A change in surgical margin: do wider surgical margins lead to decreased rates of local recurrence in T1 and T2 oral tongue cancer?

The purpose of this study was to assess the impact of a change in macroscopic/surgical margin width upon histological margins and loco-regional failure in early oral tongue squamous cell carcinoma (OTSCC). In 2009, the surgical margin protocol was increased from 10 mm to 15 mm. A retrospective review was performed of all patients who underwent treatment for early OTSCC between 2009 and 2016 with a 15-mm surgical margin (n = 142), and these patients were compared to those treated between 1999 and 2008 with a 10-mm surgical margin (n = 78). There was a significant increase in the rate of clear histological margins (P < 0.001). The rates of close (P = 0.002) and involved (P < 0.001) histological margins decreased significantly. There were significant reductions in local (P < 0.001) and regional (P < 0.001) recurrence rates. This study demonstrated that a surgical margin of 15 mm delivered significantly lower rates of close/involved histological margins and improved local and regional disease recurrence in early OTSCC when compared with a surgical margin of 10 mm.

Surgery for maxillary oral squamous cell carcinoma: the effect of surgical resection margins and elective neck dissection on oncological outcomes.

Maxillary oral squamous cell carcinoma (OSCC) is uncommon. Surgical resection is challenging due to the anatomy, and the role of elective neck dissection (END) is not well-defined. A retrospective cohort study of patients with maxillary OSCC treated with primary surgery between 2007 and 2019 was conducted. Primary tumours of sinonasal origin with extension into the oral cavity were excluded. Survival analysis was performed using Kaplan-Meier and Cox proportional hazards models. Sixty-seven patients were included; mean follow-up was 55 months. On univariate analysis, clear (≥5 mm) margins were associated with higher disease-free (68% vs 36%, P = 0.019) and overall survival (75% vs 36%, P = 0.004) than close/involved (<5 mm) margins. In clinically node-negative patients, the risk of occult cervical metastasis in tumours with depth of invasion (DOI) ≥ 3 mm and T2-4 tumours was 22% and 25%, respectively. END in these groups was associated with a lower rate of loco-regional recurrence (DOI ≥3 mm subgroup: 5% vs 38%, P = 0.029; T2-4 subgroup: 6% vs 50%, P = 0.028) and longer time to recurrence (DOI ≥3 mm subgroup: 119 months vs 96 months, P = 0.042; T2-4 subgroup: 117 months vs 56 months, P = 0.031) than observation of the neck. On multivariate analysis, close/involved margins were associated with an increased risk of overall mortality (hazard ratio 3.4, 95% confidence interval 1.0-11.3, P = 0.043) and disease recurrence (hazard ratio 2.8, 95% confidence interval 1.1-7.1, P = 0.031). In maxillary OSCC, a ≥ 5 mm histological margin should remain the goal of ablative surgery. END should be considered in tumours with DOI ≥ 3 mm.

The impact of delayed diagnosis on the outcomes of oral cancer patients: a retrospective cohort study.

The contemporary literature is discordant regarding the role of delayed diagnosis in the prognosis of patients with oral cancer. This study examined data on a previously reported cohort of 101 patients with oral squamous cell carcinoma diagnosed at a single institution between 2008 and 2010. The time interval between symptom onset and initial histological diagnosis (diagnostic delay) was recorded for each patient, as were demographic data and cancer features such as T stage, nodal status, and smoking status. The mean follow-up period was 4 years 10 months. The mean diagnostic delay was 4 months, mean overall survival was 5years 6 months, and mean disease-specific survival was 4 years 9 months. No significant correlation was found between diagnostic delay and overall survival, disease-specific survival, or recurrence rates. Patients with node-positive disease were more likely to be diagnosed earlier, whereas women and non-smokers were more likely to have a delayed diagnosis. Inherent tumour biology is likely an important prognostic factor separate to diagnostic delay. Public education efforts should focus on symptom recognition and encourage early presentation for investigation of oral lesions, particularly for females and non-smokers, so that more aggressive tumours can be treated sooner to give the best chance at survival.

Operative management of equine-related maxillofacial trauma presenting to a Melbourne level-one trauma centre over a six-year period.

The aim of this study was to examine the pattern of equine-related maxillofacial trauma that required operative treatment in patients who presented to a level-one trauma centre in Melbourne between 2011 and 2016. A total of 28 patients (16 female and 12 male, median (range) age 31 (16-76) years) were identified from a database of all operatively managed maxillofacial trauma cases, and data were collected on demographics, mechanisms and patterns of injury, and management. The most common mechanism was kicking (n=16), which was also the most likely to result in multiple injuries. Half the patients sustained an injury to the midface only, with naso-orbitoethmoidal (NOE) and orbital fractures being the most common fractures. Of the total fractures (those that did and did not require an operation), 44/54 were managed with internal fixation. Exactly half the patients were treated as inpatients and half as outpatients, and despite a longer total duration of hospital stay for inpatients, the postoperative period was the same in both. Many horse-related maxillofacial injuries were sustained by young women, and the midface was most commonly affected. More injuries overall were sustained while unmounted (particularly by kicks) than by falls.

Non-invasive screening of a microRNA-based dysregulation signature in oral cancer and oral potentially malignant disorders.

INTRODUCTION: We have previously shown that oral swirls are a robust source of microRNA protected by extracellular vesicles, potentially useful to detect oral squamous cell carcinoma (OSCC)-associated molecular aberration. OBJECTIVES: To study a developed dysregulation score and risk classification algorithm based upon a panel of OSCC-associated microRNA in oral swirls from individuals with OSCC and oral potentially malignant disorders (OPMDs). MATERIALS AND METHODS: An OSCC-associated panel of 5 microRNAs (miR-24; miR-21; miR-99a; let-7c; miR-100;) was quantified by qPCR in 190 individuals with and without mucosal abnormalities, including OSCC (n = 53) and OPMDs (n = 74). Each sample was analyzed using a developed dysregulation score (dSCORE) and risk classification algorithm, allocating a LOW- or HIGH-RISK score. The influence of demographic, systemic, oral health and mucosal disease factors on the developed test was analyzed. RESULTS: MicroRNA for analysis can be predictably isolated from oral swirls sourced from individuals with a range of demographic, systemic and oral health findings. Utilizing the presence of HIGH-RISK identified OSCC patients with 86.8% sensitivity and 81.5% specificity. Older age and female gender were associated with higher dSCOREs and higher proportions of HIGH-RISK classification amongst individuals with no mucosal abnormalities. The dSCOREs for all subgroups of OPMDs were significantly different from the OSCC group. CONCLUSION: This is the first comparison of microRNA sourced from oral swirls from individuals with OPMDs with individuals with and without OSCC. A HIGH-RISK dysregulation signature was found to be accurate in indicating the presence of OSCC and exampled to parallel malignant transformation.

Spontaneous bilateral osteonecrosis of the mandible in a bisphosphonate-naive patient.

Medication-related osteonecrosis of the jaw is a well-described, yet poorly understood disease of bone that is commonly associated with antiresorptive and antiangiogenic drugs. We report a case of spontaneous bilateral osteonecrosis of the mandible in a patient with no previous exposure to either.

Can radiological examination of mandibular bone invasion accurately predict the need for mandibular resection in oral squamous cell carcinoma?

Bone invasion by oral squamous cell carcinoma necessitates jaw resection, with preoperative imaging ideally able to guide the resection. A retrospective review of 109 patients with oral squamous cell carcinoma who underwent mandibular resection was performed. Eighty-three had preoperative computed tomography (CT) imaging and 72 underwent magnetic resonance imaging (MRI). The presence of bone invasion on imaging was compared to histopathology. Bone invasion was detected in 44 of 109 resection specimens (40.4%) and was identified on CT in 31 of 83 cases (37.4%) and on MRI in 35 of 72 cases (48.6%). The sensitivity and specificity of CT for detecting bone invasion was 69.0% and 79.6%, respectively, while for MRI was 87.1% and 80.5%, respectively. Histological detection of bone invasion was associated with greater disease-specific mortality (P=0.002), as was MRI detection of bone invasion (P=0.027). CT detection was not significant (P=0.240). Negative prediction of bone invasion was 95% accurate for both modalities in clinically non-invaded mandibles. Survival was reduced in patients who underwent marginal mandibular resection when bone invasion was detected histologically (33.3% vs. 70.5%, P=0.277) and with CT, although this was not statistically significant. More data are required to determine whether more aggressive resection is warranted when bone invasion is detected preoperatively.

Long-term outcomes of craniofacial implants for the restoration of facial defects.

The aim of this study was to evaluate the long-term survival of craniofacial implants and prostheses and to identify factors associated with failure in a cohort of patients. A 25-year retrospective analysis was conducted at Royal Melbourne Hospital. Data included demographic characteristics, age, site and cause of the deformity, and number and survival of implants. Odds ratios were calculated and event-to-time Kaplan-Meier analyses performed. One hundred and ten patients were included (341 implants); their mean age was 46.2 years. The overall implant survival rate was 79.5% (mean follow-up 10.6 years). Temporal implants had the highest success rate (97.0%), followed by nasal implants (87.5%) and orbital implants (63.3%); differences were statistically significant (P<0.0001 and P=0.033, respectively). Kaplan-Meier analyses to determine long-term implant and prosthesis survival found temporal implants had the highest prosthetic (P<0.0001) and implant survival (P<0.0001). Patients with congenital deformities demonstrated the highest success rate. Radiotherapy was found to increase the risk of implant failure (P=0.02). Craniofacial implant-retained prostheses are a reliable and effective option for the restoration of facial defects, with good long-term success rates. Orbital implants and those placed post oncological surgery have a higher failure rate.

Oral swirl samples - a robust source of microRNA protected by extracellular vesicles.

BACKGROUND: MicroRNAs are small non-coding RNAs which are dysregulated in disease states, such as oral cancer. Extracellular vesicles, a potential source of microRNA, are found in saliva. OBJECTIVE: To demonstrate that a quantifiable amount of microRNA can be isolated from oral swirl samples. Additionally, we hypothesized that extracellular vesicles may protect contained microRNA from degradation in these samples. METHOD: A polyethylene glycol-based precipitation was used for extracellular vesicle enrichment of oral swirl samples. Comparison was made between samples treated with and without RNase. Further, samples from three subjects were exposed to a range of conditions over 7 days and assessed for presence of microRNA by reverse-transcription quantitative PCR. Extracellular vesicles from samples were identified under transmission electron microscopy. RESULTS: An adequate quantity of microRNA for qPCR analysis was extractable from samples despite exposure to conditions under which degradation of RNA would be expected. CONCLUSION: A technique was developed to isolate an adequate quantity of microRNA for analysis from oral swirl samples. Extracellular vesicle-associated microRNA may be protected from degradation. This technique moves towards chairside application of translational microRNA research in the field of oral cancer prognostics.

Referral patterns for oral squamous cell carcinoma in Australia: 20 years progress.

BACKGROUND: The aim of this study was to identify changes in referral patterns and delays in diagnosis and treatment of oral squamous cell carcinoma (OSCC), managed at a tertiary institution in Victoria, Australia. METHODS: The hospital records of all patients with newly diagnosed OSCC, managed by The Royal Melbourne Hospital (RMH) Head and Neck Tumour Stream between January 2008 and December 2010, were retrospectively reviewed. RESULTS: Of the 101 patients, 52% first sought help from general medical practitioners (GMP) while 43% initially attended a general dental practitioner (GDP). The most common site of OSCC was oral tongue (42%). The most common presentation was ulceration (31%). Seventy per cent of patients presented with T1 (39%) or T2 (31%) tumours. The diagnostic delay ranged from 0 to 8 years with an average of 4.5 months. Patient delay ranged from 0 to 1.4 years with an average of 1.8 months. Professional delay ranged from 0 to 8 years with an average of 2 months. CONCLUSIONS: Delays in patients seeking advice have decreased compared to previous studies, while delays in professionals making a diagnosis have not improved considerably. There has been a significant shift towards initial presentation to GMP rather than GDP. Further decrease in delays is possible by improving both population awareness and clinician education.

Orbital Roof Fractures: A Clinically Based Classification and Treatment Algorithm.

Orbital roof fractures are relatively uncommon in craniofacial surgery but present a management challenge due to their anatomy and potential associated injuries. Currently, neither a classification system nor treatment algorithm exists for orbital roof fractures, which this article aims to provide. This article provides a literature review and clinical experience of a tertiary trauma center in Australia. All cases admitted to the Royal Melbourne Hospital with orbital roof fractures between January 2011 and July 2013 were reviewed regarding patient characteristics, mechanism, imaging (computed tomography), and management. Forty-seven patients with orbital roof fractures were treated. Three of these were isolated cases. Forty were male and seven were female. Assault (14) and falls (13) were the most common causes of injury. Forty-two patients were treated conservatively and five had orbital roof repairs. On the basis of the literature and local experience, we propose a four-point system, with subcategories allowing for different fracture characteristics to impact management. Despite the infrequency of orbital roof fractures, their potential ophthalmological, neurological, and functional sequelae can carry a significant morbidity. As such, an algorithm for management of orbital roof fractures may help to ensure appropriate and successful management of these patients.

Survey of Australasian oral and maxillofacial surgeons 2011--scope and workforce issues.

This study examined the qualifications, training, and practice patterns of oral and maxillofacial surgeons in Australia in 2011. This information was compared to similar studies performed in 1986 and 1995. It was found that dentoalveolar surgery comprised the greatest proportion of practice. There had been major growth in dental implantology, orthognathic surgery, and management of pathology. These increases were directly related to the standardization and increase in qualifications and training. The workforce had increased at the highest rate predicted, but was only just keeping up with the increases in population and the number of general health practitioners.

Ameloblastoma: demographic data and treatment outcomes from Melbourne, Australia.

BACKGROUND: There is a lack of published data on the demographics and treatment outcomes of ameloblastomas treated in Australia. Our objective was to collect this data and compare the findings to other international studies. METHODS: A retrospective study of 42 patients with ameloblastoma was conducted at The Royal Melbourne Hospital, Australia. Data on the demographic features, management techniques (ablative and reconstructive), and outcomes were collected and analysed. RESULTS: The majority of tumours were solid/multicystic (81%) and occurred most commonly in the mandible (80.5%). Unicystic ameloblastomas affected a younger age group, with Type 3 being the most common subtype. Overall, the recurrence rate for solid/multicystic ameloblastomas was 14.7%; however, radical surgery was found to have a significantly lower recurrence rate when compared to conservative management (p=0.015), with a mean of 51 months follow-up. Results indicated that vascularized free-flaps had fewer postoperative complications than non-vascularized bone grafts; however, the differences did not reach statistical significance. CONCLUSIONS: This is the largest clinicopathological study regarding ameloblastoma management from Australia, and our results support the current literature in recommending radical surgery for the treatment of solid/multicystic and Type 3 unicystic tumours.

HCV viremia drives an increment of CD86 expression by myeloid dendritic cells.

The host immune response, including innate and adaptive immunity, plays a critical role in determining the outcome of viral infection. Nevertheless, little is known about the exact reasons for the failure of the host immune system in controlling hepatitis C virus (HCV) infection. Impairment of dendritic cells (DCs) function is probably one of the mechanisms responsible for immune evasion of HCV. In this study, the frequency and phenotype of DCs subsets were analyzed in three groups: HCV-infected individuals who developed viral persistence (1), HCV-infected individuals who spontaneously cleared the virus (2) and HCV-seronegative uninfected subjects (3). The results showed that the frequency of DCs subsets was not statistically significant between groups. Plasmacytoid DCs circulating exhibited an immature phenotype characterized by low expression of CD86. On the other hand, CD86 expression in myeloid DCs was significantly higher in chronic infected individuals compared to healthy controls (P=0.037). A positive correlation was observed between CD86(+) myeloid DC (mDC) and HCV viral load (r=0.4121, P=0.0263). These results suggest that HCV did not have an inhibitory effect on mDC maturation and the HCV viremia drives the increase of CD86 expression in mDC. The regulation of DCs maturation and migration lies at the level of intracellular signaling. HCV can activate or block intracellular signaling pathways and alter DC function. In conclusion, the present study suggests that imbalance of DC maturation by the virus represents a mechanism of evasion of the immune system despite the fact that HCV viremia appears to exert a "stimulatory" effect on cell-surface immune phenotype.

Olive pulp and its effluents suitability for soil amendment.

Olive pulp (OP) and its effluents produced after digestion processes were characterised and their suitability as soil amendment materials were investigated. Results showed that OP and its effluent for hydrogen (EH2) and methane production (ECH4) contain high amount of organic matter, remarkable concentration of nutrients and negligible content of heavy metals. Decreasing concentrations of low molecular weight phenols (monomeric phenols) and increasing amount of humic-like materials were found passing from OP to EH2 and ECH4. The effects on both wheat seed germination and seedlings growth were also investigated. Addition of OP at the highest doses delayed both seed germination and seedling growth. These effects decreased when the OP and its effluents were incorporated into the soil. On the contrary an enhancement of seedlings growth was detected by addition of EH2 and ECH4. Enhancement effects also were found out by addition of lower OP concentrations. The phytotoxic effects decreased when the products were incorporated into the soil.

Selected midfacial access procedures to the skull base.

The indications and operative technique of various procedures commonly used to provide or increase access to the central skull base, anterior and middle cranial fossae, nasopharynx, infratemporal fossa and retromaxillary space are discussed with illustrative cases.

Nasopharyngeal carcinoma: clinical assessment and review of 176 cases.

OBJECTIVE: The objective of this study was to delineate salient disease characteristics and to determine factors associated with survival in a series of patients with nasopharyngeal carcinoma (NPC). STUDY DESIGN: To address our research objective, we used a retrospective cohort study design and a sample of patients who presented for evaluation and management of NPC. Demographic data, medical history, radiographic findings, staging, and histology were recorded. Treatment and follow-up information were ascertained. Survival data and descriptive statistics were calculated. Multivariate analyses identified risk factors associated with survival rates for all World Health Organization (WHO) types. RESULTS: The sample comprised 123 men and 53 women (n = 176) of which 70% were white and 23% were Asian. A neck mass was the initial symptom in 49% of patients. In 99% of cases, radiation therapy was the primary treatment mode. WHO types 1 and 3 were most common. Overall 5-year disease-free survival rate was 45.5%. Age, use of tobacco or ethanol, and number of presenting symptoms were statistically associated with decreased survival rate in WHO 1 (squamous cell) tumors. Male gender and total number of presenting symptoms were associated with decreased survival rate for WHO 2 and 3 (nonkeratinizing or undifferentiated) tumors. CONCLUSIONS: Being attuned to the presenting signs of NPC may lead to a more expedient diagnosis. The differing risk factors associated with WHO 1 tumors become clear in this predominantly white population.