Fine-needle aspiration cytology of parotid mucinous myoepithelioma with follow-up histopathology: A case report.

Myoepitheliomas are rare tumours of salivary glands. Mucinous myoepithelioma (MM) is a newly described variant with rare cases reported in the literature. This case report highlights cytopathologic features with histologic follow up of MM.

DMA, a Small Molecule, Increases Median Survival and Reduces Radiation-Induced Xerostomia via the Activation of the ERK1/2 Pathway in Oral Squamous Cell Carcinoma.

Survival, recurrence, and xerostomia are considerable problems in the treatment of oral squamous carcinoma patients. In this study, we investigated the role of DMA (5-(4-methylpiperazin-1-yl)-2-[2'-(3,4-dimethoxyphenyl)5″benzimidazoyl]benzimidazole) as a salivary gland cytoprotectant in a patient-derived xenograft mouse model. A significant increase in saliva secretion was observed in the DMA-treated xenograft compared to radiation alone. Repeated doses of DMA with a high dose of radiation showed a synergistic effect on mice survival and reduced tumor growth. The mean survival rate of tumor-bearing mice was significantly enhanced. The increased number of Ki-67-stained cells in the spleen, intestine, and lungs compared to the tumor suggests DMA ablates the tumor but protects other organs. The expression of aquaporin-5 was restored in tumor-bearing mice injected with DMA before irradiation. The reduced expression of αvß3 integrin and CD44 in DMA alone and DMA with radiation-treated mice suggests a reduced migration of cells and stemness of cancer cells. DMA along with radiation treatment results in the activation of the Ras/Raf/MEK/ERK pathway in the tumor, leading to apoptosis through caspase upregulation. In conclusion, DMA has strong potential for use as an adjuvant in radiotherapy in OSCC patients.

"Hybrid Reconstruction" for Zygomaticomaxillary Complex Defect Using CAD/CAM: A Case Report.

In this unique case report, we present a patient of left zygomatico maxillary complex reconstruction with a combination of autogenous tissue (osteocutaneous free fibula flap) and alloplastic implant [patient-specific templated polymethyl methacrylate (PMMA)]. In such large defects, reconstruction using either autogenous tissue or alloplastic implant alone is inadequate and leads to poor functional and aesthetic outcomes. In this case we used osteocutaneous free fibula flap for left alveolus and patient-specific templated PMMA implant for reconstruction of orbital wall and zygoma. Osseointegrated implants were placed secondarily in the fibula for complete dental rehabilitation. With the use of virtual surgical planning and 3D printing we were able to achieve a good result for a complex defect. Since both autogenous tissue and alloplastic implant were used for complete reconstruction, we have named this as "hybrid reconstruction."

CAD-CAM vs conventional technique for mandibular reconstruction with free fibula flap: A comparison of outcomes.

INTRODUCTION: Mandibular reconstruction always pose a challenge to the reconstructive surgeon. With the use of Computer aided designing and computer aided manufacturing (CAD-CAM) it is now possible to reconstruct mandibular defects to near normal configuration with good function and aesthetic outcomes. AIMS/OBJECTIVES: To compare the efficacy of CAD-CAM technique vs conventional technique in mandibular reconstruction with free fibula flap. MATERIALS AND METHODS: 40 consecutive patients that required mandibular reconstruction using free fibula flap were included in the study. All patients were treated using CAD-CAM technique and then compared retrospectively with 40 patients treated with conventional technique. Comparison was done between total intraoperative time, aesthetic outcome and post-operative occlusion. RESULTS: Total intraoperative time in the CAD-CAM group was significantly reduced (562 min) as compared to the conventional group (662 min). Patients in the CAD-CAM group also obtained a better Aesthetic score (3.6/5) when compared to the conventional group (2.5/5). Postoperative malocclusion was noted in 1 patient in the CAD-CAM group as opposed to 6 patients in the conventional group. CONCLUSION: Use of CAD-CAM technology in mandibular reconstruction with free fibula flap offers reduced surgical time with precise and accurate reconstruction that produces better functional and aesthetic outcomes.

Parathyroid cyst eclipsed by parathyroid adenoma: Value of adjunct imaging.

Parathyroid cyst is a rare clinical entity and often presents as a diagnostic challenge, especially when presents in conjunction with a coexistent parathyroid adenoma. Patient with primary hyperparathyroidism had presented with a localised left inferior parathyroid adenoma with a coexistent right inferior parathyroid cyst which was initially missed on routine ultrasound and sestamibi scan. Suspicion of right inferior thyroid cyst was raised on ultrasound done by a dedicated parathyroid ultrasonologist. Right inferior thyroid cyst was confirmed to be parathyroid cyst on histopathological examination. Parathyroid cysts are seldom picked on sestamibi due to compressed parathyroid tissue present only at the periphery of the cyst. Hence, use of adjunct anatomical imaging like ultrasound, CT scan or MRI is worthwhile to reduce chances of missing hyperfunctional parathyroid tissue, which can eventually lead to revision surgery for persistent primary hyperparathyroidism.

Incorporation of the Milan system in reporting salivary gland fine needle aspiration cytology-An insight into its value addition to the conventional system.

BACKGROUND: Milan System for Reporting Salivary Gland Cytology (MSRSGC) was introduced to standardise the terminology and reporting of salivary gland cytology. The purpose of our study was to compare the conventional system and the proposed Milan System to look for concordance rates in cytohistopathologic correlation and any value addition to the conventional system. METHODS: This was a retrospective cross sectional observational study. The fine needle aspiration cytology (FNAC) were reported in the conventional manner and were correlated with the surgical specimen. The cyto-histopathological correlation was studied to look for concordance rates. FNAC were retrospectively reviewed and were categorised according to the Milan system. These reports were correlated with surgical specimen category wise and concordance rates, risk of neoplasm (RON), risk of malignancy (ROM) were calculated. RESULTS: Salivary gland FNAC done during the study period was 323 in number and histopathological correlation was available for 153 cases. The concordance rate of type specific diagnosis was 80.3% as per conventional system. With the application of Milan system, the concordance rates rose to 88.07% with an improvement of 6.67%(excluding non-diagnostic). RON and ROM for non-diagnostic (I)-50%, 50%; non-neoplastic (II)-22%,0%; atypia of unknown significance (III)-66%, 11%; benign neoplasm (IVA)-98%, 3%; salivary gland neoplasm of uncertain malignant potential (IVB)-93%,14%; suspicious for malignancy (V)-100%, 60% and malignant (VI) was 100%, 94%. CONCLUSION: The broad categorisation provided by the Milan system represents the gross rate of malignancy and helps in deciding the management plan and eventual surgical plan. Thus, it adds value to conventional reporting of salivary gland cytology.

Risk of malignancy in Thyroid "Atypia of undetermined significance/Follicular lesion of undetermined significance" and its subcategories - A 5-year experience.

CONTEXT: Atypia of undetermined significance/Follicular lesion of undetermined significance [AUS/FLUS] is a heterogeneous category with a wide range of risk of malignancy [ROM] reported in the literature. The Bethesda system for reporting thyroid cytopathology [TBSRTC], 2017 has recommended subcategorization of AUS/FLUS. AIMS: To evaluate the ROM in thyroid nodules categorized as AUS/FLUS, as well as separate ROM for each of the five subcategories. SETTINGS AND DESIGN: Retrospective analytic study. METHODS AND MATERIALS: A retrospective audit was conducted for all thyroid fine-needle aspiration cytology (FNAC) from January 2013 to December 2017. Slides for cases with follow-up histopathology were reviewed, classified into the five recommended subcategories, and differential ROM was calculated. STATISTICAL ANALYSIS USED: z test for comparison of proportions was done to evaluate the difference in ROM among different subcategories of AUS/FLUS. The P value of less than 0.05 was taken as statistically significant. RESULTS: Total number of thyroid FNACs reported was 1,630, of which 122 were AUS/FLUS (7.5%). Histopathology was available in 49 cases, out of which 18 were malignant (ROM = 36.7%). The risk of malignancy (ROM) for nodules with architectural and cytologic atypia was higher (43.8%) than ROM for nodules with only architectural atypia (16.7%). CONCLUSIONS: The sub-classification of AUS/FLUS into subcategories as recommended by TBSRTC, 2017 may better stratify the malignancy risk and guide future management guidelines.

Unusually Large Brown tumor of Mandible in a Case of Secondary Hyperparathyroidism Mimicking Cherubism.

We report here a case of unusually large brown tumor of mandible mimicking cherubism in a patient with secondary hyperparathyroidism (HPT). The patient is a young male with a large head and a protruding jaw with an open mouth appearance. Initial clinical appearance looked like cherubism. However further clinical, biochemical, and radiological evaluation revealed a large brown tumor in a case of prolonged secondary HPT, which was confirmed on histopathology. All of the typical advanced radiological features of HPT were noted, highlighting the severity of progression of the disease. This case emphasizes the need for surveillance of serum calcium levels on routine biochemical investigations as to enable an early diagnosis of HPT. With timely proper management, such cases should be on the decline in the future.

Prospective analysis of 231 elective neck dissections in oral squamous cell carcinoma with node negative neck-To decide the extent of neck dissection.

OBJECTIVE: To evaluate the incidence of level IIB and IV lymph node metastases in patients of oral carcinoma with N0 necks. This study will help to decide the extent and need of routine comprehensive removal of these specific lymph node groups in selective neck dissection. METHODS: Prospective analytical study of 231 patients of oral carcinoma with N0 necks undergoing neck dissections were prospectively analyzed. The incidence of metastases at level IIB and IV were then observed. RESULTS: 71 (30.73%) out of 231 cases had microscopic metastatic lymphadenopathy. Lymph node metastases from oral cancers were seen predominantly at levels IB and IIA. Metastases at levels IIB and IV were very rare (0.86% and 0%, respectively). Metastases at level IIB was associated with metastases at the level IIA in both cases (100%) and with level IB in 1 case (50%). 27 (11.68%) out of 231 cases had positive IIA nodes and conversely, only 7.4% (2/27) of all level IIA metastases had positive nodes at level IIB. CONCLUSION: Selective neck dissection from I-III may be adequate for majority of patients with oral cancers. Level IIB and IV need not be dissected in N0 patients.

Impact of preoperative imaging on surgical approach for primary hyperparathyroidism: Data from single institution in India.

CONTEXT: Preoperative localization of parathyroid adenoma is essential in deciding the surgical approach of parathyroidectomy. AIM: To describe clinical and biochemical profile, evaluate preoperative imaging modalities and surgical approach in patients with primary hyperparathyroidism (PHPT). METHODOLOGY: This was a retrospective study conducted at the single institution. All patients who underwent evaluation and surgery for PHPT from 2011 to 2015 were included in the study. RESULTS: A total of 100 patients underwent surgery for PHPT. Mean (standard deviation) age was 51.6 (15.9) years with female to male ratio of 1.7:1. Forty patients had severe symptoms, and sixty had mild to moderate symptoms. The sensitivity of technetium-99m hexakis (2-methoxyisobutylisonitrile) (MIBI) scan and ultrasonography (USG) neck in identifying abnormal parathyroid gland was 93% (93/100) and 98% (98/100), respectively. The MIBI scan results of 90/93 (96.7%) patients corresponded with their surgical findings whereas preoperative USG findings of 96/98 patients (98%) showed correlation with operative findings. Intraoperative intact parathyroid hormone (IOPTH) levels at 10 min postexcision were measured in forty patients (minimally invasive parathyroidectomy = 38, bilateral neck exploration = 1, and unilateral neck exploration = 1). All patients except two had <50% fall in IOPTH. Adenoma weight was positively correlated with preoperative intact PTH. CONCLUSION: We found that USG has higher sensitivity (98%) than MIBI scan (93%) in localizing abnormal parathyroid gland. Moreover, USG had a higher preoperative localization accuracy (93%) than MIBI scan (90%), allowing to choose an appropriate surgical approach. A higher proportion of patients (60%) had mild/asymptomatic form of PHPT.

Isolated perifacial lymph node metastasis in oral squamous cell carcinoma with clinically node-negative neck.

OBJECTIVES/HYPOTHESIS: The incidence of occult perifacial nodal disease in oral cavity squamous cell carcinoma is not well reported. The purpose of this study was to evaluate the incidence of isolated perifacial lymph node metastasis in patients with oral squamous cell carcinoma with a clinically node-negative neck. The study will shed light on current controversies and will provide valuable clinical and pathological information in the practice of routine comprehensive removal of these lymph node pads in selective neck dissection in the node-negative neck. STUDY DESIGN: Prospective analysis. METHODS: This study was started in August 2011 when intraoperatively we routinely separated the lymph node levels from the main specimen for evaluation of the metastatic rate to different lymph node levels in 231 patients of oral squamous cell cancer with a clinically node-negative neck. RESULTS: The current study demonstrated that 19 (8.22%) out of 231 patients showed ipsilateral isolated perifacial lymph node involvement. The incidence of isolated perifacial nodes did not differ significantly between the oral tongue (7.14%) and buccal mucosa (7.75%). Incidence was statistically significant in cases with lower age group (<45 years), advanced T stage, and higher depth of tumor invasion. CONCLUSIONS: Isolated perifacial node metastasis is high in oral squamous cell carcinoma with a clinically node-negative neck. The incidence of isolated perifacial involvement is high in cases of buccal mucosal and tongue cancers. A meticulous dissection of the perifacial nodes seems prudent when treating the neck in oral cavity squamous cell carcinoma. LEVEL OF EVIDENCE: 4 Laryngoscope, 126:2252-2256, 2016.

ASYMPTOMATIC PRIMARY HYPERPARATHYROIDISM EXISTS IN NORTH INDIA: RETROSPECTIVE DATA FROM 2 TERTIARY CARE CENTERS.

OBJECTIVE: Primary hyperparathyroidism (PHPT) has evolved into an asymptomatic disease in the west. In contrast, classic symptoms of PHPT have been reported to be common in the east. Here we describe clinical and biochemical profiles of patients diagnosed with PHPT between 2009 and 2012. METHODS: This was a retrospective study conducted at 2 tertiary care centers in north India. All patients who underwent evaluation and surgery for primary hyperparathyroidism (PHPT) from January 2009 to December 2012 were included. RESULTS: A total of 50 patients were studied between 2009 and 2012. Among them 31 (62%) were symptomatic and 19 (38%) were asymptomatic. The mean age (SD) was 48.3 (15.8) years, and the female to male ratio was 1.9:1. None of the patients had brown tumors or bone deformities. The asymptomatic group had significantly lower median adenoma weight (0.57 vs. 3.4 g, P<.05), a higher mean age (57.3 vs. 42.8 years, P<.05), and a lower median intact parathyroid hormone (iPTH) level (254.5 vs. 295 pg/mL, P<.05) compared to the symptomatic group. Adenoma weight was positively correlated with baseline serum calcium, iPTH, and alkaline phosphatase (ALP) levels. CONCLUSION: The asymptomatic form of PHPT was found in a significant percentage of north Indian patients in this study. Asymptomatic PHPT patients were older in age and had lower parathyroid adenoma weights and iPTH levels compared to symptomatic PHPT patients. Positive correlations were found between parathyroid adenoma weight and serum calcium, iPTH, and ALP levels.