Role of imaging in the management of thyroglossal duct cyst carcinomas (TGC-TIRADS): a single centre retrospective study over 16 years.

Introduction: Thyroglossal duct cyst (TGDC) is the most frequently encountered developmental anomaly in thyroid genesis with a reported incidence of 7% in the adult population. The cyst is known to develop anywhere along the pathway of thyroid descent but is more frequently seen in the infrahyoid neck in the midline. The incidence of malignancy in a TGDC is approximately 1%; a majority of these are papillary carcinomas. This study was conducted at a single tertiary care centre which spanned over a decade which adds practice changing evidence-based knowledge to existing literature on this rare entity. A comprehensive study which conclusively establishes the imaging features predictive of malignancy in TGDC carcinomas (TGDCa), the protocol for optimal management, clinical outcome and long-term survival of these patients is not available. Although TGDC carcinoma is thought to have an excellent prognosis, there is not enough data available on the long-term survival of these patients. The aim of this study was to identify whether neck ultrasound (US) can serve as an accurate imaging tool for the preoperative diagnosis of TGDC carcinomas. Methods: We accessed the electronic medical records of 86 patients with TGDC between January 2005 to December 2021. Of these, 22 patients were detected with TGDC papillary carcinoma on histopathologic examination. Relevant imaging, treatment and follow up information for all cases of TGDC carcinoma were retrospectively reviewed. We compared US characteristics predictive of malignancy across outcomes groups; malignant vs benign using the Chi-square test. Based on the results, a TGC-TIRADS classification was proposed with calculation of the percentage likelihood of malignancy for each category. Results: Compared to benign TGDCs, malignant TGDCs were more likely to present with following US characteristics: irregular or lobulated margins (90.40 vs. 38.10%), solid-cystic composition (61.90 vs. 17.07%), internal vascularity (47.62 vs. 4.88 %), internal calcification (76.19 vs. 7.32 %) (each p value < 0.005). Calcifications and internal vascularity were the most specific while irregular/lobulated margins were the most sensitive feature for malignancy. AUC under the ROC curve was 0.88. Allpatients were operated and were disease free at the end of 5 years or till the recent follow up. Discussion: US is the imaging modality of choice for pre-operative diagnosis of TGDC carcinoma. Thepre-operative diagnosis and risk stratification of thyroglossal lesions will be aided by the application of the proposed TGC-TIRADS classification, for which the percentage likelihood of malignancy correlated well with the results in our study. Sistrunk procedure is adequate for isolated TGDC carcinoma; suspicious neck nodes on imaging also necessitates selective nodal dissection. Papillary carcinomas have an excellent prognosis with low incidence of disease recurrence.

Response assessment of post-treatment head and neck cancers to determine further management using NI-RADS (Neck Imaging Reporting and Data System): a subgroup analysis of a randomized controlled trial.

Objective: Interpreting complex post-treatment changes in head and neck cancer (HNC) is challenging with further added perplexity due to variable interobserver interpretation and hence evolved the NI-RADS lexicon. We evaluated the accuracy of NI-RADS in predicting disease status on 1st post-treatment follow-up CECT in a homogenous cohort of those who received only chemoradiation. Methods: Retrospective analysis of imaging was done for LASHNC patients who received radical chemoradiation in an open-label, investigator-initiated, phase 3 randomized trial (2012-2018) randomly assigned to either radical radiotherapy with concurrent weekly cisplatin (CRT) or CRT with the same schedule plus weekly nimotuzumab (NCRT). 536 patients were accrued, and 74 patients who did not undergo PET/CECT after 8 weeks post-CRT were excluded. After assessing 462 patients for eligibility to allocate NI-RADS at primary and node sites, 435 cases fell in the Primary disease cohort and 412 cases in the Node disease cohort. We evaluated sensitivity, disease prevalence, the positive and negative predictive value of the NI-RADS lexicon, and accuracy, which were expressed as percentages. We also prepared flow charts to determine concordance with allocated NI-RADS category and established accuracy with which it can identify disease status. Results: Out of 435 primary disease cohort, 92%, 55%, 48%,70% were concordant and had 100%, 72%, 70%, 82% accuracy in NI-RADS1 (n=12), NI-RADS2 (n=261), NIRADS3 (n=105), and NI-RADS 4 (n=60) respectively. Out of 412 nodes disease cohort, 95%, 90%, 48%, 70%were concordant and had 92%, 97%, 90%, 67% accuracy in NI-RADS1 (n=57), NI-RADS2 (n=255), NI-RADS3 (n=105) and NI-RADS4 (n=60) respectively. % concordance of PET/CT and CECT across all primary and node disease cohorts revealed that PET/CT was 91% concordant in primary NI-RADS2 as compared to 55% concordance of CECT whereas concordance of CECT was better with 57% in primary NI-RADS3 cohort as compared to PET/CT concordance of 41%. Conclusion: The accuracy with which the NI-RADS lexicon performed in our study at node sites was better than that at the primary site. There is a great scope of research to understand if CECT performs better over clinical disease status in NI-RADS 3 and 4 categories. Further research should be carried out to understand if PET/CECT can be used for close interval follow-up in stage III/IV NI-RADS 2 cases.

Oral cavity adjuvant therapy (OCAT) -a phase III, randomized controlled trial of surgery followed by conventional RT (5 fr/wk) versus concurrent CT-RT versus accelerated RT (6fr/wk) in locally advanced, resectable, squamous cell carcinoma of oral cavity.

BACKGROUND: Limited data exists regarding the impact of intensification of adjuvant therapy in resected Oral Cavity Squamous Cell Carcinomas (OCSCC) with adverse prognostic features on histopathology. PATIENTS AND METHODS: This was a three-arm phase III, randomised trial including patients with resected advanced OCSCC. Randomisation was done in a 1:1:1 ratio: Arm-A- standard adjuvant radiation therapy (RT) 60Gy/30 fractions over 6 weeks versus Arm-B-concurrent chemoradiation versus Arm-C-accelerated radiation therapy (6 d a week). The trial was powered to detect an absolute difference of 10% in 5-year Locoregional Control (LRC). RESULTS: The trial was conducted between June 2005 and March 2013. Majority of the patients were males, had T3-T4 disease, had N2-N3 nodal status and had Extra-Capsular Extension (ECE) in nodes. The median follow-up was 95.9 months. There was no difference between the three arms (A versus B versus C) for 10-year locoregional control (LRC): 60.2% versus 61.4% versus 65.7%, p = 0.57; disease free survival (DFS): 37.4% versus 43.9% versus 39.6%, p = 0.40; or Overall Survival (OS): 39.7% versus 46.6% versus 40.4%, p = 0.40. There was no benefit of intensification with either modality in patients with any single adverse pathological factor. A benefit of intensification could be seen in patients with a combination of high-risk features: T3-T4 primary tumours with N2-N3 nodes along with ECE for DFS (Arm B versus Arm A HR) = 0.53, Arm C versus Arm A HR = 0.63) and OS (Arm B versus Arm A HR = 0.58, Arm C versus Arm A HR = 0.60). CONCLUSIONS: All optimally resected OCSCC with adverse features did not benefit from intensification of adjuvant therapy. Only a cohort of patients with a combination of high-risk features are likely candidates for intensification. CLINICAL TRIAL REGISTRATION: NCT00193843.

MR imaging-based risk stratification scoring system to predict clinical outcomes in carotid body tumors.

Objectives: This study aims to evaluate the role of pretherapy MRI in predicting outcomes in carotid body tumors and propose a grading system for high- and low-risk characteristics. Materials and methods: A retrospective observational study of 44 patients with 51 lesions was carried out from year 2005 to 2020. MR images were reviewed for characteristics of carotid body tumor, and a score was given that was correlated with intra- and postoperative findings. The various other classifications and our proposed Mahajan classification were compared with Shamblin's classification. The area under the curve and ROC curves were used to present the accuracy of different predictive models. Results: Our scoring system allotted a score of 0 to 15 on the basis of MRI characteristics, with scores calculated for patients in our study ranging from 0 to 13. Lesions with scores of 0-6 were considered low risk (45%), and scores of 7-15 were regarded as high risk for surgery (55%). The Mahajan classification stages tumors into four grades: I (10%), II (20%), IIIa (8%), and IIIb (62%). The frequency of vascular injury was 50% in category I and 64% in category IIIb. The frequency of cranial nerve injury was 50%, 66%, and 27% in categories I, II, and IIIb. Conclusion: The Mahajan classification of CBTs evaluates high-risk factors like the distance of the tumor from the skull base and the angle of contact with ICA, which form the major predictors of neurovascular damage and morbidity associated with its surgery. Though the Shamblin classification of CBT is the most widely accepted classification, our proposed Mahajan classification system provides an imaging-based alternative to prognosticate surgical candidates preoperatively.

Eyelid carcinoma: An experience from a tertiary cancer center.

CONTEXT: Eyelid carcinoma is rare tumors of the head and neck. They are rarely lethal but can be associated with significant morbidity if not treated early and appropriately. There are limited data available from world over and in particular the Indian subcontinent regarding eyelid carcinoma and its prognostic factors influencing treatment outcomes. Setting and Design:Retrospective study of patients treated in a tertiary cancer center between 2005 and 2016. METHODOLOGY: In this study, 51 patients with eyelid carcinoma treated at single tertiary cancer center were included. The demographic, clinical data, which includes the treatment received, histopathology report and follow-up, were recorded. All the relevant variables influencing disease-free survival (DFS) were analyzed. RESULTS: Sebaceous carcinoma was the most common eyelid carcinoma followed by squamous cell carcinoma and basal cell carcinoma in descending order in this series. Lower eyelid was involved most often. The incidence of nodal metastasis was low (14%). Multivariate analysis revealed that margin status influenced the DFS (P= 0.001) (hazard ratios = 15.9 [95% confidence interval: 1.8-135.2]). The 5 years' DFS was 70%. CONCLUSION: Eyelid tumors are less common cancer with good prognosis if treated appropriately. The morbidity associated with treatment can be reduced if treated early.

To Do or Not to Do?-A Review of Cancer Surgery Triage Guidelines in COVID-19 Pandemic.

COVID-19 pandemic has emerged as a global health emergency involving more than 200 countries so far. The number of affected population is on rising, so is the mortality. This crisis has overwhelmed the healthcare infrastructures in many affected countries. Due to overall rising cancer incidence and specific concerns, a cohort of cancer patients forms a distinct subset of the population in whom a correct and timely treatment has a huge impact on the outcome. During this period, oncology care is definitely affected owing to many factors like lockdowns, reduced beds and deferral of elective cases to halt the spread of the pandemic. Surgery remains the best line of defence in many solid organ tumours especially in early stage and is potentially curative. China, the source of this pandemic, has taken more than 3 months to enter the post transitional phase of this pandemic. Deferring cancer surgeries for this long period may have a direct impact on the long-term outcomes of cancer patients. Many surgical oncology associations across the globe have come up with triage guidelines for surgical care of cancer patients; however, these are based on expert opinion rather than actual data. Herein, we intend to review these guidelines with respect to the risk of disease progression in cancer patients. In the absence of actual data on cancer surgery care during this pandemic, clinical decisions should be based on careful consideration of disease-related and patient-related factors. While some of the cancer surgeries can be safely delayed for some time, how long we can delay surgeries safely cannot be answered/ explained by any means. Thorough evaluation and discussion by an expert and experienced multidisciplinary team appears to be the most effective way forward.

Tumor induced osteomalacia in head and neck region: single center experience and systematic review.

Tumor-induced osteomalacia in the head and neck region remains a challenging diagnosis to manage. Literature pertaining to management and outcome details remains sparse. We describe two cohorts: cohort 1 included seven patients from a single center in Western India with tumors located in paranasal sinuses (n = 3), intracranial (n = 2) and maxilla (n = 2). The unique features from our series is the management of persistent disease with radiation therapy (n = 2) and peptide receptor radionuclide therapy (PRRT) (n = 1). Cohort two has 163 patients identified from 109 publications for systematic review. Paranasal sinuses, mandible, intracranial disease, maxilla and oral cavity, in descending order, are reportedly common tumor sites. Within this cohort, mean age was 46 ± 14 years at presentation with 44.1% having local symptoms. Duration of symptoms varied from 1 to 240 months. Pre-surgery mean serum phosphorus was 1.4 ± 0.4 mg/dL and median FGF-23 levels were 3.6 (IQR:1.8-6.8) times of normal upper limit of normal. Majority (97.5%) were managed primarily with surgical excision; however, primary radiotherapy (n = 2) and surgery combined with radiotherapy (n = 2) were also reported. Twenty patients had persistent disease while nine patients had recurrence, more commonly noted with intracranial and oral cavity tumors. Surgery was the most common second mode of treatment employed succeeded by radiotherapy. Four patients had metastatic disease. The most common histopathological diagnosis reported is PMT mixed connective tissue, while the newer terminology 'PMT mixed epithelial and connective tissue type' has been described in 15 patients.

Utility of response assessment PET-CT to predict residual disease in neck nodes: A comparison with the Histopathology.

OBJECTIVE: To assess the ability of Positron Emission Tomography-Computed Tomography (PET-CT) scans to detect residual disease in neck nodes with the Histopathology (HPR) as the gold standard. To obtain a Standardized Uptake Value max cutoff in these patients to predict residual disease in neck. METHODS: Head and neck squamous cell carcinoma patients who underwent Salvage neck dissection with or without primary site surgery post Concurrent Chemo-Radiotherapy (CCRT) during the period January 2008-December 2017 were included. All patients had response assessment PET-CT scan at 10-14 weeks. Agreement analysis was performed between PET-CT and HPR, fine needle aspiration cytology and HPR. Positive predictive value, Negative predictive value of PET-CT to detect residual neck nodal disease in comparison to HPR was analyzed. A Receiver Operating Characteristic (ROC) curve was plotted between the SUV max values and the HPR. A SUV max cutoff value was obtained from the ROC curve. RESULTS: A total of 75 patients were included. Thirty-one underwent salvage neck dissection along with surgery for primary disease and 45 underwent salvage neck dissection alone. PET-CT showed good agreement with the HPR to detect residual disease in neck nodes (Kappa=0.604). PET-CT had a PPV and NPV of 87.5% and 79.15% respectively as compared against the HPR. A SUV max cutoff of 4.62 had a specificity of 92.3% and sensitivity of 73.5% to detect residual disease in neck nodes on the HPR. CONCLUSION: PET-CT surveillance is an accepted treatment strategy. A neck node with SUV max of 4.62 and above is most likely to harbor residual nodal disease. LEVEL OF EVIDENCE: Level 2b.

Head and neck cancers in India.

Head and neck cancers constitute a third of the cancer burden in India. These cancers have unique patient characteristics, presentation, and etiological differences from those in the West. Socioeconomic constraints, large patient population, scarcity of trained health workers, and inadequate infrastructure are major challenges faced in the management of these cancers. Despite these constraints, patients are treated with evidence based guidelines that are tailored to the local scenario.

Outcomes of surgically treated oral cancer patients at a tertiary cancer center in India.

BACKGROUND: Oral cancers are one of the most common cancers in India. Surgery is the main modality of treatment for oral cancer patients. It is important to understand the postoperative morbidity and mortality as it influences patient outcomes. AIM: The aim of this study was to determine oral cancer patients' characteristics, treatment details, 30-day morbidity and mortality, and survival outcomes. SETTINGS AND DESIGN: This was a retrospective analysis of prospectively collected data in a tertiary cancer center. MATERIALS AND METHODS: This study included 850 surgically treated oral cancer cases between January and December 2012. STATISTICAL ANALYSIS: We performed univariate survival analysis by log-rank test, and all significant (P < 0.05) variables underwent multivariate analysis using Cox regression. RESULTS: The median age was 52 years and the male-to-female ratio was 3.4:1. Nearly one-third of the patients received some form of prior treatment. Buccal mucosa (BM) was the most common subsite (64.94%). BM cancers (81.1%) were more likely to present in advanced stage compared to tongue cancers (52%) (P = 0.000). The incidence of postoperative morbidity and mortality was 36.4% and 0.9%, respectively. Complications were higher in cT3-4 (P = 0.000), cN positive (P = 0.000), and those requiring microvascular reconstruction (P = 0.004). The 5-year overall survival of the entire study group was 70.4%. The survival of early and locally advanced stages was 75.1% and 68.4%, respectively. The factors influencing survival were age (>50 years), advanced cT stage, nodal metastasis, overall stage, and presence of orocutaneous fistula. CONCLUSION: The morbidity, mortality, and long-term outcomes of surgically treated oral cancer patients at our center are comparable to those treated in the developed world. Aggressive management of postoperative complications is crucial for early recovery and timely initiation of adjuvant treatment.

Neoadjuvant chemotherapy in technically unresectable carcinoma of external auditory canal.

BACKGROUND: Carcinoma of external auditory canal (EAC) is a very rare malignancy with surgical resection as the main modality of treatment. The outcomes with nonsurgical modalities are very dismal. We present a retrospective analysis of 4 patients evaluating the role of neoadjuvant chemotherapy in technically unresectable cancers. MATERIALS AND METHODS: This is a retrospective analysis of 4 patients from our institute from 2010 to 2014 with carcinoma EAC who were deemed unfit for surgery due to extensive disease involving occipital bone with soft tissue infiltration (n = 2), temporal dura (n = 1), left temporal lobe, and extensive soft tissue involvement (n = 1). All these patients received neoadjuvant chemotherapy with docetaxel, cisplatin and 5 fluorouracil (n = 3) and paclitaxel and cisplatin (n = 1). RESULTS: Response evaluation showed a partial response (PR) in 3 and stable disease (SD) in 1 patient by Response Evaluation Criteria in Solid Tumors criteria. All 3 patients who received 3 drug chemotherapy had PR while 1 patient who received 2 drug chemotherapy had SD. Two of these patients underwent surgery, and other 2 underwent definitive chemoradiation. One of 3 patients who achieved PR underwent surgical resection; the other 2 remained unresectable in view of the persistent intradural extension and infratemporal fossa involvement. One patient who had SD could undergo surgery in view of clearance of infraatemporal fossa. Recent follow-up shows that 3 out of these 4 patients are alive. CONCLUSION: This indicates that there may be a role of induction chemotherapy in converting potentially unresectable tumors to resectable disease that could produce better outcomes in carcinoma EAC.

A Logical levothyroxine dose Individualization: Optimization Approach at discharge from Radioiodine therapy ward and during follow-up in patients of Differentiated Thyroid Carcinoma: Balancing the Risk based strategy and the practical issues and challenges: Experience and Views of a large volume referral centre in India.

In this communication, the authors discuss the issue of individualization of thyrotropin suppressive therapy in differentiated thyroid carcinoma (DTC) patients and share their views with respect to optimizing the dose of levothyroxine (LT) prescription both during discharge from radioiodine therapy ward and during follow-up. The changing management paradigm at our Institute during post-thyroidectomy period and during the preparation for radioiodine scan is also briefly highlighted. Five factors can be identified as important determinants for the dose individualization approach: (1) Persistence or absence of metastatic disease, (2) the risk characteristics of the patient and the tumor (3) patient's clinical profile, symptomatology, and contraindications (4) the feasibility to ensure a proper thyroid stimulating hormone TSH suppression level (depends on patient's socio-economic and educational background, the connectivity with the local physician and his expertise) (5) time period elapsed since initial diagnosis. While discussing each individual case scenario, the authors, based upon their experience in one of the busiest thyroid cancer referral centers in the country, discuss certain unaddressed points in the current guideline recommendations, deviations made and some challenges toward employing them into practice, which could be situation and center specific. In addition to these, the value of clinical examination, patient profile and detailed enquiry about clinical symptomatology by the attending physician in each follow-up visit cannot be overemphasized. According to the authors, this aspect, quite important for dose determination in an individual, is relatively underrepresented in the present guidelines. It would also be worthwhile to follow a conservative approach (till clear data emerges) in patients who have characteristics of "high-risk" disease, but are clinically and biochemically disease free, if no medical contraindications exist and patient tolerates the suppressive therapy well. This would be particularly applicable in the presence of aggressive histopathological variants, where, in the event of recurrence/metastasis, the disease demonstrates adverse prognosis and higher incidence of radioiodine refractoriness. At the end, certain important and noteworthy concepts pertaining to LT prescription that has definitive practical implications for the suppressive therapy in DTC patients are described.

Angiosarcoma of the scalp associated with Xeroderma pigmentosum.

Xeroderma pigmentosum (XP) is a rare autosomal recessive genodermatosis associated with hypersensitivity to ultraviolet light due to defects in Deoxyribonucleic acid (DNA) repair. These patients have more than a 1000-fold increased risk of developing skin cancers. Although multiple cutaneous malignancies are common, the simultaneous occurrence of angiosarcoma and basal cell carcinoma is a rare phenomenon. We report a case of a 25-year-old male with XP with angiosarcoma scalp and basal cell carcinoma of face and occiput and discuss the treatment of this aggressive neoplasm with a review of the literature pertaining to it.

Tuberculosis masquerading as oral malignancy.

Tuberculosis of the oral cavity is a rare condition. A 55-year-old labourer was referred as a case of oral cancer for further management. The patient had no systemic symptoms. Biopsy of the lesion revealed caseating granulomatous inflammation. Chest X-ray and sputum revealed evidence of asymptomatic pulmonary tuberculosis. The purpose of this paper is to sensitize clinicians to consider oral tuberculosis as a differential diagnosis in patients with an Non-healing oral cavity ulcer.

Fractured tracheostomy tube in the tracheo-bronchial tree.

Tracheostomy is a life saving procedure and many a times patients are discharged with permanent tracheostomy tubes. However, fracture of tracheostomy tube with subsequent migration into the tracheobronchial tree is uncommon and carries the potentially fatal risk of respiratory obstruction. In this report, a case of a 6-year-old boy is presented, who had aspirated a fractured tracheostomy tube which had lodged in the left bronchus.

Clinical characteristics and outcome of non-squamous cell malignancies of the maxillary sinus.

BACKGROUND AND OBJECTIVES: A significant paucity of data exists on non-squamous cancers of the maxillary sinus. The purpose of this study was to assess the clinical characteristics and outcomes of these tumors. METHODS: Retrospective review of 42 patients with complete available data and a diagnosis of non-squamous cancer of the maxillary sinus treated with curative intent between 1994 and 1999 were performed. Information recorded included demography, clinical characteristics, histopathological findings, treatment methods, and outcome. Survival was also compared with that of squamous cancers of the maxillary sinus. RESULTS: The majority of patients presented with locally advanced disease (83%). Malignancies were 14 sarcomas, 8 adenoid cystic carcinoma, 8 mucoepidermoid carcinoma, 2 adenocarcinoma, and 10 miscellaneous tumors. Fifteen (35.7%) patients developed recurrent disease and six developed distant metastases. The most common site of recurrence was local (32.5%). The overall mean survival was 71.7 months and 5-year overall and disease-free survival was 51% and 48%, respectively. In contrast, the mean survival in the selected 62 patients with squamous cancers was 40 months and 5-year survival was 29% (P = 0.01). Tumor stage, histological, and treatment type was not associated with significant survival advantage. CONCLUSIONS: Patients with non-squamous cancers of the maxillary sinus present with locally advanced disease. Local tumor progression remains a significant pattern of failure; however, unlike squamous cancers they have a better prognosis.

Pediatric thyroid cancer.

BACKGROUND AND OBJECTIVE: The treatment of pediatric thyroid cancer evokes considerable controversy. The extent of surgery and role of postoperative radioactive iodine are not clearly defined. We analyzed the behavior of pediatric thyroid cancers and its management. METHODS: Eighty-three patients, from 1964-2000, were identified by a search of our database. The clinical course of 26 patients was not evaluated because of inadequate follow-up and the remaining 57 patients were included in the final survival analysis. These 26 patients were included for analyses of epidemiological data. RESULTS: There were 27 males and 56 females. Cervical lymphadenopathy was a common presentation (57.8%). The predominant histology was papillary carcinoma (57%). Sixteen patients (19.2%) had pulmonary metastases at presentation. Patients with cervical nodes had a significantly higher incidence of pulmonary metastasis compared to those who presented with thyroid nodule (P = 0.037). Five patients (31.2%) with pulmonary metastases had a negative chest X-ray and were detected only on the radioiodine scan. At median follow-up of 64 months, all 57 patients were alive, 10 with disease and 47 disease free. CONCLUSION: Despite its advanced stage at presentation, pediatric thyroid cancer is associated with an excellent prognosis. We advocate total thyroidectomy and radioactive iodine as the best management option as the incidence of pulmonary metastases is high.

Laryngeal amyloidosis.

Localized amyloidosis is characterized by the deposition of amyloid fibres in a particular site or organ system in the absence of systemic involvement. Patients with localized laryngeal amyloidosis usually present with long-standing hoarseness or dyspnea. The diagnosis is made by a high degree of suspicion on the basis of the history and a characteristic appearance on direct laryngoscopic examination. When such lesions are seen, an adequate deep punch biopsy should be obtained, and an experienced pathologist should be able to identify the lesion on routine staining. However, the slides should be stained with Congo red and examined with polarized light microscopy to establish the diagnosis. Following proper diagnosis and evaluation of the extent of disease, usually by computed tomographic scan, surgery is the treatment of choice. Preservation of the voice and airway should be the aim in all patients. Endoscopic carbon-dioxide laser excision of the mass should be the first line of therapy. Patients may require repeated removal of the amyloid deposits. The results of treatment are excellent.

Simple technique of securing intraoral skin grafts.

Small defects following intraoral resection are often resurfaced by skin grafts. Skin grafting has the advantage of ease of harvest with minimal additional operating time and post-operative hospital stay, an acceptable functional cosmetic result, and the ability to survive post-operative radiation 1. In addition to adequate vascularity of the recipient area, the most important aspect for graft survival is immobilization and adherence of the graft to the defect. However, in the oral cavity due to the uneven wound bed and constant mobility of the cheek, the graft is not completely immobilized. In addition, the salivary secretions tend to accumulate beneath the graft, separating the graft from the bed. Graft-failure can be prevented by immobilizing the graft and closing up any potential dead space that might lead to separation 2. A variety of methods have been described for immobilization and bolstering the graft to the wound. Many types of stents have been used varying from the simple cotton balls, resin molds, and foam pads, to complex stents like metal, plastic, and dental liner 34. The traditional tie over bolster technique described by Schramm and Myers involves fixation of the skin graft to the raw area, followed by placement of non-absorbable silk sutures from the adjacent mucosa, which are then tied over the bolster 1. However, the placement of this tie over sutures requires adjacent normal mucosa for anchorage, which may not be sufficient especially in the gingivo-buccal sulcus. Although external fixation of the stents to the cheek has been described, this results in ugly scarring of the cheek 2. We describe a simple technique of fixation of the skin graft in the oral cavity, which avoids the placement of additional tie over sutures and in our opinion results in better anchorage.