What is the optimal site and biopsy technique for the diagnosis of oral mucosal autoimmune blistering disease?

BACKGROUND: The aim of this study was to determine which biopsy method produces the best diagnostic yield in patients presenting with autoimmune blistering diseases (AIBDs) of the oral mucosa. METHODS: This was a retrospective audit of patients who were biopsied at least once for a suspected AIBD of the oral mucosa. The type (incisional or punch) and site of biopsies were recorded in conjunction with case notes, electronic records and histopathological reports in order to calculate sensitivity, specificity and the method of biopsy which produced the superior diagnostic yield. RESULTS: A total of 125 biopsy samples from 66 patients were identified and reviewed. A diagnosis of AIBD was established in 49 (74%) patients. The chi-square test showed there was a statistically significantly higher (P = 0.0016) diagnostic yield using the punch biopsy technique compared to the scalpel method. The gingiva was the best biopsy site in terms of achieving a definitive diagnosis (P = 0.0001) regardless of the biopsy method used. CONCLUSIONS: A punch biopsy is more likely than scalpel biopsy to obtain a definitive diagnosis in patients presenting with a suspected oral AIBD. The gingiva is the optimal site to sample.

The Post-Levator Aponeurosis Fat Pad.

PURPOSE: To examine the post-aponeurotic space and to confirm and define the presence of a post-aponeurosis fat-pad. METHODS: Experimental anatomic study. Nineteen-orbits from 10 freeze-preserved, unembalmed cadavers of caucasian subjects. In 12 orbits of 7 cadavers, a transconjunctival dissection of the everted upper eyelid was undertaken. Müller's muscle (MM) and conjunctiva were dissected as a composite flap exposing the posterior surface of the aponeurosis (LA) and the commencement of the levator palpebrae superioris (LPS) muscle. Anatomical localisation was agreed by 2 senior surgeons and an anatomist (VM). In the remaining 7 orbits a 1cm central upper eyelid wedge-excision was paraffin-embedded and studied histologically. RESULTS: Nineteen upper-eyelids from 10 freeze-preserved, unembalmed caucasian cadavers (5-male, 5-female, mean age 80.9; range 67-91 years) were studied. Of 12 eyelids of 7 cadavers, dissected and macroscopically evaluated, a fat-pad was identified in the post-aponeurotic space of all eyelids. Of these, 8 (66%) were predominantly diffuse. The remainder, mixed diffuse-discrete. All 4 of the latter category appeared multi-lobular. The fat-pad was seen to lie predominantly centro-medially, overlying MM, extending superiorly beyond the LA to lie posterior to LPS. Of the 7 upper eyelid wedge-excisions examined microscopically, a fat-pad was identified in all post-aponeurotic spaces, lying between 2 distinct tracts of smooth muscle. The anterior smooth muscle tract was intimately related to the posterior aspect of the LA, in keeping with the posterior smooth muscle layer of the aponeurosis. The posterior smooth muscle tract was in keeping with MM, thicker than the anterior layer, multi-layered and in 6 of 7 eyelids, interspersed with fat. CONCLUSIONS: We confirm and describe a distinct layer of fat in the post-aponeurotic space, consistently found between MM and the posterior smooth muscle layer of the aponeurosis. We refer to this as the post-aponeurosis fat-pad. These findings provide further anatomical detail for the surgeon undertaking blepharoptosis surgery, who may, in some cases, mistake the presence of fat in this space either for the pre-aponeurotic fat-pad, or for degenerative changes within MM that lies deep to it.

Recurrence and malignant transformation rates of high grade oral epithelial dysplasia over a 10 year follow up period and the influence of surgical intervention, size of excision biopsy and marginal clearance in a UK regional maxillofacial surgery unit.

OBJECTIVES: To determine the overall recurrence rate (RR) and malignant transformation rate (MTR) of high grade oral mucosal epithelial dysplasias (HGOED). MATERIALS & METHODS: A clinicopathological review of records of patients diagnosed with a unifocal HGOED between 2004 and 2016 on incisional biopsy who then underwent excision. The mean duration of follow-up was 47.7 months (±29.9 SD). RESULTS: Full demographic, historical and histopathological data were available for 120 patients. Six were lost to follow-up after excisional biopsy. Invasive squamous cell carcinoma (SCC) was present in 19 (18.3%) excisions. HGOED affected the lateral and ventral tongue in 58% of patients. Fourteen (11.7%) were not treated surgically but kept under surveillance. The overall RR was 34.7% (33 patients) and MTR 17.8% (17 patients). Four of the 14 (28.6%) patients who had not had the HGOED excised developed SCC, by contrast to the 13 of the 106 (12.3%) who had been treated. RR was significantly associated with positive excision margins (p = 0.007; OR = 3.6) and a clinical presentation of erythroplakia (p = 0.023; OR = 1.5). MTR was significantly associated with age (p = 0.034), clinical appearance (p = 0.030), site (p = 0.007), treatment received (p = 0.012) and positive excision margins (p = 0.007). The mean time for recurrence to develop was 62 months (±31.5 SD) (range 22-144 months), that for malignant transformation was 50 months (±32.5 SD) (range 8-97 months). CONCLUSION: Patients with HGOED require follow-up for at least 10 years after treatment. Younger age, homogeneous clinical appearance, complete excision, a larger excision specimen and clear margins all improve prognosis.