Long-term effectiveness of lycopene in the management of oral submucous fibrosis (OSMF): A 3-years follow-up study.

BACKGROUND: Long-term follow-ups after receiving lycopene therapy for management of oral submucous fibrosis (OSMF) are scarce. The study aimed to assess the long-term efficacy of lycopene for management of OSMF symptoms. METHODS: In this prospective clinical study, 400 clinically diagnosed early OSMF patients were assessed for the efficacy of lycopene in alleviation of burning sensation (BS) and reduced mouth opening (MO) symptoms in comparison to placebo. After 1-year follow-up, group A (lycopene group) was divided equally into group A1 and group A2. group A1 patients were retreated with lycopene and the A2 group was followed without retreatment. After 2-year follow-up, the Group A2 patients were advised retreatment but not followed as most of the patient did not agree for follow-up. However, group A1 patients were continued to follow-up every 6 months for a total three years. Statistical analysis was by independent sample t-test and P-value <.05 were considered as significant. RESULTS: A statistically significant difference (P < .05) in BS and MO was found between group A and B with lycopene showing better results. At one-year follow-up, a statistically significant recurrence in the symptoms was found (P < .05) in the lycopene group (group A). After the second intervention, there was a statistically significant difference in the improvement of symptoms between the group A1 and A2 at 6 months and 1 year (P < .05) with group A1 (retreatment) showing better results. CONCLUSIONS: Treatment with lycopene led to improvement in the symptoms of OSMF in the present study. The results highlight the importance of retreatment of lycopene for its long-term effect on alleviation the symptoms of OSMF.

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.

Micro-metastasis and isolated tumour cells: the span between elective neck dissection versus neck observation in early oral cancer.

Early oral squamous cell carcinoma (SCC) has a propensity for lymph-node metastasis. To address or not to address the neck electively during the ablative surgery has been an ongoing debate. In recent years, some practice-changing trial and systematic reviews have emerged and put to rest the discussion of elective neck dissection versus neck observation. Today elective neck is not a mere staging procedure. It has a definitive survival advantage, but the pathological basis of this advantage has not been elaborated. Understanding this could help answer some of the critical aspects of tumour spread.

Modified facelift approach for posterior segmental mandibulectomy: a blend of oncology and cosmesis.

BACKGROUND: The approach to the mandible for segmental resection in malignant pathologies entails a lip-split, angle-split or visor flap incision with extension of the incision into the neck for performing neck dissection. The modified facelift approach with robot-assisted neck dissection can be used to achieve oncologically safe resections with good cosmesis. METHODS: Three patients meeting the inclusion criteria underwent the procedure at the Robotic facility of HCG Cancer Centre, Bangalore. RESULTS: The patients were analyzed on the basis of bone defect length, the margin status of primary, functional and aesthetic outcomes. One patient had wound dehiscence and needed secondary suturing. At 6 months, patients were satisfied with the aesthetic outcomes and functional results CONCLUSION: Modified facelift approach is a feasible procedure ensuring better cosmesis without compromising oncological outcomes.

Is EGFR really a therapeutic target in head and neck cancers?

Epidermal growth factor receptor (EGFR) is overexpressed in 90% to 100% of squamous cell carcinoma of the head and neck (SCCHN). The overexpression of EGFR and its ligand transforming growth factor is associated with poorer survival. EGFR inhibitors such as Cetuximab (Erbitux) have shown a significant antitumoral effect in SCCHN and has improved locoregional control and as well as survival. Even though there was some success with Cetuximab, work with other EGFR inhibition has not been very fruitful and not really shown any promise. Mechanism of action of Cetuximab could be immune-mediated rather than EGFR inhibition and EGFR may not necessarily be a therapeutic target in SCCHN.

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.

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.

Allergic Fungal Otomastoiditis: A Case Report and Review of Literature.

Allergic fungal otomastoiditis, a rare known entity has only been published as case reports in literature. There have been 3 cases of adult and 1 case of pediatric allergic fungal otomastoiditis reported as of now. A young male had unilateral otorrhea and hearing difficulty for four years. The audiogram revealed moderate conductive hearing loss and radiograph showed complete opacification of tympanic cavity. He underwent tympano-mastoidectomy, showing polypoidal granulations and thick mucoid discharge. The histopathology was a surprise diagnosis of Allergic fungal otomastoiditis. The clinical and histopathological appearance of this entity matches allergic fungal rhinosinusitis. After extensive review of literature, we propose a working criterion for early identification of allergic fungal otomastoiditis in otolaryngology setting.

Transoral Laryngeal Surgery in Low-grade Myofibroblastic Sarcoma of Larynx: A Plausible Treatment Option.

The laryngeal tumor type, location and disease extent are essential determinants in deciding the type of surgery and the potential voice and swallowing outcomes. The surgical options available are conservative laryngeal surgeries like transoral laser microsurgery (TLM) or open conservative laryngeal surgery and Total laryngectomy. We report an unusual case of low-grade Myofibroblastic sarcoma of vocal cord which was managed by TLM.

Cysticercosis Infested Pectoralis Major Myocutaneous Flap Reconstruction: An Ethical Dilemma.

Disseminated cysticercosis is a rare manifestation of cysticercosis, a relatively common tropical disease in Asia, Africa and South America. Here the embryo of pork tapeworm Taenia Solium gets disseminated to multiple organs and tissues via hepatoportal system. we report here a 45 year gentleman with stage IV oral malignancy who was incidentally found to have disseminated cysticercosis on pre-operative work up. Along with the management of primary cancer and new found asymptomatic disseminated cysticercosis, the ethical challenge was to choose an appropriate reconstructive option for the composite oral cavity resection defect, since all the skeletal muscles in body where studded with cysticercosis larvae. We couldn't find any such report in literature to resolve our dilemma. After surgical board discussion, we zeroed down to pedicled pectoralis major myocutaneous flap, the most versatile and workhorse flap for head and neck reconstruction. Eventually the patient underwent surgery and adjuvant radiotherapy without any delay. He was simultaneously treated with oral albendazole under steroid cover and remained complication free at 2 years.

3D Patient-Specific Biomechanical Model of the Tongue for the Management of Tongue Tumors: Conceptualization to Reality.

Objectives: Increasing use of tobacco by the younger generation has resulted in an increase in oral cavity tumors. Surgical treatment is radical and results in severe functional morbidity. Using computer-aided designing technology, surgical and rehabilitative planning can be better. We present here our concept of a patient-specific biomechanical 3D model of the tongue and its clinical utility in the management of tongue tumors. Methods: Using fused deposition modeling, the 3D model of the tongue was printed which easily differentiates the tumor and the uninvolved tongue by printing in two different colors. The 3D tongue model was used by the surgical and rehabilitation teams to frame the treatment and plan the rehabilitation taking into account the patient preferences and needs. The model was used in two patients with operable squamous cell carcinoma (SCC) of the tongue, and the utility of the model in margin planning, surgical defect assessment, and its aid in the reconstruction and rehabilitation was assessed. Results: Two patients with Stage III SCC of the tongue underwent the surgery based on the plan evolved from the 3D model. All the surgical margins assessed by the frozen section analysis were clear. The model helped in addressing the discordance between patient expectations and surgical outcomes. We found that the model aided the reconstructive surgeon in planning the flap harvest based on the pre-operative defect assessment, which, in turn, translated into better rehabilitative outcomes. Conclusion: 3D biomechanical tongue model is a novel concept and aids in improving the overall treatment outcomes. The realistic 3D reconstructed image model helps the oncologist in planning the resection, enables the reconstructive surgery to more precisely predict the defect volume, and lastly the rehabilitative team in developing better rehabilitation strategies.

The spiral ladder technique of facial nerve trunk identification during parotidectomy: A convenient roadmap for the beginners.

The intricate relationship between the facial nerve and the parotid gland makes the surgeries involving the gland challenging. Though several landmarks have been described to locate the nerve trunk, variations do exist due to the physical and racial characteristics of an individual. The spiral ladder technique described here uses multiple landmarks that appear in a stepwise manner as a beginner proceeds through the surgery as a road map to the nerve trunk. This simple adoption of a cluster of existing landmarks increases the certainty factor. This method may help beginners and in turn, reduce the chances of iatrogenic facial nerve injuries.

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.

Swallowing: A delayed milestone post-surgery in tongue cancers.

Functional rehabilitation remains an important factor in the post-operative period following tongue cancer surgeries. Patients undergoing surgery for tongue cancers require intense rehabilitation in order to restore their swallowing function, and improve their nutritional status and quality of life. Various swallowing scales like the Functional Oral Intake Scale (FOIS), Performance status scale in head and neck cancer (PSSHNC) and 100 ml water swallow test are used to assess functionality in these patients. These aid in timely assessment and early intervention for better rehabilitation, in turn improving quality of life. Nasogastric tube (NG) or percutaneous endoscopic gastrostomy (PEG) aids in providing adequate nutrition in the immediate post-operative period and during adjuvant therapy to overcome radiation-induced dysphagia.

Residual Thyroid Tissue on Postoperative Diagnostic 131 I Radioactive Whole-Body Scan After Surgery in Differentiated Thyroid Cancer: A Tertiary Referral Centre Experience.

Residual thyroid tissue after total thyroidectomy in differentiated thyroid cancers is considered an independent risk factor for recurrence. Guidelines recommend following up patients after surgery with thyroglobulin (Tg), neck ultrasonography, and occasionally whole-body radioactive scan. However, the results of serum thyroglobulin and whole-body radioiodine scan are often discordant. The present study was undertaken to determine the levels of serum-stimulated thyroglobulin to complement the findings of residual thyroid tissue in the radioactive whole-body scan. One hundred twenty-six patients had undergone a radioiodine (131 I) whole-body scan (WBS) during the study duration, and 121 were available for analysis. The thyroglobulin level (measured by the CLIA method) was recorded at the time of these scans. The data was analysed to determine the level of stimulated thyroglobulin correlating with residual thyroid tissue, locoregional, and distant metastasis as assessed by WBS. The presence of residual thyroid tissue was noted in an overwhelmingly high 94% of cases. Twenty-four of the 28 patients with stimulated Tg < 2 ng/dl had residual thyroid tissue on a WBS. The discordancy rate (positive moderate - large WBS and negative serum thyroglobulin) of 64.28% was seen. Using ROC the serum thyroglobulin cut-offs levels for the loco-regional disease were found to be 27.705 ng/dl and 94.770 ng/dl for distant metastasis. The results highlight the fact that serum Tg levels cannot be used as an accurate predictor of the extent of the remnant thyroid tissue. Irrespective of the quality of surgery, which was analysed based on the centre and surgical specialty, over 90% of cases had residual thyroid tissue on WBS. The use of only stimulated Tg levels for follow-up may be inaccurate. Serum Tg is a useful test along with radioactive whole-body scans to distinguish local disease, loco-regional disease, and distant metastasis.