The histologic risk model is a useful and inexpensive tool to assess risk of recurrence and death in stage I or II squamous cell carcinoma of tongue and floor of mouth.

Surgery is the mainstay of treatment for low-stage (stage I/II, ie, T1N0/T2N0) squamous cell carcinoma of oral cavity. However, a significant percentage of low-stage squamous cell carcinoma of oral cavity will develop local recurrence and disease-related mortality. In this study, we stratified 64 patients with low-stage of oral tongue and floor of mouth patients into high-, intermediate- and low-risk categories based on existing histologic risk model. The classification of these risk categories was based on presence or absence of perineural invasion and evaluation of tumor-host junction for worst pattern of invasion and lymphocytic host response. We correlated risk category and other variables with recurrence and death. In a univariate model, high-risk category tumors had a significantly higher rate of recurrence and death due to recurrence compared with low/intermediate-risk categories (P=0.000 and P=0.047, respectively). Controlling for margin status and T-stage, high-risk category had a 12.4 odds ratio of later recurrence when compared with low/intermediate-risk categories, with a P-value of 0.001. In conclusion, we found low-stage oral cavity squamous cell carcinoma patients with high-risk category have a significantly higher risk for recurrence when compared with patients in the low- or intermediate-risk category, even when controlling for margin status and T-stage. These patients may be suitable candidates for adjuvant treatment to decrease morbidity and mortality associated with a recurrence. Our results indicate that the histologic risk model is a useful and simple tool to assess risk of recurrence in stage I or II squamous cell carcinoma of oral cavity.

Incomplete Thyroid Ultrasound Reports for Patients With Thyroid Nodules: Implications Regarding Risk Assessment and Management.

OBJECTIVE: The purpose of this study was to determine the completeness of thyroid ultrasound (US) reports, assess for differences in report interpretation by clinicians, and evaluate for implications in patient care. MATERIALS AND METHODS: We retrospectively reviewed thyroid US examinations performed between January and June 2013 in Nova Scotia, Canada. Baseline examinations that identified a nodule were evaluated for 10 reporting elements. Reports that lacked a comment regarding malignancy risk or a recommendation for biopsy were considered unclassified and were graded by three clinical specialists in accordance with the 2015 American Thyroid Association management guidelines. Interrater agreement was assessed using the Cohen kappa statistic. A radiologist reviewed the images of unclassified nodules, and on the basis of radiologic grading, biopsy rates and pathologic findings were compared between nodules that did and did not warrant biopsy. RESULTS: Of 971 first-time thyroid US studies, 478 detected a nodule. The number of reports lacking a comment on the 10 elements ranged from 154 to 433 (32-91%). A total of 222 nodules (46%) were unclassified, and agreement in assigned grading by the clinical specialists was very poor (κ = 0.07; p < 0.05). According to radiologist grading, only 57 of 127 biopsies were performed on nodules that warranted biopsy, and 16 of 95 biopsies were performed unnecessarily. On the basis of the three clinical specialists' interpretation, 10, 31, and 33 reports were considered too incomplete to assign a grade; 40, 10, and four biopsies would have been unnecessarily ordered; and zero, three, and four cancers would have been missed. CONCLUSION: There is widespread underreporting of established elements in thyroid US reports, and this causes confusion and discrepancy among clinical specialists regarding the risk of malignancy and the need for biopsy.

Florid Granuloma Annulare-Like Reaction in Regional Lymph Nodes After "Regression" of Red Pigment in Tattoos.

A healthy 50-year-old woman had a tattoo performed on the posterior aspect of her neck and another on the dorsum of her left foot. Several weeks later, she noted redness, tenderness, and intense pruritis at both tattoo sites. Treatment with cephalexin and hydrocortisone cream was instituted, without success. Within a few months, the red, but not black, pigment had disappeared from both tattoos and was replaced by pale areas of scarring. Persistently enlarged left supraclavicular and suboccipital lymph nodes were excised 7 and 10 months after receipt of the tattoos, respectively. The nodes were pigmented on gross examination, and on microscopy, a granuloma annulare-like reaction was observed. Normal lymphoid tissue was seen to be replaced by large palisading granulomas with central degenerative change, abundant stromal mucin, and scattered deposits of tattoo pigment. Histochemical stains, tissue culture, and serological studies revealed no evidence of infection. There are rare reports of granuloma annulare-like reactions in tattoos, and these are believed to represent delayed-type hypersensitivity reactions. Our case is unique in the observation of this reaction pattern in regional lymph nodes, and it expands the spectrum of complications known to be associated with tattoos.

Mammary analog secretory carcinoma, low-grade salivary duct carcinoma, and mimickers: a comparative study.

Mammary analog secretory carcinoma (MASC) is a recently recognized low-grade salivary carcinoma characterized by a specific ETV6 rearrangement. We describe 14 new MASCs and examine their immunophenotypic and genetic profiles in the context of look-alikes, namely, low-and high-grade salivary duct carcinoma and acinic cell carcinoma. ETV6 rearrangement, and robust expression of mammaglobin and S100, were demonstrated in 11/11, 14/14, and 12/14 MASCs, respectively. All low-grade salivary duct carcinomas coexpressed S100/mammaglobin (6/6); none harbored ETV6 rearrangements (0/5). Given that S100/mammaglobin coexpression and absence of zymogen granules are features of both MASC and low-grade salivary duct carcinoma, these two are best distinguished histologically. The former is predominantly an extraductal neoplasm with bubbly pink cytoplasm, whereas the latter is a distinct intraductal micropapillary and cribriform process. Querying ETV6 gene status may be necessary for difficult cases. No acinic cell carcinoma expressed mammaglobin (0/13) or harbored an ETV6 rearrangement (0/7); only 1/13 acinic cell carcinomas weakly expressed S100. DOG1 expression was limited or absent among all tumor types, except acinic cell carcinoma which expressed DOG1 diffusely in a canalicular pattern. Therefore, histology and immunohistochemistry (mammaglobin, S100, DOG1) suffices in distinguishing acinic cell carcinoma from both MASC and low-grade salivary duct carcinoma. HER2 (ERBB2) amplification was detected in only 1/10 acinic cell carcinomas, but none of the MASCs or low-grade salivary duct carcinomas tested. High-grade salivary duct carcinomas frequently expressed mammaglobin (11/18) and harbored HER2 amplifications (13/15); none harbored ETV6 rearrangements (0/12). High-grade salivary duct carcinomas can easily be distinguished from these other entities by histology and HER2 amplification.

Top Ten Oncocytic Head and Neck Lesions to Contemplate.

BACKGROUND: Oncocytes are a component of many metaplastic and neoplastic lesions throughout the head and neck area, primarily originating in salivary/seromucinous glands and the thyroid gland. In addition, other lesions can contain cells that mimic oncocytes (pseudo-oncocytes); these can be of epithelial or non-epithelial origin. METHODS: Review article. RESULTS: Oncocytic metaplasia is common in seromucinous glands throughout the upper aerodigestive tract, most notable in the oral cavity, nasopharynx and larynx. The main oncocytic salivary gland neoplasms are Warthin tumor and oncocytoma. Infarction of Warthin tumor may lead to recognition difficulties. Oncocytic subtypes of mucoepidermoid carcinoma and intraductal carcinoma have morphologic and immunohistochemical features that allow distinction from major oncocytic entities. Oncocytic thyroid tumors include adenoma, carcinoma (follicular, papillary and medullary), along with poorly differentiated tumors. Oncocytic papillary sinonasal and middle ear tumors must be distinguished from low grade adenocarcinomas. Pseudo-oncocytic entities include paraganglioma, Langerhans cell histiocytosis, giant cell tumor, rhabdomyoma, and metastatic tumors. CONCLUSIONS: Correct diagnosis of oncocytic head and neck lesions requires a knowledge of the spectrum of possible entities, their characteristic sites of occurrence, architecture, histomorphology, and immunohistochemistry. Oncocytic subtypes of several newly described entities are now recognized. Both epithelial and non-epithelial mimics of oncocytes exist. The molecular features of oncocytic tumors can be helpful in their diagnosis and understanding their pathogenesis.

Intraosseous Cavernous Hemangioma of the Middle Turbinate: A Case Report.

BACKGROUND: We report a case of an intraosseous cavernous hemangioma originating from the middle turbinate that expanded into the anterior skull base, without traversing the cribriform plate. METHODS: The mass was found incidentally after a computed tomography head was ordered for unrelated reasons. On questioning, the patient denied any nasal symptoms. Magnetic resonance imaging showed an enhancing mass and the radiological imaging supported a broad differential. RESULTS: The lesion was removed by endoscopic image-guided surgery, and the pathology was that of a benign intraosseous cavernous hemangioma. There was no residual hemangioma on postoperative imaging and the nasal mucosa healed well. This is the first report of an intraosseous cavernous hemangioma of the middle turbinate showing superior expansion to the anterior skull base. CONCLUSION: This case demonstrates the extent to which cavernous hemangiomas may expand into surrounding tissues. While these lesions are uncommon, they can be considered as part of a broad differential diagnosis of sinonasal tumors.

Frequency and accuracy of intraoperative bone margin sampling for T4a cancers of the head and neck at the QEII Health Sciences Centre: a retrospective chart review.

BACKGROUND: Stage T4a cancers are associated with a 5-year survival of 21.6-59.0%. Adequate resection of these tumors is a critical factor in maximizing survival. Tumors invading bone pose a unique challenge to intraoperative bone margin assessment. Due to processing limitations, there had been no formal standardized protocol for intraoperative bone sampling at the QEII Health Sciences Centre. These resections often involve extensive reconstruction, making salvage surgery difficult if positive margins are detected post-surgically. The purpose of this study was to assess the accuracy and frequency of intraoperative bone margin assessment during the study period and to determine survival and recurrence rates associated with positive final bone margins. METHODS: A retrospective chart review was conducted including patients with stage T4a head and neck cancer involving bone that underwent primary surgical resection in Nova Scotia between 2009 and 2019. Eligible patients were identified through the Cancer Care Nova Scotia registry. Exclusion criteria included patients with stage T4a tumors involving bone that did not receive primary surgical treatment with curative intent and patients with stage T4a tumors that did not invade bone. RESULTS: Of 67 patients included, 50 were amenable to intraoperative bone margin sampling while 18 had intraoperative sampling. Four patients had positive intraoperative margins and one had final positive bone margins. The incidence of final bone margin positivity was 7.5%. Median survival following surgery was 4.56 years for patients with final negative bone margins (n = 62) and 3.98 years for patients with positive final bone margins (n = 5). All patients with final positive bone margins received adjuvant radiation therapy. Of patients with negative final bone margins, 16.1% received no adjuvant therapy, 61.3% received adjuvant radiation therapy and 21.0% received adjuvant chemoradiation therapy. CONCLUSION: Intraoperative bone margin sampling occurred in 26.8% of all cases and 36.0% of amenable cases. Median survival of patients with positive final bone margins was 0.58 years lower than those with negative final bone margins, although this difference did not reach statistical significance. This will provide baseline data for comparison of the standardized intraoperative bone margin sampling protocol implemented at the QEII Health Sciences Centre.

The impact of national holidays on postoperative radiotherapy of squamous cell carcinoma of the head and neck.

Background: Delays in starting postoperative radiotherapy (PORT) have been established as negative predictors for clinical outcomes in head and neck squamous cell carcinomas (HNSCC). Our study aimed to examine the effect of delays during PORT, and the impact of national holidays in Canada, a publicly funded system, on oncologic outcomes such as Overall Survival (OS) and Local Recurrence (LR). Methods: The provincial cancer registry was queried to obtain demographic, pathologic, and outcomes data from cancer patients treated for all squamous cell carcinomas of the head and neck region treated between January 1, 2007 and November 30, 2019. All extracted information was cross-referenced and supplemented by chart review of patient electronic medical records. Extracted data were analyzed for OS and LR, in the context of Canadian national holidays causing delays during PORT. Results: 1433 patients treated for HNSCCs were identified, of whom 338 were treated curatively with surgery followed by PORT. 68.6% of patients experienced at least one day of interruption during treatments due to holidays. LR was 15.4% and OS was 59.6% at 5 years. Treatment interruptions by holidays were predictive of local recurrence (HR, 2.38; 95% CI 1.17-4.83; p = 0.017). Patients that developed early recurrence prior to PORT had very poor oncologic outcomes. Conclusion: Our findings were consistent with previously published studies in limiting the interval between surgery and PORT. We identified the novel finding of paired holidays as a significant predictor in determining LR, suggesting the importance of modifying RT delivery schedules and timing.

Margin Sampling and Survival Outcomes in Oral Cavity and p16-Positive Oropharyngeal Squamous Cell Carcinoma.

Objective: To compare the association of margin sampling technique on survival outcomes in surgically treated cT1-2 oral cavity and oropharyngeal squamous cell carcinoma. Study Design: A prospective longitudinal cohort study. Setting: Tertiary care academic teaching hospital in Halifax, Nova Scotia. Methods: All cases of surgically treated cT1-2 oral cavity and oropharyngeal cancer undergoing specimen-oriented margin analysis between January 1, 2017, and December 31, 2018 were analyzed. The specimen-oriented cohort was compared with a cohort of patients from January 1, 2009, to December 31, 2014, where a defect-oriented margin sampling protocol was used. Kaplan-Meier survival curves were used to estimate 2-year overall survival, disease-specific survival, local control, and recurrence-free survival rates in oral cavity and p16-positive oropharyngeal squamous cell carcinoma. Cox proportional hazards models were used to assess the effect of margin sampling method on disease-specific survival and local control. Results: There was no significant association between margin sampling technique and 2-year survival outcomes for surgically treated cT1-2 oral cavity and oropharyngeal squamous cell carcinoma. In the multivariate Cox proportional hazard model, the hazard ratio (HR) of specimen-oriented sampling was not significantly different for disease-specific survival (HR, 1.32; 95% CI, 0.3032-5.727; P = .713) or local control (HR, 0.4087; 95% CI, 0.0795-2.099; P = .284). Conclusion: Intraoperative margin sampling method was not associated with a significant change in 2-year survival outcomes. Despite no effect on survival outcomes, implementation of a specimen-oriented sampling method has potential for cost avoidance by decreasing the number of re-resections for positive or close margins.

A case report of surgical resection of secretory carcinoma in the maxillary and ethmoid sinus.

INTRODUCTION: Secretory Carcinoma is a recently discovered head and neck tumour. Surgical resection is generally the first line of treatment with neck dissection, radiation, and chemotherapy decided based on clinical, radiological, and histological parameters. We present a case of a Secretory Carcinoma presenting in the maxillary and ethmoid sinuses. CASE: A 39-year-old male presented with left nasal obstruction and chronic rhinosinusitis beginning after surgical repair of the mandible and maxilla due to facial trauma. A CT scan of the head showed soft tissue density in the left maxillary sinus extending through the ethmoid sinus and posterior nasal cavity. Functional endoscopic sinus surgery (FESS) was performed to remove the obstructing lesion. Biopsy was analysed and the main differential diagnosis was between a non-intestinal type adenocarcinoma of nasal origin and a salivary carcinoma. DISCUSSION: To our knowledge, there have only been two cases of Secretory Carcinoma reported in the sinuses: one case in the ethmoid sinus and the other in the maxillary sinus. This is the first to report follow up at 1 year. CONCLUSION: Both MRI and exam showed no evidence of recurrent disease at one year follow up. This report aims to further the understanding of Secretory Carcinoma tumours in the sinuses. Our report could be used to further understand diagnostic criteria for Secretory Carcinoma in the sinuses as well as treatment outcomes for surgical resection without adjuvant treatment.

Treatment Choices in Managing Bethesda III and IV Thyroid Nodules: A Canadian Multi-institutional Study.

OBJECTIVE: Patient-centered decision making is increasingly identified as a desirable component of medical care. To manage indeterminate thyroid nodules, patients are offered the options of surveillance, diagnostic hemithyroidectomy, or molecular testing. Our objective was to identify factors associated with decision making in this population. STUDY DESIGN: This is a retrospective cross-sectional study of patients with Bethesda III and IV thyroid nodules. SETTING: Multi-institutional. METHODS: Factors of interest included age, sex, socioeconomic status (SES), nodule size, institution, attending surgeon, surgeon payment model, and hospital type. Our outcome of interest was the initial management decision made by patients. RESULTS: A total of 956 patients were included. The majority of patients had Bethesda III nodules (n = 738, 77%). A total of 538 (56%) patients chose surgery, 413 (43%) chose surveillance, and 5 (1%) chose molecular testing. There was a significant variation in management decision based on attending surgeon (proportion of patients choosing surgery: 15%-83%; P≤.0001). Fee-for-service surgeon payment models (odds ratio [OR], 1.657; 95% CI, 1.263-2.175; P < .001) and community hospital settings (OR, 1.529; 95% CI, 1.145-2.042; P < .001) were associated with the decision for surgery. Larger nodule size, younger patients, and Bethesda IV nodules were also associated with surgery. CONCLUSION: While it seems appropriate that larger nodules, younger age, and higher Bethesda class were associated with decision for surgery, we also identified attending surgeon, surgeon payment model, and hospital type as important factors. Given this, standardizing management discussions may improve patient-centered shared decision making.

Data set for reporting carcinoma of the thyroid: recommendations from the International Collaboration on Cancer Reporting.

Thyroid cancer therapy is increasingly tailored to patients' risk of recurrence and death, placing renewed importance on pathologic parameters. The International Collaboration on Cancer Reporting (ICCR), an organization promoting evidence-based, internationally agreed-upon standardized pathology data sets, is the ideal conduit for the development of a pathology reporting protocol aimed at improving the care of patients with thyroid carcinomas. An international expert panel reviewed each element of thyroid pathology reporting. Recommendations were made based on the most recent literature and expert opinion.The data set uses the most recent World Health Organization (WHO) classification for the purpose of a more clinically and prognostically relevant nomenclature. One example is the restriction of the term minimally invasive follicular carcinoma to tumors with capsular invasion only. It reinforces the already established criteria for blood vessel invasion adopted by the most recent WHO classification and Armed Forces Institute of Pathology fascicle. It emphasizes the importance of the extent of blood vessel invasion and extrathyroid extension to better stratify patients for appropriate therapy. It is the first data set that requires pathologists to use the more recently recognized prognostically powerful parameters of mitotic activity and tumor necrosis. It highlights the importance of assessing nodal disease volume in predicting the risk of recurrence.The ICCR thyroid data set provides the tools to generate a report that will guide patient treatment in a more rational manner aiming to prevent the undertreatment of threatening malignancies and spare patients with indolent tumors the morbidity of unnecessary therapy. We recommend its routine use internationally for reporting thyroid carcinoma histology.

Ovarian Cancer Metastasis to the Larynx: A Case Report and Review of the Literature.

Laryngeal secondary malignancies are rare, and most spread locoregionally from hypopharyngeal or thyroid primaries. Metastasis of ovarian carcinoma to the larynx is extremely rare. A 65-year-old woman with a history of high grade serous ovarian carcinoma was undergoing carboplatin chemotherapy for recurrence. She presented with progressive dysphagia and hoarseness; a computer tomography (CT) scan demonstrated bilateral necrotic lymphadenopathy and hypopharyngeal fullness. A hypopharyngeal mass was confirmed on examination, and operative biopsy identified it as high-grade serous ovarian. To our knowledge, this report describes the second immunohistochemically proven metastatic ovarian cancer detected in the larynx in the world literature.

Primary parotid lymphoepithelial carcinoma: A case report and literature review of a rare pathological entity.

BACKGROUND: Lymphoepithelial carcinoma (LEC) of the salivary glands is a rare, but distinct, poorly-differentiated neoplasm that resembles undifferentiated nasopharyngeal carcinomas (NPC). Among primary salivary gland LECs, they most commonly arise in the parotid gland. These lesions have a noticeable racial predilection, mostly occurring in Asians and Arctic region native populations. They are strongly associated with Epstein-Barr virus (EBV), and are more common in EBV-endemic areas. The most common presenting symptoms of primary parotid LEC are parotid mass development and cervical lymphadenopathy. We report an unusual case of EBV-negative LEC in a Canadian Caucasian woman. CASE PRESENTATION: A 40-year-old female from Atlantic Canada presented with a rapidly enlarging preauricular mass and cervical lymphadenopathy. Preoperative diagnostics via radiology and fine needle aspiration alluded to an ambiguous primary parotid malignancy. She underwent a total parotidectomy with facial nerve sacrifice and ipsilateral selective neck dissection. The facial nerve was reconstructed with a lateral antecubital nerve graft. Pathology came back positive for LEC, and she began adjuvant radiotherapy. At her 1-year follow up, she was disease-free and obtained a House-Brackmann facial nerve function grade of 3. CONCLUSIONS: The case report highlights the importance of having a high index of suspicion and the need for interdisciplinary collaboration in reaching the diagnosis of primary parotid LEC. LEC can afflict patients of any ethnicity in non-EBV endemic areas and should therefore be considered in all patients with a painless parotid mass regardless of ethnicity. Further studies are required to elucidate the oncogenic role of EBV in these cancers.

Open resection and reconstruction of a Nasoseptal Chondrosarcoma: case report and literature review.

BACKGROUND: Primary chondrosarcomas of the nasal septum are rare, with a variety of clinical features that evade detection and treatment. While endoscopic surgery has become increasingly accessible, open approaches may be needed to provide adequate visualization for tumour ablation and reconstruction. We report the resection and reconstructive considerations of a septal chondrosarcoma. CASE PRESENTATION: A 75-year-old woman presented with a 3-year history of a slow growing, firm mass in the nasal tip causing protrusion and septal fullness. Computed Tomography scan of the paranasal sinuses revealed a well-circumscribed, 2.2 cm mass at the anterior nasal septum extending into the right vestibule. Biopsy of the cartilaginous lesion confirmed the diagnosis of a low-grade chondrosarcoma by histopathology. The tumour was removed using a transcolumellar open rhinoplasty approach with a large septal resection. Primary reconstruction of the surgical defect was performed using an L-shaped strut from the nasal keystone area to the columella. Follow-up examinations demonstrated no evidence of recurrent disease with satisfactory functional and cosmetic outcomes at 1-year. CONCLUSION: This report describes a case of nasal septal chondrosarcoma successfully treated with surgical excision using an open rhinoplasty approach. Only 5-10% of chondrosarcomas are located in the head and neck region and arise rarely in the nasal septum in approximately 2-4%. With this mass, an open rhinoplasty approach was required to allow optimal exposure of the margins and to facilitate reconstruction without disruption of normal sinonasal anatomy and function. Although rare, chondrosarcoma of the nasal septum should be considered in the differential diagnosis of nasal masses.

Patient and tumor factors contributing to distant metastasis in well-differentiated thyroid cancer: a retrospective cohort study.

BACKGROUND: Distant metastasis in thyroid cancer significantly reduces survival in patients with well-differentiated thyroid carcinoma (WDTC). There is limited information available to clinicians regarding pathological features that confer a higher risk of distant metastasis (DM). This study aimed to identify patient and tumor factors that were associated with the development of DM over time in patients with WDTC. METHODS: A retrospective cohort analysis of patients with WDTC (n = 584) at our institution was performed between 2007 and 2017. A total of 39 patients with DM and 529 patients with no DM (NDM) were included. Patient demographics, tumor characteristics and patient survival were compared between the DM and NDM groups using a univariate analysis. Multivariate Cox-proportional hazards model was used to evaluate the risk of developing distant metastasis over time. Kaplan-Meier analysis was used to compare survival between the DM and NDM groups. RESULTS: Distant metastasis had a substantial impact on disease-specific survival (DSS) at 5 and 10-years in the DM group; 71.0% (SE 8.4%) and 46.9% (SE 11.6%) respectively, compared to 100% survival in the NDM group (p < 0.001). The DM group had significantly higher proportions of males, lymphovascular invasion (LVI), nodal metastasis (NM), large tumor size (TS), extrathyroidal extension (ETE), positive resection margins, multifocality, follicular thyroid cancer (FTC), tall cell variant of papillary thyroid cancer (PTC), and Hurthle cell carcinoma (HCC), when compared to the NDM group (p < 0.05). A TS ≥ 2 cm (Hazard Ratio (HR) 1.370), NM (HR 3.806) and FTC (HR 7.068) were associated with a significantly increased hazard of developing distant metastasis in patients with WDTC. CONCLUSIONS: TS ≥ 2 cm, NM and FTC are associated with a significantly increased propensity for developing DM in our cohort of WDTC patients.

Intraoperative Primary Tumor Identification and Margin Assessment in Head and Neck Unknown Primary Tumors.

OBJECTIVE: Surgical management of the unknown primary head and neck squamous cell carcinoma (UP HNSCC) remains controversial due to challenging clinical diagnosis. This study compares positron emission tomography-computed tomography (PET-CT) findings with intraoperative identification of primary tumors and compares intraoperative frozen-section margins to final histopathology. In addition, adjuvant therapy indications are provided. STUDY DESIGN: Prospective cohort study. SETTING: Academic university hospital. SUBJECTS AND METHODS: Sixty-one patients with UP HNSCC were included. Patients received PET-CT, followed by oropharyngeal transoral laser microsurgery (TLM). Margins were assessed intraoperatively using frozen sections and afterward by final histopathology. Adjuvant treatment was based on final histopathology. RESULTS: The sensitivity of localizing the primary tumor with PET-CT was 50.9% with a specificity of 82.5%. The primary tumor was found intraoperatively on frozen sections in 82% (n = 50) of patients. Five more tumors were identified on final histopathology, leading to a total of 90% (n = 55). Of the 50 intraoperatively found tumors, 98% (n = 49) had negative margins on frozen sections, and 90% (n = 45) were truly negative on final histopathology. Eighteen patients (29.5%) avoided adjuvant treatment. CONCLUSION: PET-CT localized the primary tumor in fewer than half the cases. This protocol identified 90% of primary tumors. Intraoperative frozen-section margin assessment has shown potential with a specificity of 92% compared to final histopathology. As a result, adjuvant therapy was avoided in almost one-third of our patients.

Current Challenges in the Staging of Oral Cancer.

In the recently published 8th edition of the AJCC Cancer Staging Manual, new pathological elements are required for the N and T category determinations for oral cavity cancers. This includes determination of depth of tumor invasion and assessment of metastatic lymph nodes for extranodal extension. Although definitions and some guidance are provided for the interpretation of these elements, pathologists frequently encounter ambiguous situations that may result in interobserver and intraobserver variability. Pre-existing staging elements, such as assessment of bone invasion, can also be problematic to interpret. Difficulties in the interpretation of depth of invasion, bone invasion and extranodal invasion are discussed, with examples. Communication with the surgeon, proper specimen orientation, gross examination and sampling are crucial to assessment of these elements. Liberal use of deeper levels and submission of additional sections is suggested. Although general staging guidelines encourage clinicians and pathologists to choose the lower category when there is ambiguity, pathologists may choose to discuss difficulties in the interpretation of specific cases at interdisciplinary tumor boards, to allow a more informed choice of treatment on the part of treating physician and patient. More discussion is required among pathologists to develop specific guidelines for the interpretation of these staging elements.

An Unusual Case of Mandibular Squamous Cell Carcinoma in Intimacy with an Impacted Wisdom Tooth.

Squamous cell carcinoma is the most common head and neck malignancy. It can occur in the mandible or maxilla without a preexisting oral mucosal lesion. Often, the clinical and radiographic presentation of SCC directs the clinician to favour malignancy over other pathological conditions. However, SCC may also mimic an infectious condition and therefore can pose a diagnostic challenge even for the most experienced clinicians. Herein, we report a case of mandibular squamous cell carcinoma in a 53-year-old male who presented with symptoms of right facial swelling, trismus, pain, and right-sided lip paresthesia. The patient underwent a surgical removal of the presumed infected third molar of the right mandible, but histopathological analysis of the associated soft tissue unexpectedly yielded squamous cell carcinoma. Given the biopsy-proven diagnosis, the patient received a mandibular resection of the tumor followed by primary reconstruction with a fibular free flap. Patients presenting with symptoms mimicking odontogenic infections should receive vigilant attention by clinicians with regard to the disease history, clinical signs, radiographic evidence, and decision for histopathological analysis. This is especially true in the context of impacted dentition, where malignancy must be considered when formulating a differential diagnosis.