The Indications for Elective Neck Dissection in T1N0M0 Oral Cavity Squamous Cell Carcinoma.

PURPOSE: The management of the clinically node-negative neck in T1 oral cavity squamous cell carcinoma (SCC) is controversial. The purpose of this study was to investigate tumor characteristics of surgically managed patients with T1N0 oral cavity SCC and determine the possible benefits of elective neck dissection (END). MATERIALS AND METHODS: A retrospective cohort study was conducted assessing outcomes for patients with stage I oral SCC at Waikato Hospital, New Zealand, between 2008 and 2018. Clinical staging was based on the American Joint Committee on Cancer Cancer Staging Manual, 8th Edition. Patients with T1N0 SCC either had an END or had the neck observed. These data were used to determine the rate of occult nodal disease, recurrence rate, and survival. Data collected included patient demographics, location, tumor characteristics including differentiation, depth of invasion (DOI), perineural invasion (PNI), lymphovascular invasion, closest histologic margin, management of the neck, the number of pathologic lymph nodes, adjuvant treatment, recurrence, and survival. RESULTS: A total of 70 patients were included in the study (40 male, 30 female; age range 30 to 91; mean age 65 years). Twenty-seven (38.6%) patients underwent END, whereas 43 patients (61.4%) were observed. Occult nodal metastases were diagnosed in 6 of 27 (22.2%) patients who underwent END. Regional relapse occurred in 7 of 43 (16.3%) patients who were observed. Risk factors for nodal disease included increasing DOI ≥ 3 mm (P = .049), poor tumor differentiation (P = .003), and presence of PNI (P = .002). Negative prognostic factors for overall survival included male gender (P = .02, hr = 3.55, CI for HR (1.18, 10.65)), presence of PNI (P = .001, hr = 4.52, CI for HR (1.77, 11.57)), and locoregional recurrence (P < .005, hr = 6.55, CI for HR (2.69, 15.98)). Six of the 7 tumors that relapsed in the neck after observation had a primary tumor DOI < 3 mm. CONCLUSIONS: There is little data published for management outcomes of the node-negative neck in stage I oral squamous cell carcinoma. Given salvage neck dissection carries a poorer prognosis, END should be recommended for all T1N0 oral SCC with DOI ≥ 3 mm. In cases of DOI < 3 mm undergoing primary ablation only, a staging neck dissection as a second procedure should be considered in the presence of poor tumor differentiation or PNI on final histology.

Salivary gland tumours: an epidemiological review of non-neoplastic and neoplastic pathology.

Salivary gland tumours (SGT) demonstrate geographical variation. The primary objective of this study was to determine the types, frequency, distribution, and demographics of non-neoplastic and neoplastic salivary gland pathology at Waikato Hospital, New Zealand (NZ) over a 10-year period. Following this we conducted a 10-year retrospective review of SGT epidemiology from international literature. In total 825 patients were identified, 31% (256/825) with non-neoplastic salivary gland pathology, 34% (284/825) with benign neoplastic pathology, 14% (118/825) with primary malignant lesions, 18% (146/825) with metastatic SGTs, and 3% (21/825) with lymphoma. Patients had a mean (range) age of 58 (3-102) years, were predominantly male (58%, 476/825), and NZ European (65%, 536/825). Tumours were most prevalent in the parotid gland (85%, 484/569), of which 44% (211/484) were malignant. Pleomorphic adenoma was the most common benign (71%, 203/284) and overall (36%, 203/569) tumour, while mucoepidermoid carcinoma (25%, 29/118) and squamous cell carcinoma (SCC) (73%, 106/146) were the most common primary malignant and metastatic SGTs, respectively. Our literature review identified 18 studies consisting of 33,933 patients, of whom 71% (24,013/33,933) had benign SGTs. Pleomorphic adenoma (68%, 16404/24013) and mucoepidermoid carcinoma (29%, 2826/9621) were the most common benign and malignant SGTs, respectively. Low numbers of non-neoplastic and metastatic SGTs were reported in the literature. This research provides a greater understanding of differences in their global distribution. Consistent with previous literature, pleomorphic adenoma and mucoepidermoid carcinoma were the most common benign and malignant SGTs. In NZ, we found high rates of malignant SCC to the parotid gland, consistent with the epidemiology of non-melanoma skin cancer in the country.

Head and neck continued: a retrospective analysis of neck dissections from a New Zealand oral and maxillofacial surgery unit.

AIMS: The aim of this study is to analyse the demographics, diagnosis, nodal yield, metastatic rates and outcomes of patients undergoing neck dissections within the Waikato Hospital Oral and Maxillofacial Surgery (OMS) Department. METHODS: All patients that underwent neck dissections under the care of OMS at Waikato Hospital between January 2016 and December 2021 were included. Data on patient demographics, diagnosis, surgery details, nodal yields, histological results and clinical outcome were collected retrospectively for analysis. RESULTS: One hundred and five patients and 123 neck dissections were included in the final analysis. The median age was 65 years of age. The average nodal yield from a selective neck dissection of levels I-III was 20.1 and I-IV was 25.4. There was no metastatic nodal disease in level IIb, and only 2 neck dissections with nodal disease in level IV. Complications were mostly associated with free flap reconstruction rather than the neck dissection alone. CONCLUSIONS: The demographics and outcomes of the study cohort are consistent with both the current population and previously published head and neck data. The OMS unit at Waikato Hospital recommends omission of levels IIb and IV in neck dissections for cN0 cases if deemed oncologically safe to do so.

A five-year retrospective observational study of dental presentations to Waikato Hospital's emergency department.

AIM: Within New Zealand (NZ) there is limited research concerning demographics and utilisation of the Emergency Department (ED) for dental-related conditions. The aim of this research was to identify the prevalence of dental presentations to Waikato Hospital ED, defining patient demographics, discharge diagnoses, management, and re-presentation rates. METHODS: Patients who presented to the Waikato Hospital ED from 2015 to 2019 with ICD-10 dental diagnoses were included in the study. Data collected included patient demographics, discharge diagnosis and management of these presentations. Statistical analysis was completed using IBM SPSS Statistical Version 26.0. RESULTS: Over the five-year study period, 4030 presentations to Waikato Hospital ED were dentally related, making up 0.98% of all ED presentations. Patients were primarily male (54%), NZ European (45%) or Maori (42%), from regions of high deprivation, presenting outside of work hours (68%). Seventy-three percent of dental presentations were non-traumatic. Ninety percent of patients were discharged with symptomatic management. Of patients admitted only 4% required management under general anaesthesia (GA). Representation occurred in 6% of patients, primarily for non-traumatic dental disease (89%). Fifty-one percent of re-attenders were male, 42% Maori and 50% of patients had a deprivation index of 9 or 10. Forty-one percent of patients re-presented within a week. CONCLUSION: At Waikato Hospital, males, NZ European, and patients of high deprivation most commonly presented to ED for dental related presentation, which were primarily non-traumatic in origin. Many patients did not require hospital care, and were managed by ED and discharged. Few patients re-presented to ED for further care. Dental presentations to ED are potentially preventable, and may be related to barriers such as cost, access or health knowledge, or an increased need. Further research is required on strategies to reduce ED presentations for dental conditions.

Microvascular reconstruction outcomes from a New Zealand Oral and Maxillofacial Surgery Unit.

The Oral and Maxillofacial Surgery (OMS) Department at Waikato District Health Board (WDHB) is the only current OMS unit within New Zealand to reconstruct oral cavity defects with microvascular free flaps. The primary objective of the study was to retrospectively analyse the demographics, outcomes and complications of free flap surgery patients at WDHB.An OMS reconstruction database was developed and data collected retrospectively. 75 free flaps were performed on 74 patients between 2012 and 2020. There were 34 females and 40 males, with a mean and median age of 62 and 64 respectively. The tongue was the most common site of resection, and squamous cell carcinoma was the most frequent diagnosis. The radial forearm free flap was used most often followed by the fibula and anterolateral thigh flaps. The Clavien-Dindo classification was used to classify complications, with 10 patients having "major" complications and 34 patients having "minor" complications. Flap success rate was 98.7%, which meets internationally accepted standards of care.

Ameloblastoma: report on two cases and review of the literature.

The ameloblastoma is a benign odontogenic tumour that is locally aggressive and tends to recur following treatment. Several variants of this tumour exist, with the solid/multicystic and unicystic variants being the most common. We present 2 cases of mandibular ameloblastoma and review the recent literature.

Imaging of midface fractures-a retrospective study.

AIM: To determine the number of patients that received plain facial view radiographs as well as computed tomography (CT) scans in diagnosing their midface fractures. METHODS: Data was collected from our department of maxillofacial surgery trauma database. Patients with midface fractures sustained over an 18-month period were included (n=207) and further categorised into two groups; single-system facial trauma or multi-system trauma. Patient demographics, mechanism of injury, fracture location, modality of imaging and treatment were recorded. RESULTS: Of those with single-system facial trauma (n=158), 9% received plain films only, 50.5% received CT imaging only, while 40.5% received both plain films and CT. Of the population that received plain films, 82.1% of patients required a further CT scan to aid in diagnosis and treatment planning. Of those patients who received both modalities of imaging, 70% were surgically managed to reduce and/or fixate their fractures. All 49 patients with multi-system trauma received a brain/head CT as part of their routine trauma work-up, and 46 of these patients had adequate midface views included in this scan (93.9%). However, 6.1% of patients needed an additional facial bones CT for diagnosis of facial fractures. CONCLUSIONS: 40.5% of patients with single-system facial trauma received both plain radiographs as well as CT imaging. Additionally, 82.1% of all patients who had plain radiographs went on to have a further facial CT. Furthermore, 70% of these patients were surgically managed, inferring that this population may have benefitted from receiving a CT scan from the outset. This is not in line with the standard for pre-operative imaging of midface fractures in the literature, and a clinical pathway could be implemented across the Midland district health boards to guide the clinician in requesting appropriate pre-operative imaging of these fractures. This will aim to avoid delays in diagnosis, reduce radiation burden and create improved surgical planning and outcomes for our patients, while also enhancing healthcare resource allocation.

Fanconi anaemia and oral squamous cell carcinoma: management considerations.

Fanconi anaemia (FA) is a rare multi-system genetic disorder where patients are susceptible to the development of oral malignancies. Clinicians involved in their management should be vigilant in detecting lesions early, and an individualised treatment plan should then be formulated. Although surgery forms the mainstay of oncological treatment, adjuvant therapy can be instituted with care. Unfortunately, prognosis is poor, and close long-term follow-up is required. This short report describes pertinent management considerations in relation to a case of oral squamous cell carcinoma.

Immunohistochemistry of Five Molecular Markers for Typing and Management of Ameloblastomas: A Retrospective Analysis of 40 Cases.

PURPOSE: The aims of this study are to elucidate if molecular markers can be used to differentiate between the two main types of ameloblastoma (unicystic and solid/multicystic), and to determine whether a biologically 'less-aggressive' subtype exists. METHODS: A retrospective analysis of 33 solid/multicystic ameloblastomas and six unicystic ameloblastomas was completed using immunohistochemistry for five molecular markers: P16, P53, MMP-9, Survivin, and Ki-67. Tumors were graded as either negative or positive (mild, moderate, strong), and the results were related to both ameloblastoma subtypes and outcomes following treatment. RESULTS: Unicystic ameloblastomas were more likely to test strongly positive for P53 than solid/multicystic ameloblastomas (p < 0.05), whereas the latter were more likely to be negative for Survivin (p < 0.05). Solid/multicystic and Type 3 unicystic ameloblastomas that were positive for P16, but also negative for MMP-9 and Survivin, were less likely to recur than all other tumors (p < 0.05). The proliferation index of an ameloblastic carcinoma (11 %) was shown to be higher than benign ameloblastomas (4.5 %). CONCLUSIONS: Immunohistochemistry can be valuable in lesions where histological sub-typing of an ameloblastoma is unclear. A biologically 'less-aggressive' subtype may exist, and hence further research into this area is required.