Malignant eccrine spiradenoma of the neck: a case report

Cilj: Cilj je ovog rada prikazati slučaj vrlo rijetkog malignog tumora glave i vrata – malignog ekrinog spiradenoma, opisati kliničke i patohistološke karakteristike tumora, važnost rane dijagnoze s obzirom na konačni ishod te metode liječenja. Prikaz slučaja: U radu je opisan slučaj 46-godišnje pacijentice kojoj je dijagnosticiran hemangiom lijeve strane vrata te se 25 godina kontrolirala. Nekoliko mjeseci prije javljanja na Kliniku tvorba se naglo počela mijenjati. Na temelju ultrazvuka vrata, citopunkcije, magnetske rezonancije vrata i biopsije postavljena je sumnja na metastazu nepoznatog primarnog tumora. PET/CT-om nije otkriveno sijelo primarnog tumora te je tek kirurškim zahvatom i patohistološkom verifikacijom operacijskog preparata utvrđena definitivna dijagnoza malignog ekrinog spiradenima s metastazom u jednom regionalnom limfnom čvoru vrata. Pacijentica je poslijeoperacijski tretirana radiokemoterapijom. Šest mjeseci nakon liječenja utvrđene su multiple metastaze pluća, pleure, medijastinuma i jetre, pa je 3 mjeseca kasnije nastupio smrtni ishod. Rasprava i zaključak: U većini slučajeva ovaj rijedak tumor nastaje malignom transformacijom benignog ekrinog spiradenoma, premda može nastati i de novo. Rijetko se javlja u regiji glave i vrata. Dijagnoza se temelji na patohistološkom nalazu. Tumor pokazuje veliku sklonost lokalnim recidivima te regionalnim i udaljenim metastazama kada je prognoza loša. Liječenje je prvenstveno kirurško, dok je učinak radiokemoterapije upitan. Važno je bolest dijagnosticirati u ra- noj fazi, kada ne postoji regionalna i udaljena proširenost jer je tada stopa izlječenja vrlo visoka.Aim: To present a case of a very rare malignant head and neck tumor – malignant eccrine spiradenoma, describe the clinical and pathological characteristics of the tumor, as well as the importance of early diagnosis with respect to the ultimate outcome of these treatments. Case report: This paper describes the case of a 46-year-old patient who was di- agnosed with hemangioma of the left side of the neck, and was followed for 25 years. Few months before the patient came to the Clinic, the lesion suddenly began to change. Based on the neck ultrasound, fine-needle cytopuncture, MRI and biopsy a suspicion on a metastasis of unknown primary tumor was established. PET / CT has not discovered the location of the primary tumor and only surgery and histopathologic verification of operating sample established the definitive diagnosis of malignant eccrine spiradenoma with metastasis in a single regional lymph node. The patient was treated with postoperative radio- and chemotherapy. Six months after the treatment, multiple metastases of the lung, pleura, mediastinum, and liver were found and 3 months later fatal outcome occurred. Discussion and conclusion: In the majority of cases this rare tumor is caused by malignant transformation of benign eccrine spiradenoma, although it can appear de novo. It rarely occurs in the head and neck region. Diagnosis is based on pathohistological findings. The tumor shows a strong preference to local and regional recurrence and to distant metastases, the prognosis of which is poor. It is important to diagnose the disease at an early stage when there is no regional or distant spread because at that stage the survival rate is very high

Oral cavity and oropharyngeal carcinoma – sociodemographic and clinical characteristics of surgically managed patients at the Clinics for maxillofacial and oral surgery of the Clinical Hospital Centre Rijeka

Cilj: Ispitati sociodemografske karakteristike pacijenata s oralnim karcinomom, kliničkekarakteristike samog tumora te učestalost pojedine vrste kirurškog liječenja. Metode: Retrospektivna analiza povijesti bolesti 195 pacijenata s karcinomom usne šupljine i orofarinksa. Rezultati: Pacijenti su najčešće bili muškog spola (76,9 %), dok je 23,1 % pacijenata bilo ženskog spola. Medijan dobi sudionika iznosio je 61 godinu. Više od 2/3 pacijenata (67 %) konzumira alkohol, 70 % pacijenata su pušači. Pacijenti najčešće boluju od kardiovaskularnih bolesti (35,9 %). Dvije najčešće i podjednako česte lokalizacije jesu dno usne šupljine i retromolarna regija s tonzilama i nepčanim lukovima, svaka po 23,6 %. Većina pacijenata (53,8 %) imala je T2 veličinu tumora, 53,8 % pacijenata imalo je N0 status limfnih čvorova vrata, dok je 46,2 % pacijenata imalo metastaze na vratu. Najmanje pacijenata imalo je stadij I bolesti kod dolaska (9,2 %), dok su ostala tri stadija gotovo podjednako zastupljena. Samo 14,9 % pacijenata imalo je intraoralnu eksciziju tumora (bez disekcije vrata i bez resekcije mandibule), dok je 45,6 % pacijenata imalo najopsežniji kirurški zahvat „commando sa segmentnom resekcijom mandibule“. Samo kod 21,5 % pacijenata za zatvaranje postoperativnog defekta nije bila potrebna rekonstrukcija, dok je kod 78,4 % rekonstrukcija defekta bila nužna. Rekonstrukcija defekta najčešće je (46,64 %) učinjena s regionalnim vezanim režnjem „pektoralis major mišićem“ (PMR). Većina pacijenata (71,2 %) postoperativno je imala privremenu traheostomu (kanilu). Samo 12 pacijenata (6,15 %) nakon operativnog zahvata nije trebalo nazogastričnu sondu ili gastrostomu. Većina pacijenata (82,56 %) tijekom operativnog zahvata i nakon njega nije trebala transfuziju krvi. Zaključak: Istraživanje pokazuje da pacijenti s oralnim karcinomom rijetko dolaze u ranoj fazi bolesti, iako je većina karcinoma u usnoj šupljini vrlo vidljiva i dostupna pregledu. Rano otkrivanje karcinoma usne šupljine i orofarinksa smanjuje morbiditet, mortalitet i povećava kvalitetu života takvih pacijenta, dok liječenje uznapredovanog karcinoma iziskuje veći kirurški zahvat, predstavlja veću mutilaciju i lošiju prognozu bolesti.Aim: To examine the social and demographic characteristics of patients with oral cancer, clinical characteristics of the tumour and the incidence of certain types of surgical treatment. Methods: A retrospective analysis of the medical history of 195 patients with oral and oropharyngeal cancer. Results: Most patients were male (76.9 %), whereas 23.1 % of patients were female. The median age was 61 years. More than two thirds of patients (67 %) consumed alcohol, and 70 % of patients were smokers. The most common comorbidity was cardiovascular disease (35.9 %). The two most common and equally frequent localizations of the carcinoma were the floor of the mouth and retromolar region with the palatine tonsils, each with frequency of 23.6 %. Most patients (53.8 %) had a T2 tumour size and 53.8 % of them had N0 neck lymph node status, whereas 46.2 % of patients had metastases in the neck. The least number of patients had Stage I disease (9.2 %), whereas the other three stages were almost equally represented. Only 14.9 % of patients were treated with intraoral tumour excision (without neck dissection and without resection of the mandible), and 45.6 % of patients had the most extensive surgery “commando with segmental resection of the mandible”. Only 21.5 % of patients did not need reconstruction for the postoperative closure of the defect, whereas the reconstruction was necessary in 78.4 % of patients. The most common reconstruction was with regional flap “pectoralis major muscle” in 46.64 % of cases. Postoperative temporary tracheostoma was performed in 71.2 % patients. Only 12 patients (6.15 %) did not need nasogastric tube or gastrostomy after surgery. Blood transfusion was not needed in 82.56 % patients during and after the surgery. Conclusion: This study shows that patients with oral cancer rarely come at an early stage of the disease, although the majority of the oral cavity cancers are very visible and accessible. Early detection of the oral cavity and oropharyngeal cancer reduce morbidity, mortality and increase quality of life of these patients. Advanced oral cancer treatment require major surgery, greater mutilation and have worse prognosis

Temporomandibular disorders – minimally invasive surgical treatment options: arthrocenthesis and arthroscopy

Temporomandibularni poremećaj (TMP) obuhvaća različite kliničke dijagnoze orofa- cijalnog bola koji nastaje u žvačnim mišićima, čeljusnom zglobu i okolnim strukturama. Temporomandibularni poremećaj mišićne geneze liječi se konzervativno, dok je kod TMP-a artrogenog podrijetla često indicirano kirurško liječenje. Najčešće se koriste minimalno invazivne tehnike liječenja, gdje spadaju artrocenteza i artroskopija temporomandibularnog zgloba. Artrocenteza podrazumijeva lavažu zgloba „naslijepo” bez kontrole oka. Artroskopija je endo- skopska kirurška metoda koja omogućuje liječenje s minimalnim oštećenjem tkiva, s vrlo rijetkim komplikacijama, bez postoperativnog ožiljka jer je artroskop debljine svega 2 mm, te predstavlja sigurnu tehniku s dobrim rezultatima.Temporomadibular disorder (TMD) encompasses a variety of clinical diagnosis with the symptom of orofacial pain caused by the masticatory muscles, temporomandibular joint and surrounding structures. Nonarticular temporomandibular disorder (usually forms of myalgia) is treated conservatively, while the articular temporomandibular disorders often need surgical treatment. The most commonly used are minimally in- vasive treatment techniques. Arthrocentesis is ”blind” joint lavage. Arthroscopy is an endoscopic surgical method that allows treatment with minimal tissue damage, with very few complications, without postoperative scar because the arthroscope thickness is only 2 mm, it is a safe technique with good results

Temporomandibular disorders – minimally invasive surgical treatment options: arthrocenthesis and arthroscopy

Temporomandibularni poremećaj (TMP) obuhvaća različite kliničke dijagnoze orofa- cijalnog bola koji nastaje u žvačnim mišićima, čeljusnom zglobu i okolnim strukturama. Temporomandibularni poremećaj mišićne geneze liječi se konzervativno, dok je kod TMP-a artrogenog podrijetla često indicirano kirurško liječenje. Najčešće se koriste minimalno invazivne tehnike liječenja, gdje spadaju artrocenteza i artroskopija temporomandibularnog zgloba. Artrocenteza podrazumijeva lavažu zgloba „naslijepo” bez kontrole oka. Artroskopija je endo- skopska kirurška metoda koja omogućuje liječenje s minimalnim oštećenjem tkiva, s vrlo rijetkim komplikacijama, bez postoperativnog ožiljka jer je artroskop debljine svega 2 mm, te predstavlja sigurnu tehniku s dobrim rezultatima.Temporomadibular disorder (TMD) encompasses a variety of clinical diagnosis with the symptom of orofacial pain caused by the masticatory muscles, temporomandibular joint and surrounding structures. Nonarticular temporomandibular disorder (usually forms of myalgia) is treated conservatively, while the articular temporomandibular disorders often need surgical treatment. The most commonly used are minimally in- vasive treatment techniques. Arthrocentesis is ”blind” joint lavage. Arthroscopy is an endoscopic surgical method that allows treatment with minimal tissue damage, with very few complications, without postoperative scar because the arthroscope thickness is only 2 mm, it is a safe technique with good results

The use of extraoral autologous bone graft in alveolar ridge augmentation

Ekstraoralni autologni koštani transplantati koriste se za augmentaciju u slučaju vrlo velikog koštanog deficita alveolarnog grebena. Najčešća donatorska mjesta ovih transplantata su krista ilijaka i kalvarija. Transplantati uzeti s ovih mjesta koriste se najčešće kao koštani blokovi koji se vijkom pričvršćuju za površinu kosti u primajućoj regiji, a mogu se koristiti i kao mljeveni materijal, samljeven u koštanom mlincu. Oba ova transplantata količinski zadovoljavaju i u najsloženijim defektima, a razlikuju se po strukturi i embrionalnom podrijetlu što im određuje karakteristike i utiče na odabir jednoga od njih. Radi se o vrlo učinkovitoj rekonstruktivnoj metodi koja daje dobre rezultate u visokom postotku, a komplikacije su vrlo rijetke.In cases of great bone loss of the alveolar ridge, extraoral autologous grafts are used for augmentation. The most frequent donor sites for these grafts are iliac crest and calvaria. Grafts taken from these sites are mostly used as bone blocks that are fixed with a screw to the bone in the host site. These grafts can also be used as bone chips prepared with a bone mill. Both types of grafts are quantitatively sufficient even in the most complicated cases. They differ in structure and embryonic origin, which determines their characteristics and influences their selection. This is a very effective reconstructive method, which yields a high rate of good results and has rare complications

Mediastinitis and bilateral pleural empyema caused by an odontogenic infection

Background. Although odontogenic infections are relatively frequent in the general population, intrathoracic dissemination is a rare complication. Acute purulent mediastinitis, known as descending necrotizing mediastinitis (DNM), causes high mortality rate, even up to 40%, despite high efficacy of antibiotic therapy and surgical interventions. In rare cases, unilateral or bilateral pleural empyema develops as a complication of DNM. Case report. This case report presents the treatment of a young, previously healthy patient with mediastinitis and bilateral pleural empyema caused by an odontogenic infection. After a neck and pharynx re-incision, and as CT confirmed propagation of the abscess to the thorax, thoracotomy was performed followed by CT-controlled thoracic drainage with continued antibiotic therapy. The patient was cured, although the recognition of these complications was relatively delayed. Conclusions. Early diagnosis of DNM can save the patient, so if this severe complication is suspected, thoracic CT should be performed

Possibilities of enteral feeding in patients with oral and oropharyngeal cancer

Liječenje malignih tumora usne šupljine i orofarinksa uzrokuje ozbiljne mutilacije, koje zbog funkcionalnog značaja ovih anatomskih područja, ugrožavaju vitalno važne funkcije: disanje, gutanje, žvakanje i govor. Radioterapija i kemoterapija predstavljaju uobičajenu dopunu kirurškom liječenju, a njihove posljedice – radiomukozitis, edem, dehidracija, te postradijacijska fibroza, uzrokuju još izraženije disfagične teškoće. Disfagija može biti životno ugrožavajući simptom kod bolesnika s orofaringealnim karcinomom jer onemogućava uzimanje dovoljnih količina hrane na usta, a povećava i rizik od aspiracije. Posljedica je malnutricija bolesnika, porast morbiditeta, sporije i otežano cijeljenje rana, te viši mortalitet. Enteralna nutricija, s kojom ovisno o općem stanju bolesnika i očekivanoj duljini liječenja, treba započeti što ranije, najprihvatljiviji je način dugotrajnog hranjenja i dohranjivanja. Kada disfagične smetnje traju dulje od 6 tjedana, koliko je rutinski prihvatljiva nazogastrična sonda (NGS), najbolje je hranjenje izravno putem cijevi u želudac – gastrostoma. Postoji više metoda, a danas je široko u primjeni perkutana endoskopska gastrostoma – PEG. To je tehnički relativno jednostavna i brza metoda, koja ne zahtijeva opću anesteziju, čime se izbjegavaju često otežane intubacije, a za bolesnike je prihvatljiva po udobnosti i manjoj mogućnosti komplikacija.Treatment of malignant tumours of the oral cavity and oropharynx causes severe mutilations, which, due to the functional significance of these anatomical areas, endanger vitally important functions: breathing, swallowing, chewing and speech. Radiotherapy and chemotherapy are the usual complements to surgical treatment, and their consequences; radiomucositis, edema, dehydration, post-radiation fibrosis, cause even more pronounced dysphagical difficulties. Dysphagia can be a life-threatening symptom in patients with oropharyngeal cancer because it prevents taking enough food by mouth, and increases the risk of aspiration. The result is patients\u27 malnutrition, increased morbidity, slower and more difficult wound healing and higher mortality. Enteral nutrition, which, depending on the general condition of the patient and the expected length of treatment, should be started as early as possible, and it is the most acceptable way of long-term feeding. When dysphagic disturbances last longer than 6 weeks, feeding directly into the stomach is the most acceptable manner, so, if possible, a nasogastric tube is inserted. There are several methods, and today the most widespread is the use of percutaneous endoscopic gastrostomy – PEG. It is a technically relatively simple and fast method that requires no general anesthesia which avoids the often difficult intubation. That method is also convenient for patients due to being comfortable and of low complication possibility

Mandibular lesion as primary manifestation of multiple myeloma: case report and literature review

Multipli mijelom predstavlja malignu proliferaciju jednog klona plazma stanica unutar koštane srži koja uzrokuje difuzne osteolitičke lezije kralješnice, rebara, zdjelice, lubanjskih kostiju i čeljusti. Bolest se očituje bolovima u kostima, bubrežnim smetnjama, učestalim infekcijama i disfunkcijom nervnoga sustava. Čeljusti su rijetko mjesto primarne lokalizacije bolesti. Prikazan je slučaj bolesnice u dobi od 66 godina kod koje je bezbolna oteklina korpusa mandibule bila prvi simptom multiplog mijeloma. Nakon rendgenološke obrade, "punched-out”, osteolitička lezija pobudila je sumnju na maligni proces. Budući da je jače krvarenje iz koštane lezije onemogućilo rutinsku incizijsku biopsiju, citopunkcija kao zamjenska dijagnostička metoda, ukazala je na stanice multiplog mijeloma. Dodatna proširena ciljana obrada (laboratorijski nalazi krvi, kalcija, elektroforeze proteina, Bence-Jones proteini u urinu) to je i potvrdila. Da bi se što ranije postavila ispravna dijagnoza, te započelo s odgovarajućim liječenjem, osteolitička lezija čeljusti mora pobuditi sumnju i na multipli mijelom, bez obzira na rijetku pojavnost ove bolesti.Multiple myeloma is a monoclonal malignant proliferation of plasma cells in the bone marrow that causes osteolytic lesions affecting several bones. Frequently affected sites include the vertebrae, ribs, pelvis, skull, jaw. Usually the patient presents with bone pain, recurrent infections, renal failure and nervous system dysfunction. Jaw lesions, though not uncommon, rarely present as the first sign in multiple myeloma. We are reporting about a clinical case of a 66 year-old female patient who presented with painless swelling of the mandible that has evolved over the previous two months. Clinical manifestations in the jaw like gingival hemorrhage, odontalgia, paresthesias, tooth mobility were not included. In the radiographic examination, an extensive osteolytic lesion, with cortical bone destruction was observed in the left lower jaw. In this case, typical "punched out” lesion was found and enhanced doubt on malignant process. As a routine protocol, an incisional biopsy of lesion was planned but sufficient diagnostic material couldn’t be obtained because of bleeding and fine needle aspiration of tumorous masses confirmed the diagnosis of multiple myeloma (because the microscopic appearance of multiple myeloma is highly characteristic). Additional diagnostic techniques used, such as laboratorial tests (blood tests, serum electrophoresis, urine analysis-Bence Jones proteins) and established the diagnosis of multiple myeloma. To make early diagnosis and start with adequate treatment osteolitic lesion of the jaw is to suspect of multiple myeloma regardless of the rare incidence of this disease