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.

Importance of quality in referral letters sent for potentially malignant oral, head and neck lesions.

UNLABELLED: Early diagnosis of oral, head and neck cancer is very important. Delay in diagnosis and referral to a specialist unit can result in an enlarged tumour with an increased chance of metastatic spread which will result in upstaging of the tumour, thus worsening the five year survival rate. There is a great need for early identification and referral of potentially malignant lesions by general dental and medical practitioners. Referral letters are the standard and, typically, the sole method of communicating confidential information between two professionals. It is vital that the referral letters sent for potential malignant lesions are of good quality, clearly marked as urgent and contain adequate administrative and clinical data. An audit was undertaken at the Oral and Maxillofacial Department at Barnet and Chase Farm NHS Trust, to examine the quality of referral letters sent for potentially malignant oral, head and neck lesions. The outcome is discussed and a standard referral letter is also proposed if not referring using the standard local cancer network referral proforma. CLINICAL RELEVANCE: A good quality referral letter should minimize delay in diagnoses and management of a patient with an oral, head and neck lesion.

Reducing blood loss in synostosis surgery: the Liverpool experience.

Correction of craniosynostosis represents much of the workload in the pediatric designated UK craniofacial units. We reviewed recent operations as part of an ongoing unit audit cycle with outcome determined as blood use and complications or readmissions within 6 weeks of surgery. A pro forma was designed, and information from a chart search was collated on a Microsoft Excel (Microsoft, Seattle, WA) spreadsheet. Thirty-four patients were treated between March 2005 and December 2006, including 13 who underwent scaphocephaly correction (SC) and 21 who underwent fronto-orbital advancement and remodeling (FOAR). In the FOAR group, 13 patients received continuous autologous transfusion, and 8 patients did not. Continuous autologous transfusion system was not used in any of the patients who underwent SC. The results showed that allogeneic transfusion rates were 46 +/- 36% red cell volume (RCV) in FOAR when a cell saver was used and 50 +/- 21% RCV when it was not. There was no significant difference between each group; however, 25% of patients received no transfusion in the cell saver group, whereas all patients undergoing FOAR were transfused in the non-cell saver group. Transfusion in SC was calculated as 26 +/- 25% RCV, and 33% of patients underwent SC without transfusion. In conclusion, we show that significant reductions in blood transfusion are possible in correction of craniosynostosis both with and without the use of cell savers by application of a simple protocol. Our findings support the recommendation that all of these cases be carried out in multidisciplinary units where high patient throughput allows both maintenance of skills and completion of audit cycles.

Cervical silicone lymphadenopathy.

A patient presented to the department of oral and maxillofacial surgery with a rare case of cervical silicone lymphadenopathy. She had a painless ovoid mass in the left side of her neck and had had cosmetic breast augmentation 10 years before. Radiological imaging and core biopsy examination were consistent with silicone lymphadenopathy.

Spinal cord compression in patients with oral squamous cell carcinoma.

Squamous cell carcinoma (SCC) is the most common malignancy arising in the oral cavity. It can cause severe morbidity and mortality due to its propensity to metastasis. Despite the likelihood of distant metastases, commonly to the lungs, there is little report in the literature of metastatic spread to the spinal vertebrae from oral SCC with secondary spinal cord compression. We report 2 patients with advanced SCC in the tongue who developed signs of spinal cord compression due to metastasis to lumbar vertebrae. The clinical impression of metastasis causing spinal cord compression was confirmed by magnetic resonance imaging.