Immunologic parameters in patients with thyroid cancer

We evaluated various immunologic parameters in patients with papillary and follicular carcinomas of the thyroid gland. Our studies included examinations of peripheral blood lymphocytes and skin reactions to selected antigens. Preoperative peripheral blood tests were found to be normal except for an elevated percentage of IgG X Fc+ T-cells (T gamma). Skin reactions (phytohemagglutinin, purified protein derivative) were greater preoperatively than postoperatively. In postoperative cases without tumor recurrence, absolute numbers of T-cells and lymphocytes were reduced. OK-432 is a biologic response modifier of a streptococcal preparation and was used as immunotherapy in postoperative patients. This therapy seemed to augment the absolute numbers of T-cells and lymphocytes as well as purified protein derivative skin reactions in the patients without tumor recurrences. In the patients with postoperative tumor recurrences, there was an abnormal reduction in the percentage of T-cells and in the absolute numbers of T-cells and lymphocytes. OK-432 treatment was not significantly effective in normalizing this reduction.     

Immunologic parameters in patients with thyroid cancer

Summary We evaluated various immunologic parameters in patients with papillary and follicular carcinomas of the thyroid gland. Our studies included examinations of peripheral blood lymphocytes and skin reactions to selected antigens. Preoperative peripheral blood tests were found to be normal except for an elevated percentage of IgG · Fc⁺ T-cells (T). Skin reactions (phytohemagglutinin, purified protein derivative) were greater preoperatively than postoperatively. In postoperative cases without tumor recurrence, absolute numbers of T-cells and lymphocytes were reduced. OK-432 is a biologic response modifier of a streptococcal preparation and was used as immunotherapy in postoperative patients. This therapy seemed to augment the absolute numbers of T-cells and lymphocytes as well as purified protein derivative skin reactions in the patients without tumor recurrences. In the patients with postoperative tumor recurrences, there was an abnormal reduction in the percentage of T-cells and in the absolute numbers of T-cells and lymphocytes. OK-432 treatment was not significantly effective in normalizing this reduction.Presented at the 43rd Annual Meeting of Practica Otologica, Kyoto, Japan     

Cellular immunity in patients with epidermoid cancer of the head and neck.

Forty-three patients with squamous cell carcinoma of the head and neck were evaluated immunologically at various times before and after treatment. Impaired DNCB skin reactivity was found in patients with more advanced disease (Stages II-IV). In the 24 patients evaluated prior to therapy, only the mean percentages of two subpopulation T-cell tests, T-RFC29 and "active" T-RFC and mean absolute T-RFC29 per mm3 and PHA responses were significantly depressed. These depressed values could not, however, be correlated with the stage of the disease. In patients with poorly to moderatley differentiated tumors there was a significant decrease in mean percentage of active T-RFC and PHA stimulation. A marked difference in mean percentages of T-RFC29 between pretreated patients without nodal involvement (40.5 +/- 2.1) and those with this complicity (58.1 +/- 4.9) suggests that this assay may be used to detect occult nodal involvement. A comparison of the effects of surgery, irradiation and the combination of the two no patients indicated that only radiation affected any of their immune parameters. Irradiated patients demonstrated a marked decline in the mean absolute level of lymphocytes, total T-RFC and mean PHA responsiveness within one month of the termination of therapy: however, these values returned to the pretreatment level within seven months. None of the treatments was effective in "curing" the immune deficits observed in pretreatment patients.     

Lymphopenia and deranged lymphocyte subsets in nasopharyngeal carcinoma

The peripheral blood lymphocyte counts of 333 patients with a nasopharyngeal carcinoma and 125 control subjects were compared. The mean pretreatment lymphocyte count in the patients was significantly lower than that of the normal controls (P less than 0.0001). Subgroup analysis of absolute lymphocyte counts in different stages of the disease revealed a stage dependent lymphopenia which became significant when the disease was stage III or over (P less than 0.001). Characterization of peripheral blood lymphocyte subsets in 81 patients and 46 normal control subjects revealed a significant reduction of the absolute Pan T (T11) lymphocytes in the patients (P less than 0.0001). Both the absolute numbers of T helper (T4) and suppressor cells (T8) were reduced in the patients (P less than 0.0001 and less than 0.026, respectively). While the percentage of T4 was reduced (P less than 0.0001), the percentage of T8 was elevated (P less than 0.02), resulting in a reduced T4/T8 ratio (P less than 0.0001). The mean absolute and percentage counts of T11, T8 and B did not correlate with different stages of the disease.     

Suppression of lymphocyte function 2 years following surgical treatment of paranasal sinus mycosis

Prior investigations showed that acutely diseased patients with an aspergillus sinusitis manifested immune dysfunctions in respect of both T and B lymphocytes. In contrast to patients with nonmycotic sinusitis reduced in vitro and in vivo responsiveness was observed. The aim of this study, carried out after removal of the fungus ball and endoscopic surgery in clinically healthy patients, was to ascertain whether this reduced responsiveness was to be regarded as the effect or cause of an Aspergillus fumigatus infection. Two years later, the in vivo response to recall antigens was normal in both groups of patients, whereas the response to mitogens (ConA, PHA and PWM) was still decreased in the aspergillus sinusitis groups. The data suggest that the reduced immune response is a consequence of the Aspergillus fumigatus infection. Depressed skin reactivity is only present during acute infection, while proliferative capacity, as measured in the "whole blood stimulation" assay is depressed for a long time after healing the acute infection.     

A study of the pathogenesis of tonsillar focal infection--transplantation of human tonsillar lymphocytes and human skin into SCID mice

Pustulosis palmaris et plantaris (PPP) has been considered as one of the typical tonsillar focal infections, based on the marked clinical improvement of the skin lesions after tonsillectomy. In early-stage of PPP, it has been reported that lymphocytes, predominantly CD4-positive cells, infiltrate the palmar and plantar skin. However, the origin and mechanism of infiltration by these lymphocytes is not clear and there are very few reports on whether tonsillar cells react directly with the skin, possibly due to the difficulty of establishing adequate animal models. In this study, we established an experimental animal model of mice with severe combined immunodeficiency (SCID) and observed the reactions of the tonsillar lymphocytes (TL) or peripheral blood lymphocytes (PBL) of patients with PPP to their own plantar skin by transplanting the lymphocytes and skin of the patient into the mice. The results revealed that TL infiltrated the skin to a significantly greater extent than PBL. Most of these lymphocytes were T lymphocytes, and no B lymphocytes were detected in the transplanted skin. Strong expression of LFA-1 and ICAM-1 was observed in the skin after the TL transplantation. These results suggest that TL have a strong affinity for the skin in PPP, and that the adhesion molecules may play an important role in the infiltration by lymphocytes of the skin.     

Clinical study of T1a glottic-type cancer

Laser surgery is indicated for T1a glottic cancer when the tumor is localized in the membranous portion without involvement of the anterior commissure or cartilagenous portion. Treatment for T1a glottic cancer was reviewed with particular attention to indications, prognosis and the pattern of recurrent cases. A group treated with laser surgery showed 5-year local control, larynx conservation and survival rates of 90.5%, 100% and 100%, respectively. Corresponding values for a group treated with radiotherapy were 92.2%, 98.0% and 100%, respectively. In three cases of recurrence, laser surgery was carried out as second and third treatments. These cases met the above-mentioned indications for laser surgery at the time of recurrence and re-recurrence. Of the three patients, two have survived for > or = 6 years without further recurrences. Provided strict selection criteria are applied, laser surgery is indicated in some cases of recurrence.     

Clinical Study of T1a Glottic-type Cancer

Laser surgery is indicated for T1a glottic cancer when the tumor is localized in the membranous portion without involvement of the anterior commissure or cartilagenous portion. Treatment for T1a glottic cancer was reviewed with particular attention to indications, prognosis and the pattern of recurrent cases. A group treated with laser surgery showed 5-year local control, larynx conservation and survival rates of 90.5%, 100% and 100%, respectively. Corresponding values for a group treated with radiotherapy were 92.2%, 98.0% and 100%, respectively. In three cases of recurrence, laser surgery was carried out as second and third treatments. These cases met the above-mentioned indications for laser surgery at the time of recurrence and re-recurrence. Of the three patients, two have survived for &#83 6 years without further recurrences. Provided strict selection criteria are applied, laser surgery is indicated in some cases of recurrence.     

Factors affecting recurrence of sinonasal inverted papilloma

The aim is to study clinical characteristics and recurrence rates for sinonasal inverted papilloma (NIP), to evaluate relevant factors for its recurrence, and to compare the curative rates of different surgical approaches. The Krouse classification for the 156 follow-up cases of the patients with NIP was as following: 26 cases in T1, 33 cases in T2, 94 cases in T3, and 3 cases in T4. A total number of 99 cases of endoscopic sinus surgery were included, of which 26 cases of lateral rhinotomy approach were combined with Caldwell Luc approach, and 31 cases of nasal endoscopy combined with traditional surgery, with average postoperative follow-up of 3–11 years. Of the 156 studied patients with NIP, male:female = 1.69:1, age varied from 18 to 77 years, with average of 56 years, 19 cases showed postoperative recurrence, of which 8 cases developed to be squamous cell carcinoma. Among these 8 cases, 3 patients showed no recurrence after treatment in 5 years, and the other 5 patients died in 3–2 years period. Tumor recurrence rates for different surgical approach are: 9.09 % for endoscopic surgical group, 23.08 % for traditional surgical group, and 12.12 % for combined surgical group; tumor malignancy rates for different surgical approach are: 2.02 % for endoscopic surgical group, 11.54 % traditional surgical group, and 9.09 % for combined group, and Chi-square test showed that the differences in recurrence and malignancy rates for NIP patients with different surgical treatments were not statistically significant (P > 0.05). Recurrence rates for different stages are: T1 at 3.85 %, T2 at 12.12 %, T3 at 14.89 %, and T4 at 0.00 %, and the differences in the recurrence rates for different stages were not statistically significant (P > 0.05) by Chi-square test. There are clear clinical features for NIP, and the recurrence is related to the thoroughness of the first time surgical removal of lesions and is less relevant with Krouse classification stage and surgical approaches.     

Activated T cells in the nasal mucosa of patients with grass-pollen allergy. A pilot study.

Six patients with grass-pollen allergy were provoked with water-soluble grass pollen until a pronounced allergic reaction occurred. This was performed outside the grass-pollen season, and the allergen was administered on the edge of the inferior turbinate. Biopsies were taken both before provocation and during the reaction, 15-30 minutes after provocation. The nasal population of immunohistochemically positive cells for HLA-DR, CD1, interleukin-2-receptor, IgE, CD4 and CD8 were studied. There was a marked increase of IL2-R-positive cells (activated T lymphocytes) in the nasal mucosa after provocation, whilst the other cell populations approximately remained unchanged (apart from a certain increase of IgE). The increase of activated T lymphocytes may imply that certain subsets of T cells play a role in the allergic response, and that the role of helper T cells very likely is much more complex than the regulation of mast cells and eosinophils. The concomitant presence of Langerhans' cells (CD1-positive) and activated T lymphocytes may indicate a possible association on site between an antigen-presenting cell and both effector as well as memory cells in allergic reactions.     

Invertierte Papillome der Nase und ihrer Nebenhöhlen Langzeitergebnisse nach endoskopischer endonasaler Resektion

There is still some skepticism about endoscopic endonasal resection of inverted papillomas. We conducted a long-term retrospective study and examined 104 patients (82 male, 22 female) with inverted papilloma who were operated at the ENT-Department of the University of Erlangen between 1974 and 1997. The endoscopic approach was chosen in each case, either alone or in combination with external approaches. In 64.4% (67 cases), tumors of all T-classes were resected by endoscopic approach alone (T1:17.9%, T2:23.9%, T3:41.8%, T4:16.4%). For the rest of the patients an additional transoral and transfacial approach was necessary due to difficult tumor localization (T2:24.3%, T3:29.7%, T4:45.9%). The mean age of the patients was 55 years. The recurrence rate after primary endoscopic endonasal sinus surgery was 22.4% (15/67) and after combined endoscopic and external surgery 16.2% (6/37). Second salvage surgery after endoscopic sinus surgery was performed again endonasally in 46% (7/15) and externally in 53.3% (8/15). The recurrence rate after the endonasal approach was now 57.1% (4/7) and 50% (4/8) after external surgery. Third salvage surgery was performed again endoscopically in four cases and externally in four cases. The recurrence rate in both groups was 50% each, so that up to six operations, either endoscopically or externally, were necessary for complete tumor resection. The longest period for a tumor recurrence was 3.4 years after endoscopic sinus surgery and 9 years after combined endoscopic and external surgery. A tumor recurrence after endoscopic endonasal sinus surgery that could not be managed endoscopically again occurred in 12%. Tumor localization is the limiting factor for endoscopic endonasal sinus surgery of inverted papilloma. However, in 64.4% of cases, endoscopic endonasal sinus surgery alone was performed successfully without any loss of one patient. Long-term follow-up is necessary since the recurrence of tumor can happen after a long time. Endoscopic endonasal sinus surgery of inverted papilloma is safe and should be preferred due to its minimal invasive character.     

Modulation of humoral and cellular resistance in children with laryngeal papillomatosis.

As accessory cells in immunity response immunoglobulin and lymphocytes participate in antitumor immunity. Quantitative changes in concentrations and numbers were studied once before therapy, without examining the functional state. In order to gain more information on the humoral response during and after treatment, and in cases of recurrence, bactericidal antibodies against B. anthracis were determined by means of 51Cr-labeled microbes. The results of the present study show that IgG levels were normal and IgA and IgM normal or increased. In only 2 children (0.8%) the levels of serum IgM were lowered. Although a high percentage of increased trend values of bactericidity in cured children was found (75%), the percentage in children with recurrences reaching 50%, the differences are considered statistically insignificant. Following T lymphocyte, figures a significant decrease in juvenile laryngeal papillomatosis (JLP) patients were found.     

不同方法治疗耳郭瘢痕疙瘩35例

目的 探讨不同手术方法治疗耳郭瘢痕疙瘩的疗效。方法 首先锐性切除耳郭瘢痕疙瘩,瘢痕较软者,尽量保留蒂部表皮,然后对于不同部位、不同形状的瘢痕疙瘩,采取拉拢缝合、滑行或旋转皮瓣、游离植皮修复,部分患者局部注射曲安奈德20～40 mg, 5例术后1～3 d内放疗。结果 全部患者随访1～9年,痊愈29例(82.9%),其中 1例耳垂向后移位,并形成切迹,但瘢痕疙瘩未复发,仍计入痊愈病例。好转3例(8.6%),无效3例(8.6%)。结论 不同部位、形状的耳郭瘢痕疙瘩,在切除瘢痕疙瘩后,可以采取直接拉拢缝合、旋转皮瓣或植皮的方法修复皮肤缺损。局部可注射曲安奈德,整齐对合切口,术后抗感染,及时放疗可以有效减少复发。     

Definite vs adjuvant radiotherapy. Comparative effects on lymphocyte subpopulations in patients with head and neck squamous carcinoma

The recent association of alterations in T-lymphocyte subpopulations and impaired cellular immunity prompted an investigation of the effects of radiotherapy (RT) on serial levels of lymphocyte subsets in 30 patients with head and neck squamous carcinoma. Percentage and absolute levels of T3, T4, T6, T8, T10, T11, and Leu 7 cells were measured before, during, and after RT at monthly intervals for six months and compared with levels in 40 normal subjects. Sixteen patients received curative and 14 postoperative adjuvant RT. Before treatment, mean subset levels were similar among the patient and normal groups except for elevated Leu 7 (natural killer) cells in patients with stage I and II disease. There were profound decreases in absolute levels of each subpopulation during and after RT. The percentage of T4 (helper/inducer) cells decreased, whereas that of T8 (cytotoxic/suppressor) and Leu 7 cells tended to increase. Compared with normal values, the mean T4/T8 ratio decreased significantly by six months after RT, when absolute levels of the subsets had rebounded to pretreatment levels in the definitive RT group but remained profoundly decreased in the adjuvant group. The differing recovery patterns suggest that factors other than RT may contribute to persistent immunosuppression following RT.     

喉咽癌树突状细胞表型抗原表达

目的对喉咽癌中树突状细胞(Dendriticcells,DCs)的表型抗原的表达进行研究,探讨DC表型抗原的表达与喉咽癌各临床因素尤其是转移和预后的关系。方法对45例喉咽癌标本,用EnvisionHIS的方法检测DC的表型抗原S-100、CD1a、CD83的表达,并观察CD45RO T细胞与DC的关系。结果S-100 DCs在高分化组以及生存组中的数目明显多于中低分化组及死亡组,具有显著性差异。CD83 DCs的表达与喉咽癌的分化程度、远处转移、生存以及是否复发有关,差异具有显著性;CD83 DCs在癌巢中的数目较癌旁中的少,差异具有显著性。CD1a DCs的表达与喉咽癌的各临床因素间未发现明显相关性。CD45RO T细胞主要分布在CD83 DCs的周围。结论表达不同表型抗原的DC具有不同的功能,CD83 DCs被认为是成熟DC分布在癌旁与其激活T细胞的抗原提呈功能有关,对于肿瘤免疫防御机制的建立起着重要作用。DC在喉咽癌中的浸润程度及表型抗原的表达情况是反映宿主肿瘤免疫状况的重要指标,也是预测喉咽癌转移和预后的一项重要指标。     

蛋白激酶C和激活蛋白-1信号级联在变应性鼻炎患者T淋巴细胞IL-5表达中的调控作用

目的：探讨蛋白激酶C（PKC）和激活蛋白-1（AP-1）信号转导级联在变应性鼻炎（AR）患者外周血T淋巴细胞IL-5表达中的作用。方法：25例AR患者和23例鼻中隔偏曲（DNS）患者为研究对象，分别从每位受试者外周血中分离T淋巴细胞，并随机分为空白组、PKC激动剂12-肉豆蔻酰-13-乙酸佛波酯（PMA）组、PMA和AP-1抑制剂姜黄素组进行培养。将培养的T淋巴细胞涂片，用免疫细胞化学染色方法检测AP-1的表达，用酶联免疫吸附（ELISA）法检测上清液中的IL-5含量。结果：①加PMAAR组T淋巴细胞的AP-1活化细胞百分比和培养上清液中的IL-5与DNS空白组与AR空白组比较，均差异有统计学意义（均P〈0．01）；与加PMADNS组及加PMA和姜黄素DNS组T淋巴细胞比较，均差异有统计学意义（均P〈0．01）；与加PMA和姜黄素AR组T淋巴细胞比较，差异亦有统计学意义（P〈0．01）；②加PMA和姜黄素AR组T淋巴细胞AP-1活化细胞百分比、培养上清液中的IL-5含量与AR空白组、加PMAAR组、DNs空白组、加PMADNS组、加PMA和姜黄素DNS组比较，均差异有统计学意义（均P〈0．01）；③T淋巴细胞的AP-1活化与IL-5表达呈显著正相关（r=0．92，P〈0．01）。结论：AR患者T淋巴细胞PKC活化后促进IL-5表达增加的生物信号可能是通过AP-1进行转导，提示T淋巴细胞PKC—AP-1信号转导级联的激活可能是AR发病机制之一。     

喉癌肿瘤标志物和喉癌分子切缘及临床因素与喉癌复发的相关性研究

目的:从喉癌肿瘤标志物、喉癌分子切缘以及临床因素三个方面分析喉癌复发的相关因素.方法:应用免疫组织化学方法检测喉癌复发组与未复发组原发灶、喉癌外科切缘的CyclinD1、p27、p53以及eIF4E表达状况,通过回顾性分析103例喉癌的临床资料,探讨喉癌复发的临床因素;并综合三方面因素对喉癌复发进行多因素分析.结果:喉癌术后复发组与未复发组原发灶的CyclinD1、p27、p53表达差异均有统计学意义(均P<0.05),eIF4E表达差异无统计学意义(P>0.05).两组切缘的CyclinD1、p27、p53、eIF4E表达差异均有统计学意义(均P<0.05),喉癌复发组eIF4E切缘阳性表达率高于CyclinD1、p27和p53.喉癌术后复发与原发肿瘤部位、T分期、淋巴结转移、喉癌病理分化程度以及首次手术方式有关;与年龄、性别、是否术后放疗无关.Logitic多因素回归分析显示:喉癌术后复发与肿瘤T分期、淋巴结转移、喉癌病理分化程度以及首次手术方式有关.综合肿瘤标志物、喉癌分子切缘以及临床因素三个方面的Logistic多因素回归分析显示:喉癌术后复发与喉癌T分期、颈部淋巴结转移、病理分化程度以及分子切缘阳性有关.结论:影响喉癌术后复发的因素复杂多样;喉癌T分期高、有颈部淋巴结转移、病理分化程度差以及分子切缘阳性者术后容易复发;喉癌分子切缘阳性是更为敏感的喉癌复发因素.     

Outcomes of 18 cases with squamous cell carcinoma of middle ear who underwent both surgery and post-operative radiotherapy

Conclusions: Early diagnosis and treatment were critical to prevent recurrence, and the long-term outcomes were satisfactory after surgery and post-operative radiotherapy. Objectives: To present outcomes of 18 cases with squamous cell carcinoma of the middle ear who underwent both surgery and post-operative radiotherapy. Methods: Eighteen cases with squamous cell carcinoma of the middle ear (two cases of T1, five of T2, and 11 of T3) underwent surgery and post-operative radiotherapy, and a surgical approach was determined by tumour sites. Extended mastoidotympanectomy was performed on two cases, with subtotal temporal bone resection on 12 cases and temporal bone resection on four cases. The patients who had cervical metastasis underwent additional radical neck resection and post-operative radiotherapy at the neck. The patients were followed-up after surgery. Results: During the follow-up, no cases of T1 recurred, and six cases of T2 or T3 recurred, with the total recurrence rate of 37.5% among the patients of T2 and T3. At the fifth year after surgery, 15 patients were still alive, and the actual 5-year survival rate was 83.3% among all patients.     

Increased percentage of T cells with the expression of CD127 and CD132 in hypertrophic adenoid in children with otitis media with effusion

The hypertrophic adenoid may promote chronic suppurative otitis media in children as it fulfills its immune function. The number of lymphocytes in the adenoid and their cooperation in the immune response depend of on their proliferation and migration to the effector sites. Interleukin 7 (IL-7) is essential for the normal development and function lymphocytes. IL-7 plays pivotal role for activation and proliferation of T and B cells. The heterodimeric interleukin-7 receptor (IL-7R) is composed of the IL-7Rα (127) and the common cytokine receptor γc (CD132). The aim of this study was to evaluate the percentage of lymphocytes T (CD4⁺ and CD8⁺) with IL-7R (CD127 and CD132) expression in hypertrophic adenoid in children suffering with otitis media with effusion for a?duration of 3 months. Adenoid excised due to hypertrophy with or without chronic otitis media with effusion was used as study material. CD4⁺ CD127⁺, CD4⁺132⁺, CD8⁺CD127⁺ and CD8⁺CD132⁺ cell subpopulations were identified using monoclonal antibodies and flow cytometry. The percentage of CD4⁺ and CD8⁺ T cells with CD127 receptor expression in hypertrophic adenoid of children with otitis media with effusion was statistically significantly higher than in hypertrophic adenoid group. The percentage of CD4⁺ T cells with CD132 expression in the study group was statistically significantly higher than in the reference group. The percentage of CD8⁺ T cells with CD132⁺ expression was not statistically different in both groups. The increased percentage of T lymphocytes with IL-7R expression (CD127 and CD132) in hypertrophic adenoid seems to influence the quantity of lymphocytes and upset the immunological function of tonsils which can influence the course of otitis media with effusion.     

Skin carcinoma of the face: surgery or radiotherapy?

Surgical exeresis and radiation therapy are effective means of treatment for facial carcinomas. In some areas that are difficult to manage (nose, ears, periorbital region), the respective importance of both approaches is discussed. We report on the retrospective study of 309 patients seen after a skin carcinology consultation in which a dermatologist, a surgeon and a radiotherapist were associated. These 309 patients, with a mean age of 73 years, presented with 375 carcinomas, i.e. 246 basal-cell (BC) and 119 epidermoid (EC) carcinomas. The most frequent sites were the nose (33.8% of BC), the inner canthus (12.7% of BC), the lower lip (23.8% of EC) and the ear (15.6% of EC). Management mainly consisted of surgery (50.8%) then Curie therapy (37%). The rate of recurrence was the same (10.5%) after surgery and radiation therapy. The study of the results leads us to advocating surgery for carcinomas of the ear (due to the occurrence of radiation necrosis in every third case after radiation therapy) and Curie therapy for carcinomas of the lower lid (except the inner canthus) because of recurrence in every second case treated with surgery. We currently prefer surgery for carcinomas of the lower lip (radiodermatitis in 11.8% of cases) and Curie therapy for the nose (lower rate of recurrence than with surgery). However, in the last two cases, the proposals for treatment should be confirmed by randomized studies. Thus facial carcinomas of the skin surrounding the orifices of the face and/or those that affect patients who are difficult to treat must be seen during a skin carcinology consultation by a dermatologist, a surgeon and a radiotherapist working together.(ABSTRACT TRUNCATED AT 250 WORDS)