Ultrasonography for Intraoperative Determination of Tumor Thickness and Resection Margin in Tongue Carcinomas

Beneath the surface: A systematic review on intraoperative imaging techniques for deep margin assessment in oral squamous cell carcinoma

Resection margins of oral squamous cell carcinoma (SCC) are often inadequate. A systematic review on clinical intraoperative whole-specimen imaging techniques to obtain adequate deep resection margins in oral SCC is lacking. Such a review may render better alternatives for the current insufficient intraoperative techniques: palpation and frozen section analyses (FSA). This review resulted in ten publications investigating ultrasound (US), four investigating fluorescence, and three investigating MRI. Both US and fluorescence were able to image the tumor intraorally and perform ex-vivo imaging of the resection specimen. Fluorescence was also able to image residual tumor tissue in the wound bed. MRI could only be used on the ex-vivo specimen. The 95 % confidence intervals for sensitivity and specificity were large, due to the small sample sizes for all three techniques. The sensitivity and specificity of US for identifying < 5 mm margins ranged from 0 % to 100 % and 60 % to 100 %, respectively. For fluorescence, this ranged from 0 % to 100 % and 76 % to 100 %, respectively. For MRI, this ranged from 7 % to 100 % and 81 % to 100 %, respectively. US, MRI and fluorescence are the currently available imaging techniques that can potentially be used intraoperatively and which can image the entire tumor-free margin, although they have insufficient sensitivity for identifying < 5 mm margins. Further research on larger cohorts is needed to improve the sensitivity by determining cut-off points on imaging for inadequate margins. This improves the number of adequate resections of oral SCC's and pave the way for routine clinical implementation of these techniques.

Intraoperative Ultrasound for the Management of Oral Tongue Cancer: a Systematic Review and Meta-Analysis

Objective

To evaluate for correlation between intraoperative ultrasound (IOUS)-measured tumor thickness (TT) (uTT) and histopathological TT (hTT), and to compare IOUS-assisted resection with conventional resection in patients with oral tongue cancers.

Data Sources

Ovid MEDLINE (1946-2023), Embase.com (1947-2023), and Web of Science (All Databases 1900-2023).

Review Methods

Inclusion criteria were the use of IOUS for the management of oral tongue cancer. Studies that did not report quantitative data were excluded. Additionally, studies that were not contributory to meta-analysis, or a narrative analysis of pooled results were excluded. Selection was carried out by 2 reviewers. A total of 2417 studies were initially identified, with 12 ultimately being included in this review, and 7 included in the meta-analysis. Data were extracted by 2 investigators and were pooled using a random-effects model.

Results

Our meta-analysis reveals a pooled correlation coefficient of 0.92 (95% confidence interval: 0.80-0.96) for studies comparing uTT to hTT. Studies comparing IOUS-assisted resection to conventional resection found IOUS-assisted resection yielded wider nearest margins in all studies reporting this outcome.

Conclusion

IOUS reliably measures TT, similarly to that of histopathology measurement. IOUS-assisted resection, which allows the surgeon to view the deep extent of tumor invasion, may increase closest radial margin distance compared to conventional resection. IOUS-assisted resection may represent a more reliable approach to achieving clear margins than conventional resection.

Intraoral Ultrasound versus MRI for Depth of Invasion Measurement in Oral Tongue Squamous Cell Carcinoma: A Prospective Diagnostic Accuracy Study

Oral squamous cell carcinoma (OSCC) of the tongue is the most common type of oral cavity cancer, and tumor depth of invasion (DOI) is an important prognostic factor. In this study, we investigated the accuracy of intraoral ultrasound and magnetic resonance imaging (MRI) for assessing DOI in patients with OSCC. Histopathological measurement of DOI was used as a reference standard. We conducted a prospective study including patients planned for surgical treatment of OSCC in the tongue. The DOI was measured in an outpatient setting by intraoral ultrasound and MRI, and was compared to the histopathological DOI measurements. Bland-Altman analysis compared the mean difference and 95% limits of agreement (LOA) for ultrasound and MRI, and the Wilcoxon signed-rank test was used to test for significance. The correlation was evaluated using Pearson's correlation coefficient. We included 30 patients: 26 with T1 or T2 tumors, and 4 with T3 tumors. The mean difference from histopathology DOI was significantly lower for ultrasound compared to MRI (0.95 mm [95% LOA -4.15 mm to 6.06 mm] vs. 1.90 mm [95% LOA -9.02 mm and 12.81 mm], p = 0.023). Ultrasound also led to significantly more correct T-stage classifications in 86.7% (26) of patients compared to 56.7% (17) for MRI, p = 0.015. The Pearson correlation between MRI and histopathology was 0.57 (p < 0.001) and the correlation between ultrasound and histopathology was 0.86 (p < 0.001). This prospective study found that intraoral ultrasound is more accurate than MRI in assessing DOI and for the T-staging of oral tongue cancers. Clinical practice and guidelines should implement intraoral ultrasound accordingly.

Overview of Ultrasound in Dentistry for Advancing Research Methodology and Patient Care Quality with Emphasis on Periodontal/Peri-implant Applications

BACKGROUND

Ultrasound is a non-invasive, cross-sectional imaging technique emerging in dentistry. It is an adjunct tool for diagnosing pathologies in the oral cavity that overcomes some limitations of current methodologies, including direct clinical examination, 2D radiographs, and cone beam computerized tomography. Increasing demand for soft tissue imaging has led to continuous improvements on transducer miniaturization and spatial resolution. The aims of this study are (1) to create a comprehensive overview of the current literature of ultrasonic imaging relating to dentistry, and (2) to provide a view onto investigations with immediate, intermediate, and long-term impact in periodontology and implantology.

METHODS

A rapid literature review was performed using two broad searches conducted in the PubMed database, yielding 576 and 757 citations, respectively. A rating was established within a citation software (EndNote) using a 5-star classification. The broad search with 757 citations allowed for high sensitivity whereas the subsequent rating added specificity.

RESULTS

A critical review of the clinical applications of ultrasound in dentistry was provided with a focus on applications in periodontology and implantology. The role of ultrasound as a developing dental diagnostic tool was reviewed. Specific uses such as soft and hard tissue imaging, longitudinal monitoring, as well as anatomic and physiological evaluation were discussed.

CONCLUSIONS

Future efforts should be directed towards the transition of ultrasonography from a research tool to a clinical tool. Moreover, a dedicated effort is needed to introduce ultrasonic imaging to dental education and the dental community to ultimately improve the quality of patient care.

Correlation of Intraoperative Ultrasonographic Oral Tongue Shape and Border and Risk of Close Margins

Intraoperative ultrasound (IOUS) is a potentially useful adjunct to the resection of oral tongue cancers (OTC). IOUS images of the tumor-normal tissue interface show different patterns of invasion. In this retrospective series of 29 patients treated for OTC, we evaluated if there was a correlation between IOUS findings of patterns of invasion and final histology and assessed if there was any associated risk of increased incidence of positive or close margins with different patterns of invasion as seen on ultrasound. Although we found no significant correlation between ultrasound patterns of invasion and histological evaluation, we did find that an infiltrative pattern of invasion on IOUS did result in a significant risk of a close margin. Further exploration of these findings in a larger prospective study could provide definitive information on the efficacy of this modality in OTC resections.

Correlation between radiologic depth of invasion and pathologic depth of invasion in oral cavity squamous cell carcinoma: A systematic review and meta-analysis

OBJECTIVES

To comprehensively assess the correlation between radiologic depth of invasion (rDOI) and pathologic depth of invasion (pDOI) in oral cavity squamous cell carcinoma (OSCC) by meta-analysis.

MATERIALS AND METHODS

PubMed and Embase databases were searched to find pertinent articles reporting rDOI of OSCC. Studies evaluating the correlations and mean differences (MDs) between rDOI and pDOI were included. The rDOI was measured based on ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI). The correlation coefficients and MDs between rDOI and pDOI were meta-analytically pooled. Between-study heterogeneity was assessed using Higgins' inconsistency index (I²). Subgroup analysis was performed based on imaging modality.

RESULTS

Twenty-three studies with 1787 patients were included. The pooled correlation coefficient and MD were 0.86 (95 % confidence interval [CI], 0.82-0.90; I² = 66.9 %) and 1.84 mm (95 % CI, 1.02-2.65 mm; I² = 88.2 %), respectively. In subgroup analysis, MRI showed the largest MD (n = 12, 2.61 mm), followed by US (n = 2, -0.41 mm) and CT (n = 2, 0.12 mm). US showed the highest correlation coefficient (n = 3, 0.91), followed by MRI (n = 12, 0.85) and CT (n = 3, 0.82).

CONCLUSION

rDOI measured by US, CT, and MRI demonstrated excellent correlations with pDOI.

Intra-operative intaoral ultrasonograpy ensures free deep resection margins in carcinoma tongue: A pilot study

ABSTRACT

Resection of primary in carcinoma tongue is challenging as the tumor often spreads submucosal and deep in muscles. There are various Intraoperative tools available to guide tumor resection margins. We studied the use of intraoperative ultrasound-guided resection for obtaining free deep resection margins in cases of oral carcinoma tongue. To assess the feasibility of resection of tongue tumor using intraoral ultrasound intraoperatively. 5 patients of oral tongue squamous cell carcinoma were included in this prospective pilot study. Intraoral ultrasound-guided resection of the primary tongue tumor was done. The surgeon moved the probe over the tumor and focussed on the point of maximum invasion by the tumor. A 26 G needle was passed in the tongue at a point that was 10 mm away from the deepest point of infiltration. It marked the deepest plane of resection. Following the above marking, a resection of tumor was done. Deep surgical resection margin was found to be >5 mm (free) in all the USG-guided surgically resected primary tongue tumors on histopathological examination. We have found intraoperative ultrasonography a useful tool for the surgical resection of primary tongue tumours.

High-Frequency Intraoral Ultrasound for Preoperative Assessment of Depth of Invasion for Early Tongue Squamous Cell Carcinoma: Radiological-Pathological Correlations

The eighth edition of the TNM classification officially introduced "depth of invasion" (DOI) as a criterion for determining the T stage in tongue squamous cell carcinoma. The DOI is a well-known independent risk factor for nodal metastases. In fact, several experts strongly suggest elective neck dissection for tongue cancer with a DOI > 4 mm due to the high risk of early and occult nodal metastases. Imaging plays a pivotal role in preoperative assessments of the DOI and, hence, in planning the surgical approach. Intraoral ultrasound (IOUS) has been proposed for early-stage SCC of the oral tongue as an alternative to magnetic resonance imaging (MRI) for local staging. The aim of this work is to investigate the accuracy of IOUS in the assessment of the DOI in early oral SCC (CIS, pT1, and pT2). A total of 41 patients with tongue SCCs (CIS-T2) underwent a preoperative high-frequency IOUS. An IOUS was performed using a small-size, high-frequency hockey-stick linear probe. The ultrasonographic DOI (usDOI) was retrospectively compared to the pathological DOI (pDOI) as the standard reference. In patients who underwent a preoperative MRI, their usDOI, magnetic resonance DOI (mriDOI), and pDOI were compared. Specificity and sensitivity for the IOUS to predict a pDOI > 4 mm and to differentiate invasive and noninvasive tumors were also evaluated. A high correlation was found between the pDOI and usDOI, pDOI and mriDOI, and usDOI and mriDOI (Spearman's ρ = 0.84, p < 0.0001, Spearman's ρ = 0.79, p < 0.0001, and Spearman's ρ = 0.91, p < 0.0001, respectively). A Bland-Altman plot showed a high agreement between the usDOI and pDOI, even though a mean systematic error was found between the usDOI and pDOI (0.7 mm), mriDOI and pDOI (1.6 mm), and usDOI and mriDOI (-0.7 mm). The IOUS was accurate at determining the T stage (p < 0.0001). The sensitivity and specificity for the IOUS to predict a pDOI ≥4 mm were 92.31% and 82.14%, respectively, with an AUC of 0.87 (p < 0.0001). The specificity, sensitivity, negative predictive value (NPV), and positive predictive value (PPV) for the IOUS to predict an invasive cancer were 100%, 94.7%, 60%, and 100%, respectively. The AUC was 0.8 (95% CI 0.646-0.908, p < 0.0001). The IOUS was accurate in a preoperative assessment of a pDOI and T stage, and can be proposed as an alternative to MRI in the preoperative staging of tongue SCC.

Ultrasound accurately assesses depth of invasion in T1-T2 oral tongue cancer

Background

Depth of invasion (DOI) is important for the T-classification of squamous cell carcinoma of the oral tongue (SCCOT) and incorporated in the TNM 8 classification of oral cavity cancer. To determine DOI clinical palpation is performed, but the preferred radiological modality remains controversial. The aim of this study was to investigate the assessment of DOI using ultrasound (US-DOI).

Methods

The DOI was assessed in 40 patients with T1-T3 SCCOT by ultrasound, palpation, computed tomography and magnetic resonance imaging (MRI). Histopathological DOI (H-DOI) was gold standard. Bland-Altman analysis was used to compare mean difference and 95% limits of agreement (LOA).

Results

The mean difference of US-DOI was -0.5 mm (95% LOA -4.9-4.0) compared to H-DOI and the mean difference for MRI was 3.9 mm (95% LOA -2.3-10.2). In the subgroup analysis of cT1-T2 the US-DOI mean difference was 0.1 mm and the 95% LOA limits -2.5-2.7.

Conclusions

Ultrasound seems to be the most accurate method to assess DOI in T1-T2 SCCOT. MRI overestimates DOI and cannot assess a substantial proportion of the tumors.

Level of Evidence

2c.

Application and accuracy of ultrasound-guided resections of tongue cancer

OBJECTIVES

Surgical removal of squamous cell carcinoma of the tongue (SCCT) with tumour-free margin status (≥5 mm) is essential for loco-regional control. Inadequate margins (<5 mm) often indicate adjuvant treatment, which results in increased morbidity. Ultrasound (US)-guided SCCT resection may be a useful technique to achieve more adequate resection margins compared to conventional surgery. This study evaluates the application and accuracy of this technique.

METHODS

Forty patients with SCCT were included in a consecutive US cohort. During surgery, the surgeon aimed for a 10-mm echographic resection margin, while the tumour border and resection plane were captured in one image. Ex-vivo US measurements of the resection specimen determined whether there was a need for an immediate re-resection. The margin status and the administration of adjuvant treatment were compared those of with a consecutive cohort of 96 tongue cancer patients who had undergone conventional surgery. A receiver operating characteristic analysis was done to assess the optimal margin of ex-vivo US measurements to detect histopathologically inadequate margins.

RESULTS

In the US cohort, the frequency of free margin status was higher than in the conventional cohort (55% vs. 16%, p < 0.001), and the frequency of positive margins status (<1 mm) was lower (5% vs. 15%, respectively, p < 0.001). Adjuvant radiotherapy was halved (10% vs. 21%), and the need for re-resection was comparable (10% vs. 9%). A cut-off value of 8 mm for ex-vivo measurements prevented histopathologically inadequate margins in 76%.

CONCLUSION

US-guided SCCT resections improve margin status and reduce the frequency of adjuvant radiotherapy.

The applications of ultrasound, and ultrasonography in dentistry: a scoping review of the literature

OBJECTIVES

This scoping review aims to summarize the available literature on the clinical applications of ultrasonography and ultrasound in diagnostic, therapeutic, and interventional dental applications.

MATERIALS AND METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Extension for Scoping Reviews checklist and conducted a protocol-driven scoping review of randomized controlled trials, cohort studies, cross-sectional studies, case-control studies, and case series that assessed ultrasonography or ultrasound use as a stand-alone diagnostic, therapeutic, and interventional tool in dentistry. We included studies published after 1980, study samples ≥ 10, with diagnostic, concordance, or therapeutic outcomes. We searched Ovid MEDLINE, Embase, and others (up to April 2021) and extracted information regarding study level, patient level, test or treatment level, and outcome level data.

RESULTS

Five interventional studies (related to oral medicine, temporomandibular disorders, and dental anesthesia), eight therapeutic studies (related to surgery and orthodontics), and seventy-five diagnostic studies (related to orthodontics, surgery, endodontics, oral medicine, temporomandibular disorders, restorative dentistry, and periodontology) were identified and presented in this review.

CONCLUSION

Ultrasonography has a well-established niche in diagnostic dentistry, while therapeutic and interventional ultrasounds have a smaller, yet present, niche in dentistry. However, further research is needed to report the precise estimates of the diagnostic, therapeutic, and interventional effects.

CLINICAL SIGNIFICANCE

Dentists are mostly unfamiliar with ultrasonography and ultrasound and their potential uses. This review maps the diagnostic and therapeutic applications of ultrasonography and ultrasound technology in dentistry and highlights the current challenges, gaps of knowledge, and research status of ultrasound technology in this regard.

The utility of intra-oral ultrasound in improving deep margin clearance of oral tongue cancer resections

OBJECTIVES

To investigate the potential utility of intra-oral ultrasound (IOUS) in guiding deep margin clearance and measuring depth of invasion (DOI) of oral tongue carcinomas (OTC).

MATERIALS AND METHODS

Retrospective chart review of consecutive patients with T1-T3 OTC who underwent intraoperative ultrasound-guided resection and a comparator group that had undergone resection without the use of IOUS both by a single surgeon. Data was extracted from operative, pathology and radiology reports. Deep margins and DOI were reviewed by a dedicated head and neck pathologist. Correlation between histologic and ultrasound DOI was assessed using Pearson correlation.

RESULTS

A total of 23 patients were included in the study cohort with a comparator group of 21 patients in the control group. None of the patients in the study cohort had a positive (cut-through) deep margin and the mean deep margin clearance was 8.5 ± 4.9 and 6.7 ± 3.8 for the IOUS and non-IOUS groups respectively (p-value 0.18) showing a non-significant improvement in the IOUS group. As a secondary outcome, there was a strong correlation between histologic and ultrasound DOI (0.9449).

CONCLUSION

Ultrasound appears to be a potentially effective tool in guiding OTC resections. In this small series, IOUS facilitated deep margin clearance and resulted in a non-statistically significant increase in deep margin clearance. Intraoral ultrasound can accurately measure lesional DOI.

Treatment outcomes of real-time intraoral sonography-guided implantation technique of 198Au grain brachytherapy for T1 and T2 tongue cancer

It is often challenging to determine the accurate size and shape of oral lesions through computed tomography (CT) or magnetic resonance imaging (MRI) when they are very small or obscured by metallic artifacts, such as dental prostheses. Intraoral ultrasonography (IUS) has been shown to be beneficial in obtaining precise information about total tumor extension, as well as the exact location and guiding the insertion of catheters during interstitial brachytherapy. We evaluated the role of IUS in assessing the clinical outcomes of interstitial brachytherapy with 198Au grains in tongue cancer through a retrospective medical chart review. The data from 45 patients with T1 (n = 21) and T2 (n = 24) tongue cancer, who were mainly treated with 198Au grain implants between January 2005 and April 2019, were included in this study. 198Au grain implantations were carried out, and positioning of the implants was confirmed by IUS, to ensure that 198Au grains were appropriately placed for the deep border of the tongue lesion. The five-year local control rates of T1 and T2 tongue cancers were 95.2% and 95.5%, respectively. We propose that the use of IUS to identify the extent of lesions and the position of implanted grains is effective when performing brachytherapy with 198Au grains.

The accuracy of magnetic resonance imaging to measure the depth of invasion in oral tongue cancer: a systematic review and meta-analysis

The accuracy of magnetic resonance imaging (MRI)-derived depth of invasion (DOI) compared to histopathological DOI is still controversial. A meta-analysis was performed to address this controversy and further investigate the best imaging sequence to measure DOI of tongue squamous cell carcinomas (SCC). A comprehensive literature search of five electronic databases was conducted. Stata/SE was used to establish a continuous variable model to assess the consistency between MRI-derived DOI and histopathological DOI. IBM SPSS Statistics 22.0 was used to evaluate the correlation between MRI-derived DOI and histopathological DOI. The meta-analysis showed that the weighted mean difference (WMD) of DOI measured by MRI had an acceptable overestimation compared with that measured by histopathology (WMD 1.64 mm; P < 0.001). In the subgroup analyses, there was no difference between T1-weighted imaging (T1WI) and histopathological values (WMD 0.77 mm; P = 0.273), while T2-weighted imaging (T2WI) had a major overestimation (WMD 2.09 mm; P < 0.001). The overall inter-class correlation coefficient (ICC) between MRI-derived DOI and histopathological DOI was 0.869 (95% CI 0.837-0.895), and was 0.923 (95% CI 0.894-0.944) in the T1WI subgroup and 0.790 (95% CI 0.718-0.845) in the T2WI subgroup. MRI is an accurate modality for evaluating the DOI in oral tongue SCC, and T1WI showed relatively higher validity than T2WI for DOI measurements.

Relationships between intraoral ultrasonographic and histopathological findings in patients with tongue cancer

BACKGROUND

In this study, we aimed to investigate the relationships between histopathological and intraoral ultrasonographic (IUS) findings in patients with tongue cancer.

METHODS

IUS and histopathological findings in 46 patients with tongue cancer were considered for this study. We assessed the relationships between IUS findings regarding tumor thickness, margin type, border type, and internal echo intensity; internal/peripheral Doppler findings; and muscle invasion and histopathological findings regarding tumor thickness, differentiation, Yamamoto-Kohama (YK)-classification grade, blood vessel invasion, lymphatic invasion, perineural invasion, and muscle invasion.

RESULTS

Statistical associations were found between the following findings: between thickness determined through IUS measurement and that determined through histopathological measurement, between the IUS findings regarding tumor margin and border types and the histopathologically determined YK-classifications grades, and between a Doppler image of the internal area of tongue lesions and lymphatic invasion.

CONCLUSIONS

IUS findings may be used to predict histopathological findings about tumor thickness and YK-classification grades.

Assessment of the deep resection margin during oral cancer surgery: A systematic review

The main challenge for radical resection in oral cancer surgery is to obtain adequate resection margins. Especially the deep margin, which can only be estimated based on palpation during surgery, is often reported inadequate. To increase the percentage of radical resections, there is a need for a quick, easy, minimal invasive method, which assesses the deep resection margin without interrupting or prolonging surgery. This systematic review provides an overview of technologies that are currently being studied with the aim of fulfilling this demand. A literature search was conducted through the databases Medline, Embase and the Cochrane Library. A total of 62 studies were included. The results were categorized according to the type of technique: 'Frozen Section Analysis', 'Fluorescence', 'Optical Imaging', 'Conventional imaging techniques', and 'Cytological assessment'. This systematic review gives for each technique an overview of the reported performance (accuracy, sensitivity, specificity, positive predictive value, negative predictive value, or a different outcome measure), acquisition time, and sampling depth. At the moment, the most prevailing technique remains frozen section analysis. In the search for other assessment methods to evaluate the deep resection margin, some technologies are very promising for future use when effectiveness has been shown in larger trials, e.g., fluorescence (real-time, sampling depth up to 6 mm) or optical techniques such as hyperspectral imaging (real-time, sampling depth few mm) for microscopic margin assessment and ultrasound (less than 10 min, sampling depth several cm) for assessment on a macroscopic scale.

Feasibility study of ultrasound-guided resection of tongue cancer with immediate specimen examination to improve margin control - Comparison with conventional treatment

OBJECTIVES

Squamous cell carcinoma of the tongue (SCCT) is preferably treated by surgery. Free resection margins (≥5 mm) provide local control and disease-free survival. However, close (1-5 mm) and positive margins (<1 mm) are frequently encountered. We present our first experience of in-vivo ultrasound (US) guided SCCT resections followed by ex-vivo US control on the resection specimen to obtain free margins. We compare the results with those from a hisorical cohort of 91 conventionally treated SCCT patients.

MATERIALS AND METHODS

Ten patients with SCCT were included in a consecutive US-cohort. We aimed for a 5-10 mm margin during surgery, while we visualized the resection plane on US. Ex-vivo US measurements on the resection specimen determined whether there was any need for an immediate re-resection. US measurements were then compared with histopathology. Histopathological margins were compared with a consecutive cohort of 91 patients who had undergone conventional surgery for a SCCT.

RESULTS

In the US cohort, 70% of the margins were free. In the conventional cohort, this figure was 17% (P = 0.005). US predicted minimal histopathological margin distance with a mean ± SD error of 1.9 ± 1.8 mm. The mean ± SD of the histopathological overall submucosal/deep margin distance was 7.9 ± 2.1 mm in the US cohort and 7.0 ± 2.2 mm in the conventional cohort (P = 0.188). Ex-vivo examination through use of US indicated an immediate re-resection, which prevented local adjuvant treatment.

CONCLUSION

Use of US-guided SCCT resection is feasible and improves margin control.

Contrast-Enhanced Ultrasound Guided Transoral Core Needle Biopsy: A Novel, Safe and Well-Tolerated Procedure for Obtaining High-Quality Tissue in Patients with Oral Cancer

The aim of the prospective study described here was to compare the tolerability, safety and diagnostic value of contrast-enhanced ultrasound-guided transoral core needle biopsy (CEUS-CNB) with that of conventional US-guided transoral CNB (US-CNB) and standard incisional biopsy in patients with oral masses. Between June 2017 and November 2019, consecutive patients with oral masses referred for biopsy were randomly assigned to undergo incisional biopsy, US-CNB or CEUS-CNB. Procedure time, intra‑operative blood loss volume, diagnostic performance and pain level before and after the procedure assessed by visual analogue score (VAS) were recorded and compared among the three procedures. Finally, 238 patients with pathology confirmation were analyzed: 80 patients underwent incisional biopsy, 78 patients US-CNB and 80 patients CEUS-CNB. In this study, no significant difference was found in biopsy time between CEUS-CNB, US-CNB and incisional biopsy (75 ± 11 s vs. 73.6 ± 12 s vs. 77 ± 13 s, p = 0.24). CEUS-CNB achieved the highest sensitivity (CEUS-CNB: 100%, US-CNB: 88.5%, incisional biopsy: 84.3%), negative predictive value (CEUS-CNB: 100%, US-CNB: 81.3%, incisional biopsy: 78.4%) and accuracy (CEUS-CNB: 100%, US-CNB: 92.3%, incisional biopsy: 90%). The VAS score for incision biopsy was higher (p = 0.01) and the amount of bleeding was larger (p < 0.001), yet there was no significant difference between CEUS-CNB and US-CNB. Our results indicate CEUS-guided transoral CNB is an efficient, safe and well-tolerated procedure, with biopsy time comparable to and diagnostic performance better than those of conventional US-guided transoral CNB and incisional biopsy.

Intraoperative ultrasonography-guided surgery for malignant soft tissue tumor

BACKGROUND AND OBJECTIVES

A clear surgical margin is crucial for preventing the recurrence of soft tissue sarcomas (STSs). Recognizing the tumor border is difficult when the STS is impalpable or ill-defined. Ultrasonography (US) is a widely used diagnostic device that can visualize certain tumors intraoperatively. However, its usefulness for intraoperatively assessing STSs is unclear and was investigated here.

METHODS

Our study comprised 19 patients with STSs that were impalpable, ill-defined, or beneath the fascia. All patients underwent intraoperative US (IOUS), with follow-up times ranging from 5 to 103 months (mean, 49 months).

RESULTS

The mean age of the study participants was 56 years (range, 25-83 months). The most common histological diagnosis was undifferentiated pleomorphic sarcoma (UPS) (nine patients). The mean tumor size was 51 mm (range, 7-126 mm). According to the residual tumor classification, 18 tumors were microscopically negative (R0), including seven close to the fascia, and one was microscopically positive (R1). Local recurrence occurred in two cases (both classified as R0). The recurrence-free survival rate was 88.9% in 5 years.

CONCLUSIONS

IOUS-guided surgery is useful for visualizing STSs. Using this technique, STSs can be precisely localized, evaluated, and excised.

Discovering a new anatomy: exploration of oral mucosa with ultra-high frequency ultrasound

OBJECTIVES

Ultra-high frequency ultrasound (UHFUS) is a recently developed diagnostic technique involving the use of ultrasound frequencies up to 70 MHz, allowing to obtain 30 µm resolution of targets located within 1 cm from the surface. Oral mucosa can be affected by diverse pathological conditions, which are currently investigated by means of clinical examination. In this scenario, intraoral UHFUS can provide additional information and support clinical assessment of oral mucosa. In this preliminary study, typical features of normal oral mucosa are described, in order to set a benchmark for the future identification of oral soft tissue alterations.

METHODS

Twenty healthy subjects (10 males and 10 females, mean age 30 years) were enrolled and underwent intraoral UHFUS examination. In all the subjects, tongue, buccal mucosa, gingiva, lip mucosa, and palate were scanned, and images acquired. Intraoral UHFUS scan included Brightness-mode and Doppler mode acquisitions performed with a standardized protocol. UHFUS images were postprocessed and analyzed using a dedicated software. UHFUS-based biomarkers (epithelial thickness, echogenicity, and vascularization) were employed for image description.

RESULTS

Normal oral anatomy of the different sites analyzed was described. For all the sites, UHFUS biomarkers were characterized, and information on typical aspect of oral mucosa was retrieved.

CONCLUSIONS

In this explorative study, we suggest a potential role for intraoral UHFUS in the study of oral mucosa, giving insights into the possibility to improve the assessment, diagnosis, and management of the conditions involving oral mucosa. UHFUS seems a promising tool, which could potentially support clinical examination in daily oral medicine practice.

Magnetic Resonance vs. Intraoral Ultrasonography in the Preoperative Assessment of Oral Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

Background: Preoperative assessment is critical to decide the most adequate surgical strategy for oral squamous cell carcinoma (SCC). Magnetic resonance (MR) and intraoral ultrasonography (US) have been reported to be of great value for preoperative estimation of depth of invasion (DOI) and/or tumor thickness (TT). This review aims to analyze the accuracy of MR and intraoral US in determining DOI/TT in oral SCC, by assuming histological evaluation as the reference method.

Methods: The procedure was conducted following the modified 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We performed a systematic search of papers on PubMed, Scopus, Web of Science, and Cochrane Library databases until July 31st, 2019. For quantitative synthesis, we included nine studies (487 patients) focused on MR, and 12 (520 patients) focused on intraoral US. The Pearson correlation coefficient (r) between DOI/TT evaluated with MR or intraoral US was assumed as effect size. A meta-analysis (MA) for each study group (MR and US) was performed by using the random-effects models with the DerSimonian–Laird estimator and r-to-z transformation.

Results: In the MA for MR studies, a high heterogeneity was found (I² = 94.84%; Q = 154.915, P < 0.001). No significant risk of bias occurred by evaluating funnel plot asymmetry (P = 0.563). The pooled (overall) r of the MR studies was 0.87 (95% CI from 0.82 to 0.92), whereas the pooled r-to-z transformed was 1.44 (95% CI from 1.02 to 1.85). In the MA for US studies a high heterogeneity was found (I² = 93.56%; Q = 170.884, P < 0.001). However, no significant risk of bias occurred (P = 0.779). The pooled r of the US studies was 0.96 (95% CI from 0.94 to 0.97), whereas the pooled r-to-z transformed was 1.76 (95% CI from 1.39 to 2.13). These outputs were confirmed in additional MA performed by enrolling only MR (n = 8) and US (n = 11) studies that evaluated TT.

Conclusions: MR and intraoral US seem to be promising approaches for preoperative assessment of DOI/TT in oral SCC. Remarkably, a higher pooled r and r-to-z transformed were observed in the intraoral US studies, suggesting that this approach could be more closely related to histopathological findings.

Contemporary Approach to Locally Advanced Oral Cavity Squamous Cell Carcinoma

PURPOSE OF REVIEW

Surgical management of locally advanced oral cavity squamous cell carcinomas (OCSCC) has long been recognized as a primary treatment modality. Technological advances have led to significant improvements in our surgical approach, from improvement in the visualization of tumors to more efficient and precise reconstruction. Here, we review the latest technological advances in surgical extirpation and reconstruction of locally advanced OCSCCs.

RECENT FINDINGS

The focus of technological innovation in surgical extirpation has been on improving visualization, with the use of intraoperative ultrasound for margin delineation, intraoperative navigation, narrow-band imaging, and the use of fluorescence. Though early, these are promising steps to ensuring complete resection of the cancer. Advances in reconstruction have been centered on the incorporation of computer assisted design, manufacturing, and virtual surgical planning, allowing for more complex three-dimensional defects to be expeditiously reconstructed. As these technologies are still under development, their impact on oncologic outcomes are not yet robustly defined; however, as technology continues to advance and become more widely available, new technologies will undoubtedly become integrated into enhancing surgical precision and planning.

Intra-operative point-of-procedure delineation of oral cancer margins using optical coherence tomography

OBJECTIVES

Surgical margin status is a significant determinant of treatment outcome in oral cancer. Negative surgical margins can decrease the loco-regional recurrence by five-fold. The current standard of care of intraoperative clinical examination supplemented by histological frozen section, can result in a risk of positive margins from 5 to 17 percent. In this study, we attempted to assess the utility of intraoperative optical coherence tomography (OCT) imaging with automated diagnostic algorithm to improve on the current method of clinical evaluation of surgical margin in oral cancer.

MATERIALS AND METHODS

We have used a modified handheld OCT device with automated algorithm based diagnostic platform for imaging. Intraoperatively, images of 125 sites were captured from multiple zones around the tumor of oral cancer patients (n = 14) and compared with the clinical and pathologic diagnosis.

RESULTS

OCT showed sensitivity and specificity of 100%, equivalent to histological diagnosis (kappa, ĸ = 0.922), in detection of malignancy within tumor and tumor margin areas. In comparison, for dysplastic lesions, OCT-based detection showed a sensitivity of 92.5% and specificity of 68.8% and a moderate concordance with histopathology diagnosis (ĸ = 0.59). Additionally, the OCT scores could significantly differentiate squamous cell carcinoma (SCC) from dysplastic lesions (mild/moderate/severe; p ≤ 0.005) as well as the latter from the non-dysplastic lesions (p ≤ 0.05).

CONCLUSION

The current challenges associated with clinical examination-based margin assessment could be improved with intra-operative OCT imaging. OCT is capable of identifying microscopic tumor at the surgical margins and demonstrated the feasibility of mapping of field cancerization around the tumor.

Toward complete oral cavity cancer resection using a handheld diffuse reflectance spectroscopy probe

This ex-vivo study evaluates the feasibility of diffuse reflectance spectroscopy (DRS) for discriminating tumor from healthy tissue, with the aim to develop a technology that can assess resection margins for the presence of tumor cells during oral cavity cancer surgery. Diffuse reflectance spectra were acquired on fresh surgical specimens from 28 patients with oral cavity squamous cell carcinoma. The spectra (400 to 1600 nm) were detected after illuminating tissue with a source fiber at 0.3-, 0.7-, 1.0-, and 2.0-mm distances from a detection fiber, obtaining spectral information from different sampling depths. The spectra were correlated with histopathology. A total of 76 spectra were obtained from tumor tissue and 110 spectra from healthy muscle tissue. The first- and second-order derivatives of the spectra were calculated and a classification algorithm was developed using fivefold cross validation with a linear support vector machine. The best results were obtained by the reflectance measured with a 1-mm source-detector distance (sensitivity, specificity, and accuracy are 89%, 82%, and 86%, respectively). DRS can accurately discriminate tumor from healthy tissue in an ex-vivo setting using a 1-mm source-detector distance. Accurate validation methods are warranted for larger sampling depths to allow for guidance during oral cavity cancer excision.

Utility of intraoral ultrasound in managing oral tongue squamous cell carcinoma: Systematic review

OBJECTIVES/HYPOTHESIS

Adequate surgical resection of early stage oral tongue cancer provides the best chance at preventing locoregional disease recurrence. Determination of tumor dimensions and margin location is challenging and can lead to inadequate resections with close/positive margins. Ultrasonography has proven its utility in determining the thickness and extent of tongue tumors. Preoperative tumor dimension measurements carry increased significance with the addition of depth of invasion (DOI) to the eighth edition of the American Joint Committee on Cancer (AJCC) TNM staging system. We report the results of a systematic review of the literature pertaining to the use of ultrasound in the diagnosis and management of oral tongue carcinoma.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analysis statement checklist was used to inform the design of this systematic review. All studies that utilized ultrasound in the diagnosis/management of primary carcinoma of the oral tongue were included. PubMed, Embase, and Cochrane were reviewed to identify eligible studies.

RESULTS

Nineteen articles were included in our analysis. Six hundred seventy-eight patients were studied in the articles included. Ultrasound tumor thickness measurements correlate well with those on histopathology and show promise as a predictor of cervical lymph node metastasis. Ultrasound can be safely used intraoperatively for deep margin assessment.

CONCLUSIONS

Ultrasound is useful in the evaluation of oral tongue malignancies. More experience is needed to determine if it is reliable in determining preoperative DOI in light of the role this tumor parameter plays in the eighth edition of the AJCC staging manual. Laryngoscope, 129:662-670, 2019.

Intraoperative Ultrasound in Oral Tongue Cancer Resection: Feasibility Study and Early Outcomes

The current standard of care in oral tongue cancer surgery is complete resection with a target of 5-mm microscopic clearance at all margins on final pathologic review. While current methods of resection are often successful at determining the mucosal margins of the lesion, they may be limited when attempting to achieve an adequate deep margin. A number of previous studies suggested that ultrasound is superior to manual palpation and other imaging modalities (computed tomography, magnetic resonance imaging) at demarcating the margins of tongue lesions. Recent clinical reports of the intraoperative use of this modality have used an invasive method to mark the proposed deep resection margin. In this communication, we report our initial experience with the use of intraoperative ultrasound as an adjunct to oral tongue cancer surgery without the use of an invasive method to mark the deep resection margin.

Feasibility of intraoral ultrasonography in the diagnosis of oral soft tissue lesions: a preclinical assessment on an ex vivo specimen

OBJECTIVES

The early detection of oral soft tissue lesions is an important prognostic factor, and the possibility of using ultrasonography (US) as a diagnostic tool may improve the diagnosis and characterization of tissue alterations at an early stage. This study aims to evaluate the feasibility of intraoral US by performing a preclinical assessment of an ex vivo specimen in which focal lesions were simulated.

MATERIALS AND METHODS

Fourteen lesions were simulated on a freshly extracted calf tongue, by introducing in the tongue different materials mimicking the appearance of various focal lesions. The specimen was scanned with a 8 MHz US probe and computed tomography (CT) was performed to compare the two imaging techniques. Later, the specimen was dissected to set a benchmark for size assessment.

RESULTS

US was able to identify all the simulated lesions within the tongue, resulting in one case more accurate than CT. Statistical analysis demonstrated high correlation between the measurements of the simulated lesions performed on the US images and the real size of the materials introduced in the tongue (p < 0.05).

CONCLUSIONS

This preclinical study proves that US performs well in the detection and characterization of simulated lesions of the tongue. These findings suggest that US could be effectively used in clinical applications. However, further research is mandatory to assess the reliability of in vivo US in the detection and characterization of tongue lesions as well as of other oral soft tissue alterations.

Transoral bisected resection for T1-2 oral tongue squamous cell carcinoma to secure adequate deep margin

BACKGROUND

To investigate the clinical usefulness of transoral bisected resection (TBR) asa new method to secure adequate deep resection margin in T1-2 oral tongue squamous cell carcinomas (SCC).

METHODS

Among 75 patients with cT1-2N0 oral tongue SCCs, 45 (60%) received transoral en-bloc resection (TER) while 30 (40%) received patients underwent TBR. Primary tumor resection was performed with 1.5-cm surgical resection margin for both groups. Mucosal and deep resection margins, adjuvant treatments including re-resection of the tongue and cheomoradiotherapy, local and regional recurrence free survival, and overall survival were compared between the two groups.

RESULTS

Mean deep resection margin in the TBR group was 9.9mm (95% CI: 8.4-11.4mm), which was significantly (P<0.001) wider than that of the TER group (mean: 5.4mm, 95% CI: 4.5-6.3mm). However, mucosal resection margins were not significantly (P=0.153) different between the two groups. Re-resection of tongue was performed for 6 (13.3%) of 17 (37.8%) patients with inadequate deep resection margin in the TER group and none (0%) in 4 (13.3%) patients with inadequate deep resection margin in the TBR group. Adjuvant radiation due to inadequate deep resection margin was performed for 6.7% of patients in both groups. The TBR group had better local recurrence free survival than the TER group. However, regional recurrence free survival and overall survival were not significantly different between the two groups.

CONCLUSION

TBR could provide adequate deep resection margin for early stage tongue cancers with better local tumor control than TER. It can decrease the necessity of adjuvant treatment for re-resection of the tongue.

Operable Oral Tongue Squamous Cell Cancer: 15 Years Experience at a Tertiary Care Center in North India

The aim of the present study was to provide insight into various demographic, clinical, and management profile of Indian patients with oral tongue squamous cell cancer (OTSCC). All the OTSCC patients who had undergone surgical treatment during 1995 to 2010 at a tertiary care center in North India were considered for the present study. The details of the patients were retrieved from a prospectively maintained computerized database. A total of 124 patients were included in the present study. Mean age of the patients was 50.4 ± 12.0 years. Lateral border of the tongue was the most common sub-site involved in 110 (88.7%) patients. Neck nodes were clinically palpable in 56.4% patients. Hemiglossectomy and anterior partial glossectomy were common surgical procedure undertaken in 57.2 and 25.8% patients. Negative resection margin was achieved in 97.5% patients. Pathological neck metastasis was seen in 40.3% patients. Occult neck metastasis was present in 25.9% patients among clinical N0 neck. At a mean follow-up of 29.8 months (SD 3.1), 20.1% developed disease relapse and 4.0% patients developed second primaries. Kaplan-Meier analysis estimated a 5-year disease-free survival of 81.5% and a 5 years overall survival of 78.6%. Cox proportional regression analysis predicted tumor size and number of positive nodes to be independent predictive variables for disease recurrence. Quality controlled surgery, coupled with adjuvant treatment when required, provides a safe and effective treatment of OTSCC with a good disease-free survival and loco-regional control.

Evaluation of tongue squamous cell carcinoma resection margins using ex-vivo MR

Purpose

Purpose of this feasibility study was (1) to evaluate whether application of ex-vivo 7T MR of the resected tongue specimen containing squamous cell carcinoma may provide information on the resection margin status and (2) to evaluate the research and developmental issues that have to be solved for this technique to have the beneficial impact on clinical outcome that we expect: better oncologic and functional outcomes, better quality of life, and lower costs.

Methods

We performed a non-blinded validation of ex-vivo 7T MR to detect the tongue squamous cell carcinoma and resection margin in 10 fresh tongue specimens using histopathology as gold standard.

Results

In six of seven specimens with a histopathologically determined invasion depth of the tumor of \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\ge }3$$\end{document}≥3 mm, the tumor could be recognized on MR, with a resection margin within a 2 mm range as compared to histopathology. In three specimens with an invasion depth of \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${<}1$$\end{document}<1 mm, the tumor was not visible on MR. Technical limitations mainly included scan time, image resolution, and the fact that we used a less available small-bore 7T MR machine.

Conclusion

Ex-vivo 7T probably will have a low negative predictive value but a high positive predictive value, meaning that in tumors thicker than a few millimeters we expect to be able to predict whether the resection margin is too small. A randomized controlled trial needs to be performed to show our hypothesis: better oncologic and functional outcomes, better quality of life, and lower costs.

Macroscopic technique for the evaluation of oral tongue tumour thickness: a reliable intraoperative method

There is no reliable method to assess tumour thickness preoperatively or intraoperatively in cases of oral tongue squamous cell carcinoma (SCC). The purpose of this study was to evaluate the efficacy of a macroscopic technique to measure tumour thickness. This was a prospective study of 51 consecutive patients with T1/T2 primary SCC of the oral tongue. All patients underwent primary resection with ipsilateral neck dissection. Thickness measurements were obtained using Vernier calipers on the fresh specimen. The technique was correlated with the microscopic evaluation statistically using (1) Pearson's correlation coefficient, (2) intra-class correlation, and (3) Bland-Altman plot with 95% confidence intervals. On comparing the macroscopic technique to the microscopic evaluation, Pearson's correlation (r) was 0.915 (P<0.001). The inter-rater reliability using the intra-class correlation coefficient was 0.955. The Bland-Altman plot to test the agreement between the techniques showed the average difference between macroscopic thickness and microscopic thickness (bias) to be -0.421, with 95% limits of agreement of -3.166 and 2.82. There was a significant correlation and agreement between the macroscopic and microscopic measures of tumour thickness. The macroscopic technique could be used as a reliable tool to measure tumour thickness intraoperatively, prior to neck dissection.

Intraoral ultrasonography of tongue mass lesions

OBJECTIVES

To demonstrate the usefulness of intraoral ultrasonography (IOUS) for tongue mass lesions, we analyzed surgery cases excluding squamous-cell carcinoma and leukoplakia and compared IOUS and pathological findings.

METHODS

We used the hospital information system and Radiology Information System to evaluate the IOUS and pathological findings of patients who underwent surgeries for tongue masses in the past 11 years.

RESULTS

Surgeries for the tongues were performed in 268 cases. Imaging examinations were carried out in 52 (19.4%) cases including 42 (15.7%) cases by IOUS. The pathological results of the surgeries were as follows: 36 cases were inflammatory lesions, 74 cases were tumours, 131 cases were hyperplasia, 8 cases were cystic lesions and 19 cases were other miscellaneous lesions. On the other hand, the number of patients who received IOUS in the same period was 87, and 42 of them had surgeries. In 32 out of the 42 (76.2%) cases, pre-operative IOUS features matched with pathological results. Most of the haemangiomas and lipomas could be diagnosed by IOUS alone.

CONCLUSIONS

IOUS of the tongue revealed the nature of the lesions including the border, size, location, depth, the presence or absence of a capsule and the internal structure including vascularity of the mass. The ultrasonographic findings well reflected the histological findings. IOUS is a simple and useful technique that provides additional information beyond inspection, clarifying the internal structure, blood flow and relationships with the adjacent tissues. In this article, we indicated 11 representative cases (fibrous polyp, haemangioma, pyogenic granuloma, lipoma, liposarcoma, chondroma, lymphangioma, schwannoma, neurofibroma, pleomorphic adenoma and amyloidosis) to show the usefulness of IOUS.

An Inventory of Current Available Ultrasound Devices for Dental Use

Objective : The first aim of the study was to make an inventory of the currently available ultrasound imaging devices on the market. The second aim was to identify portable ultrasound devices which could be used in general dental offices to image salivary glands, masticatory muscles and lymph nodes. Material and Methods : A list of ultrasound devices was collected from 11 international and American manufacturers using company websites and ultrasound retailer’s websites using the search engine Google^®. Results : A total of 86 ultrasound machines from 11 different manufacturers were identified, of which only 14 devices are portable. Transducers are usually transferrable between devices of the same brand, and the non-portable machines have multiple transducer ports (three or four), while portable machines typically have only one or two ports. Portable machine weights range from 10 to 20 pounds, and often resemble large laptops, which are convenient to carry and take up minimal space in clinics. Conclusion : Some manufacturers provide portable and non-portable ultrasound devices. The first ones could be valuable in dental settings, as they can easily be moved around in the office.

Open questions and novel concepts in oral cancer surgery

The persistence of cancerous cells after surgery in oral squamous cell carcinoma (OSCC) represents a major challenge, as it often leads to local recurrences and secondary primary tumors, which are eventually responsible for a large proportion of deaths. This persistence is currently evaluated by histological analyses. In this review we discuss some important pitfalls of the histopathological analysis, such as margin evaluation, specimen shrinkage and T staging. In addition, we critically analyze the appropriateness of current surgical techniques in relation to the concept of field cancerization. Finally, we describe some novel imaging and molecular approaches, which might be useful in tailoring surgical resections and encourage the use of OSCC animal models to explore and provide proof of concept of the feasibility and potential clinical utility of innovative surgical protocols.

Use of transoral sonography with an endocavitary transducer in diagnosis, fine-needle aspiration biopsy, and intraoperative localization of retropharyngeal masses

OBJECTIVE

The purpose of this article is to describe the use of transoral sonography in the diagnosis, fine-needle aspiration (FNA) biopsy, and intraoperative localization of retropharyngeal masses.

MATERIALS AND METHODS

We reviewed images and data for eight patients with a retropharyngeal mass identified on CT, MRI, or PET/CT as being suspicious for a metastatic Rouviere node. Transoral ultrasound was performed using a commercially available endorectal or endovaginal transducer. Transoral ultrasound-guided FNA biopsy was performed using a needle guide attached to the transducer shaft. Color and power Doppler imaging were used to identify the internal carotid artery and jugular vein and to plan the safest path to the targeted mass. The mass was intraoperatively localized by marking the mucosa with a permanent marker or by injecting methylene blue.

RESULTS

There were six patients with a history of thyroid cancer (five papillary cancers and one medullary cancer), one patient with a history of esthesioneuroblastoma, and one patient with no history of cancer. Transoral ultrasound imaging was successful in all eight patients. Transoral ultrasound-guided FNA biopsy was performed in four patients, and a satisfactory cytologic diagnosis was obtained in all cases, although in one of those four cases, an additional core biopsy with an 18-gauge needle was performed to completely rule out lymphoma. Six patients underwent a transoral resection of the lesion. In three of them, the lesion was localized intraoperatively by making a mark on the mucosa and in one case by adding transoral ultrasound-guided injection of methylene blue.

CONCLUSION

Transoral ultrasound can be used to visualize, sample, and localize abnormal masses in the retropharyngeal space, such as metastatic Rouviere nodes in patients with a history of head and neck cancer.

Imaging in oral cancers

Oral cavity squamous cell cancers form a significant percentage of the cancers seen in India. While clinical examination allows direct visualization, it cannot evaluate deep extension of disease. Cross-sectional imaging has become the cornerstone in the pretreatment evaluation of these cancers and provides accurate information about the extent and depth of disease that can help decide the appropriate management strategy and indicate prognosis. Early cancers are treated with a single modality, either surgery or radiotherapy while advanced cancers are offered a combination of surgery, radiotherapy and chemotherapy. Imaging can decide resectability, help plan the precise extent of resection, and indicate whether organ conservation therapy should be offered. Quality of life issues necessitate preservation of form and function and pretreatment imaging helps plan appropriate reconstruction and counsel patients regarding lifestyle changes. Oral cavity has several subsites and the focus of the review is squamous cancers of the gingivobuccal region, oral tongue and retromolar trigone as these are most frequently encountered in the subcontinent. References for this review were identified by searching Medline and PubMed databases. Only articles published in English language literature were selected. This review aims to familiarize the radiologist with the relevant anatomy of the oral cavity, discuss the specific issues that influence prognosis and management at the above subsites, the optimal imaging methods, the role of imaging in accurately staging these cancers and in influencing management. A checklist for reporting will emphasize the information to be conveyed by the radiologist.

Accuracy of imaging methods for detection of bone tissue invasion in patients with oral squamous cell carcinoma

The objective of this review is to evaluate the diagnostic accuracy of imaging methods for detection of mandibular bone tissue invasion by squamous cell carcinoma (SCC). A systematic review was carried out of studies in MEDLINE, SciELO and Science Direct, published between 1960 and 2012, in English, Spanish or German, which compared detection of mandibular bone tissue invasion via different imaging tests against a histopathology reference standard. Sensitivity and specificity data were extracted from each study. The outcome measure was diagnostic accuracy. We found 338 articles, of which 5 fulfilled the inclusion criteria. Tests included were: CT (four articles), MRI (four articles), panoramic radiography (one article), positron emission tomography (PET)/CT (one article) and cone beam CT (CBCT) (one article). The quality of articles was low to moderate and the evidence showed that all tests have a high diagnostic accuracy for detection of mandibular bone tissue invasion by SCC, with sensitivity values of 94% (MRI), 91% (CBCT), 83% (CT) and 55% (panoramic radiography), and specificity values of 100% (CT, MRI, CBCT), 97% (PET/CT) and 91.7% (panoramic radiography). Available evidence is scarce and of only low to moderate quality. However, it is consistently shown that current imaging methods give a moderate to high diagnostic accuracy for the detection of mandibular bone tissue invasion by SCC. Recommendations are given for improving the quality of future reports, in particular provision of a detailed description of the patients' conditions, the imaging instrument and both imaging and histopathological invasion criteria.

Electroporation therapy for T1 and T2 oral tongue cancer

CONCLUSION

Electroporation therapy appears to be a safe treatment achieving excellent local tumor control and very good functional results in our study and it should be further clinically evaluated.

OBJECTIVES

The objectives of this study were to assess local tumor control, survival, and effects on speech and eating after treatment of tongue cancer with electroporation therapy, a new local therapeutic modality. In this approach intracellular accumulation of a chemotherapeutic agent is achieved by using a locally applied electrical field.

METHODS

Fifteen patients with primary T1 and T2 oral tongue cancer were treated with electroporation therapy with intratumorally administered bleomycin. Postoperative radiotherapy was performed when the tumor infiltration was 5 mm or more. The follow-up time was 24 months for the surviving patients and 20.4 months overall. The effects on eating and speech were assessed using the PSS-HN scale and voice recordings.

RESULTS

No local recurrence was recorded in any patient during the follow-up. Three patients died, two from progressive regional disease. Of the 12 surviving patients, 2 patients had regional recurrence and 10 patients including the 5 patients treated with EPT alone were tumor-free both locally and regionally at the last follow-up. The functional outcome for speech and eating were very good.