A unique location of branchial cleft cyst: case report and review of the literature.

Branchial cleft cysts (BCC) are benign lesions caused by anomalous development of the branchial apparatus. This case report describes a 63-year-old woman with a 12 cm×12cm sized cystic mass located anterior to the manubrium sternum and sternum. MRI revealed a cystic lesion with a sinus tracking to the piriform sinus. Postoperative histopathological examination confirmed the diagnosis of branchial cleft cyst. Because of the course of the sinus track, it is believed that this was a fourth branchial cleft cyst. These are the rarest of the branchial anomalies, and extension below the peri-thyroid region is very infrequently described. When this extension occurs, it is always post-sternal into the mediastinum, and the pre-sternal presentation here appears to be unique. A review of the relevant literature was performed to summarize the clinical features of fourth branchial cleft cyst and to identify the best options for diagnosis and treatment.

Head and neck cancer surgery in an elderly patient population: a retrospective review.

Should advanced age be a contraindication to the surgical management of head and neck cancer patients? A retrospective chart review was performed of patients aged ≥80 years treated surgically for a head and neck malignancy during the period 1996-2011 in a tertiary care cancer centre. The average follow-up was 32 months. Fifty-three patients were identified (mean age 85 years). Cardiovascular disease was the most prevalent co-morbidity (43%). Forty-five patients (85%) had oral cavity/oropharynx squamous cell carcinoma. Surgeries performed included 40 neck dissections and 12 microvascular free flaps. The average length of hospital stay (LOS) was 6.4 days. An increased LOS was significant in patients requiring free flap reconstruction (P<0.01). There were no perioperative deaths or free flap failures. The most common postoperative complications were cardiovascular (n=8), infection (n=10), and delirium (n=6). Thirty-four patients were discharged directly home. Free flap reconstruction did not adversely affect discharge disposition (P>0.05). More than 75% of patients did not report any major limitations to their activities of daily living. Major head and neck surgical procedures can be tolerated by patients of advanced age using careful patient selection. Age alone should not be a primary factor in the management of head and neck cancer patients.

Surgical management of the N0 neck in early stage T1-2 oral cancer; a personal perspective of early and late impalpable disease.

INTRODUCTION: The management of the N0 neck in early stage oral cancer remains controversial. The evidence in the literature for elective neck dissection, which is reviewed in this paper, is conflicting. My personal view is that most papers mistakenly assume that the N0 equates to an "early stage" neck whereas a neck with palpable nodes represents disease at a "late" stage. DISCUSSION: I believe that this is the same mindset that prevented us from realizing that depth rather than size was the important prognostic determinant for the primary tumor; because the T stage was based on tumor size. The N stage is also based on size and number of nodes and by these criteria N0 would be the earliest stage. However, although an N0 neck with impalpable intra-nodal disease may be regarded as early impalpable disease an N0 neck with microscopic extra-capsular spread (ECS) would be "late/advanced" impalpable disease. Likewise, a clinically positive neck with intra-nodal disease still represents early disease compared to a clinically positive neck with ECS. CONCLUSION: The lack of trials and studies stratifying NO and N +ve necks into early and late disease and comparing outcomes between these cohorts may explain the lack of clear-cut evidence regarding the role for elective neck dissection.

Sublingual lymph node metastasis of early tongue cancer: report of two cases and review of the literature.

Sublingual lymph node metastasis of early stage squamous cell carcinoma of the tongue (SCCT) is seldom reported. Lymphatic tissue in the floor of mouth, which intervenes between the tongue and neck, will be left behind by a primary tumour resection with discontinuous neck dissection. The authors present two cases of early stage SCCT with sublingual lymph node metastasis, review the literature, and discuss the management of the floor of mouth for early stage SCCT. The authors suggest that more attention should be paid to possible sublingual lymph node metastasis for T1/T2 SCC of the ventral tongue with deeply endophytic infiltration.

Osteochondroma of the condyle: review of 8 cases.

This study is a retrospective review of the records of all cases treated in the authors' department since 1991 to identify patients with condylar masses diagnosed as osteochondromas. In 2186 cases of benign and malignant cysts/tumours of the maxillofacial region (1560 malignant and 626 benign), 8 osteochondromas of the mandibular condyle were identified. These 8 cases and the current English literature are reviewed.

Free-flap failures and complications in an American oral and maxillofacial surgery unit.

Free tissue transfer is a reliable surgical technique that enables primary reconstruction following ablative surgery. Widely practised in many European units, acceptance into mainstream oral and maxillofacial surgery in the USA has been slow. The authors reviewed free flap practice patterns and outcomes in a US oral and maxillofacial surgery training program with specific emphasis on failures and complications to illustrate obstacles encountered during the initial phase of practice implementation. The demographic and clinical data of 71 consecutive patients who underwent microvascular reconstruction over 3 years (2002-2005) were reviewed. The study group included 48 males and 23 females who underwent 72 free tissue transfer procedures. Fourteen patients required operative exploration in the perioperative period. Six patients were explored for clinically compromised flaps. Thrombotic events occurred in 4 patients; 1 flap was successfully salvaged. There were 4 flap failures and 9 complications related to the donor site. Two perioperative deaths occurred from non-flap-related complications. Prolonged hospital stay and ICU utilization was observed in patients with surgical complications. Complications in this study did not affect the overall success rates of free-flaps. Salvage rates from thrombotic events were unaffected despite rigid flap monitoring protocols.

Treatment rationale for pathological fractures of the mandible: a series of 44 fractures.

This paper reports on the largest series of pathological fractures of the mandible (n=44) in the literature, with the aim of proposing an aetiologic classification and algorithm for treatment. A retrospective review was undertaken of cases treated in the Department of Oral and Maxillofacial Surgery at the University of Maryland Medical Center from 1991 to 2005. Data collected included age, gender, race, aetiology, site, management and outcome. Forty-three patients with 44 pathologic fractures were included. The most common aetiology was osteoradionecrosis (49%), followed by infections (19%) and malignancy (19%). The most frequent primary treatment utilized was mandibular resection of diseased bone and fixation with a locking reconstruction plate alone (55%). Either primary or secondary mandibular reconstruction was performed when co-morbid disease allowed such treatment. Management of pathological fractures is aimed initially at systemic issues, followed by focusing on site-specific issues. This is a complex problem with a 40% complication rate, with radiation therapy associated with 59% of the complications. Free flap reconstruction should be considered when possible, especially in cases secondary to osteoradionecrosis.

Paediatric necrotizing fasciitis complicating third molar extraction: report of a case.

Necrotizing fasciitis is an uncommon but well-described entity. In the paediatric population compromising risk factors are frequently absent. We describe the successful treatment of a case of cervicofacial necrotizing fasciitis in a healthy 14-year-old male following routine extraction of an uninfected wisdom tooth for orthodontic purposes.

Vanishing bone disease in a five year old: report of a case and review of the literature.

Vanishing bone disease is a rare condition of unknown aetiology. It can affect almost any bone, including those of the maxillofacial region. It is most commonly seen in the second and third decades of life. To the author's knowledge, this is the second case reported in the maxillofacial region of a child within the first decade of life, and the first who survived.

Variations in the course of the hypoglossal nerve: a case report and literature review.

The extracranial hypoglossal nerve has a well described course as it traverses the neck, and is frequently identified during neck dissection, carotid endarterectomy and other procedures involving the deep spaces of the neck. A case is presented which demonstrates aberrancy of its anatomic position. Variations of its course are well documented, however none have demonstrated a course lateral to the internal jugular vein. This serves to alert the surgeon to be mindful of such atypical presentations as the consequences of iatrogenic injury to such structures may be significant.

Paediatric mucoepidermoid carcinoma of the palate.

The purpose of this paper is to review our experience with mucoepidermoid carcinoma (MEC), a rare tumour in minor salivary glands, in a small series of paediatric patients. A retrospective analysis of minor salivary gland tumours seen by one surgeon from March 1991 to December 1999 was undertaken. A total of 58 cases were identified and of these, five (9%) occurred in children. There were 23 cases of MEC, four (17%) of which occurred in patients under the age of 18 who presented with T1 or T2N0M0 low- to intermediate-grade MEC of the palate and adjacent structures. These patients form the basis of this study. All patients were treated with wide local excision, obtaining tumour-free margins, and followed for a mean number of 58 months. None of these tumours invaded bone and resection of bone was not performed in any case as the periosteum was intact and the tumours were low to intermediate grade. To date, all patients remain free of disease. One patient who went elsewhere for treatment, was treated with local resection only, and has also experienced no recurrence. Wide local excision is the treatment of choice for low to intermediate grade MEC of the minor salivary glands in paediatric patients.

Ameloblastoma in children.

PURPOSE: The purpose of this report was 1) to report the experience of the University of Maryland, Department of Oral and Maxillofacial Surgery (OMS Department) in the treatment of ameloblastoma in children and 2) to review the world literature on the treatment of ameloblastoma in children from 1970 to 2001. METHODS AND MATERIALS: This study first reviews the experience of the OMS Department of the University of Maryland with ameloblastomas in children and then reviews the literature on this subject. The first part of the study was undertaken by a retrospective chart review of all patients with a diagnosis of ameloblastoma in the OMS Department between May 1991 and December 1999. The literature on ameloblastoma in Western societies and Africa was separately reviewed from 1970 through 2001. Reports earlier than 1970 were not reviewed, as the histologic diagnosis of ameloblastoma was not well defined before that period. RESULTS: In the Maryland series, 11 patients under the age of 20 years with ameloblastoma were treated. Eight patients were seen primarily, and 3 presented with recurrent lesions. The average age was 15.5 years; 5 of 11 patients were black, and 9 of 11 tumors were unicystic ameloblastomas. The literature review showed 85 children in the Western reports and 77 reported from Africa. The average ages were 14.3 and 14.7 years, respectively, but unicystic ameloblastomas accounted for 76.5% of the Western and only 19.5% of the African children, with an increased frequency of occurrence in the mandibular symphisis in African (44.2%) versus Western (5.8%) patients. Analysis of recurrence after enucleation of unicystic ameloblastomas in 20 children followed at least 5 years or until recurrence showed a recurrence of 40%. CONCLUSIONS: Ameloblastomas in children differ from adults, with a higher percentage of unicystic tumors. African children appear to resemble the adult pattern. Although enucleation has been claimed to give acceptable recurrence rates in unicystic ameloblastoma, there are no large series with long follow-up in children. The histologic pattern that exhibits mural invasion in unicystic ameloblastoma suggests that more aggressive surgery is necessary.

Amplification and protein expression of chromosome 12q13-15 genes in osteosarcomas of the jaws.

Overexpression and amplification of several genes (MDM2, CDK4 and SAS) located on chromosome 12q13-15 have been noted to occur in various human sarcomas. As a result, two major growth regulation pathways may be inhibited. MDM2 may down regulate the p53-mediated growth control and CDK4 may affect pRB-mediated events. To determine the frequency of alterations in these genes and their correlation with clinicopathologic features, we analyzed the MDM2 and CDK4 protein levels by immunohistochemistry and assessed MDM2, CDK4 and SAS amplification by real-time PCR in nine osteosarcomas of the jaws. Positive staining for CDK4 and MDM2 was observed in eight cases (88.8%) and five cases (55.5%), respectively. Intense CDK4 staining was noted in four cases (two high grade, one intermediate grade and one low grade). Intense MDM2 staining was observed in the same four previous cases, as well as, one additional high-grade tumor. Individual DNA amplification for CDK4, MDM2 and SAS was observed in six cases for each gene. Co-amplification was observed in five cases that showed CDK4 and MDM2 concomitant amplification and four cases that displayed amplification for all of the genes. In addition, among the five cases that presented CDK4 and MDM2 amplification, strong overexpression of CDK4 and MDM2 was observed in three and in four cases, respectively (three high grade and one intermediate grade). These results suggest that 12q13-15 genes are involved in neoplastic disease and concurrent amplification and overexpression of these genes might help to define high-grade tumors.

MDM2+/CDK4+/p53+ oral liposarcoma: case report and review of the literature.

Although liposarcoma is one of the most common soft tissue sarcomas, its location in the oral cavity is very rare. To our knowledge, only 43 cases of liposarcoma originating in the oral tissues have been reported in the English-language literature. In this article, we report a case of well-differentiated liposarcoma affecting the cheek of a 28-year-old man and review the oral liposarcoma literature. Immunohistochemical analysis of the tumor revealed an MDM2+/CDK4+/p53+ immunophenotype that is consistent with the immunohistochemical profile of well-differentiated liposarcoma originating in other areas of the body. Quantitative polymerase chain reaction analysis of the DNA levels of the MDM2 (human homologue of the murine double-minute type 2), CDK4 (cyclin-dependent kinase 4), and SAS (sarcoma amplified sequence), genes was performed, revealing only SAS gene amplification. The possibility of misdiagnosis of oral liposarcoma because of its sometimes inconspicuous clinical and microscopic features is emphasized. Careful pathologic examination of liposarcoma is essential for discrimination from benign adipose tissue neoplasms and for precise histologic classification, both of major prognostic significance. Possible implications of molecular and cytogenetic analysis for unraveling the pathogenesis and determining the prognosis of liposarcoma are discussed.

Management of oral squamous cell carcinoma treated with inadequate excisional biopsy.

PURPOSE: When an initial "excisional biopsy" has been performed on a primary oral carcinoma, microscopic tumor may remain and the usual landmarks that enable the surgeon to plan his safe margin are destroyed. This article analyzes the impact that such a biopsy may have on treatment and patient outcome. PATIENTS AND METHODS: A retrospective chart review of a consecutive series of 350 oral cancer patients treated by 1 surgeon in an 8-year period identified 33 (9.4%) patients who originally had inadequate excisional biopsies. Exclusion criteria eliminated 7 patients who were lost to follow-up or who had undergone previous treatment with radiation therapy or chemotherapy. Data extracted included age, sex, race, primary intraoral site, estimated tumor (T) stage, method of treatment, histology, follow-up, and outcome. RESULTS: Twenty-four of the 26 patients underwent re-excision of their oral cancer. Ten of these patients (38.4%) also underwent selective neck dissection. Fifteen of the 24 patients (62.5%) had residual carcinoma identified in the re-excision specimen, and 3 of the patients who underwent elective neck dissection had micrometastasis identified. The patients were followed for an average of 35.5 months. Two of 24 (8.3%) patients had local recurrence at 36 and 84 months, respectively. Both patients were managed with re-excision and are still alive with no evidence of disease. Of the 10 patients originally treated with elective neck dissection, there has been no regional recurrence. However, of the 14 patients who underwent re-excision of the lesion without neck dissection, 3 developed regional disease at 1, 5, and 6 months, respectively, postoperatively. These patients underwent neck dissection and radiation therapy. Two patients are alive with no evidence of disease, and the third died of a second primary lung cancer. Twenty-five of the 26 patients (96.2%) are still alive and well with no evidence of disease. CONCLUSIONS: Patients who have had inadequate excisional biopsies can be effectively managed with re-excision plus neck dissection when indicated by T stage or more than 3 mm depth of invasion.

Predictors of response and survival after concurrent chemotherapy and radiation for locally advanced squamous cell carcinomas of the head and neck.

BACKGROUND: The objective of this study was to determine prognostic factors for response and survival on three consecutive institutional trials utilizing concurrent chemotherapy and radiation for locally advanced squamous cell carcinomas of the head and neck (SCCHN). METHODS: Since 1985, patients with locally advanced SCCHN at the University of Maryland have been managed with concurrent chemotherapy and radiation therapy (RT). Three consecutive pilot studies have been performed evaluating the utility of weekly chemotherapy with standard fractionated RT. Chemotherapy consisted of carboplatin either alone (28 patients) or in combination with bleomycin (23 patients) or paclitaxel (60 patients). In all three studies, RT was given to 70.2 gray (Gy) at 1.8 Gy/fraction/day to the primary site. All patients had locally advanced SCCHN and were believed to be poor surgical candidates. Sixty-seven percent of patients had T4 disease, and 21% had T3 disease. Seventy-five percent of patients had N2-N3 disease. One hundred eleven patients were examinable for toxicity, response, and survival analysis. Factors including age, race, gender, primary site location, histologic grade, T classification, N classification, and treatment regimen were evaluated to identify predictors of these endpoints. RESULTS: The median follow-up for patients treated on study 1 (carboplatin and RT) and study 2 (carboplatin and bleomycin [C + B]/RT) was 98 months, and it was 30 months for study 3 (carboplatin and paclitaxel [C + P]/RT). The complete response rates were 54%, 52%, and 70% respectively (P = 0.01). Multivariate analysis identified length of treatment break (< 1 week vs. > 1 week) as the only predictor of complete response to therapy. The local control for the entire group was 50%. The local control for C + P/RT was 63%, versus 32% and 36% for C/RT and C + B/RT respectively (P = 0.004). The 2-, 3-, and 5-year disease free and overall survivals for the entire population were 41%, 41%, and 35% and 42%, 36%, and 33%, respectively. The 3-year overall survival rates by treatment regimen were 18% (C/RT), 35% (C + B/RT), and 47% (C + P/RT; P = 0.01). On univariate analysis, age younger than 50 years (P = 0.01), treatment with C + P/RT (P = 0.005), and treatment break of 5 days or fewer (P < 0.05) were also predictive of improved overall survival. On multivariate analysis, only complete response (P < 0.0001) and treatment with C + P/RT (P = 0.02) remained statistically significant. CONCLUSIONS: Chemoradiation provides patients with locally advanced SCCHN the opportunity for long term survival. Among the three chemoradiation regimens studied, C + P/RT was associated with the best complete response and survival rates. Complete response to therapy was the single most important predictor of overall survival. These three consecutive concurrent chemotherapy and radiation trials achieved a 5-year survival of greater than 30% for the entire population. These results support the use of this nonoperative approach for this group of patients with a historically poor prognosis.

Current management of oral cancer. A multidisciplinary approach.

BACKGROUND: Recent basic science discoveries have contributed to our understanding of the etiology of oral cancer and allowed us to consider innovative approaches to therapy. METHODS: The authors evaluated and summarized current approaches to the management of oral cancer, emphasizing the multidisciplinary team approach to coordinate surgery, radiation therapy and chemotherapy. Current concepts in management, including complications of therapy, are described. RESULTS: State-of-the-art surgical techniques can spare patients with oral cancer from much of the morbidity and complications common in the past. The refinement of treatment strategies reduces complications and improves efficacy. Many exciting new clinical trials in the areas of gene therapy and immunomodulation are showing promise. CONCLUSIONS: Management of oral cancer has undergone radical change in the past 10 years and continues to evolve rapidly. Discoveries in molecular biology, diagnosis, surgery, radiation therapy and medical oncology have altered many traditional concepts and practices. CLINICAL IMPLICATIONS: General dental practitioners need to understand current treatment modalities for oral and pharyngeal cancers to determine to whom they should refer patients for the most appropriate treatment, and to make recommendations regarding complications associated with these cancers.