Critical Review of the Current Evidence on Sentinel Node Biopsy in Oral Cancer.

PURPOSE OF REVIEW: With contemporary surgery of the cN0 neck in early oral cancer becoming more selective, sentinel node biopsy (SNB) is gaining popularity as a possible alternate option to elective neck dissection (END). This review attempts to critically appraise the current evidence and highlight pertinent arguments for the use of SNB in early oral cancers. RECENT FINDINGS: Based on the recent randomized trials, it is imperative to perform an END at the time of primary resection in cN0 oral cancers. The much criticized false negative rate of SNB can be argued to be equal to the regional failure rate after END for pN0 necks, possibly making a case for SNB due to the reduction in number of neck dissections. There still lies ambiguity on the technique, protocols, and benefit of SNB over END. The role of extended histopathological techniques and the implications of micrometastasis and isolated tumor cells for treatment intensification remain questionable. Currently, SNB is an intermediary between routine imaging and END that needs to evolve before it can become a practice changing alternative to END itself. More efforts are needed in standardizing the protocols for SNB.

Monolithic Approach for Next-Generation Aircraft Design Considering Airline Operations and Economics.

Traditional approaches to design and optimization of a new system often use a system-centric objective that does not consider how the operator will use this new system alongside other existing systems. When the new system design is incorporated into the broader group of systems, the performance of the operator-level objective can be sub-optimal due to the unmodeled interaction between the new system and the other systems. Among the few available references that describe attempts to address this disconnect, most follow an MDO-motivated sequential decomposition approach of first designing an optimal system and then providing this system to the operator who decides the best way to use this new system along with the existing systems. This paper addresses this issue by including aircraft design, airline operations, and revenue management "subspaces"; and presents an approach that could simultaneously solve these subspaces posed as a monolithic optimization problem. The monolithic approach makes the problem an expensive MINLP problem and is extremely difficult to solve. We use a recently developed optimization framework that simultaneously solves the subspaces to capture the "synergy" in the problem. The results demonstrate that simultaneously optimizing the subspaces leads to significant improvement in the fleet-level objective of the airline when compared to the previously developed sequential subspace decomposition approach. The results also showcase that maximizing revenue and minimizing operating cost independently need not lead to a maximized profit solution for the airline.

Incidence and impact of skip metastasis in the neck in early oral cancer: Reality or a myth?

OBJECTIVES: Varying evidence exists surrounding skip metastasis in clinically node-negative oral cancer. We aim to report its incidence, identify factors predicting its presence, and determine survival outcomes to possibly decide "adequacy" of neck dissection for this select group. METHODS: A review of audit records (clinical and pathologic) was undertaken to identify early stage (cT1/T2 cN0) oral squamous carcinoma patients operated between January 2016 and December 2020. Skip metastasis was defined as presence of nodal metastases distant from the primary tumour and at a lower level without metastases at levels above this. The factors predicting its presence were determined using chi-square and multivariate tests. Survival analysis was performed using Kaplan-Meier and regression hazard models. RESULTS: Occult metastasis rate was 17.9 % among 761 patients, with 47.1 % travelling to level I. Skip metastasis at level III was seen in 1.2 % and level IV was 0.3 %. Presence of PNI predicted the presence of skip metastasis at level III (p = 0.041, OR-0.241, 95 %CI 0.062-0.942) and no significant factors were identified for level IV. The 5-year disease-free survival was significantly reduced with isolated level IV metastasis (50 % vs 79.6 %, p = 0.017). Isolated occult metastasis at level Ia was in 0.3 %, all from tongue cancers. Their presence did not impact the 5-year overall survival (100 % vs 90.7 %, p = 0.628) and disease-specific survival (100 % vs 92.5 %, p = 0.675). CONCLUSION: The negligible incidence of skip metastasis to level IV in a clinically node negative neck suggests that clearance up to level III might be adequate in a large majority of patients.

Ponderous Pleomorphic Adenoma of Parotid Obscuring a Grievous Tumor of the Head and Neck: A Rare Case Report.

We present a rare case of simultaneous occurrence of pleomorphic adenoma of the left parotid gland and squamous cell carcinoma (SCC) of left buccal mucosa in a 59-year-old patient. The synchronous occurrence of these two entities has not been reported in the literature. A PubMed database search did not yield any results for search words involving "Oral Cancer," "Synchronous Oral Cancer and Pleomorphic Adenoma of Parotid gland" and "Oral SCC and Pleomorphic Adenoma of Parotid gland." Furthermore, synchronous development of these two tumors may give rise to diagnostic and ma?nagement conundrums as the parotid growth may be considered to be a nodal metastasis.

A contemporary narrative review to guide molecular epidemiology of oral submucous fibrosis.

Oral submucous Fibrosis (OSMF) is a chronic disease that mainly affects the upper part of the aerodigestive tract. Areca nut and betel quid chewing has been established as the most significant causative factor for this condition. While OSMF is a predominantly Asian disease, the migrant populations from the region have taken the disease across the globe. Additionally, areca nut is now easily accessible in flavors and aggressively marketed. Many research activities have been undertaken for decades to understand the etiopathogenesis and risk factors of OSMF. Although OSMF is a slowly progressing disease, it has the potential to transform to an oral malignancy. This article is an attempt to review the literature and provide an update on its prevalence, etiopthogenesis and its diagnosis. We also highlight certain clinical, histopathological and molecular features that aid in the diagnosis and prognostication of OSMF, highlighting the importance of identifying the possibly high risk OSMF that is prone to malignant transformation. Using this information, future directions can be developed to include treatmentof OSMF through a dynamic gene-specific approach.

Evaluation of Four Incisions Used For Radical Neck Dissection- A Comparative Study

Objective: To evaluate the four commonly used incisions for Radical Neck Dissection on the basis of certain defined parameters. Patients and Methods: The investigators designed and implemented a prospective comparative study composed of patients with oral squamous cell carcinoma. The predictor variable was time taken to raise and close the flaps, accessibility to the neck lymph nodes, injury to vital structures and scar cosmesis followed up to a period of three months. Descriptive statistics were computed. Results: The sample was composed of 40 patients grouped as follows: Macfee Incision (=10 patients), Modified Macfee Incision (=10 patients), Modified Schobinger Incision (=10 patients) and Reverse Hockey Stick Incision (=10 patients). Group A, consisiting of the patients with Macfee Incision, took the least time to close among all the groups ( Mean= 32.60 minutes) while Group C (patients with Modified Schobinger Incision) required the most time for closure ( Mean= 51.90 minutes). The Modified Schobinger Incision provided best exposure to neck node levels. The Macfee Incision was found to have the best scar cosmesis among the four incisions. Conclusion: The results of this study suggest that Modified Schobinger Incision is the preferred incision for adequate access to neck lymphatics while Macfee Incision was found to provide the best scar cosmesis.

Tumor Infiltration Depth as a Prognostic Parameter for Nodal Metastasis in Oral Squamous Cell Carcinoma.

Oral squamous cell carcinoma (OSCC) has locoregional evolution, with frequent neck involvement. Significant number of studies have been undertaken to assess the parameters for treatment of N0 neck patients with a high likelihood of harboring occult node metastases. Many studies have indicated tumor infiltration depth (or tumor thickness) as one of the most important criteria in determining the further management. Growing evidence in the literature shows that tumor infiltration depth is a reliable parameter for predicting regional node involvement and patient survival in OSCC. The substantial agreement among authors, despite the lack of comparable study groups, of measurement techniques, and cutoff values paradoxically enforced its reliability. Further studies are clearly awaited to reach a consensus on these topics to develop therapy protocols that are also based on this parameter. This article is an attempt to substantiate the use of tumor infiltration depth as a prognostic factor for nodal metastasis in OSCC.