Targeting Cell Cycle Facilitates E1A-Independent Adenoviral Replication.

DNA replication of E1-deleted first-generation adenoviruses (AdV) in cultured cancer cells has been reported repeatedly and it was suggested that certain cellular proteins could functionally compensate for E1A, leading to the expression of the early region 2 (E2)-encoded proteins and subsequently virus replication. Referring to this, the observation was named E1A-like activity. In this study, we investigated different cell cycle inhibitors with respect to their ability to increase viral DNA replication of dl70-3, an E1-deleted adenovirus. Our analyses of this issue revealed that in particular inhibition of cyclin-dependent kinases 4/6 (CDK4/6i) increased E1-independent adenovirus E2-expression and viral DNA replication. Detailed analysis of the E2-expression in dl70-3 infected cells by RT-qPCR showed that the increase in E2-expression originated from the E2-early promoter. Mutations of the two E2F-binding sites in the E2-early promoter (pE2early-LucM) caused a significant reduction in E2-early promoter activity in trans-activation assays. Accordingly, mutations of the E2F-binding sites in the E2-early promoter in a virus named dl70-3/E2Fm completely abolished CDK4/6i induced viral DNA replication. Thus, our data show that E2F-binding sites in the E2-early promoter are crucial for E1A independent adenoviral DNA replication of E1-deleted vectors in cancer cells. IMPORTANCE E1-deleted AdV vectors are considered replication deficient and are important tools for the study of virus biology, gene therapy, and large-scale vaccine development. However, deletion of the E1 genes does not completely abolish viral DNA replication in cancer cells. Here, we report, that the two E2F-binding sites in the adenoviral E2-early promoter contribute substantially to the so-called E1A-like activity in tumor cells. With this finding, on the one hand, the safety profile of viral vaccine vectors can be increased and, on the other hand, the oncolytic property for cancer therapy might be improved through targeted manipulation of the host cell.

Do Surgical Intervention Type and Baseline Condylar Position Affect Spatial Dimension Changes of the Temporomandibular Joint in the Surgical Correction of Skeletal Class II Deformities?

BACKGROUND: One of the key features of orthognathic surgery is altering temporomandibular joint (TMJ) condylar positions. PURPOSE: This multivariate study aimed to identify surgical interventions and patient factors significantly associated with changes in TMJ spatial dimensions after the surgical correction of skeletal Class II deformities. STUDY DESIGN, SETTING, SAMPLE: This is a retrospective cohort study including patients who had undergone an isolated bilateral sagittal split ramus osteotomy (BSSO) or a bimaxillary osteotomy (BMO) for mandibular advancement and a control sample of patients treated with the removal of odontogenic cysts in the mandibular posterior region. Excluded were those who presented with specific radiographic signs of TMJ osteoarthrosis, severe facial asymmetry, or deformity secondary to trauma. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: The primary predictors were condylar position at baseline (anterior, concentric, and posterior), time points (T0, preoperatively; T1, immediately after surgery; and T2, 1-year follow-up), and surgical intervention type (BSSO, BMO, and control group). MAIN OUTCOME VARIABLES: The primary outcomes were changes in posterior spatial dimension (PSD), superior spatial dimension, and medial spatial dimension assessed by cone-beam computed tomography preoperatively, immediately after surgery, and at 1-year follow-up. COVARIATES: Covariates included sex, age, and amount of mandibular advancement. ANALYSES: Estimations of independent effects of primary predictors on outcome variables were made by applying generalized estimation equation models. The value of statistical significance was P < .05. RESULTS: The study sample included 88 participants. The BSSO samples included 39 patients, and the BMO group included 22 patients; the control group comprised 27 subjects. The average age was 31.2 years; the majority were female (61.4%). Adjusted generalized estimation equation models yielded a significant time interaction between BSSO and spatial dimensions over time (PSD, P < .001). Key predictors of spatial dimension changes were the baseline posterior (PSD, P < .001) and the central condylar position (PSD, P < .001). CONCLUSION AND RELEVANCE: This controlled study, for the first time, provides scientific evidence on the effects of surgical intervention type and baseline condylar position on spatial dimension changes in the TMJ. It shows a more favorable outcome in long-term spatial dimension changes for patients treated by a BMO procedure.

Perioperative anticoagulation in head and neck free flap reconstructions: Experience of an anticoagulative scheme and its modification.

OBJECTIVES: Microvascular anastomoses in microvascular reconstructions induce rheological changes in the anastomosed vessels and are usually counteracted by anticoagulative medication. There is no regimen commonly agreed on. This study provides an easy to use anticoagulative regimen. PATIENTS AND METHODS: Consecutive cases of either anticoagulative regimen between 2013 and 2018 that underwent microvascular reconstruction in the head and neck area were included in this retrospective study, resulting in 400 cases in total. Two different anticoagulative regimens were applied to 200 patients in each group: (a) intraoperatively administered unfractionated 5000 I.U. high molecular weight heparin (HMWH) and postoperatively low molecular weight heparin (LMWH, Enoxaparin) 1 mg/kg/body weight postoperatively and (b) intraoperatively LMWH 0.5 mg/kg/body weight as well as 12 h later and 1 mg/kg/body weight postoperatively. RESULTS: The LMWH cohort showed fewer overall thromboembolic (8.5% vs. 11%; p = .40) and peripheral thrombotic events (1% vs. 3.5%; p = .18) and lung embolisms (3% vs. 4%; p = .59). The number of thromboses at the site of the anastomosis was equally distributed. In regard to flap-specific complications, LMWH was associated with a positive effect, in particular with respect to total flap losses (5% vs. 7%; p = .40) and wound-healing disorders (14.5% vs. 20%; p = .145). CONCLUSION: Findings indicate that intra- and postoperatively administered LMWH as the only anticoagulative medication seems reliable in our clinical routine of head and neck free flap reconstructions.

Rhinoresistometry as a Cost-Efficient and Time-Saving Alternative to Acoustic Rhinometry for Longitudinal Assessment of Nasal Patency in Orthognathic Surgery.

Rhinoresistometry (RRM) is implemented along with active anterior rhinomanometry (AAR) and can evaluate nasal dimensions [hydraulic diameter (HD)]. As acoustic rhinometry (AR) is time-consuming, the authors investigated if RRM can be an efficient alternative to AR in nasal dimension assessment in orthognathic surgery. In patients undergoing maxillary advancement and impaction (cases) and removal of maxillary cysts (controls), the authors evaluated RRM and AR, before and 1 year after surgery. Furthermore, the authors investigated the correlation of HD with Nasal Obstruction Symptom Evaluation score and volume by computed tomography and AAR. Lastly, the authors measured RMM reproducibility by the Bland-Altman agreement method in controls. In 14 cases, AR and RMM revealed a significant increase on both sides (all P < 0.011) and the right side, respectively (P = 0.028). The authors noted no changes in 14 controls. Hydraulic diameter correlated only with AAR (most P < 0.004). Acoustic rhinometry lasted ~4 minutes before or after decongestion. In controls, HD after surgery was as large (1.05 times larger) as before surgery (up to 39% error rates). Rhinoresistometry can reproducibly assess nasal dimension changes in orthognathic surgery in a way that is different from AR and correlates with nasal function. Rhinoresistometry can help clinicians avoid AR and save significant time, as well as financial and human resources.

Modeling the effect of bilateral sagittal split osteotomy on posterior, superior and medial space dimensions of the temporomandibular joint: a retrospective controlled cohort study.

BACKGROUND: To model the effect of isolated bilateral sagittal split osteotomy (BSSO) on changes in posterior (PSD), superior (SSD), and medial space dimensions (MSD) of the temporomandibular joint. METHODS: Using a retrospective cohort study design, pre- and postoperative (immediately after surgery; 1 year follow-up) cone-beam computed tomography measurements of 36 patients who had undergone BSSO for mandibular advancement were compared with a control group of 25 subjects from whom a mandibular odontogenic cyst was removed under general anesthesia. Generalized estimation equation (GEE) models were used to examine the independent effects of study group, preoperative condylar position, and time points on PSD, SSD, and MSD adjusting for covariates (age, sex, and mandibular advancement). RESULTS: No significant differences were found regarding changes in PSD (p = 0.144), SSD (p = 0.607), or MSD (p = 0.565) between the BSSO and control groups. However, the preoperative posterior condylar position showed significant effects on PSD (p < 0.001) and MSD (p = 0.043), while the preoperative central condylar position demonstrated a significant effect on PSD (p < 0.001). CONCLUSION: The data suggest that preoperative posterior condylar position is a significant effect modifier of PSD and MSD over time in this cohort.

Factors Associated With Postoperative Delirium in Patients Undergoing Complex Head and Neck Flap Surgery.

PURPOSE: Postoperative delirium (PD) is a common and severe complication, following extensive surgery and prolonged stays in intensive care units (ICU). The study aimed to estimate the frequency of and identify risk factors for PD in a unified sample of head and neck surgery patients. METHODS: The investigators implemented a retrospective cohort study composing of patients undergoing free flap reconstructive surgery over 1 year. The predictor variables were identified as 146 general and periprocedural parameters. The primary outcome variable was PD (+ or -). Descriptive and bivariate statistics were performed to identify existing correlations between the predictive factors and PD and the P-value was set at .05. A logistic regression model (LRM) was created to adjust for possible confounding factors and reveal possible independent prognostic factors for the onset of PD. RESULTS: Hundred patients (group 1, 18 with PD+, group 2, 82 without PD) undergoing microvascular free flap (65 males, 35 females, mean age = 65 [range 18 to 84 years]) surgery were recruited. The investigators identified 15 variables that were statistically associated with PD. In the LRM, after adjusting for age, diabetes status, and preoperative TSH, free fibula transplants (FT) as type of surgery was associated with an increased risk for PD (FT, Odds Ratio (OR) 6.3 (1.6 to 25.7, P = .01). CONCLUSION: The investigators identified 15 variables associated with an increased risk of developing PD, one of which had a statistically significant association after adjusting for other variables in a LRM. Future research efforts should be devoted to assessing the use of these variables for predicting PD further. Since the use of FT showed to be an independent prognostic parameter for the development of PD in this study, patients receiving FT should get special attention in the first days after surgery to prevent PD and associated complications such as increased mortality and prolonged hospital stays.

Composition and Clinical Impact of the Immunologic Tumor Microenvironment in Oral Squamous Cell Carcinoma.

Immunotherapy shows promising results and revolutionizes treatment of oral squamous cell carcinoma (OSCC). The immunologic microenvironment might have prognostic/predictive implications. Morphologic immunologic parameters (inflammatory infiltrate, stromal content, and budding activity [BA] [potentially indicating epithelial-mesenchymal transition]) were evaluated in 66 human primary therapy-naive OSCCs. Intraepithelial/stromal tumor-infiltrating lymphocytes (TILs; CD3+/CD4+/CD8+/CD4+FOXP3+/IL-17A+) were quantified, and ratios were calculated. HLA class I in tumor cells was evaluated immunohistochemically. mRNA in situ hybridization to detect IFN-γ was performed. Analysis was performed within invasive front (IF) and tumor center (TCe). Decreased HLA expression was associated with low TIL density, pronounced stromal content, and high BA; IFN-γ in TILs was correlated with high-density TILs; and IFN-γ in tumor cells was correlated with absence of BA (p < 0.05). Heterogeneity of parameters (TCe/IF) was rare. Low density of stromal CD4+FOXP3+ TILs within TCe and IF was identified as an independent prognostic factor for poor overall, disease-specific, and disease-free survival (p ≤ 0.011). Refining prognostication in OSCC with high-density CD4+FOXP3+ infiltrate within TCe and/or IF, high FOXP3:CD4 ratio was significantly correlated with favorable outcome in this subgroup. Furthermore, high-stromal CD8:CD4 ratio was found to be an independent favorable prognostic factor. In summary, immunologic parameters were closely intertwined. Morphologic correlates of epithelial-mesenchymal transition were associated with downregulation of HLA and decreased inflammation. Heterogeneity was infrequent. Low-density stromal CD4+FOXP3+ infiltrate within TCe and IF was an independent poor prognostic factor. Stratification of cases with high-density CD4+FOXP3+ TILs by FOXP3:CD4 ratio enables refinement of prognostication of this subgroup. CD8:CD4 ratio was identified as an independent prognostic factor.

Dental pathologies in tumor patients with bone metastases or multiple myeloma scheduled for antiresorptive therapy.

Background: Medication-related osteonecrosis of the jaw (MRONJ) is a potentially severe complication of mainly antiresorptive drugs. We evaluated the frequency of dentoalveolar pathologies in patients scheduled for antiresorptive therapy in a 'real-world' setting, also including patients with poor oral health potentially requiring tooth extractions and/or other dentoalveolar surgery. This approach is in contrast to the setting of recent randomized trials with restrictive exclusion criteria. Patients & methods: We prospectively included patients suffering from solid tumors with osseous metastases or multiple myeloma. Screening for dentoalveolar pathologies was done prior to initiation of antiresorptive therapy at the specialized MRONJ clinic of the University Hospital for Cranio-Maxillofacial and Oral Surgery, Innsbruck, Austria. Results: 119 subjects could be included. In 76 patients (63.9%), a dental focus was revealed including deep caries (24.4% of patients), chronic apical periodontitis (26.9%), periodontal disease (45.8%), root remnants (16%), jaw cysts (2.5%), partially impacted teeth (5.0%) and peri-implantitis (5.0%). Conclusion: Considering the high number of dentoalveolar pathologies (63.9%), systematic dental focus screening prior to initiation of antiresorptive therapy is of utmost importance to lower the risk for MRONJ.

Is There a Significant Difference in Relapse and Complication Rate of Surgically Assisted Rapid Palatal Expansion Using Tooth-Borne, Bone-Borne, and Orthodontic Mini-Implant-Borne Appliances?

PURPOSE: For surgically assisted rapid palatal expansion (SARPE), studies comparing different devices are missing. The aim was to evaluate expansion, relapse, and the complication rates for 3 different appliances. PATIENTS AND METHODS: In this retrospective cohort study, tooth-borne (TB, n = 29), bone-borne (BB, n = 12), or orthodontic mini-implant (OMI)-borne (n = 13) appliances were used for SARPE in 2 clinical centers. Patients presenting with a maxillary width discrepancy greater than 5 mm were included. Measurements of cast models and radiographs were performed preoperatively, immediately after consolidation, and at 1 year postoperatively. All distances were measured between canines, premolars, and molars. Complications (tooth damage, infection, technical failure) were evaluated. The outcome variables were expansion, relapse, and complications. Type of appliance was selected as predictor variable. Within- and between-group differences regarding expansion, relapse, and complications for the 3 appliances were statistically analyzed. RESULTS: In 54 patients (aged 28.8 ± 8.6 years), mean expansion (±standard deviation) for the TB, BB, and OMI appliances immediately after consolidation was 5.29 ± 1.39 mm, 5.22 ± 1.72 mm, and 3.81 ± 2.19 mm, respectively, at the dental level, and 5.51 ± 1.40 mm, 4.66 ± 2.03 mm, and 3.51 ± 1.66 mm, respectively, at the bone level. Mean (±standard deviation) relapse for the TB, BB, and OMI appliances at 1 year postoperatively measured 1.44 ± 1.01 mm, 0.76 ± 1.37 mm, and 0.27 ± 1.63 mm, respectively, at the tooth level and 1.19 ± 0.93 mm, 0.71 ± 0.96 mm, and 0.12 ± 1.56 mm, respectively, at the bone level. Analysis of variance and the Tukey test showed significant differences between the TB and OMI appliances for expansion and relapse (P = .034 and P = .024, respectively). The overall complication rate differed significantly (P < .001), with rates of 17.2%, 66.7%, and 15.4% for the TB, BB, and OMI appliances, respectively. CONCLUSIONS: BB and OMI appliances resulted in less relapse. Owing to the high complication rate, the further use of BB appliances is questionable.

The Effect of Orthognathic Surgery on Temporomandibular Joint Function and Symptoms: What are the Risk Factors? A Longitudinal Analysis of 375 Patients.

PURPOSE: The effects of orthognathic surgery (OGS) on the temporomandibular joint (TMJ) are still controversial. Based on a high-volume uniform collective, the function and clinical symptoms of the TMJ and the dysfunction index (Di) by Helkimo were evaluated prior and up to 2 years after OGS. METHODS: A longitudinal cohort study was performed between 2006 and 2016. A comprehensive examination focusing on TMJ function, temporomandibular disorder (TMD) symptoms, and the Di had been performed preopertaively (T0) and postoperatively at 6 weeks (T1), 6 months (T2), 1 year (T3), and 2 years (T4). The predictor variables used were sex, age, skeletal class, type of surgery, and amount of dysfunction or number of TMD complaints before treatment. The outcome of this study was TMD symptoms and the Di. Descriptive and bivariate statistics were computed, and the significance level was set at P < .05. RESULTS: The sample consisted of 375 patients (247 women, 128 men, mean age 28.1 ± 9.4 years), 269 with skeletal Class II (71.7%) and 106 with skeletal Class III (28.3%) treated with sagittal split osteotomy bilateral sagittal split osteotomy (n = 173) or Le Fort I and bilateral sagittal split osteotomy (n = 202). Severe signs of dysfunction (Di 2/3) were seen in 5.9% of the patients before OGS and in 2.1% of the patients 2 years after OGS. The difference in Di (Di0/1 and Di2/3) between T0 and T1/T2 was statistically significant (P = .028; P = .011, respectively). TMD symptoms were significantly reduced 2 years after OGS (P = .028). Female gender (P = .013), skeletal Class II (P < .001), and counterclockwise rotation (P < .001) were the only risk factors significantly associated with the occurrence of TMD at T1. CONCLUSIONS: The results of this study suggest that in most cases TMD symptoms can be significantly reduced and only a few can be induced with OGS. No risk factors were found for long-term effects on the TMJ.

Pre-operative cellular dissociation grading in biopsies is highly predictive of post-operative tumour stage and patient outcome in head and neck squamous cell carcinoma.

BACKGROUND: Pre-operative treatment planning in head and neck squamous cell carcinoma (HNSCC) is mainly dictated by clinical staging, which has major shortcomings. Histologic grading is irrelevant due to its lack of prognostic impact. Recently, a novel grading termed Cellular Dissociation Grade (CDG) based on Tumour Budding and Cell Nest Size was shown to be highly prognostic for resected HNSCC. We aimed to probe the predictive and prognostic impact of CDG in the pre-operative biopsies of HNSCC. METHODS: We evaluated CDG in n = 160 pre-therapeutic biopsies from patients who received standardised treatment following German guidelines, and correlated the results with pre- and post-therapeutic staging data and clinical outcome. RESULTS: Pre-operative CDG was highly predictive of post-operative tumour stage, including the prediction of occult lymph node metastasis. Uni- and multivariate analysis revealed CDG to be an independent prognosticator of overall, disease-specific and disease-free survival (p < 0.001). Hazard ratio for disease-specific survival was 6.1 (11.1) for nG2 (nG3) compared with nG1 tumours. CONCLUSIONS: CDG is a strong outcome predictor in the pre-treatment scenario of HNSCC and identifies patients with nodal-negative disease. CDG is a purely histology-based prognosticator in the pre-therapeutic setting that supplements clinical staging and may aide therapeutic stratification of HNSCC patients.

Comparison between Different Perforator Imaging Modalities for the Anterolateral Thigh Perforator Flap Transfer: A Prospective Study.

BACKGROUND: Perforator imaging is routinely performed before perforator flap harvest. Hand-held Doppler (hhD) and color duplex ultrasonography (CDU) are currently the most popular radiation-free methods for this purpose that can be applied by the surgeon alone. The aim of this study was to compare the accuracy, reliability, and feasibility of hhD and CDU with indocyanine green angiography (ICGA) in the anterolateral thigh perforator flap (ALTPF). METHODS: All consecutive ALTPF procedures between May 2017 and April 2018 were included in this prospective study. The perforators were visualized by three investigators independently and randomized, applying hhD, CDU, and ICGA. The presence and the distance to the identified perforator were registered. Further, body mass index (BMI), American Society of Anesthesiologists-status, and the patient's history regarding smoking, alcohol use, and diabetes mellitus were registered alongside gender and age to analyze possible confounders. RESULTS: A total of 12 patients were enrolled with a median age of 67 (52-87) years. In total, 30 perforators were detected intraoperatively as well as with the ICGA. The latter visualized the perforators significantly more precisely than hhD and CDU (p < 0.001 and p = 0.001). The sensitivity and positive predictive value were 67 and 62% for hhD, 73 and 64% for CDU, and 100 and 100% for ICGA, respectively. CONCLUSION: According to this study, ICGA visualized perforators more accurately than the standard methods hhD and CDU. Further, it was associated with the highest sensitivity and positive predictive value. ICGA consistently delivered excellent results, whereas hhD and CDU showed variability.

Skeletal-versus soft-tissue-based cephalometric analyses: is the correlation reproducible?

OBJECTIVES: Dentofacial deformities can be analyzed by skeletal and soft tissue cephalometric analysis (CA). The aim was to evaluate the difference in reproducibility between both methods. MATERIALS AND METHODS: Lateral cephalograms of 112 patients (65 females and 47 males, 27.7 ± 9.0 years) were oriented in natural head position (NHP) and digitized. The distances of skeletal (SNA, SNB, SnPog) and soft tissue (A', B' and Pog') landmarks relative to the respective norm values and the angles between the Nasion Sella line (NSL) and Frankfurt horizontal (FH) to NHP were measured for statistical evaluation and compared with respective data of an adult control group (CG) with class I occlusion and harmonic facial balance. RESULTS: The mean differences (mm ± SD) of skeletal and soft tissue landmarks were -2.4 ± 4.4 (A), -7.0 ± 9.3 (B), -6.3 ± 11.2 (Pog), -0.9 ± 1.8 (A'), -4.7 ± 6.2 (B'), and -6.1 ± 7.8 (Pog'), respectively. Pearsons's correlation (r) between the measurements of SNA/A', SNB/B' and SNPog/Pog' were r = .158 (p = .092), r = .662 (p < .001) and r = .655 (p < .001), respectively. The mean (±SD) angles between NSL and FH to NHP were -9.8° ± 5 and 0.0° ± 3.9, respectively. CONCLUSION: Variability of cranial-based measurements could give a possible explanation for the high variation and the low reproducibility of skeletal cephalometric analysis with soft tissue measurements. Soft-tissue cephalometric analysis would probably improve facial analysis and treatment planning.

Effect of Segment Length and Number of Osteotomy Sites on Cancellous Bone Perfusion in Free Fibula Flaps.

BACKGROUND: Indocyanine green (ICG) videoangiography is routinely used to evaluate skin and organ perfusion and to assess patency rates of microvascular anastomoses. This study uses ICG angiography as a novel approach to qualitatively and quantitatively evaluate bone perfusion of microvascular fibula grafts intraoperatively and to assess the effect of fibula segment length and number of osteotomies on bone perfusion. METHODS: All patients planned for mandible reconstruction using a microvascular fibula graft between January 2013 and May 2017 were considered for this study. ICG videoangiography of cancellous bone perfusion was performed using a handheld ICG camera. Videos were analyzed, and a perfusion curve was generated. Peak enhancement, time to peak, slope, and wash-in area under the curve were extracted; rise time, wash-in rate (WiR), and wash-in perfusion index were calculated. Results were statistically analyzed with regard to distal fibula segment length and number of osteotomy sites. RESULTS: Thirty-nine patients (age 59 ± 8 years) were included in the study. Mandible reconstruction was achieved with 1 (n = 15), 2 (n = 13), or 3 (n = 11) fibula segments. The WiR was 6.4 ± 2.3 and 4.4 ± 0.2 before and after proximal osteotomy, respectively. The wash-in perfusion index was 114.2 ± 48.4 before and 84.4 ± 20.0 after proximal osteotomy. Bone perfusion was significantly reduced after additional proximal osteotomies. Both the segment length and number of proximal osteotomies correlated with bone perfusion, with longer segments and fewer osteotomies showing higher perfusion. CONCLUSION: This study demonstrates the feasibility of cancellous bone perfusion analysis using ICG and can serve as a basis for future bone perfusion studies. Additional osteotomies and short segment length negatively affects cancellous bone perfusion of the distal fibula segment in free fibula flaps. The extent to which the observed decrease in arterial inflow to the distal fibula segment affects the further course of healing needs to be addressed in future studies.

Immunohistochemical expression of CD44 in oral squamous cell carcinoma in relation to histomorphological parameters and clinicopathological factors.

AIMS: Oral squamous cell carcinoma (OSCC) is characterised by its variable clinical course. In addition to the routinely used TNM and Union for International Cancer Control systems, patient-specific prognostic/predictive biomarkers are needed. Promising biomarkers include the determination of the cancer stem cell compartment, which can be identified by CD44 expression (among other things). The aim of this study was to evaluate the impact of CD44 in OSCC in terms of correlation with histomorphology, especially targeting features of EMT, and its influence on patient prognosis. METHODS AND RESULTS: A well-characterised cohort of 108 therapy-naive OSCCs with complete long-term follow-up and matched lymph node metastases were evaluated for CD44 expression by immunohistochemistry. CD44 expression was correlated with histomorphological characteristics (including tumour differentiation and tumour budding), clinicopathological parameters, and follow-up data. Overexpression of CD44 was detected in 37% of OSCCs within the tumour centre, in 39% of OSCCs at the invasive margin, and in 16% of lymph node metastases. CD44 overexpression at the invasive margin was significantly correlated with poor histopathological differentiation, and specifically with high tumour budding activity and single-cell invasion as signs of epithelial-mesenchymal transition (EMT). CD44 overexpression within the tumour core region and in lymph node metastases was identified as an independent prognostic factor for poor overall, disease-specific and disease-free survival in subsets of patients with advanced OSCC. CONCLUSION: Our study demonstrates the association of CD44 with tumour aggressiveness and EMT, as well as the independent prognostic impact of CD44 in a subset of OSCCs, which underlines the role of tumour cell stemness as a key factor in malignant behaviour in this disease.

Extraocular muscle repositioning as the last therapeutic option for a patient with a severe course of Graves' Ophthalmopathy: a case report.

BACKGROUND: Graves' disease is a common autoimmune inflammatory condition of the thyroid. About one in four of affected patients also develop orbital symptoms like exophthalmos, proptosis and diplopia - called Graves' Ophthalmopathy. Not all patients respond well to the standard therapy of systemic glucocorticoid administration. The inflammatory swelling of the intraorbital muscles can lead to pressure-induced damage of the optic nerve. Orbital decompression surgery is a therapeutic option for these patients with varying success. Other symptoms like the extreme malposition of the ocular globe are poorly addressed by decompression surgery and demand for different therapeutic approaches. CASE PRESENTATION: Presented is the case of a 46-year old patient with an acute exacerbation of Graves' ophthalmopathy. Clinically apparent was a convergent strabismus fixus with severe hypotropia of both eyes. The patient suffered from attacks of heavy retrobulbar pain and eyesight deteriorated dramatically. Since neither systemic glucocorticoid therapy nor orbital decompression surgery had helped to halt the progress of the disease, a decision was made in favour of the surgical release and repositioning of the inferior and medial rectus muscle as a final therapeutic option. Surgery of both eyes was performed consecutively within one week. Detailed descriptions and illustrations of the surgical steps and treatment outcome are provided supplemented by a discussion of the current literature. CONCLUSIONS: Graves' Ophthalmopathy is a variant and therapeutically challenging disease. Exceptional courses of the disease call for therapeutic approaches off the beaten track. Surgical extraocular muscle repositioning, which has not been described before in the context of Graves' Ophthalmopathy, proved to be effective in improving the patient's eyesight and quality of life. Furthermore, we regard the measurement of extraocular muscle volume as a valuable method to monitor the course of Graves' Ophthalmopathy.

Tumour budding activity and cell nest size determine patient outcome in oral squamous cell carcinoma: proposal for an adjusted grading system.

AIMS: Oral squamous cell carcinoma (OSCC) is a common malignancy with a variable clinical course. One of the established survival predictors in carcinomas in general is tumour grade; in OSCC, however, grading according to the World Health Organization (WHO) has no independent prognostic impact. Recently, a novel grading scheme associated with high impact on patient outcome has been proposed for squamous cell carcinoma of the lung. METHODS AND RESULTS: To probe whether this scheme could be applied to the upper aerodigestive tract, we retrospectively evaluated 157 chemo- and radiotherapy-naive OSCCs with complete clinical follow-up data and standardized treatment for tumour budding activity (BA), cell nest size (CNS), extent of keratinization, stromal content, nuclear size and mitotic count. Histomorphological characteristics were correlated with clinicopathological data and patient outcome. As in squamous cell carcinoma of the lung, high BA and small CNS were correlated significantly with shortened overall, disease-specific and disease-free survival. A three-tiered grading system based on a sum score of these two prognostic markers proved to be a strong age-, stage- and sex-independent prognosticator for survival with a hazard ratio for overall survival of 2.1 for intermediately differentiated (G2) tumours and 3.4 for poorly differentiated (G3) tumours compared to well-differentiated (G1) tumours (P < 0.001). CONCLUSIONS: We recapitulated and validated almost exactly the strong prognostic impact of a grading algorithm proposed recently for squamous cell carcinoma of the lung in OSCC. Our data may pave the way for a prognostically highly relevant future squamous cell carcinoma grading system broadly applicable in the aerodigestive tract.

Comparative 3D micro-CT and 2D histomorphometry analysis of dental implant osseointegration in the maxilla of minipigs.

AIM: The bone implant contact (BIC) has traditionally been evaluated with histological methods. Thereupon, strong correlations of two-dimensional (2D) BIC have been detected between µCT and destructive histology. However, due to the high intra-sample variability in BIC values, one histological slice is not sufficient to represent 3D BIC. Therefore, our aim has been to correlate the averaged values of 3-4 histological sections to 3D µCT. MATERIAL AND METHODS: Fifty-four implants inserted into the maxilla of 14 minipigs were evaluated. Two different time points were selected to assess the 3D BIC (distance to implant: 2-5 voxels), an inner ring (6-30 voxels) and an outer ring (55-100 voxels) using µCT (voxel size: 10 µm) and to correlate the values to histomorphometry. RESULTS: Strong correlations (p < 0.0001; 28 days, 56 days, total) were seen between µCT and histomorphometry concerning BIC (r = 0.84, r = 0.85, r = 0.83), the inner ring (r = 0.87, r = 0.87, r = 0.88) and the outer ring (r = 0.85, r = 0.85, r = 0.88). Closer to the implant, µCT values were higher compared with histomorphometry. CONCLUSION: Although 3-4 histological slices per implant seem to predict the 3D BIC, µCT might be advantageous because of its non-destructive 3D character. The healing time may not impact on the comparability.

Piezosurgery for Sagittal Split Osteotomy: Procedure Duration and Postoperative Sensory Perturbation.

PURPOSE: To evaluate piezosurgery for bilateral sagittal split osteotomy (BSSO) for its duration and inferior alveolar nerve (IAN) perturbation. PATIENTS AND METHODS: In this prospective randomized study, the authors evaluated 100 BSSO procedures in 50 patients. Piezoelectric (group I) and conventional (group II) osteotomies were carried out on each side of the mandible of a patient by 2 specialists. The surgeons had at least 1 year of experience using piezosurgery. The period from incision to complete splitting of the mandibular bone was recorded (ie, procedure duration). The intraoperative status (visibility and relocation) of the IAN also was recorded. The neurosensory function of the IAN was measured by the 2-point discrimination threshold and static light touch methods before surgery and postoperatively (1, 3, and 6 weeks and 6 and 12 months). Parameters were compared between the test groups by the paired t, nonparametric Wilcoxon, or χ2 test. RESULTS: Intergroup comparison showed the mean duration of osteotomy was significantly shorter for group I (17 ± 6 vs 25 ± 9 minutes; P < .001). The rate of intraoperative exposures of the IAN was slightly lower for group I (68%) compared with group II (81%). However, the difference was not relevant. Neurosensory disturbance and recovery of the IAN did not differ between groups. CONCLUSION: Piezoelectric osteotomy requires considerably less time than conventional mechanical approaches, but shows no advantage in preventing neurosensory perturbation.

Clinical Impact of Intraoperative Cytological Assessment of Bone Resection Margins in Patients with Head and Neck Carcinoma.

BACKGROUND: Surgical treatment of head and neck squamous cell carcinoma (HNSCC) patients often results in complex defects, affecting functional structures. Frozen sections are valuable to guide resections and control for adequate margins; however, intraoperative assessment of bone remains challenging. OBJECTIVE: The objective of this study was to evaluate the clinical impact of an intraoperative cytological assessment of bone margins (ICAB) on resection status and patient outcome. METHODS: ICAB analysis (n = 267) was implemented in 102 patients during resection of HNSCC for a guided resection of affected bone. The cytological findings were compared with the final histological results of the corresponding bone margins, and the surgical consequences, R1 rates, and patient outcome of the ICAB intervention group were compared with an equal control group of 100 patients. RESULTS: ICAB revealed a sensitivity of 94.4 % [95 % confidence interval (CI) 81.3-99.3], specificity of 97.4 % (95 % CI 94.4-99.0), positive predictive value of 85.0 % (95 % CI 70.2-94.3), and negative predictive value of 99.1 % (95 % CI 96.9-99.9). Osseous R1 resections were reduced from 8 to 2.9 % (∆R1 = 5.1 %; p = 0.113), rendering a relative risk reduction (RRR) of 63.2 % with a number needed to treat (NNT) of 19.57. ICAB influenced final resection status, with a reduction of R1 resections from 17 to 7.8 % (∆R1 = 9.2 %; p = 0.026), with an RRR of 59.65 % and an NNT of 9.66. The ICAB intervention group revealed a higher disease-free survival [p(log-rank) = 0.045] and overall survival [p(log-rank) = 0.014] according to multivariable analysis. CONCLUSION: ICAB, applied as a routine diagnostic tool to supplement frozen sections, can help to reduce R1 resections in order to improve patient outcome.