The Number of Positive Lymph Nodes Instead of Extranodal Extension and Nodal Diameter is an Independent Predictor of Survival and Treatment Outcome of High-Grade Parotid Gland Carcinoma.

BACKGROUND: There is emerging evidence that current 8th edition of the American Joint Committee staging system is not sensitive enough to predict parotid gland carcinoma (PGC) survival outcomes. PURPOSE: The present study aimed to analyze pathological nodal factors related to survival and treatment outcomes in a cohort of patients surgically treated with PGC. STUDY DESIGN, SETTING, SAMPLE: We performed a retrospective cohort study of consecutive patients surgically treated with PGC at the authors' institution from January 1993 to December 2018. The inclusion criteria were as follows: confirmed high-grade parotid gland malignancy on histopathology first surgical treatment of the parotid cancer with neck dissection with curative intent at the study clinic; and sufficient data for review. The exclusion criteria were previous treatment in another institution, low-grade carcinomas, cases where neck dissection was not performed, incurable local disease and distant metastases at the time of first diagnosis, and patients lost to follow-up. PREDICTOR VARIABLE: Predictor variable comprised pathological nodal factors grouped as the number of cervical node metastases, extranodal extension (ENE), largest diameter of nodal metastasis, and involvement of parotid lymph nodes. MAIN OUTCOME VARIABLES: Outcomes evaluated were overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), locoregional recurrence-free survival, and distant metastasis-free survival (DMFS). OS was calculated from the day of biopsy or definitive surgery to the last known hospital follow-up date or the date of death found in the hospital records or social security data. DSS was calculated from the day of biopsy or definitive surgery until the last known follow-up or death from PGC reported in the patient record. Patients who died from causes other than the disease being studied are not counted in this measurement. Treatment outcome was evaluated through the occurrence of locoregional relapse of the disease or development of distant metastases. RFS was defined as the time from the date of biopsy or definitive surgery to the date of locoregional recurrence free survivalor DMFS reported in the patient record. COVARIATES: Covariates were composed of a set of heterogeneous variables grouped into the following categories: demographic, pathologic, and clinical. ANALYSES: Unadjusted and adjusted hazard ratios for each variable were calculated with univariate and multivariable Cox regression. The tatistical significance was defined at a P value of < .05. RESULTS: The cohort of 112 patients included 62 males (55%) and 50 (45%) females. The mean age of the patients was 60.52 ± 15.22 years. The median follow-up time was 59 months (3-221 months). Adenoid cystic carcinoma was the most common tumor type with the incidence of 45%. Cumulative OS for the 5-and 10-year follow-up period was 75 and 61%, respectively. Locoregional recurrences occurred with 27 patients (24%), distant metastases occurred with 25 patients (22%), and both were diagnosed with 5 patients (6%). The number of metastatic nodes was the most important nodal prognostic factor related to OS (P = .02; HR = 2.67; CI = 0.03-6.35), DSS (P = .011; HR = 2.55; CI = .61-6.83), and DMFS (P = .005; HR = 2.85; CI = 0.12-4.76). The presence of pathological parotid nodes was associated with poorer RFS (P = .015; HR = 3.45; CI = 0.25-6.02). CONCLUSION AND RELEVANCE: The number of metastatic lymph nodes, instead of ENE and largest nodal diameter, was the contributing factor associated with survival and treatment outcomes of surgically treated patients with high-grade PGC. Since the main function of staging system is to predict outcomes, the significance of ENE and nodal dimension in salivary gland cancer staging system requires further clarification. An important finding in the present study was that the presence of positive parotid lymph nodes was associated to locoregional treatment failure.

Prognostic factors for development of distant metastases in surgically treated high-grade salivary gland carcinomas: results of retrospective single center study with 213 patients.

PURPOSE: Distant metastases (DM) are the primary cause of treatment failure and death of patients with salivary gland carcinomas (SGC). The purpose of present study was to evaluate factors predictive on DM development in a cohort of patients with high-grade salivary gland carcinomas. METHODS: This was a retrospective cohort study of consecutive patients surgically treated with curative intention at the authors' institution from January 1993 to December 2018. Outcomes evaluated were overall survival (OS), disease specific survival (DSS), recurrence free survival (RFS), locoregional recurrence free survival (LRFS) and distant metastasis free survival (DMFS). RESULTS: A total of 213 patients, 117 males (55%) and 96 females (45%), were included in the study. Parotid gland malignancies accounted for 56% of all cases. Adenoid cystic carcinoma (119 cases; 56%) was the most common tumor type. Cumulative OS for the 5-and 10-year follow-up period was 80% and 58% respectively. DM occurred with 75 patients (35%). The most common locations for DM were lung (55 cases; 73%) and liver (12 cases; 16%). Pathological nodal status, particularly the number of metastatic nodes, was the independent prognostic factor for OS, DSS, RFS and DMFS. CONCLUSION: Number of metastatic lymph nodes, instead of extranodal extension and largest nodal diameter, was the contributing factor related to DMFS. Since the main function of staging system is to predict outcomes, the significance of extranodal extension and nodal dimension in salivary gland cancer staging system requires further clarification. The elective neck dissection could be considered therapeutic approach for high-grade SGC since occult metastases were detected in 33% of cases.

Pathological nodal status as a main predictive factor of survival and treatment outcomes of submandibular salivary gland cancers: A 25-year single center experience.

INTRODUCTION: Aim of this study was to explore the survival predictive factors and treatment outcomes in a cohort of SGC patients treated at a single center over a period of 25 years. MATERIALS AND METHODS: Patients who had received primary treatment for SGC were enroled. Outcomes evaluated were: overall survival (OS), disease specific survival (DSS), recurrence free survival (RFS), locoregional recurrence free survival (LRFS) and distant metastasis free survival (DFS). RESULTS: A total of 40 patients with SGC were enroled in the study. The most common tumor was the adenoid cystic carcinoma (60% of cases). Cumulative OS for 5-and 10-year follow up period was 81% and 60%, respectively. Thirteen patients (32.5%) developed distant metastases during follow-up. Nodal status, high-grade histology, tumor stage and adjuvant radiation-therapy (RT) were significant variables on multivariate analysis for survival and treatment outcomes. CONCLUSIONS: Submandibular gland carcinomas represent rare and heterogenous tumor group regarding histological appearance and locoregional and distant metastatic potential. Tumor histological grade, AJCC tumor stage and nodal status were the strongest predictive factors for survival and treatment outcomes. RT improved OS and locoregional treatment outcome, but not DFS. Elective neck dissection (END) could be beneficial for selected cases of SGC. Superselective neck dissection of levels I-IIa may be the level of dissection for END. Distant metastases were the main cause of death and treatment failure. Prognostic factors for poor DMFS were AJCC stage III and IV, high tumor grade and nodal status.

Predictive factors for survival and treatment outcomes of patients with minor salivary gland malignancies: a retrospective study.

INTRODUCTION: Aim of this study was to explore the incidence, pathology, clinical behaviour and evaluate factors predictive on survival and treatment outcomes in a cohort of patients with minor salivary gland (MiSG) malignancies treated at a single center over a period of 25 years. MATERIALS AND METHODS: Patients who had received primary treatment for MiSG malignancy during 25 years observation period were identified. Outcomes that were evaluated were overall survival (OS), disease specific survival (DSS), recurrence free survival (RFS), locoregional recurrence free survival (LRFS) and distant metastasis free survival (DFS). RESULTS: A total of 88 patients with MSG malignancies were included in the study. The most common location for MiSG malignancies was the oral cavity (65 tumors; 77%). Cumulative OS for 5 and 10 year follow up period was 82% and 62% respectively. Cumulative DSS for 5 and 10 year follow up period was 85% and 73% respectively. Twenty one (23%) patients developed distant metastases during follow-up. High-grade pathology and tumor stage were significant variables on multivariate analysis for all survival and treatment outcomes. CONCLUSIONS: Minor salivary gland malignancies are minor only by name. Tumor histological grade, AJCC tumor stage and pT stage were the strongest predictive factors for survival and treatment outcomes. The elective neck dissection could be considered therapeutic approach for selected cases of high grade MiSG malignancies. Distant metastases were the main cause of death and treatment failure.

Evaluation of clinical parameters affecting the prognosis in surgically treated patients with descending necrotizing mediastinitis - A retrospective study.

OBJECTIVES: Descending necrotizing mediastinitis (DNM) is the most serious complication of maxillofacial infections followed with high mortality. The objective of this retrospective study was to evaluate possible prognostic clinical factors for survival of patients with DNM based on single center clinical data. METHODS: The study enrolled patients admitted to the Emergency Center of Vojvodina with the diagnosis of DNM either as the primary diagnosis or with discharged diagnosis after surgical treatment during 11-years period. The data were obtained from patient medical records. RESULTS: After final analysis total of 28 charts were randomized for statystical analysis, 19 charts in survivors and 9 in non-survivors group. The most common cause of infection in survivors group was odontogenic and in non-survivors group pharyngeal infection. On multivariate regression analysis of collected data results of control computed tomography, preoperative Endo status, early postoperative C-reactive protein (CRP) and procalcitonine (PCT) values and postoperative complications were statistically significant predictors for mortality. CONCLUSIONS: Based on results of this study, extent of infection in the mediastinum based on Endo's criteria, progression of infection on control cervicothoracic CT, increase of CRP and PCT values in immediate postoperative period and presence of postoperative complications and septic shock provide poor prognosis for patients with DNM.

Prognostic factors for descending necrotizing mediastinitis development in deep space neck infections-a retrospective study.

OBJECTIVES: Descending necrotizing mediastinitis (DNM) is the most serious complication of deep neck infections (DNI). The objective of this retrospective study was to evaluate prognostic factors for DNM development in deep space neck infections. METHODS: The study enrolled patients admitted to the Emergency Center of Vojvodina with the diagnosis of multispace DNI with or without DNM either as the primary diagnosis or with discharged diagnosis after surgical treatment during 7-year period. The data were obtained from patient medical records. RESULTS: After final analysis total of 141 charts were randomized for statystical analysis, 124 charts in DNI and 17 in DNI + DNM groups. The most common cause of infection in both groups was odontogenic. On multivariate regression analysis of collected data infection of retropharyngeal, pretracheal and carotid space, C-reactive protein and procalcitonine values were statistically significant predictors for DNM development. CONCLUSIONS: Treatment and diagnosis of DNM requires multidisciplinary approach, with prompt clinical and radiological examinations, empirical broad spectrum antibiotic therapy and radical surgical debridement. Multispace neck infection and especially infection of retropharyngeal, carotid and pretracheal spaces are the most sensitive predictors for DNM development in deep space neck infections. CLINICAL RELEVANCE: If the infection from deep neck spaces reach retropharyngeal, carotid or pretracheal space, the DNM is probable to occur. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT04865003. Date of registration 27.4.2021.

Impact of Chronic Kidney Disease Mineral and Bone Disorder on Jaw and Alveolar Bone Metabolism: A Narrative Review.

Chronic kidney disease (CKD) has become a worldwide public health problem. It is estimated that nearly 90% of patients with chronic renal failure manifest some symptoms of oral disease. With advances in medical treatment, CKD patients are living longer and require oral care. Chronic kidney disease is often accompanied by disturbances in mineral metabolism which are classified as their own clinical entity known as CKD-mineral and bone disorder (CKD-MBD). CKD-MBD affects all aspects of bone physiology: bone volume, bone turnover and bone mineralization. Jaw bones affected with CKD-MBD can have important clinical implications for the survival and osseointegration of dental implants, success of bone regeneration therapy, and increased risk of bone loss in patients with periodontitis or risk of bone fracture. Assessment of bone turnover is the most important diagnostic tool to monitor progression of CKD-MBD. Bone biomarkers and radiographical examination of bone density may be particularly useful to both, diagnosis and monitoring of bone turnover. Cone beam computed tomography (CBCT) as a reliable method with many advantages over other radiographic methods can be used for analysis of jaw bone micro-architectural changes and may be of a great help in bone quality determination in CKD-MBD.

Efficacy and safety of 1% ropivacaine for postoperative analgesia after lower third molar surgery: a prospective, randomized, double-blinded clinical study.

OBJECTIVES: The purpose of this study was to investigate postoperative analgesic effect of ropivacaine administered as main or supplemental injection for the inferior alveolar nerve block (IANB) in patients undergoing lower third molar surgery. MATERIALS AND METHODS: The double-blind randomized study comprised 72 healthy patients. All patients received two blocks, the IANB for surgical procedure + IANB after surgery for postoperative pain control, and were divided into three groups: (1) 2 % lidocaine/epinephrine + 1 % ropivacaine, (2) 2 % lidocaine/epinephrine + saline, and (3) 1 % ropivacaine + saline. The occurrence of postoperative pain, pain intensity and analgesic requirements were recorded. Data were statistically analyzed using chi-square, Fisher, and Kruskal-Wallis tests and analysis of variance (ANOVA) with Bonferroni and Tukey correction. RESULTS: Ropivacaine was more successful than lidocaine/epinephrine in obtaining duration of postoperative analgesia, reduction of pain, and analgesic requirements whether ropivacaine was used for surgical block or administered as a supplemental injection after surgery. CONCLUSIONS: Ropivacaine (1 %, 2 ml) resulted in effective postoperative analgesia after lower third molar surgery. CLINICAL RELEVANCE: Since pain control related to third molar surgery requires the effective surgical anesthesia and postoperative analgesia, the use of 1 % ropivacaine could be clinically relevant in a selection of appropriate pain control regimen for both surgical procedure and early postsurgical treatment.

The relationship between the immune system and oral manifestations of inflammatory bowel disease: a review.

Inflammatory bowel diseases (IBDs) are chronic, relapsing inflammatory diseases characterized by exacerbations and remissions of the gastrointestinal tract, clinically manifested as Crohn's disease and ulcerative colitis. The etiology of IBDs is considered to be multi factorial, comprising environmental, immune, microbial and genetic factors. Clinical signs may include abdominal pain, frequent bloody diarrheas, mucorrhea, vomiting, fever, fatigue or weight loss. Changes in the oral cavity often precede intestinal symptoms. Inflammatory bowel disease leads to a significant deterioration of oral health, which indicates that cooperation between the dentist and the gastroenterologist is necessary when considering patients' welfare. Patients with IBD have an altered immune response, but microorganisms of the oral cavity may also be responsible for its modification. This review paper discusses the correlation between the immune system and inflammatory bowel disease manifestations in the oral cavity.

Decompression as an effective primary approach to large radicular cyst in the maxillary sinus--A case report.

INTRODUCTION: Therapeutic approach to jaw cysts may depend on their dimensions and localization. Enucleation of cystic lesion is not always preferable in the first act, especially if large cysts are in close proximity to important anatomical structures. The aim of this paper was to present the outcome of the treatment protocol comprising preoperative decompression and subsequent enucleation of a large maxillary cyst. CASE REPORT: A 21-year-old male patient with large asymptomatic radicular cyst in the right maxillary sinus was presented to our clinic. Cone-beam computed tomography (CBCT) showed a large cyst, which perforated the right anterior maxillary wall by 1.5 cm, and was in the intimate contact with the orbital floor. Surgical treatment of the cystic lesion comprised: preoperative decompression with biopsy in the first act and enucleation, performed under general anesthesia, 6 months after the observation period. CONCLUSION: Decompression with subsequent enucleation proved to be effective treatment of large radicular cyst in maxillary sinus with low-morbidity.

Quality of analgesia after lower third molar surgery: A randomised, double-blind study of levobupivacaine, bupivacaine and lidocaine with epinephrine.

BACKGROUND/AIM: Surgical extraction of lower third molars is followed by mild or severe postoperative pain which peaks at maximal intensity in the first 12 hours and has a significant impact on a patient's postoperative quality of life. The use of long-acting local anaesthetics is a promising strategy to improve postoperative analgesia. The aim of the present study was to investigate analgesic parameters and patient satisfaction after using 0.5% levobupivacaine (Lbup), 0.5% bupivacaine (Bup) and 2% lidocaine with epinephrine 1:80,000 (Lid + Epi) for an inferior alveolar nerve block following lower third molar surgery. METHODS: A total of 102 patients (ASA I) were divided into three groups, each of which received either 3 mL of Lbup, Bup or Lid + Epi. The intensity of postoperative analgesia was measured using a verbal rating scale (VRS). The total amounts of rescue analgesics were recorded on the first and during seven postoperative days. Patients satisfaction was noted using a modified verbal scales. RESULTS: A significantly higher level of postoperative pain was recorded in Lid + Epi group compared to Bup and Lbup groups. No significant differences were seen between Bup and Lbup, but a significant reduction in the need for rescue analgesics was seen postoperatively in both Lbup and Bup (50%) in comparison with Lid + Epi (80%) in the first 24 hours. The same significant trend in rescue analgesic consumption was recorded for seven postoperative days. Patients' overall satisfaction was significantly lower for Lid + Epi (10%) than for Lbup (56%) and Bup (52%). CONCLUSION: The use of a new and long-acting local anaesthetic 0.5% levobupivacaine is clinically relevant and effective for an inferior alveolar nerve block and postoperative pain control after third molar surgery. In our study Lbup and Bup controled postoperative pain more efficiently after lower third molar surgery compared to Lid + Epi.

Levobupivacaine vs. bupivacaine for third molar surgery: quality of anaesthesia, postoperative analgesia and local vascular effects.

OBJECTIVES: The main purpose of this prospective, double-blind, randomized study was to evaluate anaesthetic parameters, postoperative analgesia and vasoactive properties of levobupivacaine and bupivacaine for lower third molar surgery. MATERIAL AND METHODS: Sixty patients (ASA I) were scheduled for lower third molar surgery under inferior alveolar nerve block, lingual nerve block and buccal nerve block (mandibular nerve blocks) obtained with 3 ml of 0.5 % levobupivacaine and 3 ml of 0.5 % bupivacaine. Success rate, onset and duration of three nerve bocks were evaluated by electrical pulp testing, pinprick testing and signs of soft tissue anaesthesia (patient-reported numbness). Intensity of intraoperative anaesthesia and postoperative analgesia were measured with visual analogue scale (VAS) and numeric rating scale (NRS). The time of first postoperative pain reported and analgesic consumption were also recorded. The laser Doppler flowmetry was used for the measurement of the first premolar pulpal blood flow. RESULTS: There were no differences between levobupivacaine and bupivacaine regarding the success rate, onset and duration of mandibular nerve blocks as well as intensity of postoperative analgesia and analgesic consumption. Intensity of intraoperative anaesthesia and duration of postoperative analgesia were significantly higher in the levobupivacaine than in the bupivacaine group. Both anaesthetics showed similar biphasic vasoactive effect. CONCLUSIONS: Levobupivacaine 0.5 % achieved superiority over bupivacaine 0.5 % in the intensity of intraoperative anaesthesia and duration of postoperative analgesia for lower third molar surgery under the mandibular nerve blocks. CLINICAL RELEVANCE: It seems that the plain levobupivacaine (0.5 %) could be an effective alternative to plain bupivacaine (0.5 %) in those dental procedures which require profound bone and soft tissue anaesthesia.