Prognosis of oral epithelial dysplasia in individuals with and without oral lichen planus.

OBJECTIVES: To investigate the role of oral lichen planus (OLP) on the long-term prognosis of oral epithelial dysplasia (OED). METHODS: Retrospective single-centre cohort study using the 2007-2019 database of the Head and Neck Cancer and Oral Medicine units of University College London Hospital. The exposure of interest was the presence of OLP, and the prognostic outcomes included the development of new primary episodes of OED, progression to malignancy and mortality. Cox proportional hazard and Poisson regression models were performed. RESULTS: A total of 299 patients, of whom 144 had OED arising on the background of OLP (OLP/OED) and 155 had OED without underlying OLP (non-OLP/OED), were included. A pre-existing diagnosis of OLP was significantly associated with a twofold increased risk of subsequent primary OED events (HR = 2.02, p = 0.04), which also developed faster (1.46 vs. 2.96 years, p = 0.04) and with more involvement of non-cancer-prone sites (p = 0.001) than in the non-OLP/OED group. There was no difference between groups in the progression to malignancy or mortality. CONCLUSIONS: Oral lichen planus/OED patients are at higher risk of multiple episodes of primary OED, which can develop faster and at non-cancer-prone sites as compared to non-OLP/OED individuals. Further research is needed to clarify the effects of OLP upon progression to OSCC and mortality.

Incidental Thyroid Tissue in Sentinel Nodes From Oral Squamous Cell Carcinoma.

OBJECTIVE: Sentinel node biopsy (SNB) is a surgical staging test in which sentinel nodes (SNs) undergo intensive histological analysis. SNB diagnoses early cancer spread, but can also reveal unexpected findings within the SNs. We review cases of incidental thyroid cells (TC) found in SNs from patients with oral squamous cell carcinoma (OSCC) to assess the prevalence of TC, and the clinical significance of these. METHODS: Multicenter retrospective review of SNB performed for cT1-T2N0 OSCC. Incidental TC were identified by TTF-1 or thyroglobulin positivity. Anatomical location of nodes containing TC, TC morphology, and ongoing management/follow up of this incidental finding was recorded. Neck dissections performed during the same period were reviewed to establish the expected incidence of TC in neck nodes without serial sectioning analysis. RESULTS: 278 SNB cases were reviewed. Ten procedures detected TC in nine patients (10/278, 3.6%). During the same time period 725 neck dissections were performed, six containing TCs (6/725, 0.8%). One patient underwent SNB twice with TC identified on both occasions. Three patients had both OSCC metastasis and thyroid cells. All SNB patients with TC identified underwent thyroid USS with no primary tumours identified. Three patients underwent thyroidectomy, in all cases no primary thyroid tumour was found. CONCLUSION: Prevalence of incidental TC in SNs appears to be higher than that reported in neck dissections, these are not likely to be clinically relevant and can be managed on a conservative basis in the absence of clear metastatic features. LEVEL OF EVIDENCE: Multicentre retrospective cohort study, 3 Laryngoscope, 134:1278-1281, 2024.

A training tool for clinicians in segmenting medical images to make 3D models.

Introduction: 3D models produced from medical imaging can be used to plan treatment, design prosthesis, teach and for communication. Despite the clinical benefit, few clinicians have experience of how 3D models are produced.This is the first study evaluating a training tool to teach clinicians to produce 3D models and reporting the perceived impact on their clinical practice. Method: Following ethical approval, 10 clinicians completed a bespoke training tool, comprising written and video material alongside online support. Each clinician and 2 technicians (included as control) were sent 3 CT scans and asked to produce 6 fibula 3D models using an open-source software (3Dslicer). The produced models were compared to those produced by the technicians using Hausdorff distance calculation. Thematic analysis was used to study the post-intervention questionnaire. Results: The mean Hausdorff distance between the final model produced by the clinicians and technicians was 0.65mm SD0.54mm. The first model made by clinicians took a mean time of 1hr 25mins and the final model took 16:04mins (5:00-46:00mins). 100% of learners reported finding the training tool useful and will employ it in future practice. Discussion: The training tool described in this paper is able to successfully train clinicians to produce fibula models from CT scans. Learners were able to produce comparable models to technicians within an acceptable timeframe. This does not replace technicians. However, the learners perceived this training will allow them to use this technology in more cases, with appropriate case selection and they appreciate the limits of this technology.

Academic Training in Oral and Maxillofacial Surgery - when and how to enter the pathway.

Entering into surgical academia can seem a daunting prospect for an oral and maxillofacial surgery (OMFS) trainee. However, the streamlining of academic training by the NIHR to create the integrated academic training (IAT) pathway has simplified academic training and more clearly defined academic positions and entry points for trainees. In this article we review the current NIHR IAT pathway and the various grades and entry points available to OMF surgeons, both pre- and post-doctoral. We highlight the unique challenges facing OMF trainees and provide advice and insight from both junior and senior OMFS academics. Finally, we focus on the planning and application for a doctoral research fellowship - discussing funding streams available to OMF surgeons.

Systematic review of techniques used to validate the registration of augmented-reality images using a head-mounted device to navigate surgery.

Augmented-reality (AR) head-mounted devices (HMD) allow the wearer to have digital images superposed on to their field of vision. They are being used to superpose annotations on to the surgical field akin to a navigation system. This review examines published validation studies on HMD-AR systems, their reported protocols, and outcomes. The aim was to establish commonalities and an acceptable registration outcome. Multiple databases were systematically searched for relevant articles between January 2015 and January 2021. Studies that examined the registration of AR content using a HMD to guide surgery were eligible for inclusion. The country of origin, year of publication, medical specialty, HMD device, software, and method of registration, were recorded. A meta-analysis of the mean registration error was conducted. A total of 4784 papers were identified, of which 23 met the inclusion criteria. They included studies using HoloLens (Microsoft) (n = 22) and nVisor ST60 (NVIS Inc) (n = 1). Sixty-six per cent of studies were in hard tissue specialties. Eleven studies reported registration errors using pattern markers (mean (SD) 2.6 (1.8) mm), and four reported registration errors using surface markers (mean (SD) 3.8 (3.7) mm). Three studies reported registration errors using manual alignment (mean (SD) 2.2 (1.3) mm). The majority of studies in this review used in-house software with a variety of registration methods and reported errors. The mean registration error calculated in this study can be considered as a minimum acceptable standard. It should be taken into consideration when procedural applications are selected.

Systematic review and meta-analysis of occult contralateral nodal metastases in patients with oropharyngeal squamous carcinoma undergoing elective neck dissection.

A systematic review and meta-analysis was conducted to evaluate the occult contralateral nodal metastases (OCM) in patients undergoing bilateral neck dissection for surgically treated oropharyngeal squamous cell carcinoma (OPSCC). Following PRISMA guidelines, MEDLINE, Embase and Cochrane Controlled Register of Trials databases were searched for observational and experimental studies until March 2021. Search yielded 175 articles, of which 13 were included. Overall, OCM were seen in 9.8% of patients (95% CI: [5.7, 16.4], 839 patients, 12 studies, I2 65%). For ipsilateral cN0 necks, the OCM rate was 1.7% (95% CI: [0.1, 22.4], 150 patients, 8 studies, I2 0%) and for cN + necks the OCM rate was 9.8% (95% CI: [4.4, 20.3], 429 patients, 8 studies, I2 72%). Occult contralateral nodal metastases are uncommon in OPSCC patients with clinico-radiologically negative ipsilateral necks. Occult rates are higher in the contralateral neck when the ipsilateral neck is clinico-radiologically node positive.

Machine learning methods applied to risk adjustment of cumulative sum chart methodology to audit free flap outcomes after head and neck surgery.

We describe a risk adjustment algorithm to benchmark and report free flap failure rates after immediate reconstruction of head and neck defects. A dataset of surgical care episodes for curative surgery for head and neck cancer and immediate reconstruction (n = 1593) was compiled from multiple NHS hospitals (n = 8). The outcome variable was complete flap failure. Classification models using preoperative patient demographic data, operation data, functional status data and tumour stage data, were built. Machine learning processes are described to model free flap failure. Overall complete flap failure was uncommon (4.7%) with a non-statistical difference seen between hospitals. The champion predictive model had acceptable discrimination (AUROC 0.66). This model was used to risk-adjust cumulative sum (CuSUM) charts. The use of CuSUM charts is a viable way to monitor in a 'Live Dashboard' this quality metric as part of the quality outcomes in oral and maxillofacial surgery audit.

Intraoperative Positioning in Maxillofacial Trauma Patients With Cervical Spine Injury - Is It Safe? Radiological Simulation in a Healthy Volunteer.

Study Design: Observational. Objective: To investigate the effects on the cervical spine of positioning patients for maxillofacial procedures by simulating intraoperative positions for common maxillofacial procedures. Methods: Magnetic resonance imaging was used to assess the effects of head position in common intraoperative configurations - neutral (anterior mandible position), extended (tracheostomy position) and laterally rotated (mandibular condyle position) on the C-spine of a healthy volunteer. Results: In the tracheostomy position, maximal movement occurred in the sagittal plane between the cervico-occipital junction and C4-C5, as well as at the cervico-thoracic junction. Minimal movement occurred at C2 (on C3), C5 (on C6) and C6 (on C7). In the mandibular condyle position, C-spine movements occurred in both rotational and sagittal planes. Maximal movement occurred above the level of C4, concentrated at atlanto-occipital and atlanto-axial (C1-2) joints. Conclusions: Neck extension is likely to be relatively safe in injuries that are stable in flexion and extension, such as odontoid peg fracture and fractures between C5 and C7. Head rotation is likely to be relatively safe in fractures below C4, as well as vertebral body fractures, and laminar fractures without disc disruption. Early dialogue with the neurosurgical team remains a central tenet of safe management of patients with combined maxillofacial and C-spine injuries.

Precision surgery: the role of intra-operative real-time image guidance - outcomes from a multidisciplinary European consensus conference.

Developments within the field of image-guided surgery are ever expanding, driven by collective involvement of clinicians, researchers, and industry. While the general conception of the potential of image-guided surgery is to improve surgical outcome, the specific motives and goals that drive can differ between the different expert groups. To establish the current and future role of intra-operative image guidance within the field of image-guided surgery a Delphi consensus survey was conducted during the 2nd European Congress on Image-guided surgery. This multidisciplinary survey included questions on the conceptual potential and clinical value of image-guided surgery and was aimed at defining specific areas of research and development in the field in order to stimulate further advances towards precision surgery. Obtained results based on questionnaires filled in by 56 panel experts (clinicians: N=30, researchers: N=20 and industry: N=6) were discussed during a dedicated expert discussion session during the conference. The outcome of this Delphi consensus is indicative of the potential improvements offered by image-guided surgery and of the need for further research in this emerging field, that can be enriched by the identification of reliable molecular targets.

Centralised pathology service for sentinel node biopsy in oral cavity cancer: The Southeast England Consortium experience.

BACKGROUND: Sentinel lymph node biopsy is an increasingly recognised option for accurate staging and subsequent management of the clinically negative neck in early stage oral cavity squamous cell carcinoma. However, the technique is currently underused due to several logistic constraints including increased burden on pathology services. Here, we describe the feasibility of an outsourced centralised pathology processing and reporting service for sentinel lymph node biopsies in oral cavity squamous cell carcinoma. PATIENTS AND METHODS: The Southeast England Consortium comprises four surgical centres utilising a central pathology service. Consecutive cases between January 2016 and February 2020 were retrospectively evaluated for survival outcomes and laboratory turnaround times. RESULTS: Twenty-eight per cent from a cohort of 139 patients had positive sentinel nodes. There was a trend towards greater overall, disease-free and disease-specific survival (OS, DFS and DSS, respectively) in sentinel node negative compared to sentinel node positive patients, but these differences were not statistically significant. The sensitivity, negative predictive value and false negative rate were 92.8%, 97.0% and 6.8%, respectively. The mean and mode laboratory TAT were 5 and 4 working days, respectively. CONCLUSION: An outsourced centralised pathology service is a feasible option to widen the availability of sentinel node biopsy in oral cavity squamous cell carcinoma.

Single-photon emission computed tomography (SPECT/CT) images of sentinel node distribution in oral cancer.

This audit describes the lymphatic flow from oral tumours seen on single-photon emission computed tomography (SPECT/CT) to help sentinel node (SN) identification. A total of 95 consecutive sentinel node biopsies (SNB) were taken between 2010 and 2019. Eligibility criteria for SNB were patients over 18 years of age with a T1-T2 oral or oropharyngeal squamous cell carcinoma and an N0 neck. SNs collect at high-frequency sites irrespective of the primary tumour (22.7% level Ib; 64.8% levels II/III; and 7.6% level IV), but with individual variation. Radiotracer activity did not influence the number of nodes identified, and metastatic deposits were found in the hottest nodes. SNs occur at the same high-frequency locations in the neck, so familiarity with anatomical detail may reduce false-negative results.

PET- and SPECT-based navigation strategies to advance procedural accuracy in interventional radiology and image-guided surgery.

INTRODUCTION: Nuclear medicine has a crucial role in interventional strategies where a combination between the increasing use of targeted radiotracers and intraprocedural detection modalities enable novel, but often complex, targeted procedures in both the fields of interventional radiology and surgery. 3D navigation approaches could assist the interventional radiologist or surgeon in such complex procedures. EVIDENCE ACQUISITION: This review aimed to provide a comprehensive overview of the current application of computer-assisted navigation strategies based on nuclear imaging to assist in interventional radiology and image-guided surgery. This work starts with a brief overview of the typical navigation workflow from a technical perspective, which is followed by the different clinical applications organized based on their anatomical organ of interest. EVIDENCE SYNTHESIS: Although many studies have proven the feasibility of PET- and SPECT-based navigation strategies for various clinical applications in both interventional radiology and surgery, the strategies are spread widely in both navigation workflows and clinical indications, evaluated in small patient groups. Hence, no golden standard has yet been established. CONCLUSIONS: Despite that the clinical outcome is yet to be determined in large patient cohorts, navigation seems to be a promising technology to translate nuclear medicine findings, provided by PET- and SPECT-based molecular imaging, to the intervention and operating room. Interventional Nuclear Medicine (iNM) has an exciting future to come using both PET- and SPECT-based navigation.

Serial step sections at narrow intervals with immunohistochemistry are required for accurate histological assessment of sentinel lymph node biopsy in oral squamous cell carcinoma.

BACKGROUND: Sentinel lymph node (SLN) biopsy is an accurate staging modality in early oral squamous cell carcinoma (OSCC), but its accuracy relies on labor-intensive histopathology protocols. We sought to determine whether serial step sections with immunohistochemistry (SSSIHC) at narrow intervals of the entire SLN are required to accurately exclude metastasis. METHODS: Consecutive SLN biopsies over a 13-year period were retrospectively evaluated. If the index section was negative for carcinoma, the entire SLN was subjected to SSSIHC at 150 µm intervals. The first section level and total number of section levels to contain carcinoma were recorded. RESULTS: One hundred and eighteen SLN+ from 90 patients were included. SSSIHC upstaged the nodal status in 19.5% of patients. Metastasis was identified in 16.7% and 10.2% beyond section levels 4 and 6, respectively. Among SLNs requiring SSSIHC, 47.5% contained carcinoma in a single section level. CONCLUSION: SSSIHC of the entire SLN at 150 µm intervals are required to identify occult metastasis in OSCC.

Development of sentinel lymph node biopsy technique in patients with salivary gland cancer using the IDEAL framework.

BACKGROUND: Salivary cancer is rare and comprises a variety of histological subtypes and clinical behaviors. There is no agreed method of estimating the risk of occult metastasis or managing the clinically N0 neck.Sentinel node biopsy (SNB) may offer a solution but previous studies have not produced a reliable imaging protocol. This study uses novel technology and trial methodology to develop a reliable SNB technique, with primary aim to identify peri-and intraglandular sentinel nodes. METHODS: IDEAL framework was used to undertake SNB in clinically node negative salivary gland cancer. Patients with cT1-2 N0 salivary cancer were eligible. Lymphoscintigraphy was undertaken using Tc-99 m labelled nanocoll. Injection technique as well as adjunctive use of freehand SPECT (fhSPECT), near-infrared (NIR) fluorescence imaging, and navigation-guided surgery were used and optimisied during the study protocol. RESULTS: 10 patients were recruited. Initial protocol of peritumoural injection of Tc99 m nanocoll showed poor image resolution. Subsequent adjustment to single intratumoural injection allowed identification of intraglandular sentinel nodes. Fh/SPECT and NIR fluorescence imaging found intraglandular lymph nodes otherwise not recognizable to the naked eye. In two cases occult lymph node metastasis were identified. CONCLUSION: This study has shown the IDEAL framework is vital in allowing iterative changes in surgical protocol in the light of experience. This study has produced a reliable method for detection of sentinel nodes, in particular the ability to identify intra- and periglandular nodes with diagnosis of occult metastatic deposits and no false negative results. Our protocol can be readily transferred in to larger scale studies.

Surgical consensus guidelines on sentinel node biopsy (SNB) in patients with oral cancer.

BACKGROUND: The eighth international symposium for sentinel node biopsy (SNB) in head and neck cancer was held in 2018. This consensus conference aimed to deliver current multidisciplinary guidelines. This document focuses on the surgical aspects of SNB for oral cancer. METHOD: Invited expert faculty selected topics requiring guidelines. Topics were reviewed and evidence evaluated where available. Data were presented at the consensus meeting, with live debate from panels comprising expert, nonexpert, and patient representatives followed by voting to assess the level of support for proposed recommendations. Evidence review, debate, and voting results were all considered in constructing these guidelines. RESULTS/CONCLUSION: A range of topics were considered, from patient selection to surgical technique and follow-up schedule. Consensus was not achieved in all areas, highlighting potential issues that would benefit from prospective studies. Nevertheless these guidelines represent an up-to-date pragmatic recommendation based on current evidence and expert opinion.

The EANM practical guidelines for sentinel lymph node localisation in oral cavity squamous cell carcinoma.

PURPOSE: Sentinel lymph node biopsy is an essential staging tool in patients with clinically localized oral cavity squamous cell carcinoma. The harvesting of a sentinel lymph node entails a sequence of procedures with participation of specialists in nuclear medicine, radiology, surgery, and pathology. The aim of this document is to provide guidelines for nuclear medicine physicians performing lymphoscintigraphy for sentinel lymph node detection in patients with early N0 oral cavity squamous cell carcinoma. METHODS: These practice guidelines were written and have been approved by the European Association of Nuclear Medicine (EANM) and the International Atomic Energy Agency (IAEA) to promote high-quality lymphoscintigraphy. The final result has been discussed by distinguished experts from the EANM Oncology Committee, and national nuclear medicine societies. The document has been endorsed by the Society of Nuclear Medicine and Molecular Imaging (SNMMI). These guidelines, together with another two focused on Surgery and Pathology (and published in specialised journals), are part of the synergistic efforts developed in preparation for the "2018 Sentinel Node Biopsy in Head and Neck Consensus Conference". CONCLUSION: The present practice guidelines will help nuclear medicine practitioners play their essential role in providing high-quality lymphatic mapping for the care of early N0 oral cavity squamous cell carcinoma patients.