Improvement of oral cancer screening quality and reach: The promise of artificial intelligence.

Oral cancer is easily detectable by physical (self) examination. However, many cases of oral cancer are detected late, which causes unnecessary morbidity and mortality. Screening of high-risk populations seems beneficial, but these populations are commonly located in regions with limited access to health care. The advent of information technology and its modern derivative artificial intelligence (AI) promises to improve oral cancer screening but to date, few efforts have been made to apply these techniques and relatively little research has been conducted to retrieve meaningful information from AI data. In this paper, we discuss the promise of AI to improve the quality and reach of oral cancer screening and its potential effect on improving mortality and unequal access to health care around the world.

The E-cigarette ban in India-A step in the right direction?

Electronic cigarettes (e-cigarettes) are a popular method to help quit tobacco smoking. However, there is a paucity of data in the literature on their safety and efficacy. Recently, the Indian Government has called for a ban on all e-cigarettes and taken steps to restrict access to vaping products from the market. This major decision was an attempt to safeguard the younger population from using e-cigarette and their possible longer-term addiction together with its promotions by domestic industries. In this article, we evaluate the role of e-cigarettes to help stop smoking tobacco cessation and consider the factors that have facilitated the ban on e-cigarettes in India.

Circulating tumour cells in head and neck cancers: Biological insights.

Tumour metastasis is one of the leading cause of cancer-related mortality. Circulating tumour cells (CTCs) have been implicated in loco-regional and distant metastasis and its role is being extensively studied in various malignancies, including those from the head and neck region. The main challenge in understanding their significance lies in the rarity of these cells in the blood. However, newer technologies have attempted to overcome these pitfalls. This review explores the evolution of CTC research and other related areas, including its biological significance, sustainability within the circulating vascular environment and possible clinical implications.

Lymph node level ratio: Are we relying too much on numbers?

The lymph node level ratio appears to be a continuation of nodal yield and nodal density, two prognostic metrics already in use. A retrospective analysis conducted in the current study showed that a value of fewer than 4 lymph nodes/level is linked to a lower overall and disease-specific survival. This letter aims to review the reasoning behind the use of node level ratios and nodal yields as quality and prognostic indicators, and to explore possible factors that could affect these.

Role of Imaging in Predicting the Deep Surgical Margin in Gingivobuccal Complex Cancers: A Pilot Study.

Cancers arising from the gingivobuccal complex are one of the most common types of cancer in the oral cavity and are associated with poor prognosis. Among the various prognostic factors, positive surgical margin is the most important one that can be controlled by the operating surgeon. The deep surgical margins for buccal mucosa cancers is normally assessed by palpating the skin for induration and skin pinchability. The present study evaluates the role of imaging in assessing the deep surgical margin and its efficacy for skin preservation in buccal mucosa/ gingivobuccal carcinomas. The patients of gingivobuccal complex squamous cell carcinomas after histopathological confirmation were selected for the study. In imaging, the distance between the base of the tumour and skin (epidermis) of the cheek was measured by a senior radiologist preoperatively. The frozen section findings were confirmed by histopathological examination and the depth of invasion of the tumour was measured and the clearance of the deep surgical margin was confirmed. The correlation between imaging, skin pinch test and histopathological examination of the specimen was assessed. The sensitivity and specificity of imaging to predict the skin preservation (deep surgical margin more than 5 mm) is 100% and 75% respectively compared to sensitivity and specificity of skin pinch test of 82.6% and 50% respectively. Imaging is an effective tool in predicting the skin preservation and skin excision compared to skin pinch test. Compared to the skin pinch test, imaging appears to be a useful tool for advising surgeons on skin preservation vs excision.

Hepatoprotective and cardioprotective effect of Artemisia nilagirica leaf extract on E. coli challenged broiler chicken.

Artemisia nilagirica is an important medicinal plant found to exhibit several medicinal properties but the use of its leaves for combating E. coli infection has not been scientifically validated in poultry. The present study was conducted to evaluate the protective effects of methanol leaf extract of A. nilagirica (ANE) on E. coli challenged broiler chickens. Three hundred and thirty, day-old broiler chickens, were divided into 6 groups of 55 each, with group EX infected intraperitoneally (I/P) with LD50 dose of 1 × 107 cfu/ml of E. coli; group(s) EA1, EA2 and EA3 infected I/P with 1 × 107 cfu/ml of E. coli and supplemented with ANE @ 0.5, 1.0 and 2.0 g/L of drinking water, respectively; group AX were only given ANE @ 2.0 g/L in the drinking water. ANE treatment was started from day 4 and was continuously given in the drinking water up to day 21. E. coli infection was given to the birds on day 7 of their age. The effect of the plant extract was evaluated on the basis of gross, microscopic and ultrastructural alterations in E. coli challenged broiler chickens. The extract of A. nilagirica was found to show antibacterial, cardioprotective and hepatoprotective properties in a dose-dependent manner on the basis of gross and microscopic examination. The methanol extract of A. nilagirica leaves revealed no toxic effect on the hepatocytes on ultrastructural evaluation. This study demonstrates the antimicrobial, hepatoprotective and cardioprotective activities of ANE in broiler chickens infected with E. coli organism.

Upper oral cavity tumors: Is the risk of nodal metastasis different?

The state of the clinically evident cervical lymph nodes at the time of diagnosis is one of the most important factors impacting long-term survival. While squamous cell carcinomas (SCC) of the hard palate and maxillary alveolus are uncommon in comparison to other primary sites, there is a scarcity of published data on the effective management of the neck nodes for malignancies of these specific subsites. In such circumstances, an intraoperative frozen section or Sentinel node biopsy would aid in the optimal therapy of the neck.

The Impact and Prognostic Significance of Extra-Nodal Extension in Clinically N0 Oral Cancer: A Prospective Clinical Study.

Oral cavity squamous cell carcinoma (OCSCC) demonstrates a high propensity to metastasize to regional lymph nodes. Despite technological and scientific advances, identification of pathological adverse features preoperatively remains elusive. This study intended to identify the true occurrence of extra-nodal extension (ENE) in clinically and radiologically N0 OCSCC patients and to investigate its impact and prognostic significance. A prospective, single-centre, non-randomized study was conducted at a tertiary cancer centre in South India to include all untreated operable patients of OCSCC without clinical, radiological, or cytological evidence of nodal metastasis (cN0). All the patients underwent tumor resection surgery with neck dissection and received adjuvant therapy when indicated. Patients were followed up and neck dissection specimens were histopathologically analyzed. The primary outcome was to assess the presence of ENE in cN0 OCSCC patients and its extent. The secondary outcomes were 2-year disease-free survival (DFS) and tumor characteristics. A total of 237 patients with operable OCSCC were evaluated. Out of these, 80 patients who were clinically and radiologically N0 were included in the study and they underwent tumor resection surgery and neck dissection. The final histopathological evaluation revealed that 21.25% of patients (n = 17) had metastatic neck disease and 7.5% of patients (n = 6) had ENE, and all were reported as microscopic ENE. Within the node-positive group, the 2-year DFS for patients with and without ENE were 50% and 90.9%, respectively (p = 0.0362). The results suggest that ENE remains a strong predictor of adverse outcomes, recurrence, and survival in oral cancer patients.

Incorporation of Core Biopsy and FNAB in the Diagnostic Algorithm for Endophytic and Submucosal Laryngeal Malignancies: A Technical Note.

Aim to determine the effectiveness of Endolaryngeal Core Biopsy and Fine Needle aspiration Cytology in endophytic or submucosal laryngeal malignancies. BACKGROUND: Endophytic and submucosal laryngeal tumours pose as diagnostic as well as management challenges to the head and neck surgeon. Identifying the tumour location and extent of disease is crucial for the surgeon to determine the treatment options and the potential outcomes. Persistent laryngeal edema following radiotherapy also presents with a diagnostic dilemma, as distinguishing between recurrent laryngeal carcinoma and radiotherapy sequels; which include fibrosis, oedema and soft tissue and cartilage necrosis, can be confusing and punch biopsies performed in such cases would more than often yield inadequate or superficial tissue. Using a core biopsy gun for acquiring biopsy specimen is known to have more cellular material, less damage to the surrounding structure depth control, immediate analysis with higher accuracy rates. TECHNIQUE: Patients with suspected laryngeal malignancy are initially evaluated with flexible endoscopy with Narrow band imaging (NBI) and appropriate imaging. These patients are subjected to Microlaryngoscopic under general anaesthesia. A core biopsy gun is used to obtain samples from the suspicious area. Simultaneously, with the aid of microlaryngeal forceps, an FNAC is also done and sent for rapid processing. CONCLUSION: Trucut biopsy is a novel diagnostic tool that can be commonly used in early laryngeal malignancies especially in those cases where there is strong suspicion of malignancy and the lesion is found to be submucosal. CLINICAL SIGNIFICANCE: we noted that a routine DL scopy and Biopsy in submucoal disease often results in a acquiring a non-representative sample as well as causing inadvertent trauma to the surrounding mucosa. We encourage Laryngeal surgeons to routinely use Core biopsies and FNAC during routine microlaryngeal Examination for better yield, faster diagnosis and faster planning of treatment protocols.

Oral cancer in India, a growing problem: Is limiting the exposure to avoidable risk factors the only way to reduce the disease burden?

Cancer represents an uncontrolled growth of cells that invade and cause damage to the adjacent tissues. Globally oral cancer ranks as the sixth most common type of cancer. As compared to the west, the problem of oral cancer is significantly higher in India. The spectrum of oral diseases is formed with oral cancer at one extreme and potentially malignant disorders (PMDs) at the other extreme. Screening programs for the early detection and prevention of oral cancer indicate that visual examination as a part of a population-based screening program reduces the mortality rate of oral cancer in high-risk individuals. Tobacco and alcohol consumption remains the main factors for oral cancer and education of the population about the ill effects of tobacco and alcohol consumption is necessary at a broader scale.

"Haemophilia A" - Presenting with oral squamous cell carcinoma diagnosis and management strategies.

Hemophilia is a hereditary disorder of coagulation that results in deficiency of factor VIII (Hemophilia A) or Factor IX (Hemophilia B) with characteristic X linked mode of inheritance, almost exclusively seen in males while females are asymptomatic carriers.The common clinical manifestation in both is prolonged bleeding on trivial trauma, mainly into larger joints or muscles. Life threatening bleeding episodes can result spontaneously or from trauma to the head or internal organs. Replacement of deficient clotting protein, known as Anti Hemophilic Factor (AHF) is the main stay in the treatment of haemophilia. Any Surgical treatment of these patients is to be planned in Institution hospital where comprehensive care is available. The availability of AHF has enabled surgeons to take up surgeries in patients with haemophilia. We discuss PWH with congenital factor VIII deficiency presented with oral squamous cell carcinoma of left side lower jaw with main aim is to provide insight into surgical management and care protocol of these patients.

Does SLNB substitute END in the future with the sole advantage of preventing shoulder morbidity?

SLNB has emerged as a rational proposition in the management of early-stage oral cancer and has mixed responses within the oncological community. It is high time for the clinicians to look into the fact that, when a patient post-surgery has a regional recurrence within 6 months, it could be reasonable to believe that a tumor seed which was earlier an isolated tumor cell (ITC) or in the form of a micro-metastasis (MM) would have led to this. SLNB has the potential to become a standard of care in the future owing to the development and utility of better evaluation tools to pick nodal metastasis. It is not an overemphasizing statement to say that SLNB could become a standard recommendation in the near future, however, it still looks like a distant dream considering its logistical and technological limitations.

The impact of positive resection margins on survival requires further study?

Squamous cell carcinoma of oral cavity is usually treated by surgery followed by adjuvant treatment. In most standard cancer institutions, margin analysis is a key barometer for measuring the quality of surgical resection. Many studies reported that positive margins have at least a 50% reduction in the overall survival. The contributing factors that could improve surgical outcomes have to be explored. Patterns of outcomes in patients with positive margins can be understood better by analyzing the subsites involved. In the past, positive margins have been associated with a poor prognosis. A detailed analysis of the NCDB and other larger databases would aid in revising our practices to optimize oncological outcomes.

Role of Adjuvant Radiotherapy in Early Stage Tongue Cancer: Need for Establishing Stringent Guidelines.

The primary objective of this study was to determine, using population-based data, whether the addition of postoperative radiotherapy (RT) provides an overall survival benefit in patients with early primary squamous cell carcinoma (SCC) of tongue. The study included the data of tongue cancer patients treated between January 2016 and July 2019 retrieved from our hospital database. Tumours limited to pathologic T1 and T2 category managed with primary surgery with or without postoperative external beam RT were included. Overall survival (OS) and disease-free survival (DFS) were the main outcomes of interest. A total of 211 cases of oral cancer were evaluated and all the patients had clear surgical and pathological margins. Postoperative adjuvant therapy (PORT) was received by 16 patients. Comparison of DFS and OS at 2-year follow-up depicted a similar outcome (p = 0.582 and p = 0.312 respectively). Findings from our study suggest that in the absence of any absolute advantage on quantifiable survival and disease control, it is necessary to define stringent criteria when advocating PORT in early tongue cancer.

Electronic cigarette use amongst youth: A threat to public health?

Electronic cigarettes is an unregulated commercially available nicotine dispensing tool. E-cigarettes contains nicotine which is a highly toxic chemical that can adversely affect any organ and is also potentially carcinogenic. Nicotine is the route to addiction and industry is using this drug to help people not forget tobacco. If not for nicotine these cigarettes will be useless. Thus it is just another way of keeping nicotine in blood to maintain cigarette smoking habits among existing customers and new way to attract young customers using technology to lure young minds, while serving purpose to deliver nicotine.

Periodontitis and oral Cancer-A striking link.

Oral squamous cell carcinoma (OSCC) has become a major public health problem in the worldwide for its increasing incidence and mortality, especially in younger trends. Risk factors for OSCC apart from alcohol and tobacco use, include poor oral hygiene, inflammation caused by inadequately fitting dentures and other rough teeth surfaces, poor nutrition and some chronic infections caused by fungi, bacteria or viruses. Several studies have also found that the risk of developing OSCC may increase with periodontal disease (PD). In addition to reduce harm caused by tobacco, alcohol and betel quid it seems prudent to take measures to improve oral hygiene in periodontally compromised patients to minimize OSCC risks. This further intensifies the need for oral health education programs and large cohurt studies to edify individuals about the importance of regular oral health maintenance and routine dental care towards the prevention of oral diseases including OSCC.

Mesenchymal stem cells-bridge catalyst between innate and adaptive immunity in COVID 19.

Majority of patients infected with the COVID 19 virus display a mild to moderate course of disease and spontaneously recover at 14-20 days. However, about 15% of patients progress to severe stages and 2.5% of these patients succumb to this illness. Most patients with severe disease belong to the elderly age group (<65 years of age) and have multiple associated co-morbidities. The immune responses induced by the COVID 19 virus, during the incubation and non-severe stages, requires the early initiation of a specific adaptive immune response to eliminate the virus and prevent the progress to severe stages. In patients with a dysfunctional bridge adaptive immunity, the innate immune response becomes exaggerated due to the lack of feedback from the adaptive immune cells. The resultant cytokine storm is responsible for the severe lung injury leading to acute respiratory distress syndrome seen in COVID 19 patients. Mesenchymal stem cells are known to suppress overactive immune responses as well as bring about tissue regeneration and repair. This immuno-modulatory effect of MSCs could hold potential to manage a patient with severe symptoms of COVID 19 infection due to a dysfunctional adaptive immune system.

Nascent verrucous hyperplasia - A transition to cutaneous squamous cell carcinoma.

Cutaneous squamous cell carcinoma is a common global cancer with Ultraviolet light recognized as the most significant risk factor. The other definite or plausible risk factors include immunosuppression, infection with oncogenic viruses, exposure to toxins, chemicals, chronic inflammatory skin disease and a high body mass index. This case highlights the rarity of the pathology in terms of size, the subtle transition of verrucous hyperplasia to cutaneous squamous cell carcinoma over a period of time and the fallibility of the frozen section report in deciding the optimum resection margins. The initial innocuous presentation represented a diagnostic challenge as it can be mistaken for other benign entities. A correlation between the history, clinical presentation, tumor biology and the histopathological characteristics helped us to unlock the jigsaw puzzle of approaching a rare condition with a modification in the surgical approach.