exenteration in elderly patients: personal experience

Orbital exenteration is a disfiguring procedure which typically involves removal of the entire contents of the orbit including the periorbita, appendages, eyelids and, sometimes, a varying amount of surrounding skin. This operation is reserved for the treatment of potentially life-threatening malignancies arising from the orbit, paranasal sinuses or periocular skin. The marked increase in the average life span and resulting greater incidence of invasive malignant skin tumours of the face, typical of old age, is the reason for the increased rate of exenterations in elderly patients. The purpose of this report is to describe personal experience regarding 8 operations of orbital exenteration carried out on elderly patients, 6 males and 2 females, age range 66-85 years (mean 75), who came to our observation, from January 2002 to December 2007, on account of cancer (7 cases: 4 basal cell carcinomas; 1 squamous cell carcinoma; 1 fibrosarcoma; 1 melanoma) or infectious inflammatory disease (1 case of rhinocerebral mucormycosis) and were treated with type III orbital exenteration (2 cases) and type IV orbital exenteration (6 cases according to Meyer and Zaoli's classification). The methods used to reconstruct the eye-socket consisted of a full-thickness skin graft in 5 cases, pedicled myocutaneous flaps in 2 cases--a latissimus dorsi muscle flap alone, in one patient, and combined with a pectoralis major muscle flap in another - and a combined lateral-based frontal fasciocutaneous pedicled flap and full-thickness skin graft in the oldest patient. Regarding survival and the local clinical situation, 3 of the 4 patients with basal cell carcinomas are alive and disease-free after 6 years, 2 years and 20 months, respectively, while the oldest patient died of the disease after 10 months. The subject who underwent surgery for squamous cell carcinoma is alive and disease-free after 2 years. The patients with melanoma, fibrosarcoma and mucormycosis died. Although there are various options available for reconstruction, full-thickness skin graft or a pedicled muscolocutaneous flap provide the simplest solution in the elderly population with significant co-morbidities. The final outcome is, in our experience, comparable to that of more complex flap reconstruction, obtaining very good final results with minimal donor site morbility and a reduced operation time.

Study of immune alterations in patients with chronic fatigue syndrome with different etiologies

The Chronic Fatigue Syndrome (CFS) is characterized by symptoms lasting for at least six months and accompanied by disabling fatigue. The etiology of CFS is still unclear. At the National Center for Study of the Infectious Diseases Department of the Chieti University some immune investigations were performed with the purpose of detecting markers of the disease. CD4+, CD8+, NK CD56+ and B CD19+ lymphocytes were studied in 92 male and 47 female patients and in 36 control subjects. CFS patients were divided in three groups with a post-infectious onset (PI-CFS), an non post-infectious onset (NPI-CFS) and a non post-infectious onset with associated infections (NPI-CFS + AI). Both CD4+ and CD8+ lymphocytes were reduced in the CFS patients. However, the CD4+/CD8+ ratio was increased in the CFS patients without difference between males and females. CD56+ cells of CFS patients were also reduced. In particular, blood CD56+ cells counts were significantly higher in PI-CFS patients than in the NPI-CFS subjects. These data confirm our preliminary results suggesting a key-role of a dysfunction of the immune system as a precipitating and-or perpetuating factor of the syndrome.

Cytomegalovirus Infection in Heart-Transplant Recipients in a Central Region of Italy

Cytomegalovirus (CMV) infection occurs very often after solid organ transplantation and is often a life-threatening complication of long-term immunosoppressive therapy. Actually it is unknown which type of drug is indicated to control the infection in immunocompromised patients. We studied 10 consecutive patients who had undergone heart-transplantation and in which CMV infection was the commonest post-transplant infectious disease. Our results suggest a careful monitoring of IgG seropositivity in heart transplant patients, especially when it is not possible to know the serum status of the donor.

Metabolic Modifications in HIV-Infected Women

To assess metabolic alterations and/or abnormal fat distribution in Human Immunodeficiency Virus (HIV)-infected women undergoing Highly Active Antiretroviral Therapy (HAART), a case-control study was carried out in a population of twenty-two HIV-infected, normal weight, non-diabetic, normotensive women. Twenty-five healthy non infected subjects matched for sex, age and Body Mass Index (BMI) were also included as a control group. Blood samples were collected for leptin and insulin measurements. Fasting glucose, triglycerides, total cholesterol and HDL-cholesterol were also measured. Insulin resistance was determined using the homeostasis model assessment index (HOMA-IR). Body fat distribution was evaluated using waist-to-hip ratio (WHR), Bioelectric Impedance Analysis (BIA) and abdominal CT-scan. Immunologic and virologic parameters included CD4- and CD8-T cell counts and HIV-RNA levels. HIV-infected patients showed higher levels of total cholesterol, LDL-cholesterol and triglycerides (P<0.05), higher fasting insulin and HOMA-IR (P<0.001), lower levels of HDL-cholesterol (P<0.001) and serum leptin (P<0.001) than the control group. With regard to body fat distribution, no statistically significant difference between cases and controls was found. Among the control women leptin levels were positively correlated with body fat distribution parameters (P<0.001).

[Surgical treatment of malignant lip tumors. Personal experience]

The malignant tumours of the lip account for nearly 1-2% of the cervicofacial neoplasms. These lesions are frequently spinous cell carcinomas and basal cell carcinomas (25% of all oral cancers). The spinous cell carcinoma is mainly located in the lower lip, the basal cell carcinoma is more common in the upper lip. The incidence of lip cancer in males is much high than in females. The etiopathogenesis of these lesions is connected with exposure to sun, smoking, genetics predisposition (mutation of the p53 suppressor factor) and with the evolution of precancerous lesions (radiodermatitis, chronic cheilitis, xeroderma pigmentosum). Some Authors emphasized the viral etiopathogenesis: HPV16, HPV24, HSV1, HSV2. The treatment of lip carcinoma is surgical: excision and reconstruction. The numerous reconstructive techniques are mostly the cutaneous local sliding flaps and the rotation flaps. The lip reconstruction require a remarkable diligence for preserve, as much possible, the shape and functions of lip. The Authors report their experience about the surgical treatment of 19 patients with lip carcinoma (16 spinous cell carcinomas, 3 basal cell carcinomas) and describe the main surgical reconstructive techniques to preserve the feeding, phonation and mimic expression.

Interleukin-4 and interferon-gamma production during HIV-1 infection and changes induced by antiretroviral therapy

Several lines of evidence indicate that a switch of the cytokine pattern from a predominant type 1 (antiviral and cell mediated response) to type 2 (polyclonal humoral immune response) occurs during the course of Human Immunodeficiency Virus-1 (HIV-1) infection, and represents a key event in the progression of immunodeficiency and dysregulated immune activation. We proposed to further investigate this immunological aspect of HIV-1 disease, in naive and in patients treated with Highly Active Antiretroviral Therapy (HAART). The prototypic cytokines chosen were Interleukin (IL)-4 and Interferon-gamma (IFN-gamma), whose in vitro production was determined in mononuclear cell cultures stimulated with different T lymphocyte mitogenic agents (anti-CD3, Phytohaemoagglutin-P -PHA-, E. coli B04/035 Lipopolysaccharide -LPS-). We classified all the patients on the basis of the number of CD4+ lymphocytes and we found a progressive, even if not significant decrease in the baseline production of IFN-gamma with the progression of the immunodeficiency. The mean value of baseline IFN-gamma in the group of patients with CD4+>500 cells/microL was 7.79 +/- 3.1 pg/mL while in the group with CD4+<200 cells/microL it was 4.66 +/- 2.22. We didn't find significant differences in the baseline production of IL-4 in these groups and in IFN-gamma and IL-4 production in LPS-stimulated cultures. We also re-assessed 12 patients after one year's follow-up. They presented a significant increase in IFN-gamma production compared to the first assessment in the LPS-stimulated cultures (baseline IFN-gamma 2.87 +/- 1.17 pg/mL, after 12 months 19.15 +/- 5.19 pg/mL; p= 0.03). In the 12 patients in follow-up IL-4 production showed a decreased in PHA-stimulated cultures with mean values of 16.65 +/- 14.32 pg/mL at baseline and 6.54 +/- 6.54 pg/mL after follow-up. These results highlight the immunorestoring effects of HAART. IL-4 production was lower in the treated subjects compared to the naive ones in PHA-stimulated cultures (mean values: IL-4=13.42 +/- 11.08 pg/mL in the naive patients and 9.75 +/- 65 pg/mL in the treated patients). The IFN-gamma values in anti-CD3 stimulated cultures were also higher in the treated patients, but this increase was not significant.