Hypervascular floor of mouth tumor: Rare presentation of oral cavity squamous cell carcinoma.

Oral squamous cell carcinoma (OSCC) is the most common malignancy affecting the oral cavity and commonly presents as an exophytic lesion with red or white granular ulcerations. Most diagnoses are confirmed by biopsy and clinical features; however, early SCC has been shown to hide within benign appearing lesions, such as vascular tumors, resulting in missed diagnoses and delay in treatment. The following case report will discuss a patient who presented with a mass in the floor of the mouth which appeared as a vascular tumor on exam and imaging. This was originally thought to be benign based on FNA findings however was found to harbor invasive squamous cell carcinoma on final pathology. The goal of this case report is to provide a background on the variable presentations of OSCC, vascular tumors, and uncommon presentations for which specialists should be aware of in their practice.

MRI and frozen section evaluation of mylohyoid muscle in determining surgical approach for T2-T3 floor of the mouth cancer.

PURPOSE: The choice of surgical approach for floor of the mouth (FOM) cancer, particularly for intermediate-stage tumors (cT2-cT3), remains controversial. This study aims to evaluate a method considering mylohyoid muscle (MM) invasion as a determinant for surgical approach selection, utilizing magnetic resonance imaging (MRI) preoperatively and frozen section (FS) analysis intraoperatively. METHODS: This observational retrospective cohort study analyzed patients undergoing surgical resection of cT2 and cT3 FOM squamous cell carcinoma (SCC) between January 2013 and June 2023. MM infiltration assessed by preoperative MRI determined the surgical approach: clear infiltration led to compartmental surgery (CS), while doubtful or absent infiltration led to transoral surgery (TOS). Conversion from TOS to CS occurred intraoperatively based on macroscopic evidence or positive FS. Data collected included demographic, clinical, surgical, and pathological variables. Survival analysis was conducted using Kaplan-Meier method. RESULTS: Among 44 patients included, majority had cT2 tumors (59.1%). MM resection was necessary in 22.7% of cases. Overall survival (OS) and progression-free survival (PFS) did not significantly differ between TOS and CS groups. Radiological depth of invasion (rDOI) < 10 mm is correlated with MM preservation in 89% of cases, while rDOI > 10 mm is correlated with MM resection only in 23.8% of cases. Pathological depth of invasion (pDOI) discrepancies were observed in the two groups: in CS group is shown a higher pDOI (> 10 mm) confirmation (90%). Surgical complications and functional outcomes differed between TOS and CS groups. CONCLUSION: Considering MM invasion for surgical approach selection in cT2-cT3 FOM tumors appears oncologically safe, with better functional outcomes in muscle preservation. Preoperative MRI for MM assessment combined with intraoperative FS analysis provides reliable guidance for surgical decision-making.

Treatment strategy for cervical lymph node metastases from early-stage tongue and floor of the mouth squamous cell carcinoma using tumour budding and depth of invasion as predictors.

OBJECTIVES: This study aimed to determine whether elective neck dissection can help improve outcomes in early-stage tongue and floor squamous cell carcinoma (SCC) by statistically analysing the relationship between information obtained from biopsy specimens and the incidence and prognosis of cervical lymph node metastasis (CLM). MATERIALS AND METHODS: Biopsy specimens of 103 patients diagnosed with early cT1-T2 cancer of the tongue and floor of the mouth were included. RESULTS: Multivariate analysis showed that the three parameters significantly correlated with CLM, and univariate analyses showed that budding score (BS) ≥ 5 and pathological depth of invasion (pDOI) ≥ 5 mm were independent risk factors for CLM. There were significant differences in the 5-year cumulative disease-specific survival between the BS < 5 and BS ≥ 5 groups, the pDOI < 5 mm and pDOI ≥ 5 mm groups, and the positive and negative budding and depth of invasion (BD) score groups. CONCLUSION: In early-stage tongue and floor of the mouth cancers with maximum tumour diameter ≤ 20 mm, it may be necessary to treat occult CLM during initial surgery based on the following preoperative criteria: pDOI ≥ 5 mm or BS ≥ 5 in biopsy specimens and DOI ≥ 8 mm on imaging. The BD model exhibited the highest specificity and proved helpful for CLM prediction. CLINICAL RELEVANCE: pDOI ≥ 5 mm and BS ≥ 5 were independent predictors of CLM and prognosis in early-stage tongue and floor of the mouth cancers with a maximum tumour diameter of 20 mm.

Dermoid Cysts on the Floor of the Mouth.

OBJECTIVE: The authors analyzed the clinical features and treatment results of surgical patients with a final diagnosis of dermoid cyst on the floor of the mouth over 14 years at our hospital. PATIENTS AND METHODS: A total of 5 patients with a final diagnosis of dermoid cyst of the floor of the mouth from January 2010 to December 2023 were enrolled. RESULTS: All patients complained of swelling in the submentum or floor of the mouth. The mean tumor size was 4.2±1.0 cm. All patients underwent complete surgical resection. A transcervical approach was performed in 3 patients, and an intraoral approach was implemented in 2 patients. There were no major complications after surgery with either method. The follow-up period was 71.4±75.7 months. There was no disease recurrence during follow-up. CONCLUSION: Dermoid cysts rarely occur on the floor of the mouth but should be considered in the differential diagnosis of other oral cavity tumors. Dermoid cysts on the floor of the mouth can be safely removed using the current transoral approach without scarring or recurrence.

[A neonate with a swelling in the floor of the mouth]. / Een pasgeborene met een zwelling in de mondbodem.

A significant swelling was seen in the floor of the mouth of a newborn girl. The girl could only drink with difficulty. On examination, a soft-elastic swelling was seen beneath the tongue. Ultrasonography and MRI showed a mass located above the hyoid bone. Upon the initial differential diagnosis of a dermoid cyst, an enucleation of the lesion was performed. Histopathological examination suggested a branchiogenic cyst or a digestive duplication cyst. Given the inconclusiveness of additional diagnostic examination, the lesion was diagnosed as a developmental cyst. Six months after enucleation, the infant girl's tongue motility was not restricted and there were no indications of a recurrence. This rare case illustrates the variety in differential diagnosis and the limitations of additional diagnostic examination.

Prognostic Significance of the Metastatic Lingual Lymph Node in Oral Tongue and Floor of Mouth Squamous Cell Carcinoma.

PURPOSE: The lingual lymph node (LLN) located on the internal surface of mylohyoid muscle is not currently included in oral cavity cancer surgery or conventional neck dissection. We investigated the risk factors for LLN metastasis and evaluated its oncologic significance in patients with oral tongue and floor of mouth squamous cell carcinoma. PATIENTS AND METHODS: Adult patients (≥20 years) undergoing upfront surgery and LLN dissection for oral tongue and floor of mouth squamous cell carcinoma between 2009 and 2018 were retrospectively analyzed. Patients who had relapsed after previous treatment or had neoadjuvant chemotherapy or had not undergone surgery were excluded. Association between clinicopathological risk factors (age, gender, tumor differentiation, stage, lymphatic invasion, perineural invasion, vascular invasion, metastatic lymph node ratio, and extranodal extension) and LLN metastasis was evaluated using logistic regression analysis. Disease-free survival in accordance with LLN metastasis was evaluated by the Kaplan-Meier method. RESULTS: A total of 51 patients were included, and LLN metastasis was found in 9 patients (17.6%). LLN metastasis was significantly associated with advanced nodal stage, poor tumor differentiation, and vascular invasion. Cox proportional-hazards regression models showed that LLN metastasis was associated with an 8.0-fold higher risk of mortality than the absence of LLN metastasis. Patients with LLN metastasis had significantly worse 5-year disease-free survival rate than those without metastasis (22.2% vs 85.7%; P < .001). CONCLUSIONS: This study suggests that LLN metastasis is a poor prognostic factor in patients with oral tongue and floor of mouth squamous cell carcinoma. The sublingual space should be carefully evaluated preoperatively and intraoperatively.

Diagnosis and management of hypoglossal nerve-derived schwannoma in the floor of mouth: a case series.

BACKGROUND: Schwannomas or neurilemmomas are well-encapsulated, benign, solitary, and slow-growing tumors that originate from Schwann cells of the nerve sheath. Extracranial schwannoma is reported to have a relatively high incidence in the tongue while an extremely low incidence in the floor of mouth. In the current study, we presented the first case series of hypoglossal nerve-derived schwannoma in the floor of mouth in Asia. METHODS: A retrospective study of 9 surgical cases of hypoglossal nerve-derived schwannoma in the floor of mouth was performed. The patient and tumor characteristics were evaluated by physical, radiological and pathological examination. Details of operation and complications were also recorded. RESULTS: Hypoglossal nerve-derived schwannoma in the floor of mouth showed a well-defined boundary with a firm texture, smooth surface and good mobility on palpation. The median maximum diameter of the tumors was 4.3 cm (range 2.8-7.0 cm). The median operative time and bleeding volumes were 89.4 min (range 47-180 min) and 99.2 mL (range 15-200 mL), respectively. All cases received complete surgical excision. CONCLUSION: In this study, we presented the diagnosis and management of hypoglossal nerve-derived schwannoma in the floor of mouth for the first time in Asia. The study provided us with a recommendation for consideration of the diagnosis of hypoglossal schwannoma when a patient presents with a mass in the floor of mouth.

Central neck lymph node metastasis in oral squamous cell carcinoma at the floor of mouth.

BACKGROUND: Our goal was to analyze the incidence of level VI metastasis in previously untreated oral squamous cell carcinoma (SCC) patients and their clinicopathological and prognostic characteristics. METHODS: Oral SCC patients with level VI metastasis were retrospectively enrolled, and their demographic and pathologic features as well as their survival data were descriptively analyzed. RESULTS: A total of 13 cases from 1875 patients were included, all patients had SCC at the floor of mouth (SCCFOM). Eight (61.5%) patients had a pT4 tumor, and all patients had a pathological N3 neck with multiple positive lymph nodes. Adverse pathologic features were present in 100% of the patients. The size of the metastatic foci in level VI ranged from 2.6 cm to 4.5 cm with a mean value of 3.2 cm, and 5 patients showed a soft tissue deposit with no lymph node component. Recurrence occurred in all patients, and 11 patients died of uncontrolled cancer within 5 years after surgery. CONCLUSION: Level VI metastasis in primary oral SCCFOM is rare, and its prognosis is poor.

Downregulation of CCL22 and mutated NOTCH1 in tongue and mouth floor squamous cell carcinoma results in decreased Th2 cell recruitment and expression, predicting poor clinical outcome.

OBJECTIVE: Tongue and mouth floor squamous cell carcinoma (T/MF SCC) exhibits a high rate of local recurrence and cervical lymph node metastasis. The effect of the tumor microenvironment on T/MF SCC remains unclear. MATERIALS AND METHODS: Transcriptome and somatic mutation data of patients with T/MF SCC were obtained from HNSC projects of the Cancer Genome Atlas. Immune infiltration quantification in early- (clinical stage I-II) and advanced-stage (clinical stage III-IV) T/MF SCC was performed using single sample Gene Set Enrichment Analysis and MCPcounter. Differentially expressed gene data were filtered, and their function was assessed through Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses. Kaplan-Meier survival curve analysis and Cox regression model were conducted to evaluate the survival of patients with the CCL22 signature. Maftools was used to present the overview of somatic mutations. RESULTS: In T/MF SCC, T helper (Th)2 cell counts were significantly increased in patients with early-stage disease compared to those with advanced-stage disease. Expression of the Th2 cell-related chemokine, CCL22, was downregulated in patients with advanced-stage T/MF SCC. Univariate and multivariate Cox analyses revealed that CCL22 was a good prognostic factor in T/MF SCC. A nomogram based on the expression of CCL22 was constructed to serve as a prognostic indicator for T/MF SCC. NOTCH1 mutations were found at a higher rate in patients with advanced-stage T/MF SCC than in those with early-stage T/MF SCC, resulting in the inhibition of the activation of the NOTCH1-Th2 cell differentiation pathway. The expression levels of CCL22, GATA-3, and IL4 were higher in patients with early-stage T/MF SCC than in those with advanced-stage T/MF SCC. CONCLUSION: In T/MF SCC, high expression of CCL22 may promote the recruitment of Th2 cells and help predict a better survival. Mutations in NOTCH1 inhibit the differentiation of Th2 cells, facilitating tumor progression through a decrease in Th2 cell recruitment and differentiation.

Synovial sarcoma of the floor of the mouth: a rare case report.

BACKGROUND: Head and neck Synovial sarcoma (SS) accounts for 3-10% of all total body SS. It is rare to find it in the oral cavity, especially on the floor of the mouth. CASE PRESENTATION: We present a 44-year-old Chinese male, who had been misdiagnosed as fibroadenoma, with a swelling on the right submandibular region for more than 3 months. The radiology examinations and the pathology results indicate the diagnosis of SS of the floor of the mouth. The patient only had a surgical operation, without radiotherapy and chemotherapy. At the first follow-up, the patient exhibited no clinical or radiographic complications, and the patient was asymptomatic on subsequent visits. CONCLUSIONS: Misdiagnosis results the delay of diagnosis and treatment of SS. Immunohistological analysis might be the most important tool to confirm the diagnosis of SS.

Transoral Marsupialization of a Large Dermoid Cyst.

True dermoid cysts are rare congenital entities with a predilection for periorbital, floor-of-mouth, and submental areas in the head and neck region. They are usually asymptomatic unless they substantially enlarge, causing pain or difficulty in swallowing, breathing, speech, or vision, depending on their location. Conventionally, complete excision is the treatment of choice. The authors describe a transoral approach to marsupialize a large dermoid cyst, with a successful outcome and minimal complications. Using this technique, it is hoped that surgeons can minimize the risk of damaging vital structures, shorten operating time, and provide an esthetically better result with a comparable outcome.

Reconstruction of Anterior Mandible and Mouth Floor Using the Myofascial Iliac Crest Free Flap After Tumor Resection.

The current study introduces a novel approach of anterior mandible and mouth floor reconstruction with the myofascial iliac crest free flap. A series of 4 patients who presented between May 2015 and July 2017 had benefited from this technique. The myofascial component of this flap was designed to be attached to the iliac crest, and the flap was obtained after identifying the neurovascular pedicle. We transferred the iliac crest, with an outward-oriented placement, to the mandibular defect as the base of the alveolar process. We found that the iliac crest can provide sufficient bone height and an aesthetic shape for the reconstruction of the anterior mandible. More important, we also observed that the myofascial component on the flap surface completely replaced the oral mucosa in as early as 1 month after the operation. Moreover, the proper soft tissue volume can be achieved using this approach for better functional reconstruction of the oral mucosa. No obvious scar contracture of the myofascial component was observed during the follow-up period. The myofascial iliac crest free flap could provide a suitable reconstruction method for combined oral mucosa-mandible defects.

Sublingual microcirculatory alterations in cirrhotic patients.

OBJECTIVE: To assess sublingual microcirculation in cirrhotic patients and its relationship to spider angiomas, complications, and outcome. METHODS: Thirty-one cirrhotic patients were prospectively compared to 31 matched controls. Sublingual microcirculation was evaluated by videomicroscopy. We specifically looked for capillaries with increased RBCV, which was defined as a velocity higher than the percentile 100th of controls. RESULTS: Compared to controls, cirrhotic patients showed decreased total and PVD (14.4 ± 2.2 vs 16.0 ± 1.3 and 14.1 ± 2.3 vs 15.9 ± 1.6 mm/mm2 , respectively, P < .001 for both) and increased HFI (0.64 ± 0.39 vs 0.36 ± 0.21, P = .001). They also exhibited high RBCV in 2% of the microvessels (P < .0001). Patients with MELD score ≥10 had higher RBCV than patients with score <10 (1414 ± 290 vs 1206 ± 239 µm/s, P < .05). Patients with spider angiomas showed lower vascular densities. Microcirculation did not differ between survivors and nonsurvivors. CONCLUSIONS: Cirrhosis is associated with microcirculatory alterations that can be easily monitored in the sublingual mucosa. Alterations included decreased density and PPV and hyperdynamic microvessels. The most striking finding, however, was the microvascular heterogeneity. Patients with spider angiomas had more severe alterations. Larger studies should clarify the relationship between microcirculatory abnormalities and outcome.

The histologic risk model is a useful and inexpensive tool to assess risk of recurrence and death in stage I or II squamous cell carcinoma of tongue and floor of mouth.

Surgery is the mainstay of treatment for low-stage (stage I/II, ie, T1N0/T2N0) squamous cell carcinoma of oral cavity. However, a significant percentage of low-stage squamous cell carcinoma of oral cavity will develop local recurrence and disease-related mortality. In this study, we stratified 64 patients with low-stage of oral tongue and floor of mouth patients into high-, intermediate- and low-risk categories based on existing histologic risk model. The classification of these risk categories was based on presence or absence of perineural invasion and evaluation of tumor-host junction for worst pattern of invasion and lymphocytic host response. We correlated risk category and other variables with recurrence and death. In a univariate model, high-risk category tumors had a significantly higher rate of recurrence and death due to recurrence compared with low/intermediate-risk categories (P=0.000 and P=0.047, respectively). Controlling for margin status and T-stage, high-risk category had a 12.4 odds ratio of later recurrence when compared with low/intermediate-risk categories, with a P-value of 0.001. In conclusion, we found low-stage oral cavity squamous cell carcinoma patients with high-risk category have a significantly higher risk for recurrence when compared with patients in the low- or intermediate-risk category, even when controlling for margin status and T-stage. These patients may be suitable candidates for adjuvant treatment to decrease morbidity and mortality associated with a recurrence. Our results indicate that the histologic risk model is a useful and simple tool to assess risk of recurrence in stage I or II squamous cell carcinoma of oral cavity.

Incidence of intraglandular lymph nodes within submandibular gland, and involvement by floor of mouth cancer.

Resection of the submandibular gland is generally undertaken as an integral component of level I neck dissection for oral cancer. However, it is unclear whether lymph nodes are present within the submandibular gland which may form the basis of lymphatic spread. Our purpose was to investigate the frequency of lymph nodes within the submandibular gland, and the incidence and mechanism of submandibular gland involvement in floor of mouth cancer. Retrospective review of 177 patients with oral cancer undergoing neck dissection. Original pathology slides of floor of mouth cases were re-reviewed by two pathologists to determine frequency of intraglandular lymph nodes, and incidence and mechanism of submandibular gland involvement by cancer. The overall incidence of cervical metastases was 36.4 %, of whom 44 % had level I metastases. Level I metastases were significantly more common in floor of mouth than tongue cancers (p = 0.004). Among 50 patients with floor of mouth cancer undergoing re-review of pathology slides, intraglandular lymph nodes were not found in any of 69 submandibular glands. Submandibular gland involvement by cancer was present in two patients, representing 1 % of all oral cancers, and 4 % FOM cases. Mechanisms of involvement were direct extension, and by an apparent novel mechanism of carcinoma growing along bilateral Wharton's ducts. Despite the high incidence of level I metastasis in floor of mouth, lymphatic metastases to submandibular gland are unlikely based on absence of intraglandular lymph nodes. We describe a previously unreported mechanism of submandibular gland involvement.

Case report: a patient who had not removed her lower denture for 54 years.

BACKGROUND: A 71-year-old female presented with a left submandibular space abscess. This was found to be due to large accumulations of calculus on the lingual flanges of her lower denture ulcerating the floor of the mouth. She had not taken the prosthesis out since it was provided as an immediate denture after extractions 54 years previously. At presentation she could not take her denture out as the calculus locked the denture under lingual undercuts. The denture was sectioned in the midline to remove it and the submandibular abscess was drained via a neck incision. FINDINGS: Prior to removal the denture was remarkably stable and she had enjoyed a long period of problem free denture wearing and had had exceptional value from it. There was also surprisingly little mandibular alveolar bone resorption. CONCLUSION: The case demonstrates what may happen if a lower denture is not taken out for over half a century. The calculus on the lingual flanges provided both stability and retention for the denture, and it appeared to have protected the ridge from resorption. While the calculus may have provided some surprising benefits to her lower denture it ultimately led to a serious infection.

Large plunging schwannoma of the floor of the mouth involving the mylohyoid nerve: a case report and review of the literature.

Extracranial schwannomas are rare in the oral cavity, accounting for only 1% of all tumors of this type. This article presents a case study of a schwannoma arising from the mylohyoid nerve that presented as a large nodular swelling in the floor of the mouth extending into the submandibular space.

Mucoceles of minor salivary glands in children. Own clinical observations.

INTRODUCTION: Mucoceles are benign lesions associated with the pathology of the oral mucosa of minor salivary glands. Two types of cysts are distinguished depending on their pathogenesis. Most often they occur as a result of mechanical trauma and mucus extravasation into tissues or obstruction of the gland ducts. AIM: The aim of the study was to present our own experiences regarding mucoceles of minor salivary glands in the oral cavity taking into account how frequently the individual types of cysts occur in children. MATERIAL AND METHODS: The research was carried out based on medical files from the years 2005-2015. These were: medical case records, operating books and the medical registry of patients treated at the Clinic of Maxillofacial Surgery, Frederic Chopin Clinical Regional Hospital in Rzeszow. In that period 64 children and teenagers, 28 girls and 36 boys were treated. What was considered was the age and gender of the patients, the reason for their appointment with a doctor, the location, size and histopathological type of the cysts, as well as the course and results of the diagnostic and therapeutic process. RESULTS: In the group analyzed, the reasons for referral to the Clinic were: in 25 patients accidental ascertainment of a non-symptomatic tumor in the oral cavity during examination by a dentist, pediatrician or laryngologist which had not caused any discomfort to the children; in 13 patients concern had been raised by a gradually increasing tumor; in 18 cases there was an increased tissue tension surrounding the tumor, while in 3 children red oedema was observed in the oral cavity (suspicion of abscess). The most frequent mucocele location was the lower lip (34 children). The most frequent size was 2.1-3 cm (28 children). The most frequent histological type was MEP. All the patients were treated at the Clinic in the one-day surgery mode, with good outcome. CONCLUSIONS: Mucocele ascertainment in children's oral cavity could be made accidentally in routine pediatric examination, therefore it is necessary to extend pediatricians' knowledge about small salivary gland mucoceles. The most frequent type of MEP could be related to different types of trauma in the oral mucose.

[Reconstructive plastic surgeries in patients with malignancies of tongue and floor of the mouth. Types of plastics].

The problem of restoring tissue defects after radical surgery for malignant tumors of the head and neck remains relevant, as there is no standardized approach for solving this problem. This article describes the various options for plastics of combined through defects of the floor of the mouth, of angle of the mouth, of the upper and lower lips, of lateral parts of the neck. The use of a particular type of arterialized flap depended on the depth and character of the existing tissue defect. The use of this methodology allowed to reach satisfactory cosmetic and functional results, as well as improve the quality of patient's life.

Anatomic-histologic study of the floor of the mouth: the lingual lymph nodes.

OBJECTIVE: The lingual lymph nodes are inconstant nodes located within the fascial/intermuscular spaces of the floor of the mouth. Oral tongue squamous cell carcinoma has been reported to recur and metastasize in lingual lymph nodes with poor prognosis. Lingual lymph nodes are not currently included in basic tongue squamous cell carcinoma surgery. METHODS: Twenty-one cadavers (7 males, 14 females) were studied, aged from 57 to 94 years (mean age 76.3 years). The gross specimen of the floor of the mouth was divided into blocks: A (median nodes), B, B' (parahyoid), C, C' (paraglandular). Serial histological microslides were cut and stained with hematoxylin-eosin. Frequency of lingual lymph nodes in each block and their microscopic features were assessed. RESULTS: The lingual lymph nodes in overall number of 7 were detected in 5 of the 21 cadavers (23.8%). The total incidence of lingual lymph node was 33.3% (7 nodes/21 cadavers). Block A failed to demonstrate any lymph nodes (0%); Blocks B, B'-2 nodes (9.5%) and 2 nodes (9.5%), respectively; Blocks C, C'-1 node (4.8%) and 2 nodes (9.5%), respectively. The mean lingual lymph node length was 4.1 mm (from 1.4 to 8.7 mm), the mean thickness was 2.8 mm (from 0.8 to 7.5 mm). Five cadavers (23.8%) revealed mucosa-associated lymphoid tissue. Atrophic changes appeared in 4 (57.1%) lingual lymph nodes. CONCLUSION: The presence of lymph node-bearing tissue in the floor of the mouth is demonstrated. In account of resection radicalism and better local control the fat tissue of the floor of the mouth should be removed in conjunction to glossectomy. Further anatomic and clinical research is required to establish the role of lingual lymph node in oral squamous cell carcinoma recurrence and metastasis.