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.

Perineural and lymphovascular invasion in squamous cell carcinoma of the tongue.

BACKGROUND: Perineural invasion (PNI) and lymphovascular invasion (LVI) may be adverse prognostic indicators in squamous cell carcinoma (SCC) of the tongue. METHODS: The percentages of histological PNI and LVI were determined in 335 patients with tongue SCC. Sixty tumours originally reported as negative for these features were tested to determine how many more were positive with "immunohistochemical enhancement." RESULTS: PNI was found in 141 (42.1%) and LVI in 51 (15.2%) patients. 79.4% of the 141 patients who had PNI and 72.6% of the 51 with LVI had a T3 or T4 tumour. Lymph node metastasis was identified in 145 (51.2%) of the 280 patients who had undergone neck dissection; 58.2% of the 141 patients with PNI and 80.4% of the 51 patients with LVI had lymph node metastasis. There was a highly statistically significant correlation between PNI with increasing pT (P < .00001) and pN (P < .0001) stage, and a statistically significant correlation between LVI and pT stage (P < .001), the association of LVI with pN status could not be reliably tested statistically. Immunohistochemistry for S100 identified five further cases of PNI, but review of the original H&E showed the feature was present in four and had been missed at original reporting. CD31 identified three further possible cases of LVI and D2-40 none. The endothelium of some vascular channels was positive for both CD31 and D2-40 and cross-reactivity with other cells compromised interpretation. CONCLUSIONS: Histological identification of PNI and LVI per se remains of uncertain prognostic significance. "Immunohistochemical enhancement" offered little benefit.

Management of the clinically N0 neck in early-stage oral squamous cell carcinoma (OSCC). An EACMFS position paper.

Metastasis of oral squamous cell carcinoma (OSCC) to the cervical lymph nodes has a significant impact on prognosis. Accurate staging of the neck is important in order to deliver appropriate treatment for locoregional control of the disease and for prognosis. The management of the neck in early, low volume disease (clinically T1/T2 oral cavity tumours) has long been debated. The risk of occult nodal involvement in cT1/T2 OSCC is estimated around 20-30%. We describe the natural evolutionary history of OSCC and its patterns of spread and metastasis to the local lymphatic basins. We discuss most published literature and studies on management of the clinically negative neck (cN0). Particular focus is given to prospective randomized trials comparing the outcomes of upfront elective neck dissection against the observational stance, and we summarize the results of the sentinel node biopsy studies. The paper discusses the significance of the primary tumour histological characteristics and specifically the tumour's depth of invasion (DOI) and its impact on predicting nodal metastasis. The DOI has been incorporated in the TNM staging highlighting its significance in aiding the treatment decision making and this is reflected in world-wide oncological guidelines. The critical analysis of all available literature amalgamates the existing evidence in early OSCC and provides recommendations in the management of the clinically N0 neck.

Head and neck oncological ablation and reconstruction in the COVID-19 era - our experience to date.

The COVID-19 pandemic has caused unprecedented disruption to the routine operations of healthcare services across the world. As the potential duration of the pandemic remains uncertain, the need to develop strategies to continue urgent elective services has received increasing attention. A solution adopted in the Kent, Sussex and Surrey area of England has been to create COVID-19-protected cancer hubs. The Queen Victoria Hospital is the designated hub for head and neck cancer services in the area. We report on the evolution of the head and neck cancer care pathway and standard operating protocols put in place and how these have combined both national guidelines and local problem solving. It is hoped that our experience can help guide other centres as they re-establish head and neck cancer services during the ongoing pandemic.

Cystic Squamous Cell Carcinomas of the Jaws: Twelve Cases Highlighting Histopathological Pitfalls.

Cystic squamous cell carcinomas (SCCs) of the jaws, including carcinoma cuniculatum, are rare, slow growing, and relentlessly invasive. The aim of this article is to present 12 cases, 4 of which were designated as carcinoma cuniculatum on the basis of deeply endophytic, anastomosing channels of cystic stratified squamous epithelium and keratin microabscesses. The other 8 were also cystic, but more heterogeneous morphologically and were diagnosed as well differentiated SCCs. Six patients were female, 6 were male (mean age = 74.0 years, range = 50-94 years). Six tumors affected the mandible, 6 the maxillary alveolus with or without extension into the hard palate. All patients underwent primary resection with neck dissection and were staged as T4a N0 M0. In 4 patients, diagnosis was delayed as a result of superficial biopsies and/or confusing histopathology. Cystic SCCs of the jaws can be difficult to diagnose and clinicoradiological correlation is essential. Long-term follow-up is mandatory.

What is the optimal site and biopsy technique for the diagnosis of oral mucosal autoimmune blistering disease?

BACKGROUND: The aim of this study was to determine which biopsy method produces the best diagnostic yield in patients presenting with autoimmune blistering diseases (AIBDs) of the oral mucosa. METHODS: This was a retrospective audit of patients who were biopsied at least once for a suspected AIBD of the oral mucosa. The type (incisional or punch) and site of biopsies were recorded in conjunction with case notes, electronic records and histopathological reports in order to calculate sensitivity, specificity and the method of biopsy which produced the superior diagnostic yield. RESULTS: A total of 125 biopsy samples from 66 patients were identified and reviewed. A diagnosis of AIBD was established in 49 (74%) patients. The chi-square test showed there was a statistically significantly higher (P = 0.0016) diagnostic yield using the punch biopsy technique compared to the scalpel method. The gingiva was the best biopsy site in terms of achieving a definitive diagnosis (P = 0.0001) regardless of the biopsy method used. CONCLUSIONS: A punch biopsy is more likely than scalpel biopsy to obtain a definitive diagnosis in patients presenting with a suspected oral AIBD. The gingiva is the optimal site to sample.

Dentigerous Cyst and Ameloblastoma of the Jaws.

AIM: To determine how many ameloblastomas were misdiagnosed as dentigerous cysts (DCs) by correlating the radiological and histopathological features of a series of both entities. METHODS AND RESULTS: Histopathology reports and radiological imaging of 135 DCs and 43 ameloblastomas were reviewed. Any clinical or radiological feature that suggested that the diagnosis of DC was wrong-for example, absence of an unerupted tooth-prompted review of the original histology. A total of 34 cases coded as DC at diagnosis were excluded; in the remaining 101 patients, the clinicoradiological and histopathological features were consistent with DC in 96 (95.0%). Review of the histology revealed that 4 patients had actually had odontogenic keratocysts (OKCs) and one a luminal/simple unicystic ameloblastoma (UA). One other OKC and 3 other ameloblastomas (1 luminal UA, 2 solid/multicystic) had originally been diagnosed as DC; these had been identified prior to the study. Of the 9 misdiagnosed patients, 6 were ≤20 years old. Clinically, DC had been the only, or one of the differential, diagnoses in 7 patients; in the other 2, the clinical diagnosis was radicular cyst. In none of the 4 misdiagnosed ameloblastomas was the radiology compatible with a diagnosis of DC. Incorrect terminology had been used on the histopathology request form in 5 of the 34 excluded cases where the clinical diagnosis was DC, despite the cyst being periapical to an erupted carious or root-filled tooth. CONCLUSIONS: The entire clinical team must ensure that a histopathological diagnosis of DC is consistent with the clinicoradiological scenario, particularly in younger patients.

A scanning electron microscope characterisation of biofilm on failed craniofacial osteosynthesis miniplates.

INTRODUCTION: Between 3 and 18% of craniofacial osteosynthesis plates are removed due to chronic infection. Removal of the plate is necessary to manage the chronic infective state i.e. miniplate removal results in resolution of the infection. These observations are suggestive of a biofilm-related infection. The aim of this retrospective study was to characterise the presence of biofilm on the removed miniplates from oral and maxillofacial surgery. MATERIALS AND METHODS: A total of 12 plates and associated screws were recovered from eleven patients suffering from persistent, trauma site infection. The recovered plates plus 1 control plate were imaged using scanning electron microscopy (SEM). One recovered plate was also imaged using confocal microscopy (CM) for comparative purposes. RESULTS: Of the 12 plates, 3 (25%) demonstrated highly localised polymicrobial biofilms, five (42%) demonstrated coccal biofilms, one possessed a filamentous biofilm and one showed attached yeast. Overall, 75% of the plates and 82% of the patients exhibited evidence of biofilm to varying degrees. All of the infections resolved following removal of the plates and antibiotic treatment. CONCLUSION: Microbial biofilms can explain the clinical course of chronic infections associated with miniplates.

A novel approach to teaching surgical skills to medical students using an ex vivo animal training model.

OBJECTIVES: Traditional surgical teaching is influenced by restrictive factors, such as financial pressures and ethical constraints. The teaching of surgical skills during a medical school education seems not to be robust enough at present, possibly resulting in stressful circumstance for surgical novices. However, the authors are convinced that practical training is fundamental for preparing medical students optimally for challenges in the operating theater and have, therefore, examined a novel method of teaching basic surgical skills to medical students. METHODS: A total of 20 medical students received surgical skill training, which included theoretical lessons, working with ex vivo pig training models, and active participation in the operating theater. All the trainees took written tests and were rated in an Objective Structured Clinical Examination. Before and after training, the students completed a self-assessment form involving the choice of the correct surgical indication and the performance of surgical procedures. RESULTS: The students' performance in the written examination and in the Objective Structured Clinical Examination increased significantly after training (p ≤ 0.001). Furthermore, the evaluation of the self-assessment form revealed significant improvements in all categories (p ≤ 0.001). CONCLUSIONS: Our surgical training method appears to improve the surgical abilities of medical students and to increase their self-confidence with respect to surgical procedures. Therefore, the authors recommend the integration of this method into the medical school curriculum to prepare medical students well for surgical challenges.

Repair of oronasal fistulae by interposition of multilayered amniotic membrane allograft.

BACKGROUND: Oronasal fistulas are a frequent complication after cleft palate surgery. Numerous repair methods have been described, but wound-healing problems occur often. The authors investigated, for the first time, the suitability of multilayered amniotic membrane allograft for fistula repair in a laboratory experiment (part A), a swine model (part B), and an initial patient series (part C). METHODS: In part A, one-, two-, and four-layer porcine and human amniotic membranes (n = 20 each) were fixed in a digital towing device and the force needed for rupture was determined. In part B, iatrogenic oronasal fistulas in 18 piglets were repaired with amniotic membrane allograft, autofetal amniotic membrane, or small intestinal submucosa (n = 6 each). Healing was evaluated by probing and visual inflammation control (no/moderate/strong) on postoperative days 3, 7, 10, and 76. Histological analysis was performed to visualize tissue architecture. In part C, four patients (two women and two men, ages 21 to 51 years) were treated with multilayered amniotic membrane allograft. RESULTS: In part A, forces needed for amniotic membrane rupture increased with additional layers (p < 0.001). Human amniotic membrane was stronger than porcine membrane (p < 0.001). In part B, fistula closure succeeded in all animals treated with amniotic membrane with less inflammation than in the small intestinal submucosa group. One fistula remained persistent in the small intestinal submucosa group. In part C, all fistulas healed completely without inflammation. CONCLUSIONS: Amniotic membrane is an easily available biomaterial and can be used successfully for oronasal fistula repair. The multilayer technique and protective plates should be utilized to prevent membrane ruptures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Review of salivary papers published in the British Journal of Oral & Maxillofacial Surgery during 2009-2010.

The management of salivary gland disease forms an appreciable part of the work undertaken by our specialty. Fast-track and one-stop clinics for head and neck lumps allow for early diagnosis of salivary gland tumours in most units, and for the sharing of cases between our ear, nose and throat (ENT) colleagues. The emphasis on benign salivary gland disease is very much on outcome after operation, and there have been improvements in surgical technique, particularly in relation to minimal dissection of salivary adenomas and sialendoscopy. This article continues a series of reviews, which aim to provide readers with a quick overview and update of recent publications in the British Journal of Oral and Maxillofacial Surgery (BJOMS) within a particular subspecialty.

Carcinoid tumour metastasis to the submandibular gland: a case report.

Carcinoid tumours are slow growing tumours of neuroendocrine origin that primarily affect the gastrointestinal tract and pulmonary system. They can behave aggressively, with regional and distant metastases, although metastases to the head and neck region are uncommon. We present a rare case of carcinoid metastasis to the submandibular gland, which to the best of our knowledge has not been previously reported in the literature.

Use of carbon dioxide laser in lingual frenectomy.

We prospectively studied 21 cases of attachment of the lingual frenulum treated with laser excision, and report the results of a questionnaire survey of patients in the immediate postoperative phase.

Penetrating knife injury to the frontal lobe--a case report.

Penetrating injuries of the craniofacial region are increasing and have the potential to cause severe vascular and neurological deficit. We present our management of a case with a knife stab injury to the infra-orbital region, traversing the orbit and penetrating into the anterior cranial fossa, the tip lying in close proximity to the anterior cerebral circulation.

Squamous cell carcinoma presenting as peri-implantitis: a case report.

Dental implants have proved to be a useful adjunct in the rehabilitation of oral cancer patients. We describe the case of a 62-year-old woman who presented with a white patch in the oral cavity, diagnosed to be a squamous cell carcinoma. She underwent extensive surgery including microvascular reconstruction, followed by implant rehabilitation. Unfortunately, she suffered from multiple episodes of peri-implantitis and later on went on to develop oral squamous cell carcinoma around two of the dental implants. Here, we highlight the importance of regular follow-up and maintaining a high index of suspicion in high-risk patients.

Micro-scooter induced dental trauma: a case report.

There has been a remarkable increase in the popularity of micro-scooters over the past few years. This has brought with it an astonishing rise in the number of associated injuries. Highlighted here is a case report which outlines the dental injuries associated with the use of a micro-scooter.