Epithelial-myoepithelial carcinoma of the maxillofacial and sinonasal region: a systematic review of presenting characteristics, treatment modalities, and associated outcomes.

Epithelial-myoepithelial carcinoma (EMC) is a rare salivary gland malignancy. Controversy exists in the literature regarding the effectiveness of treatment modalities employed in the management of EMC. This systematic review was undertaken to understand the presenting characteristics of EMC and identify the most common treatment modalities and their associated outcomes, in order to help guide an evidenced-based approach to the algorithm of care. The MEDLINE (PubMed) and Embase databases were searched (up to February 23, 2022), and the review was performed in accordance with the PRISMA statement. Fifty-seven studies (51 case reports and six case series) describing 91 cases of EMC were included in this review. In the included studies, a slow-growing painless mass was the most common presenting clinical feature. EMC was most frequently treated with surgery alone (65%). Local disease recurrence occurred in 24% of the cases and metastatic disease in 11%. A positive surgical margin was found to be associated with a higher risk of recurrence (P < 0.001), while adjuvant radiotherapy was associated with a decreased risk of local disease recurrence (P = 0.034). Metastatic disease and multimodal therapy were found to be associated with decreased disease-free and overall survival (all P < 0.05). The current literature supports surgery with clear margins as the mainstay of treatment for EMC of the salivary and seromucous glands of the head and neck. In certain situations, radiotherapy may improve disease-free survival.

Electrochemotherapy in the treatment of cutaneous malignancy: Outcomes and subgroup analysis from the cumulative results from the pan-European International Network for Sharing Practice in Electrochemotherapy database for 2482 lesions in 987 patients (2008-2019).

BACKGROUND: Electrochemotherapy (ECT) is a treatment for both primary and secondary cutaneous tumours. The international Network for sharing practices on ECT group investigates treatment outcomes after ECT using a common database with defined parameters. METHODS: Twenty-eight centres across Europe prospectively uploaded data over an 11-year period. Response rates were investigated in relation to primary diagnosis, tumour size, choice of electrode type, route of bleomycin administration, electrical parameters recorded and previous irradiation in the treated field. RESULTS: Nine hundred eighty-seven patients, with 2482 tumour lesions were included in analysis. The overall response (OR) rate was 85% (complete response [CR]: 70%, partial response rate: 15%, stable disease: 11%, and progressive disease: 2%). For different histologies, OR and CR rates for metastases of malignant melanoma were 82% and 64%, basal cell carcinoma were 96% and 85%, breast cancer metastases were 77% and 62%, squamous cell carcinoma were 80% and 63% as well as Kaposi's sarcoma were 98% and 91%, respectively. Variance was demonstrated across histotypes (p < 0.0001) and in accordance with size of lesion treated (dichotomised at diameter of 3 cm (p < 0.0001). Hexagonal electrodes were generally used for larger tumours, but for tumours up to 3 cm, linear array electrodes provided better tumour control than hexagonal electrodes (80%:74%, p < 0.003). For tumours more than 2 cm, intravenous administration was superior to intratumoural (IT) administration (p < 0.05). Current recorded varied across tumour histologies and size but did not influence response rate. In previously irradiated areas, responses were selectively lower for IT administration. CONCLUSIONS: These cumulative data endorse efficiency of ECT across a broad range of histotypes. Analysis of 2482 lesions details subgroup analysis on treatment response informing future treatment choices.

Immunotherapy in the management of squamous cell carcinoma of the head and neck.

Despite many advances in surgery, radiotherapy, and systemic treatments, only modest improvements in survival, function, and quality of life have been achieved after treatment of squamous cell carcinoma (SCC) of the head and neck. With a better understanding of the biology and genetics of tumours, the emergence of a paradigm shift towards the further development of non-surgical treatments may result in less morbidity and better outcomes than are seen currently. SCC of the head and neck is known to be a complex disease that has a sophisticated interaction with the human immune system. At the forefront of emerging treatments is immunotherapy, which has already been established in many other areas of oncology. The rapidly evolving nature of immunotherapeutic agents and, sometimes, their complex mechanisms can make the understanding of these concepts challenging, and could discourage clinicians from engaging in clinical trials. The aim of this paper therefore was to review the current premise for immunotherapeutic approaches, and to provide a contemporary evidence-based rationale for their use.

Recruitment of patients into head and neck clinical trials: acceptability of studies to patients from perspective of the research team.

We reviewed longitudinal recruitment data to assess recruitment into head and neck cancer trials, and to identify factors that could influence this and affect their acceptability to patients. We retrieved data from the prospective computerised database (2009-2016) to measure acceptability to patients using the recruitment:screening ratio, and compared observational with interventional studies, single specialty (or site) with multispecialty (or site) studies, and "step-up" randomisation with "non-inferiority" randomisation designs. A total of 1283 patients were screened and 583 recruited. The recruitment:screening ratio for all National Institute for Health Research (NIHR) portfolio studies combined was 0.47 (486/1133). Studies that involved treatment by several specialties or at several sites had a significantly adverse impact on acceptability (p=0.01). Recruitment into non-inferiority randomised controlled studies was lower than that into step-up randomised studies (p=0.06). The complexity of a study's design did not compromise recruitment. Treatment across several specialties or several sites and perceived non-inferiority designs, reduced the acceptability of some trials.

Management of cervicofacial infections: a survey of current practice in maxillofacial units in the UK.

Cervicofacial infections are common emergency presentations to maxillofacial departments in the UK, there is no consensus about their management and, in particular, the role of corticosteroids is not clear. Our aim was to find out the current practice of UK maxillofacial surgeons in managing these infections using a multicentre questionnaire study. The questionnaire was designed, piloted, and revised before distribution, and questions were asked to assess preoperative, operative, and postoperative management. It was distributed to maxillofacial surgeons throughout the UK through the Maxillofacial Research Trainee Collaborative (MTReC) network, and at the 2016 British Association of Oral and Maxillofacial Surgeons (BAOMS) Junior Trainees Group conference. A total of 350 questionnaires were distributed to 17 maxillofacial units. Eighty-six questionnaires were distributed at the BAOMS Junior Trainee conference. An overall response rate of 92% (n=324) was achieved. The results showed that there were important differences in reported practice between and within maxillofacial units in the UK in managing these infections. The antibiotic regimens and use of steroids varied widely. Twenty-three per cent of respondents had to wait over 24hours for access to emergency theatres. However, these results provide no hard evidence for or against the use of corticosteroids in cervicofacial infections.

Leading article: Use of smartphones to pass on information about patients - what are the current issues?

Many doctors now use mobile devices such as smartphones to communicate with one another about their patients, and sometimes this is without the knowledge and approval of their employer. We know of little information about the use of texting and other web-based messaging services by doctors in hospitals, so we reviewed relevant published studies to assess the safety and usefulness of current methods of digital communication.

To treat...or not to treat? Clinicians' views on the management of oral potentially malignant disorders.

Oral potentially malignant disorders (PMD) are recognisable mucosal conditions that have a variable and unpredictable risk of transformation to invasive squamous cell carcinoma (SCC). Modern management relies initially on clinical recognition of suspicious lesions and histopathological assessment and grading after incisional biopsy. However, it then varies from wide excision to observation and review, and depends not only on the severity of dysplasia but also on the clinician's preference as there is no high-level evidence to support best practice. We invited clinicians from oral and maxillofacial surgery, oral medicine, ear, nose, and throat (ENT), and plastic surgery, to complete an online questionnaire on current practice, which included 3 fictitious cases, to ascertain their views on the management of PMD and to find out whether they would be interested in becoming involved in a proposed future randomised controlled trial (RCT). Of the 251 who replied, 178 (71%) were oral and maxillofacial surgeons, and 99 (39%) expressed an interest in participating in a future RCT. Most respondents (n=164 or 99%) would always treat severely dysplastic lesions by excision or laser ablation, whereas only 8% (n=13) would always excise mild dysplasia. The greatest equipoise among those interested in taking part in a RCT was found in the case of moderate dysplasia for which 27% (n=27) favoured observation compared with surgical excision or laser ablation. This study shows that there is support for a multicentre, prospective RCT that compares observation with resection and laser ablation in patients with moderate dysplasia.

Sirtuins, bioageing, and cancer.

The Sirtuins are a family of orthologues of yeast Sir2 found in a wide range of organisms from bacteria to man. They display a high degree of conservation between species, in both sequence and function, indicative of their key biochemical roles. Sirtuins are heavily implicated in cell cycle, cell division, transcription regulation, and metabolism, which places the various family members at critical junctures in cellular metabolism. Typically, Sirtuins have been implicated in the preservation of genomic stability and in the prolongation of lifespan though many of their target interactions remain unknown. Sirtuins play key roles in tumourigenesis, as some have tumour-suppressor functions and others influence tumours through their control of the metabolic state of the cell. Their links to ageing have also highlighted involvement in various age-related and degenerative diseases. Here, we discuss the current understanding of the role of Sirtuins in age-related diseases while taking a closer look at their roles and functions in maintaining genomic stability and their influence on telomerase and telomere function.

An exploratory trial of preventative rehabilitation on shoulder disability and quality of life in patients following neck dissection surgery.

Patients commonly develop shoulder disability and reduction in quality of life (QOL) following neck dissection surgery. There is a lack of studies investigating the impact of preventative rehabilitation to prevent shoulder disability in this population. An exploratory trial was undertaken to investigate this gap in the head and neck cancer literature. Thirty-two subjects were randomly assigned to either one of two groups: early physiotherapy for a period of 3 months following surgery and current routine inpatient care and advice. Blinded measurement of shoulder function and QOL were recorded pre-operatively and at 1 year following surgery. No difference was found using between-group analysis (Mann-Whitney U-Test) for any outcome measures observed. Descriptive data analysis suggests that subjects receiving early physiotherapy had a perception of increased physical well-being when compared with subjects receiving routine care. There may be some clinical significance that subjects receiving a course of physiotherapy did appear to rate their physical well-being higher than those subjects not undergoing rehabilitation. Further research to investigate the preventative effects of physiotherapy on this population should consider the use of head and neck cancer-specific outcome measurement of both shoulder disability and QOL.

Lugol's iodine identifies synchronous invasive carcinoma--time for a clinical trial.

Lugol's iodine is currently under investigation as a technique to detect dysplasia, carcinoma in situ and invasive carcinoma at resection margins, plus further afield. Lugol's iodine is inexpensive and easy to use. We present two cases where the technique revealed abnormal mucosa (one carcinoma, one squamous cell carcinoma in situ) at distant sites from the tumour being treated within oral cavity and oropharynx.

Neck dissection and the clinical appearance of post-operative shoulder disability: the post-operative role of physiotherapy.

This paper critically reviews the literature, describing a post-operative phenomenon which is traditionally seen by physiotherapists in the immediate inpatient setting, following neck dissection (ND) for head and neck cancer. The presence and incidence of this condition is explored and the potential impact on the surviving patient's quality of life is considered. The nature and development of shoulder disability following ND is investigated and proposed roles of key anatomical structures involved are considered with relation to pathodynamics. A model for understanding the assessment and holistic management of this condition is offered and the potential implications for physiotherapy practice in primary care are considered.

The future of academic surgery--a consensus conference held at the Royal College of Surgeons of England, 2 September 2005.

A consensus conference organised by the Association of Surgeons of Great Britain and Ireland (ASGBI) and the Association of Surgeons of Training (ASIT) was held at the Royal College of Surgeons of England on 2 September 2005. All Specialist Advisory Committees and specialist associations were represented, except for orthopaedic surgery. The future of both academic surgery and training were discussed. We concluded that the European Working Time Directive, and Modernising Medical Careers are likely to have an adverse effect on future of research in oral and maxillofacial surgery. Most surgeons were concerned about the future of training and the development of surgery in general.

Dyskeratosis congenita.

Dyskeratosis congenita is an inherited disorder that usually presents in males, consisting of the triad of leukoplakia of the mucous membranes, nail dystrophy and skin pigmentation. Whilst most cases are X-linked, autosomal dominant and recessive forms have been reported. The significance of the condition lies in premature mortality arising from either bone marrow failure or malignant change within the areas of leukoplakia. Various mucocutaneous and non-mucocutaneous manifestations have been reported. The syndrome arises from an inherited defect within the DKC1 gene that codes for the protein dyskerin in the X-linked recessive form of the disorder, whereas mutations in the RNA component of telomerase (TERC) result in the autosomal dominant form of the condition. The identification of a white patch within the mouth of a child in the absence of any other obvious cause should arouse suspicion of this rare condition. Greater understanding of the molecular biology surrounding this syndrome should lead to improvements in diagnosis, monitoring of disease progression and therapy.

A new method for temporary maxillo-mandibular fixation.

We present a novel device which is an alternative to surgical wire for per operative maxillo-mandibular fixation prior to plate placement. It is easy to apply, causes minimal mucosal trauma and can be used in association with elastic chain.

Trainees' perceptions of UK maxillofacial training.

Training is a central component of the work of many units around the UK. Many changes to the way that junior doctors are trained have taken place over the past few years and maxillofacial surgery, of all the surgical specialities, has perhaps undergone the most far-reaching. A postal survey of 93 maxillofacial specialist registrars (SpRs) in all regions of the UK was carried out, of whom 81 (87%) responded. The aim was to seek their views on subjects directly related to the quality of, and access to, training. Information was gathered on age of trainees, entitlement to annual and study leave, certification for Advanced Trauma Life Support (ATLS) and office and research facilities.

Transient hemi-diaphragmatic paralysis following neck surgery: report of a case and review of the literature.

Diaphragmatic paresis following trauma to the phrenic nerves is a rare complication after neck surgery. The resulting elevation of the ipsilateral hemi-diaphragm is diagnosed on post-operative chest radiography and may be confirmed by ultrasound or fluoroscopy. When unilateral, this may lead to respiratory, cardiac or gastrointestinal symptoms and atelectasis and pulmonary infiltrates on radiography. If nerve damage is bilateral a period of ventilation may be required.

Aetiology of seroma formation in patients undergoing surgery for breast cancer.

Surgery for primary breast cancer and regional nodes often involves the use of suction drains post-operatively. It is believed that the fluid accumulating following axillary surgery is lymph from divided lymphatics or alternatively serum, although the composition of this fluid has never been studied in detail. Drain fluid following surgery for primary breast cancer was analysed for a number of haematological and biochemical parameters. Comparison of these values with plasma concentration produced a ratio that was compared with established lymph to plasma ratios. Haematological analysis indicates minimal contamination with blood. Comparison of drain fluid to plasma ratios with known lymph to plasma values for biochemical parameters showed that this fluid is compositionally different from lymph, but is similar to inflammatory exudate. Altering surgical technique to close dead space may avert the need for wound drainage, lead to reduced hospital stay and reduce the incidence of 'seroma' formation.