Nationwide randomised trial evaluating elective neck dissection for early stage oral cancer (SEND study) with meta-analysis and concurrent real-world cohort.

BACKGROUND: Guidelines remain unclear over whether patients with early stage oral cancer without overt neck disease benefit from upfront elective neck dissection (END), particularly those with the smallest tumours. METHODS: We conducted a randomised trial of patients with stage T1/T2 N0 disease, who had their mouth tumour resected either with or without END. Data were also collected from a concurrent cohort of patients who had their preferred surgery. Endpoints included overall survival (OS) and disease-free survival (DFS). We conducted a meta-analysis of all six randomised trials. RESULTS: Two hundred fifty randomised and 346 observational cohort patients were studied (27 hospitals). Occult neck disease was found in 19.1% (T1) and 34.7% (T2) patients respectively. Five-year intention-to-treat hazard ratios (HR) were: OS HR = 0.71 (p = 0.18), and DFS HR = 0.66 (p = 0.04). Corresponding per-protocol results were: OS HR = 0.59 (p = 0.054), and DFS HR = 0.56 (p = 0.007). END was effective for small tumours. END patients experienced more facial/neck nerve damage; QoL was largely unaffected. The observational cohort supported the randomised findings. The meta-analysis produced HR OS 0.64 and DFS 0.54 (p < 0.001). CONCLUSION: SEND and the cumulative evidence show that within a generalisable setting oral cancer patients who have an upfront END have a lower risk of death/recurrence, even with small tumours. CLINICAL TRIAL REGISTRATION: NIHR UK Clinical Research Network database ID number: UKCRN 2069 (registered on 17/02/2006), ISCRTN number: 65018995, ClinicalTrials.gov Identifier: NCT00571883.

Unusually sited lower third molar.

We present the case of a 60-year-old woman who presented to our unit with left-sided facial swelling, pain and trismus. Initially managed as a parotitis by a different specialty, an ultrasound subsequently showed a collection deep to the parotid associated with an ectopic wisdom tooth within the mandibular posterior ramus/condyle and the patient was referred to our department. After treating the acute infection, the wisdom tooth was surgically removed. Our case highlights the importance of the clinician maintaining an open mind to differential diagnoses and details a technique for surgical removal of a tooth with difficult access.

Delayed metastasis to the mandible of esophageal adenocarcinoma.

Around 1 % of oral cancers are metastases from distant sites. Tumor metastases to the jaw bones are uncommon and are most likely to arise from primary lung, breast, prostate or kidney tumors. Jaw bone metastases from a primary esophageal adenocarcinoma are especially rare, with only 7 reports published in the literature. Here, we describe a case of a 69 year-old male patient where 7 years elapsed between the diagnosis and successful treatment of a poorly differentiated, stage pT2N0 primary esophageal adenocarcinoma and re-presentation with jaw pain due to a metastatic mandibular deposit. The morphological appearance of the metastasis and immunohistochemical positivity with CK20, CK7 and CDX2 strongly supported an adenocarcinoma of upper gastrointestinal tract origin. This case is of particular interest as there is an unusually long time between the detection of the primary esophageal adenocarcinoma and diagnosis of metastatic disease. The longest period of time we have found for this in the literature is 9 months, although it is also reported that some oral metastases may appear more than 10 years following the primary tumor diagnosis.

Manuka honey dressing: An effective treatment for chronic wound infections.

The battle against methicillin-resistant Staphylococcus aureus (MRSA) wound infection is becoming more difficult as drug resistance is widespread and the incidence of MRSA in the community increases. Manuka honey dressing has long been available as a non-antibiotic treatment in the management of chronic wound infections. We have been using honey-impregnated dressings successfully in our wound care clinic and on the maxillofacial ward for over a year.