Impact of comorbidity, symptoms, and patients' characteristics on the prognosis of oral carcinomas

OBJECTIVES

To evaluate the impact of comorbidities, symptoms, and patients' characteristics on the 5-year overall survival of patients who underwent surgery for cancer of the oral tongue or floor of the mouth and to improve the survival estimates by the creation of a new staging system.

PATIENTS AND METHODS

A cohort of 110 patients with squamous cell carcinoma of the oral tongue or floor of the mouth, who were admitted to a tertiary cancer hospital from January 1, 1990, to December 31, 1994, and who underwent surgery was studied. Multivariate analysis distinguished that patients' characteristics, symptoms, and comorbidities have a significant impact on 5-year overall survival. This functional severity index combined with the TNM stage created the extended clinical severity staging system.

RESULTS

The 5-year overall survival was 33.4%. Survival by TNM cancer stage was 64.6% (stage I), 67.5% (stage II), 28.9% (stage III), and 13.1% (stage IV) (chi(2) = 22.88, P<.001). When patients were categorized according to the extended clinical severity staging system, survival was as follows: 74.0% (stage 1), 47.1% (stage 2), 28.6% (stage 3), and 8.4% (stage 4) (chi(2) = 38.67, P<.001).

CONCLUSION

Clinical variables have a prognostic impact on oral cancer that is surgically treated, and the consistency of results confirms that survival estimates can be improved by the addition of these elements to the TNM classification, creating a more powerful and precise system in the determination of a prognosis.

Primary thinning of the myocutaneous vastus lateralis flap

To expand the indicational spectrum of the myocutaneous vastus lateralis flap, which is often too voluminous for intraoral application, primary thinning of the fat and muscle component of this microsurgical transplant was performed in 14 patients. The surgical technique includes subfascial localization of at least one myocutaneous perforating vessel of the lateral circumflex femoral artery and its dissection through the fascia, muscles and fatty tissue up to the skin. The epifascial fatty tissue is completely removed except for a 1-2 cm wide cuff around the perforating vessel. The thinning technique was used for covering 10 intraoral and 4 extraoral defects and enabled the raising of skin flaps with a thickness of 4 mm even in obese patients. The vessel pedicle length of the thinned flaps was between 12 and 16 cm; flap size varied between 4x5 and 9x15 cm and the donor sites were directly closed. In one case, there was a partial necrosis (20%), but the other flaps healed without complications. The described method allows the raising of thick myocutaneous as well as thin skin flaps from the same donor region.

Verrucous carcinoma occurring in a lesion of oral lichen planus

Verrucous carcinoma of the oral cavity is relatively rare. Well-documented associations include human papillomavirus and carcinogens such as tobacco. Less well understood is the association with chronic inflammation, such as seen in lichen planus. Verrucous carcinoma has previously been described occurring in lesions of lichen planus of the foot and penis. We report the first case, to our knowledge, of verrucous carcinoma occurring in a lesion of oral lichen planus.

Human papillomavirus in head and neck carcinomas: prevalence, physical status and relationship with clinical/pathological parameters

The association of human papillomavirus (HPV) infection to head and neck squamous cell carcinomas was evaluated in 66 patients affected by tumours of the oral cavity (n = 38), the tonsil (n = 4), the pharynx (n = 2), and the larynx (n = 22). HPV DNA was detected by PCR-based assays, recognizing late and early genes. Twenty-four cases were HPV infected (36.4%), mostly by high and/or intermediate risk types. HPV 16 was integrated in 7/12 positive tumours without site-specificity. HPV infection was not related to age, gender, tumour stage, differentiation grade, and use of alcohol and/or tobacco. The findings indicate that HPV infection may be related to a proportion of head and neck carcinomas but its association is not as clear as that found in cervical cancer.

Massive postoperative swelling of the tongue: manual decompression and tactile intubation as a life-saving measure

Massive swelling of the tongue due to haemorrhage is a rare but potentially fatal complication secondary to trauma, surgery, tumour invasion or uncontrolled anticoagulant therapy. This article presents a report of bleeding from the left lingual artery secondary to elective excision of a lipoma of the floor of the mouth and subsequent life-threatening upper airway obstruction. In this case, the upper airway obstruction was managed by manual decompression of the tongue and tactile nasal intubation. To our knowledge this case provides the first description of using this method in life-threatening upper airway obstruction caused by massive haemorrhagic swelling of the tongue.

Epignathus teratoma: report of three cases with a review of the literature

Three cases of epignathus teratoma associated with other midline anomalies are reported. The first case involved Pierre Robin sequence and a bifid tongue. The second case was characterized by two teratomas, a meningoencephalocele, and a cleft lip and nose. The third case had Pierre Robin sequence associated with duplication of the pituitary gland and hypoplasia of the corpus callosum.

An unusual association between oral sarcoma and bulbar palsy

A 90 year old male presented with symptoms and signs of right lower cranial nerves palsy. A small mass was found on the right side at the back of his mouth. Light microscopy and histoimmunochemical studies of the biopsy of the mass showed an alveolar soft part sarcoma arising from the right myohyoid muscle. The unusual location and presentation of this rare tumor is discussed.

Second primary tumors after prostate carcinoma

BACKGROUND

Several large datasets have shown a reduced risk of all neoplasms after a diagnosis of prostate carcinoma but an increased incidence rate of urologic carcinoma has been suggested.

METHODS

Data collected by the Cancer Registries of the Swiss Cantons of Vaud and Neuchâtel (approximately 760,000 inhabitants) were used to estimate the incidence rate of a second primary tumor after a diagnosis of prostate carcinoma. A total of 4503 cases registered between 1974 and 1994 were followed until the end of 1996 (17,065 person-years).

RESULTS

A total of 380 second primary neoplasms were observed versus 534.1 expected primary neoplasms (standardized incidence ratio [SIR] = 0.7; 95% confidence interval, 0.6-0.8). SIRs were significantly below unity for lung carcinoma (SIR = 0.7) and other major tobacco-related neoplasms, including those of the mouth or pharynx (SIR = 0.5), esophagus (SIR = 0.4), pancreas (SIR = 0.5), and larynx (SIR = 0.8). There was no excess rate of subsequent urologic carcinoma (SIR = 1.0) or colorectal carcinoma (SIR = 0.9). The reduced SIRs for lung carcinoma were stronger in elderly men (age >/= 75 years) and in patients with a shorter period since diagnosis (< 5 years).

CONCLUSIONS

The incidence of all neoplasms was reduced significantly in men diagnosed with prostate carcinoma. Selection of the population, under-registration of second primary tumors, and reduced surveillance in elderly men with prostate carcinoma may, at least in part, explain this reduction in risk. No excess risk was observed for the complex of urologic neoplasms nor for tobacco-related neoplasms. This finding would not support an association between cigarette smoking and prostate carcinoma.

Psychologic response of the edentulous patient after primary surgery for oral cancer: A cross-sectional study

STATEMENT OF PROBLEM

Edentulous patients can have difficulty in tolerating dentures and this may lead to psychologic disturbance. The problem is potentially more severe for edentulous patients after primary surgery for oral cancer, where treatment can include composite resection and reconstruction, followed by adjuvant radiotherapy.

PURPOSE

This study investigated the psychologic response and oral satisfaction of edentulous patients treated by surgery for oral squamous cell carcinoma, and to make a comparison to edentulous noncancer counterparts.

METHODS AND MATERIAL

The cross-sectional study included patients who were alive and disease-free 2 to 3 years after primary surgery. Seventy patients underwent surgery at the Regional Maxillofacial Unit, Liverpool, in 1993 and 1994. Twenty-eight patients were disease-free; 26 completed questionnaires that included a general health questionnaire (GHQ), a body satisfaction scale, a self-esteem scale, an oral symptom checklist, and a denture satisfaction questionnaire. Comparison was made with 98 noncancer edentulous patients from the same unit.

RESULTS

There were similarities in psychologic and oral satisfaction scores between the noncancer and cancer edentulous patients. Cancer patients reported lower self-esteem (P <.02). Cancer patients who were not rehabilitated with either conventional or implant-retained prostheses had significant psychologic morbidity as measured by the GHQ, self-esteem, and body satisfaction scales. Cancer patients with implant-retained overdentures reported greater satisfaction with their dentures compared with their counterparts who wore conventional dentures (P <.05).

CONCLUSION

Edentulous cancer patients who do not achieve oral rehabilitation after surgery for oral cancer exhibited significant psychologic morbidity. Patients with implant-retained overdentures exhibited a tendency to adopt the same psychologic response with improved denture satisfaction as edentulous patients with conventional dentures, despite the former having more extensive disease that would otherwise make the provision of dentures much more difficult if implants were not used.

Epstein-Barr virus and oral squamous cell carcinoma in patients without HIV infection: viral detection by polymerase chain reaction

In order to test the hypothesis that Epstein-Barr virus (EBV) may be a cofactor for oral squamous cell carcinoma (OSCC) the authors evaluated tumour cells from OSCC of 108 patients without HIV infection, for the presence of EBV DNA by polymerase chain reaction. The sequences of oligonucleotides used in the amplification and hybridization included a set for the DNA polymerase region. The amplification was detected using an ELISA assay with peroxidase. EBV DNA was detected in 17.59% of the tumours. Inhibition studies showed that the ability to detect EBV DNA was not affected by the pathological material, suggesting that the negative PCR results in these samples were not caused by PCR inhibitors in the biopsy. Results revealed that 63.1% of the tumours (12 cases) were DNA positive affecting the lateral margin of the tongue, and were statistically significant (p < 0.001; chi 2). In the pool of tumours with EBV DNA only 26.3% (5 of 19 cases) were well differentiated OSCCs whereas the remaining 73.7% (14 of 19 cases) were moderately and poorly differentiated OSCCs, with a statistical significance of p = 0.08; chi 2. This study suggests a relationship between OSCC and EBV.

A retrospective study of oral lichen planus patients with concurrent or subsequent development of malignancy

Oral lichen planus (OLP) carries a very small probability of becoming malignant. Our Finnish series comprised eight patients suffering from OLP and concurrent or subsequent oral squamous cell carcinoma over a 10-year period. The mean interval between the histologically suggested initial diagnosis of OLP and carcinoma was 3.4 years. An oral ulcer as a clinical manifestation of malignant change appeared in seven of these eight patients; five of the eight died of carcinoma on average 13 months (range 7-20) after the final squamous cell carcinoma diagnosis. These eight patients were compared to eight control OLP patients without malignant transformation matched as to follow-up time, age, gender, sites of the lesions, etc. We could discover no histological features leading to malignant development. However, the clinically unilateral atrophic/erosive type of OLP more often preceded the malignant change, compared to the situation for control patients, in whom the most prevalent type was the bilateral reticular OLP. However, the probability seems to be very small.

Factors related to dropout in a study of head and neck cancer patients after surgery

The extent and nature of dropout was assessed in a longitudinal study whose objective was to define and quantify the functional effects of oral surgical resection and reconstruction on speech and swallowing function in patients with head and neck cancer. Of 150 patients who were enrolled to be followed up with speech and swallow assessments for 1 year after surgery, 113 (75%) dropped out and 37 (25%) returned to complete the study at the final 12-month evaluation point. In general, those completing the study had a smaller resection than the patients who dropped out before the 12-month evaluation. Fifty percent of the dropout was accounted for by medical reasons, 23% by administrative reasons, and 27% by patient-specific reasons (i.e., reasons known only to the patient). Analysis of the dropout categories revealed that higher cancer stage, larger volume of resection, and having a flap surgical closure versus a primary closure or skin graft increased a patient's chance of dropping out. A larger volume of resection was also related to an increased chance of being a patient-specific dropout. Patients who reported no or low alcohol usage had a greater chance of completing follow-up than being a patient-specific dropout.

Successful treatment of obstructive sleep apnea with use of nasal continuous positive airway pressure in three patients with mucosal hemangiomas of the oral cavity

Cysts and benign tumors are uncommon causes of obstructive sleep apnea (OSA), and surgical removal is usually favored. In patients in whom an operation poses a high risk, however, nasal continuous positive airway pressure (CPAP) may prove beneficial. We describe three patients with hemangiomas of the oral cavity in whom polysomnography revealed moderate to severe OSA. In all three patients, nasal CPAP effectively decreased sleep-related disordered breathing events and dramatically improved their sleep. To our knowledge, this is the first report of OSA associated with hemangiomas involving the upper airway. Our experience suggests that nasal CPAP therapy is effective and well tolerated in such patients.

Orofacial disease: update for the dental clinical team: 2. Ulcers, erosions and other causes of sore mouth. Part I

Mouth ulcers are one of the most common oral complaints. The term ulcer is used usually where there is damage to both epithelium and lamina propria, and a crater, sometimes made more obvious clinically by swelling caused by oedema or proliferation in the surrounding tissue. The term erosion is usually used where the damage is somewhat more superficial. Most ulcers/erosions are due to local causes such as trauma or burns. Some are caused by aphthae or malignant neoplasms, and a few have aetiology in obvious systemic disease. Ulcers of local cause, drugs, aphthous ulcers, Behcet's syndrome and malignant ulcers are discussed in this article. The next two articles discuss the ulcers due to systemic disease including disorders of the blood, gastrointestinal disorders, skin diseases, connective tissue disease and infective diseases.

Oral ulcerations in individuals infected with human immunodeficiency virus: clinical presentations, diagnosis, management, and relevance to disease progression

Oral ulcerations can be both a localized disease entity and a manifestation of an underlying systemic condition. In individuals infected with the human immunodeficiency virus, oral ulceration may serve as a marker for a specific systemic illness, early immunosuppression, and disease progression. This article reviews clinical manifestations, diagnosis, and management of oral ulcerations in individuals with the human immunodeficiency virus.

Pain preceding recurrent head and neck cancer

Over a 7-year period, 12 patients experienced recurrence of primary head and neck cancers preceded by severe orofacial pain. Pain began within 6 months following treatment in 10 of 12 patients and was progressive in 11 of 12 patients. Six patients died from recurrence, five within 2 years following onset of pain. No clear indication of malignant disease was evident despite clinical examination, plain radiography, magnetic resonance imaging, and computed tomography. Pain was often mistaken for denture irritation. Frequently, no area of irritation was apparent.

Multiple nodular lesions of the chin and oral mucosa in a patient with Sjögren's syndrome

Sjögren's syndrome is an autoimmune disease characterised by generalised lymphoproliferation. Patients have an increased risk of developing lymphomas which are usually derived from mucosa-associated lymphoid tissue (MALT). We report a low grade, non-Hodgkin's lymphoma of the skin and oral mucosa in a patient with Sjögren's syndrome.

[Cowden disease: treatment with acitretine]

INTRODUCTION

Cowden's disease is a rare hereditary skin disease which is important to recognize due to the risk of cancer.

CASE REPORT

A 40-year-old man was hospitalized for psoriasis. He presented florid papillomatous lesions involving the lip and the buccal cavity, a thyroid adenoma and polyposis of the gut. The diagnosis of Cowden's disease was retained. Treatment with acitretin, 0.75 mg/kg/d was initiated for the psoriatic lesions. Hypertrophic lesions of the lip and mouth regressed during treatment but reappeared when the drug dose was tapered of then withdrawn. The course of the polyposis was not verified.

DISCUSSION

This case demonstrates the frequency of digestive tract involvement in Cowden's disease and the favorable, though transient, effect of oral retinoids on mucosal lesions in Cowden's disease.

Pathological fractures of the mandible. A review of the etiology and treatment

A retrospective study was undertaken to analyse the etiology, site and treatment procedures of 30 pathological fractures of the mandible. Fifty percent of the fractures had an inflammatory cause. The remaining cases were associated with severe atrophy of edentulous mandibles (4), benign tumours (3), cysts (3), and primary or secondary malignancies (5). Regardless of the cause, the majority of the fractures occurred in the body of the mandible. Pathological fractures of the mandible most often have to be treated by eliminating the cause of the underlying condition while immobilizing the fragments either with osteosynthesis or archbars and intermaxillary fixation.