Merkel Cell Carcinoma, Version 1.2018, NCCN Clinical Practice Guidelines in Oncology.

This selection from the NCCN Guidelines for Merkel Cell Carcinoma (MCC) focuses on areas impacted by recently emerging data, including sections describing MCC risk factors, diagnosis, workup, follow-up, and management of advanced disease with radiation and systemic therapy. Included in these sections are discussion of the new recommendations for use of Merkel cell polyomavirus as a biomarker and new recommendations for use of checkpoint immunotherapies to treat metastatic or unresectable disease. The next update of the complete version of the NCCN Guidelines for MCC will include more detailed information about elements of pathology and addresses additional aspects of management of MCC, including surgical management of the primary tumor and draining nodal basin, radiation therapy as primary treatment, and management of recurrence.

Basal Cell Skin Cancer, Version 1.2016, NCCN Clinical Practice Guidelines in Oncology.

Basal cell carcinoma (BCC) of the skin is the most common cancer, with a higher incidence than all other malignancies combined. Although it is rare to metastasize, patients with multiple or frequently recurring BCC can suffer substantial comorbidity and be difficult to manage. Assessment of risk is a key element of management needed to inform treatment selection. The overall management of BCC primarily consists of surgical approaches, with radiation therapy as an alternate or adjuvant option. Many superficial therapies for BCC have been explored and continue to be developed, including topicals, cryosurgery, and photodynamic therapy. Two hedgehog pathway inhibitors were recently approved by the FDA for systemic treatment of advanced and metastatic BCC, and others are in development. The NCCN Guidelines for Basal Cell Skin Cancer, published in full herein, include recommendations for selecting among the various surgical approaches based on patient-, lesion-, and disease-specific factors, as well as guidance on when to use radiation therapy, superficial therapies, and hedgehog pathway inhibitors.

Dermatofibrosarcoma protuberans, version 1.2014.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft tissue tumor characterized by a relatively high risk of local recurrence and low risk of metastasis. The NCCN Guidelines for DFSP provide multidisciplinary recommendations on the management of patients with this rare disease. These NCCN Guidelines Insights highlight the addition of the Principles of Pathology section, which provides recommendations on the pathologic assessment of DFSP. Because DFSP can mimic other lesions, immunohistochemical studies are often required to establish diagnosis. Cytogenetic testing for the characteristic translocation t(17;22)(q22;q13) can also be valuable in the differential diagnosis of DFSP with other histologically similar tumors.

Merkel cell carcinoma, version 1.2014.

Merkel cell carcinoma is a rare, aggressive cutaneous tumor that combines the local recurrence rates of infiltrative nonmelanoma skin cancer with the regional and distant metastatic rates of thick melanoma. The NCCN Guidelines for Merkel Cell Carcinoma provide recommendations on the diagnosis and management of this aggressive disease based on clinical evidence and expert consensus. This version includes revisions regarding the use of PET/CT imaging and the addition of a new section on the principles of pathology to provide guidance on the analysis, interpretation, and reporting of pathology results.

Evaluation of Agreement Among Frailty Assessment Tools in Head and Neck Surgery.

OBJECTIVE: To evaluate intertest agreement among hand grip strength (HGS), the modified Frailty Index (mFI), and the Edmonton Frail Scale (EFS) in patients presenting for presurgical assessment in a head and neck surgery clinic. STUDY DESIGN: Prospective observational study. SETTING: Academic tertiary medical center. METHODS: Prospective data relating to 3 frailty measurements were collected for 96 consecutive adults presenting for presurgical counseling at a single high-volume head and neck surgical oncology clinic. Frailty was determined with previously validated thresholds for the mFI (≥3) and EFS (>7). The highest of 2 HGS measurements performed for the dominant hand was used to determine frail status based on previously validated sex- and body mass index-specific thresholds. Baseline characteristics were identified to determine the association of such variables to each tool. Agreement among frailty assessment tools was examined. RESULTS: The frequency of frailty in the cohort varied among tools, ranging from 29.2% (28/96) for HGS to 12.5% (12/96) for the mFI and 4.2% (4/96) for the EFS. The overall agreement among the 3 frailty tools via the Fleiss index was poor (kappa, 0.088; 95% CI, -0.028 to 0.203). CONCLUSION: Assessment of frailty is complex, and established frailty assessment tools may not agree on which patients are frail. When assessing a patient as frail, clinicians must be vigilant to the influence of frailty assessment tools on such determinations, which may contribute critical input during shared decision making for patients considering head and neck surgery or nonsurgical alternatives.

De-Novo Depression, Prophylactic Antidepressant, and Survival in Patients With Head and Neck Cancer.

OBJECTIVE: To study the association between the development of moderate or greater depression during curative-intent therapy and overall survival (OS) in patients with stages II-IV head and neck cancer (HNC). METHODS: In this secondary analysis of a randomized double-blind placebo-controlled trial, of 148 eligible participants diagnosed with stages II-IV HNC but without baseline depression, 125 were evaluable and were randomly allocated to prophylactic escitalopram oxalate (n = 60) or placebo (n = 65). Participants were followed for development of moderate or greater depression, using Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR, range 0-27, score ≥11 indicated moderate or greater depression), and were stratified by demographics; cancer site and stage; and primary treatment modality (surgery with or without radiotherapy vs. radiotherapy with or without chemotherapy). Single variable and multivariable Cox proportional-hazard models were used to evaluate differences in OS. RESULTS: Clinically significant depression developed in 22 of 125 patients (17.6%) during HNC treatment. The mean follow-up was 5.0 years (SD 2.4). OS was similar for patient groups, when stratified by development of moderate or greater depression (HR 0.54 [CI, 0.21-1.43]) or use of prophylactic antidepressant (HR 0.64 [CI, 0.34-1.21]). CONCLUSION: There was no significant association between OS and development of moderate or greater depression in patients being treated for stages II-IV HNC, or between OS and use of prophylactic antidepressant escitalopram. Prophylactic antidepressant may be considered in patients with HNC for prevention of clinically significant depression and may offer improved quality of life outcomes. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:856-862, 2023.

The historical evolution of the understanding of the submandibular and sublingual salivary glands.

The discovery of the major salivary glands was primarily a story of the establishment of the glands major excretory ducts. Occurring during the Renaissance: religious, political, and philosophical considerations played a role in defining the structure's function. We describe the history and background of these political, religious, and philosophical factors. Next, we present a translation of the original texts, describing the establishment of the submandibular and sublingual salivary glands. We place these translations into historical context and comment on their naming propriety. Initially we translate the works of the 15th century anatomists. Next, we look at the discovery and description of the submandibular gland's duct by Thomas Wharton (1614-1673) in his landmark book, Adenographia sive glandularum totius corporis descriptio (Adenographia or the description of the glands of the entire body) (1656). Next, the somewhat unexpected discovery of the duct of the parotid gland by Nicholas Stenson (1638-1686) and his publication, De glandulis oris et novis earundum vasis (On the glands of the mouth and their new ducts) (1661), done primarily for his discussion of the submandibular and sublingual gland anatomy. Finally we outline the description and discussion by Caspar Bartholin (1655-1738), in De ductu salivali, hactenus non descripto observatio anatomica (Anatomical observation of a salivary duct not hitherto described) (1685) of the origin of the complex drainage system of the sublingual gland. The honor of naming these glands rested with the discoverer of their ducts. All original works were published in Latin, and we have translated these texts to more fully understand the author's perspectives and historical context for a more interesting and complete story.

Historical vignettes of the thyroid gland.

Although "glands" in the neck corresponding to the thyroid were known for thousands of years, they were mainly considered pathological when encountered. Recognition of the thyroid gland as an anatomical and physiological entity required human dissection, which began in earnest in the 16th century. Leonardo Da Vinci is generally credited as the first to draw the thyroid gland as an anatomical organ. The drawings were subsequently "lost" to medicine for nearly 260 years. The drawings were probably of a nonhuman specimen. Da Vinci vowed to produce an anatomical atlas, but it was never completed. Michelangelo Buonarroti promised to complete drawings for the anatomical work of Realdus Columbus, De Re Anatomica, but these were also never completed. Andreas Vesalius established the thyroid gland as an anatomical organ with his description and drawings in the Fabrica. The thyroid was still depicted in a nonhuman form during this time. The copper etchings of Bartholomew Eustachius made in the 1560s were obviously of humans, but were not actually published until 1714 with a description by Johannes Maria Lancisius. These etchings also depicted some interesting anatomy, which we describe. The Adenographia by Thomas Wharton in 1656 named the thyroid gland for the first time and more fully described it. The book also attempted to assign a function to the gland. The thyroid gland's interesting history thus touches a number of famous men from diverse backgrounds.

The historical Latin and etymology of selected anatomical terms of the larynx.

The etymological evolution of the anatomical terms larynx, cricoid, glottis, epiglottis, and thyroid (cartilage) dates to antiquity. Human dissection replaced animal in the 16th and 17th centuries and terms evolved. This evolution was recorded in the literature largely in Latin. We translated key studies of laryngeal anatomy from the 16th century to better understand this evolution. We present the Latin with our translations, and historical commentary as essential to this understanding. Vesalius favored the Latin scutiform (shield) for the thyroid cartilage, but recognized peltalis (shield). The Basle Nomina Anatomica (BNA) chose the Greek thyroid (theta upsilon rho epsilon omicron epsilon iota delta eta) for modern convention. Vesalius used the name "innominate" for the cricoid cartilage, but described its resemblance to a ring, drawn in the margin of the Fabrica. Krikoid, the Greek for ring shaped, was adopted by the BNA. Although the term arytenoid was used for centuries, Vesalius argued the Greek name referred to the spout of a cup or ladle. He recognized the human arytenoids as two separate cartilages as opposed to single in certain animals. The glottis was defined by Vesalius as the vocal fold or rima glottidis of today, and he advanced its function by understanding the paired, mobile arytenoid cartilages. He defined the function of the epiglottis and first described the pre-epiglottic space. Vesalius' student at Padua, Italy, Columbo contributed to anatomical knowledge, but animosity between them clouded the record. Harvey, working 75 years later in England, offers an evolutionary window from Vesalius. Harvey's laryngeal studies preceded by a decade his groundbreaking studies on the circulation of blood.

Association of multimodal analgesia with perioperative safety and opioid use following head and neck microvascular reconstruction.

BACKGROUND: This study examines the association of multimodal analgesia (MMA) protocol for head and neck microvascular reconstruction with postoperative safety and opioid use. METHODS: Retrospective, intention-to-treat analysis of 226 patients undergoing head and neck microvascular reconstruction between January 1, 2014 and August 30, 2018 at a tertiary-care hospital following MMA protocol implementation. Multivariable models examined outcomes of interest. RESULTS: There were no differences between groups in frequency of bleeding, return to operating room, complete flap loss, readmissions, wound complications, and 30-day mortality. Patients in MMA protocol experienced reduced likelihood of partial flap loss (OR 0.18, confidence interval 0.04-0.91), meaningful reduction in postoperative opioid use (cumulative inpatient morphine equivalents [64 vs 141 mg; P < .001], daily morphine equivalents [8 vs 22 mg/d; P < .001]; and 22.5% lower frequency of opioid prescription at discharge [55.6% vs 78.1%; P = .001]). CONCLUSIONS: In patients undergoing head and neck microvascular reconstruction, MMA is safe and associated with reduced postoperative opioid use.

Medical malpractice and sinonasal disease.

OBJECTIVE: Sinonasal disease is a common diagnosis that is encountered by nearly all specialties. This study examines medical malpractice trends in sinonasal disease. METHODS: One hundred fifty-two malpractice cases involving sinonasal disease between 1988 and 2005 were obtained from a computerized legal database. RESULTS: Defendants prevailed in 62 percent of the cases with a median monetary award of $650,000. Younger patients prevailed at a higher rate than did older patients (50% vs 35%), and men had a higher median award than did women ($1.0 million vs $314,000). These results approached but did not reach statistical significance (P = 0.09, P = 0.06). Otolaryngologists were the most commonly sued specialty (56%). The most common complications of endoscopic sinus surgery included cerebrospinal fluid leak, orbital trauma, and anosmia. Cancer plaintiffs received the highest median award of $1.5 million. CONCLUSIONS: Physicians must be diligent in forming differential diagnoses, and surgeons must ensure informed consent is obtained and documented. Future studies should continue to identify risk management strategies and areas for malpractice reform.

Cancers of the Major Salivary Gland.

Salivary gland malignancies are rare tumors that comprise multiple histologic entities with diverse clinical behavior. Mucoepidermoid carcinoma is the most frequent primary salivary malignancy, followed by adenoid cystic and acinic cell carcinoma. Although most salivary malignancies are asymptomatic, presentation with a rapidly enlarging mass may be accompanied by pain, functional neurologic deficits, soft-tissue invasion, or nodal enlargement. Assessment of clinical behavior and physical exam greatly contributes to diagnostic workup. Preoperative imaging, to include ultrasound, computed tomography, or magnetic resonance imaging, may assist with surgical planning. Limitations of preoperative fine-needle aspiration cytology mean that, in some cases, definitive histologic diagnosis may not be established until therapeutic surgery is undertaken. Treatment strategies rely on oncologic resection of the primary site with negative margins as well as adjuvant radiotherapy in patients with high-risk features, such as high-grade histology, advanced T class, or perineural invasion. Regional lymphadenectomy is recommended for involved nodal basins. Patients with clinically node-negative disease at high risk for occult nodal metastases may be considered for elective lymphadenectomy or radiotherapy. Use of chemotherapy in the adjuvant setting, in combination with radiotherapy, remains controversial. The rate of objective response to palliative chemotherapy in recurrent or metastatic salivary gland malignancy remains low. In studies that include a significant proportion of adenoid cystic carcinomas, whether disease stability represents an indolent disease process or the true effect of a therapeutic drug may be difficult to discern. Recognition of genetic alterations and protein expression unique to salivary malignancies presents exciting new opportunities for molecularly targeted therapy, although the response to molecularly targeted therapy in studies has been modest thus far.

Development of Multimodal Analgesia Pathways in Outpatient Thyroid and Parathyroid Surgery and Association With Postoperative Opioid Prescription Patterns.

Importance: Prescription opioid use contributes to drug-related adverse effects and risk for dependence and abuse. Multimodal analgesia (MMA) has been shown to be useful in reducing opioid use following orthopedic, gynecologic, and colorectal surgery, but adoption in head and neck surgery has lagged. Recently, we published findings related to the feasibility of MMA protocols in same-day thyroid, parathyroid, and parotid surgery. However, whether such strategies lead to effective and durable reduction in frequency of opioid prescriptions, and affect physician prescribing practices, remains unclear. Objective: To observe trends in adoption and adherence to institutional MMA protocols following thyroid and parathyroid surgery, and to assess the association of institutional multimodal (nonopioid) analgesia protocols with opioid use and physician prescribing patterns following outpatient thyroid and parathyroid surgery. Design, Setting, and Participants: Cohort study at a head and neck surgery service at a tertiary care hospital of prescription patterns and retrospective review of patient medical records following implementation of an optional institutional MMA protocol in 2015, based on preoperative administration of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin, and postoperative use of acetaminophen and ibuprofen for analgesia after thyroid and parathyroid surgery. There were 528 adult patients who underwent thyroid and parathyroid surgery between January 1, 2015, and June 30, 2017. Main Outcomes and Measures: We report on adherence to the MMA protocol over the study period as measure of physician buy-in and adoption of the technique. The frequency of opioid use and physician prescription patterns following thyroid and parathyroid surgery is reported over the study period to study the association of the available MMA pathway with these variables. Results: A total of 528 patients (mean [SD] age, 53.1 [15.7] years; 80.3% female) underwent outpatient thyroid and parathyroid surgery. The frequency of postoperative opioid prescriptions decreased during the study period (16 of 122 [13.1%] in 2015, 22 of 244 [9.0%] in 2016, 3 of 162 [1.9%] in 2017). Adherence to the MMA protocol increased (0 of 122 cases in 2015, 106 of 244 [43.4%] cases in 2016, 142 of 162 [87.7%] cases in 2017), with reduced likelihood of opioid prescription on discharge (2017 vs 2015 odds ratio, 0.13; 95% CI, 0.04-0.44). Only 1 postoperative hematoma was recorded in the study cohort, and 352 (66.7%) patients achieved same-day discharge, whereas 176 (33.3%) maintained outpatient status but received overnight observation prior to discharge. Conclusions and Relevance: Adoption and adherence to the MMA protocol increased substantially over the study period for patients undergoing thyroid and parathyroid surgery and was associated with a simultaneous significant decline in prescription of postoperative opioid analgesics. Use of nonopioid multimodal agents, incorporating NSAIDs, was safe and did not lead to increased incidence of bleeding. Availability of effective nonopioid MMA pathways may favorably influence physician prescribing practices and avoid unnecessary opioid prescriptions.

Prediction of Discharge Destination following Laryngectomy.

OBJECTIVE: To identify factors that may predict discharge to intermediate-care facilities following total laryngectomy and may promote earlier discharge planning and optimize resource utilization. STUDY DESIGN: Retrospective review of large national data set. SETTING: Academic and nonacademic health care facilities in United States, contributing deidentified, risk-adjusted clinical data to the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP). SUBJECTS AND METHODS: Retrospective evaluation of the NSQIP database (2011-2014) identified 487 patients who underwent total laryngectomy without free tissue transfer. Risk of discharge to intermediate-care facilities was evaluated. Role of preoperative and postoperative factors and their association with discharge disposition were assessed using multivariable regression analysis. RESULTS: Compared to reference groups, advanced age (61-70 years: odds ratio [OR], 3.16; 95% confidence interval [CI], 1.12-8.89; >70 years: OR, 3.77; 95% CI, 1.33-10.65), baseline functional dependence (OR, 5.61; 95% CI, 2.62-12.02), cardiac failure (OR, 3.80; 95% CI, 1.08-13.42), and steroid dependence (OR, 3.30; 95% CI, 1.36-8.0) independently predicted discharge to intermediate-care facilities. CONCLUSION: Patients with advanced age, functional dependence, cardiac failure, and steroid dependence may benefit from preemptive counseling and discharge planning in anticipation of postlaryngectomy discharge to intermediate-care facilities.

Impact of Primary Tracheoesophageal Puncture on Outcomes after Total Laryngectomy.

Objectives To identify differences in postoperative wound complications associated with a primary tracheoesophageal puncture (TEP) at the time of laryngectomy versus no TEP. Study Design Retrospective review of large national data set. Setting Academic and nonacademic health care facilities in United States, contributing de-identified, risk-adjusted clinical data to the American College of Surgeons National Surgical Quality Improvement Program. Subjects and Methods The National Surgical Quality Improvement Program data set for years 2006 to 2012 identified 430 patients who underwent total laryngectomy with or without a primary TEP. Patients who underwent a TEP at the time of laryngectomy (n = 68) were compared with patients who underwent laryngectomy without a TEP (n = 362). Postoperative wound complications and secondary outcomes, including medical complications and length of hospitalization, were compared between the groups. Results The incidence of "superficial" and "deep or organ space" surgical site infection, medical complications, return to the operating room, and length of hospitalization were similar between the groups. Patients in the TEP group had a higher overall wound complication rate (relative risk, 2.02; 95% CI = 1.06-3.84; attributable risk, 8.17%; number needed to harm, 12). Conclusions Performance of a primary TEP concurrent to total laryngectomy contributed to a small increase in attributable risk for overall wound complications but did not add substantial risk for "superficial" or "deep or organ space" surgical site infection, medical complications, or increased burden for resource utilization. These data may help inform patient choice and physician recommendations for primary alaryngeal speech rehabilitation.

Medical malpractice and transoral robotic surgery: Evaluation and some preemptive thoughts.

Medical malpractice is costly and disruptive, and it is important to prevent. We conducted a study with the objective to look at medical malpractice in robotic surgery overall, to evaluate reasons for litigation, and to comment on possible strategies to avoid litigation with transoral robotic surgery. We used the Westlaw computerized database to identify all state and federal verdict summaries in medical malpractice cases. We found 17 cases alleging malpractice that involved the use of robotic surgery. In all, the plaintiffs in 6 cases (35%) contended that an open rather than a robotic approach should have been used, 5 (29%) alleged negligent credentialing, 4 (24%) alleged training deficiencies, 2 (12%) alleged manufacturing problems, and 1 (6%) charged that robotic surgery should have been performed instead of open surgery (1 case involved two of these allegations). In 11 cases (65%), plaintiffs charged that robotic surgery contributed to an undesirable outcome, and in 6 cases (35%) they raised concerns about informed consent. In all, only 5 of the 17 lawsuits (29%) resulted in plaintiff verdicts or settlements; damages ranged from $95,000 to $7.5 million. We believe the courts should not play a major role in establishing safety guidelines for the introduction of new technology such as robotic surgery. Instead, training and credentialing guidelines should be established by appropriate national associations and societies to assist hospitals in doing so.

Vascularized tissue transfer in head and neck surgery: Is intensive care unit-based management necessary?

OBJECTIVES/HYPOTHESIS: To study the impact of a non-intensive care unit (ICU)-based postoperative management strategy on patient outcomes following vascularized free tissue transfer for head and neck surgical defects. STUDY DESIGN: Retrospective cohort study. METHODS: The patients consisted of two groups of adults who underwent vascularized free tissue transfer for head and neck reconstruction between July 2007 and June 2012, at an academic and a community-based hospital. By protocol, the first group of patients had a planned admission to the intensive care unit. After creation of a designated head and neck surgical unit, the second group was cared for in a protocol driven, non-ICU setting. Outcomes and costs were compared between the two patient groups. RESULTS: There was no adverse impact on flap survival, inpatient morbidity, or mortality with the implementation of postoperative care outside of an ICU. The patients who stayed in the ICU in the immediate postoperative period had a longer median length of hospital stay (ICU vs. non-ICU, 8 days [interquartile range {IQR}= 7-11 days] vs. 7 days [IQR = 6-9.5 days], P = .001). Median hospital charges and cost of care for patients who received ICU-based care (US$109,367 [IQR = US$88,112-US$130,833] and US$33,642 [IQR = US$28,143-US$43,196], respectively) were significantly higher than those for non-ICU-based care (US$86,195 [IQR = US$71,208-US$101,199] and US$28,524 [IQR = US$22,611-US$33,226], P < .0001). CONCLUSIONS: We demonstrate that care in a non-intensive care setting following vascularized free tissue transfer is safe, less costly, and decreases length of hospital stay compared to routine intensive care-based management.

Medical malpractice and cancer of the skin.

BACKGROUND: A litigation crisis exists in this country, and it may be better understood through analysis of lawsuits. Verdict summary analysis has been used for this purpose. METHODS: Ninety-nine jury verdict reviews from 1986 to 2001 were obtained from a computerized database. Reviews compiled data on defendants, plaintiffs, allegations of wrongdoing, cancer cell types, sites, outcomes, and case summaries. Data was entered into a spreadsheet for analysis. RESULTS: Failure to diagnose was alleged in 54%; of these, 48% alleged biopsies were inappropriately omitted. Allegations were highest for failure to diagnose in dermatologists and general practice physicians, for misdiagnosis in pathologists, and for complications in surgeons. Young patients and those with poor outcomes received more and larger awards. Trauma appears to have support for a role in causation of skin cancer in some courts. CONCLUSIONS: The study of skin cancer suits may help develop risk management and prevention strategies.

Cancer of the oral cavity and medical malpractice.

OBJECTIVE: To analyze malpractice litigation initiated by patients with cancer of the oral cavity as a result of allegations concerning their diagnosis and treatment. STUDY DESIGN: Retrospective review. METHODS: Jury verdict reviews from 1984 to 2000 were obtained from a computerized legal database and analyzed. Reviews compile pertinent data on defendants, plaintiffs, verdict outcomes, indemnity payments, and allegations of wrongdoing and provide case summaries. Fifty cases from 21 of all 50 states were obtained. Data were entered into a spreadsheet for analysis. RESULTS: Overall, a young age (mean age, 45 y) and poor oncological outcome (47% dead) were seen. The younger age group (<47 y) had a better outcome (65% without disease), were more often misdiagnosed (19%), won awards (60%), and had higher awards (average award, $755,824) as compared with those older than 47 years of age, who had 39% without disease, 0% misdiagnosed, and 52% who won awards that were less, on average, at $495,417. Failure to diagnose the cancer was alleged, overall, in 43 of 50 cases (86%), and in general practice, dentists, and otolaryngologist in 100%, 85%, and 89%, respectively. Suits alleging a delay in diagnosis of less than 3 months were defendant verdicts in 86%, and of more than 3 months, in 40%. Failures to perform biopsy and to refer were common allegations. CONCLUSIONS: Young age of patients bringing litigation is seen in patients with oral cancer. These patients frequently have poor oncological outcomes. Risk management goals to prevent delays in diagnosis may help prevent subsequent litigation.