Management of gingivobuccal complex cancer

Pre-vascular Facial Nodes: Sentinel Station for Metastasis in Gingivobuccal Complex Cancers

BACKGROUND

Pre-vascular facial nodes (PV-FNs; perifacial lymph nodes) are supra-mandibular lymph nodes above the inferior border of the mandible. These are not part of routine neck dissection done for OCSCC. These lymph nodes can be sentinel station for metastatic lymph nodes from gingivobuccal complex cancers and are missed during routine neck dissection. It is imperative to include this sentinel station in routine neck dissection to prevent nodal recurrences.

MATERIALS AND METHODS

One hundred thirty-seven patients with GBCC (T1-T4) were prospectively recruited between May 2020 and June 2022 with the intent to evaluate the incidence of PV-FN metastases and clinicopathological factors predicting them.

RESULTS

PV-FN metastases were seen in 26 patients (18.9%; 26/137). The occult metastasis rate was 8.7% (12/137). On multivariate analysis, pathological T4 stage (pT4), LVE positivity, and intermediate-high BGS were statistically significant predictors of PV-FN metastases in our study.

CONCLUSIONS

Incidence of PV-FN metastasis is high (18.9%) in GBCC, which can be potentially the first sentinel station in the lymphatic drainage pattern for this sub-site. Meticulous clearance of this nodal basin is of paramount importance during neck dissection to prevent nodal recurrences.

LEVEL OF EVIDENCE

Level 2 (CEBM-Level of Evidence-2.1) Laryngoscope, 2024.

The Trans-facial Approach for Simultaneous Resection and Reconstruction of Retromolar Trigone Tumors: A Pilot Study

Introduction

Early retromolar trigone (RMT) lesions are difficult to access and free tissue transfer is often an overkill for such small lesions. The aim was to devise a novel surgical approach that would aid the resection without raising a cheek flap and simultaneously provide a local reconstructive option for small lesions in the RMT.

Methodology

This study was to demonstrate the outcomes of the "trans-facial" approach used to simultaneously access and reconstruct small RMT tumors through an islanded nasolabial flap. Patients with histologically proven squamous cell carcinoma of RMT requiring surgery were included from January 2021 to September 2022. Case selection was done based on the location of the disease and its size (cT1/T2). All needed bone and soft tissue resection via per oral trans-facial approach, along with an ipsilateral neck dissection. The technique is described along with their post-operative and pathologic outcomes.

Results

Out of the eight patients included in this study, six underwent a bi-alveolar marginal resection and reconstructed using the trans-facial approach. No major complications were noted in the post-operative period. 50% were pT1 tumors and 75% were pN0 status. One patient had a close margin; while, the others had adequate resection margins. All patients were followed up for a median of 18 months with a locoregionally controlled status.

Conclusion

The trans-facial approach can be a suitable option with a reasonable oncologic outcome to address small RMT lesions.

"Survival patterns and prognostic factors of gingivobuccal complex squamous cell cancer: A monocentric retrospective chart audit"

OBJECTIVE

To analyze the impact of clinico-pathological prognostic factors on survival in patients with GBC OSCC. To evaluate the association between various clino-pathological and treatment factors influencing the 3-year and 5-year Overall survival (OS), and Disease specific survival (DSS) in patients with lower GBC OSCC.

PATIENTS & METHODS

An Institutional Ethical Committee (IEC) approved retrospective chart audit was performed. Biopsy proven squamous cell cancer of gingivobuccal complex (GBC OSCC) patients from 2010 to 2019 who were treated primarily with surgery with or without adjuvant therapy having complete clinicopathological and follow up data were included. Survival outcomes including 2-year, 3-year & 5-year OS, and DSS were calculated and analyzed. A multivariate analysis was performed to identify significant predictor for the survival outcomes. A p-value < 0.05 was considered significant.

RESULTS

183 patients with primary OSCC were identified out of which 83 patients comprised of OSCC of lower GBC. Age (p < 0.001), tumor grade (p = 0.009), pN status (p = 0.002), PNI (p < 0.001), lymph node metastasis (p = 0.002), treatment given (p = 0.02) and adjuvant therapy (p = 0.02) were found as a significant prognostic factor in univariate analysis.

CONCLUSION

The OS & DSS of the patients with lower GBC SCC is 78.3%. The 2-year, 3-year, and 5-year OS of the study population was reported to be 95.2%, 87.9%, and 78.8% respectively. PNI & lymph node metastasis were significant prognostic factor for OS with an adjusted hazard ratio 4.91 and 7.75 respectively.

A concise review of the regulatory, diagnostic, and prognostic implications of HOXB-AS3 in tumors

Recent studies have reported that HOXB-AS3 (HOXB Cluster Antisense RNA 3) is an intriguing molecule with dual functionality as a long noncoding RNA (lncRNA) and putative coding peptide in tumorigenesis and progression. The significant expression alterations of HOXB-AS3 were detected in diverse cancer types and closely correlated with clinical stage and patient survival. Furthermore, HOXB-AS3 was involved in a spectrum of biological processes in solid tumors and hematological malignancies, such as stemness, lipid metabolism, migration, invasion, and tumor growth. This review comprehensively analyzes its clinical relevance for diagnosis and prognosis across human tumors and summarizes its functional role and regulatory mechanisms in different malignant tumors, including liver cancer, acute myeloid leukemia, ovarian cancer, lung cancer, endometrial carcinoma, colon cancer, and oral squamous cell carcinoma. Overall, HOXB-AS3 emerges as a promising biomarker and novel therapeutic target in multiple human tumors.

'AJ's Orbicularis Oris Stitch: A Novel and Simple Technique of Reconstructing Central Arch Mandibular Defects in Resource-Constrained Set Up'

Lip and oral cavity SCC account for 2nd highest incidence of cancers and 3rd most common cause of mortality from cancer in India. Reconstruction of defects of central arch invading cancers results in poor cosmetic and functional outcomes if free flaps are not used. 30 patients with Oral SCC in the age group 20-75 years requiring central arch segmental mandibulectomy were included. Reconstruction was done with pedicled bipaddled PMMC flap with 'AJ's orbicularis oris stitch' using Fiber wire. Patients were divided into 4 groups according to extent of lip and skin loss post excision of primary tumour. Patients were evaluated with subjective scores for drooling, oral competence and cosmesis. There were 4, 12, 9 and 5 patients in Group A, B, C and D respectively. Mean subjective scores using our technique for drooling, oral competence and cosmesis were 3.75/4,3.75/4 and 3.5/4 for group A, 3.45/4, 3.36/4 and 3.09/4 for group B, 2.8/4, 2.6/4 and 2.3/4 for group C defects and 2.5/4, 3/4 and 2.5/4 for group D defects respectively. Over all scores for all patients were 3.2/4, 3.14/4 and 2.84/4 for drooling, oral competence and cosmesis. This simple, quick and inexpensive technique of reconstruction of central mandibular arch defects can drastically improve cosmetic and functional outcomes in a resource restrained set up. However, long term results and comparison studies are required for standardisation of the technique.

Invasion of the bucco-mandibular space by oral squamous cell carcinoma: histopathological analysis of invasion pattern

Background

This study aimed to determine the patterns of invasion of oral squamous cell carcinoma (OSCC) into the bucco-mandibular space (BMS) using detailed histopathological analysis and to assess clinical outcomes.

Methods

Patients with OSCC who underwent segmental mandibulectomy or hemi-mandibulectomy combined with resection of the BMS between 2012 and 2021 were included. The invasions of the BMS were classified into three patterns. Pattern A was defined as a horizontal invasion, Pattern B as a vertical invasion, and Pattern C as an expansive invasion.

Results

In total, 109 patients were reviewed. Of these 109 patients, the primary tumor affected the lower gingiva in 78 patients, the buccal mucosa in 18 patients, and was a primary intraosseous carcinoma of the mandible in 13 patients. Invasion of the BMS was significantly associated with a higher pathological T stage, positive/close margins, and lower disease-free survival (DFS) rates. The DFS rates were 86.7% and 66.0% in the BMS non-invasion and invasion groups, respectively. The DFS rates for each type of invasion were 82.1% for Pattern A, 67.4% for Pattern B, and 48.0% for Pattern C (P=0.277).

Conclusion

Patients with BMS invasion have a poorer prognosis than those without invasion of the BMS. Therefore, adjuvant therapy is necessary, especially in Patterns B and C. Evaluation of preoperative BMS invasion patterns is important for predicting the prognosis of OSCC.

Prognostic Significance of Proliferative Markers: Cyclin D1 and CENPF in Oral Squamous Cell Carcinoma Patients-A Cohort Study

Introduction

Oral cancer ranks sixth place worldwide among other cancers and is known for its high morbidity and mortality rates. Among oral cancer, oral squamous cell carcinomas (OSCC) remains the most common. Expression of specific biomarkers are known to be related to the prognosis of the OSCC.

Methodology

An immunohistochemistry study was performed to evaluate the expression of Cyclin D1 and CENPF for their prognostic significance in twenty OSCC patients. The follow-up period ranged from 10 to 18 months. The expression of these proliferative markers was correlated with demographic, clinical and histopathological grade of the disease.

Results

The results revealed 28% mortality rates in relation to OSCC involving retro-molar trigone. Based on the Cyclin D1 and CENPF expression, high mortality rate (Pearson coefficient = 0.800) was seen with grade 3 and 4 expressions of the markers. Decreased survival rates (Pearson coefficient = 0.824) were observed with stage III and IV disease with grade 3 and 4 expressions of the markers.

Conclusion

Cyclin D1 and CENPF have shown promising results as proliferative markers which can be linked with prognosis of OSCC in this study. Further studies with larger sample size are needed to extrapolate our findings.

NOTCH pathway inactivation reprograms stem-like oral cancer cells to JAK-STAT dependent state and provides the opportunity of synthetic lethality

BACKGROUND

We have recently provided the evidence of interconvertible cellular states, driving non-genetic heterogeneity among stem-like oral cancer cells (oral-SLCCs). Here, NOTCH pathway-activity status is explored as one of the possible mechanisms behind this stochastic plasticity.

METHODS

Oral-SLCCs were enriched in 3D-spheroids. Constitutively-active and inactive status of NOTCH pathway was achieved by genetic or pharmacological approaches. RNA sequencing and real-time PCR was performed for gene expression studies. in vitro cytotoxicity assessments were performed by AlamarBlue assay and in vivo effects were studied by xenograft growth in zebrafish embryo.

RESULTS

We have observed stochastic plasticity in oral-SLCCs, spontaneously maintaining both NOTCH-active and inactive states. While cisplatin refraction was associated with post-treatment adaptation to the active-state of NOTCH pathway, oral-SLCCs with inactive NOTCH pathway status showed aggressive tumor growth and poor prognosis. RNAseq analysis clearly suggested the upregulation of JAK-STAT pathway in NOTCH pathway-inactive subset. The 3D-spheroids with lower NOTCH-activity status displayed significantly higher sensitivity to JAK-selective drugs, Ruxolitinib or Tofacitinib or siRNA mediated downregulation of tested partners STAT3/4. Oral-SLCCs were programmed to adapt the inactive status of NOTCH pathway by exposing to γ-secretase inhibitors, LY411575 or RO4929097, followed by targeting with JAK-inhibitors, Ruxolitinib or Tofacitinib. This approach resulted in a very significant inhibition in viability of 3D-spheroids as well as xenograft initiation in Zebrafish embryos.

CONCLUSION

Study revealed for the first time that NOTCH pathway-inactive state exhibit activation of JAK-STAT pathways, as synthetic lethal pair. Therefore, co-inhibition of these pathway may serve as novel therapeutic strategy against aggressive oral cancer.

Worst Pattern of Invasion as a Predictor of Nodal Metastasis in Early-Stage Oral Squamous Cell Carcinoma

About one-third of early stage oral cancer patients have occult nodal metastasis. High grade worst pattern of invasion (WPOI) is associated with an increased risk of nodal metastasis and poor prognosis. However, it still remains unanswered whether to perform an elective neck dissection for clinically node-negative disease or not. This study aims to evaluate the role of histological parameters including WPOI in predicting nodal metastasis in early-stage oral cancers. This analytical observational study comprised 100 patients of early-stage, node-negative, oral squamous cell carcinoma, admitted in the Surgical Oncology Department from April, 2018 till the sample size was reached. The socio-demographic data, clinical history, and findings of clinical and radiological examination were noted. The association of nodal metastasis with various histological parameters like tumour size, degree of differentiation, depth of invasion (DOI), WPOI, perineural invasion (PNI), lymphovascular invasion (LVI) and lymphocytic response was determined. SPSS 20.0 statistical tool; student's 't' test and chi-square tests were applied. While the buccal mucosa was the commonest site, the rate of occult metastasis was highest in the tongue. Nodal metastasis was not significantly associated with age, sex, smoking and primary site. While the nodal positivity was not significantly associated with tumour size, pathological stage, DOI, PNI and lymphocytic response, it was associated with LVI, degree of differentiation and WPOI. Increasing WPOI grade correlated significantly with the nodal stage, LVI and PNI, but not with DOI. WPOI is not only a significant predictor of occult nodal metastasis but can also be a novel therapeutic tool in the management of early-stage oral cancers. In patients with an aggressive WPOI pattern or other high-risk histological parameters, the neck can be addressed with either elective neck dissection or radiotherapy after wide excision of the primary tumor; otherwise, an active surveillance approach can be followed.

Characterizing diversity among human oral stem-like cancer cells using flow cytometry

We have developed the protocol of flow cytometry for characterizing diversity among oral stem-like cancer cells (SLCCs) using CD44, CD24, and aldehyde dehydrogenase (ALDH) in oral tumors. We are also reporting the protocol for tumor-derived explant cultures to develop oral cancer cell lines and enriching these diverse hybrid states of cancer cells in 3D spheroids from established cell lines. For complete details on the use and execution of this protocol, please refer to Vipparthi et al. (2022) and Vipparthi et al. (2021).

Quality of Life in Patients with Recurrent Oral Squamous Cell Carcinoma: A Study from India

Background

Locoregional recurrence of oral cancer causes significant morbidity. This study aims at assessing the functional outcomes of patients undergoing treatment for recurrent oral squamous cell carcinoma.

Methods

This study was done in a tertiary care center in North India and includes prospective cohort of 179 recurrent oral carcinoma patients, from September 2017 to September 2018. Patients undergoing treatment of recurrent oral carcinoma were assessed for quality-of-life score at baseline before starting treatment and two months after the completion of the treatment. For the assessment, EORTC QLQH&N35 questionnaire was used.

Results

Of 179 patients included, 71 (39.66%) patients underwent salvage surgery and 104 patients (58.10%) received palliative chemotherapy. One hundred and thirty patients could complete the "EORTC-QOL-H&N-35" questionnaire on required two occasions. Forty-nine patients died before completing second questionnaire. More than half (55.6%) of patients who underwent salvage surgery had improved quality of life after the procedures. They have little or no pain in oral cavity, improved swallowing, less odynophagia, improvement in neck and shoulder pain, less problems with the external appearance and socialization, and enjoyed better sexual life. In patients receiving palliative chemotherapy, the quality of life declined in majority (88.1%) of the patients.

Conclusions

Although salvage surgery is the best modality of treatment for recurrent oral carcinoma, only about one-third of patients qualify for surgery and enjoy improved quality of life following surgery. On the other hand, in majority of the patients receiving palliative chemotherapy, the quality of life worsened with time and treatment.

Prognostic factors and related complications/sequalae of squamous cell carcinoma located in the gingivobuccal complex

Background

Gingivobuccal complex (GBC) was a relatively new concept of oral subsite that was comprises of the upper and/or lower gingiva, gingival buccal sulcus, and adjacent buccal mucosa. Squamous cell carcinoma (SCC) of the GBC had a poor prognosis, with few studies analyzing this particular entity. The objective of this study was to analyze the risk factors affecting the prognosis and complications/sequalae of gingivobuccal complex cancer.

Methods

Between December 2014 and August 2019, a total of 122 patients diagnosed with primary gingivobuccal complex cancer in Beijing Stomatological Hospital, Capital Medical University were enrolled in the study. Through outpatient reviewed and telephone followed-up for 2-5 years postoperatively, postoperative relapse and complications/sequalae were assessed. The primary outcome parameter was 2-year disease-free survival.

Results

The most common central site of the tumor was the buccal mucosa (45.1%), followed by the lower gingiva (36.9%). The most diseases were pT4a (45.1%) and there was lymph node invasion (pN+) in 41.8% of patients. Moderate differentiated squamous carcinoma (77.9%) accounted for the vast majority of the histopathological differentiation. A total of 62.3% of tumors invaded the bone, while, 5.7% invaded the skin layer. Survival analysis found that 44.3% of patients experienced relapse within two years postoperatively and the mortality rate after relapse was 75.9%. Almost 60.0% of the tumors involving the maxilla and/or mandible developed relapse. Cox proportional hazards model found that pN stage (p= 0.002) and bone invasion (p= 0.007) were significant independent predictors of 2-year disease-free survival. Importantly, 63.1% of patients had postoperative (and postradiotherapy) complications/sequalae. It was noteworthy that 18 of 43 patients (41.9%) who implanted with titanium plates had hardware-related complications/sequalae, and the most of them were titanium plate exposure (61.1%).

Conclusions

Squamous cell carcinoma of the gingivobuccal complex cancer, as a new subsite worthy of attention in oral cancer, has a high complication/sequalae rate, high relapse rate and poor prognosis.

Trial registration

Prospective, Observational, Real-world Oral Malignant Tumors Study (clinicaltrials.gov identifier: NCT02395367). The approval of the Institutional Review Board of the Beijing Stomatological Hospital of Capital Medical University (Approval number: CMUSH-IRB-KJPJ-2015-08)

Oral squamous cell carcinoma in coca chewers from a north region of Argentina: A case series and review of literature

Chewing coca leaves is a habit still practiced in Bolivia, Peru and Argentina. There is scarce evidence in the relationship between this habit and development of oral squamous cell carcinoma (OSCC), some authors have found oral epithelial changes in coca chewers. This study aimed to present a case series of patients with a coca chewing habit that developed OSCC, in the absence of risk factors for oral cancer. Patients were evaluated in Hospital Señor del Milagro, Salta, Argentina. None of them had a relevant morbid history and presented intraoral tumors, with an ulcerated surface on the gingivobuccal complex. Coca chewing habit was recorded in all cases. Present cases could start discussions and new lines of researches focusing on the habit of coca leaves chewing as a risk factor for OSCC. It would be very useful to know the underlying mechanisms between this habit and a possible role in oral carcinogenesis.

Primary intraosseous carcinoma in the pediatric and adolescent mandible

BACKGROUND

Primary intraosseous carcinoma (PIOC) is a rare malignant odontogenic tumor that predominantly occurs in males older than 50 years. PIOC can be misdiagnosed as odontogenic cyst because it occasionally shows a well-defined border on radiography. In this study, related literatures of pediatric and adolescent PIOC cases were analyzed under strict PRISMA guidelines along with an adolescent case who was provisionally misdiagnosed as an odontogenic cyst.

METHODS

All case reports for PIOC published in English from 1966 to 2021 were collected. Cases under the age of 20 were classified as pediatric and adolescent populations in this study. A total of 12 pediatric and adolescent cases including 11 PIOCs from the literature and one new case of a 14-year-old female were analyzed. Clinical and radiographic features, diagnosis and treatment approaches, and prognosis were investigated.

RESULTS

Ages ranged from 4 to 18 years. The female to male ratio was 1.4:1. Seven cases occurred in the mandible. Swelling was observed in 11 patients. The radiologic borders were well-defined in six cases and corticated in four cases. Tooth displacement and root resorption were observed in four and six cases, respectively. The provisional diagnosis for seven patients was odontogenic cyst and enucleation was performed in six cases including the new case. During the follow-up period, local recurrence occurred in three patients. The pediatric and adolescent PIOC cases with local recurrence showed poor prognosis. The locally recurred lesion in the new case did not decrease in size despite concurrent chemo-radiation therapy.

CONCLUSIONS

Three-dimensional imaging modalities and incisional biopsy with multiple specimens are necessary to rule out PIOC in the lesions with atypical radiographic findings. PIOC should be diagnosed differentially from odontogenic cyst even in pediatric and adolescent populations to properly manage the disease with poor prognosis.

Mango-shaped Bi-paddled pectoralis major myocutaneous flap reconstruction for large full-thickness defects post resection of squamous cell carcinoma of oral cavity: An analysis of 232 cases

Objectives:

The objective of the study was to examine the feasibility of bi-paddled pectoralis major myocutaneous (PMMC) flap reconstruction in patient undergoing full thickness composite resection.

Materials and Methods:

Inclusion criteria: The subjects chosen were patients with clinically T4A squamous cell carcinoma of buccal mucosa, lower alveolus, and maxilla in with skin involvement. Patients required a full-thickness composite resection of intraoral lesion, bone (mandibular segment and/or maxilla), and overlying involved skin and had modified radical neck dissection. Exclusion criteria: Patients not requiring full thickness composite resection including skin. Patients were observed postoperatively for early and late postoperative complications, starting of oral feeding, post-operative trismus, and dysphagia during subsequent follow-up and cosmetic outcome.

Results:

Overall, the complication rate was 33.8% out of which only 7.8% required major re-surgery with second flap reconstruction. This is comparable with other large series of PMMC flap. Clavien-Dindo Grade I complications were seen in 9.5%, Grade II in 69.7%, Grade IIIA in 13.4%, and Grade IIIB in 7.45% of patients. Full-thickness partial flap necrosis included necrosis of either the external or the internal skin paddle. There were 15 cases – 6.5% of full thickness external paddle necrosis. These were mostly in patients with bite composite resections and having a larger random fasciocutaneous distal component of the flap without underlying muscle. Furthermore, 40% of these patients were females. In females, the flap necrosis comprised 4 of the 12 patients (33.33%).

Conclusion:

Pectoralis major mycocutaneous flap has been a boon to reconstruction of the oral cavity post its inception. In case of locally advanced squamous cell carcinomas of the oral cavity, in many instances, there is a clinically significant cervical lymph nodal spread vessels post mandating a comprehensive lymph node dissection. PMMC flap provides a robust well vascularized muscular cover to the cervical vessels poststernocleidomastoid excision.

A Prospective Observational Study to Determine the Correlation of Clinical, Ultrasonography, and Pathological Examination of Cervical Lymph Nodal Staging in Oral Squamous Cell Carcinoma

Oral cancer is one of the most common cancers in our population. These cancers are drained by the nodes located in the cervical region which are easily accessible for clinical examination. However, these cervical nodes may also be enlarged due to various other nonmalignant causes. Hence, accuracy of clinical examination and ultrasound screening for cervical lymph nodes is invaluable. The aims of this study are (1) to correlate the clinical, radiological, and pathological results of cervical lymph nodes in patients with oral malignancy and (2) to calculate the accuracy of clinical and radiological methods in detecting malignant cervical lymph nodes. A prospective observational study was undertaken from January 2016 to December 2016 amounting to a total of 76 patients. All patients diagnosed with squamous cell carcinoma of the oral cavity and having a palpable neck node(s), who were planned for surgery were included. Clinical examination, ultrasonographic (USG) screening of the neck, and the final histopathology reports were noted. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for radiological screening by ultrasound were 90.5%, 90.9%, 79.2%, and 96.2%, respectively, and that for clinical examination were 61.9%, 69.1%, 43.3%, and 82.6%, respectively. Area under the curve (AUC) for ultrasound screening was 0.907, and the AUC for clinical examination was 0.655. Ultrasonography is a reliable, cost-effective imaging method in the assessment of malignant cervical nodes in patients with oral cancer, which is to be used along with clinical palpation for improving the accuracy of clinical staging and surgical planning preoperatively.

Guide flange Prosthesis for management of hemimandibulectomy

Guide flange is given to patients who have undergone surgical hemi/segmental/subtotal mandibulectomy due to various reasons (leading cause being squamous cell carcinoma), with resultant mandibular deviation. If procedures such as secondary osseous grafting are planned, the clinician has to wait for healing of the graft, lesion, or radiotherapeutic effects to abate. Only after the healing of the graft, a definitive prosthesis can be planned. During this time lag, prosthesis must be given to the patient to correct mandibular deviation on account of unilateral muscle pull. Furthermore, in certain cases, a definitive prosthesis has to be put on hold due to failure of bone grafting or when the patient is not willing for a second surgery. This report describes the fabrication of such a mandibular guide flange prosthesis.

Oral Cancer in the Indian Subcontinent-Survival Outcomes and Risk Factors with Primary Surgery

OBJECTIVE

To assess the oncological outcome and prognostic factors for primary Oral Squamous Cell Cancer (OSCC) staged as per AJCC 8th pTNM, and treated by the contemporary standard of primary surgery and pathology directed adjuvant radiation-chemoradiation.

METHODS

A single institution cohort from a tertiary care academic institution in North India. Case inclusion 2013 to 2016; n = 218, median follow-up 35 months. All patients were restaged as per the AJCC 8th pTNM classification. Analysis for Overall Survival (OS), Disease-free Survival(DFS), and factors impacting outcome (Cox proportionate model Multivariate analysis).

RESULTS

AJCC pTNM 7th to 8th edition conversion led to upstaging in 16.5%. Stage-II demonstrated greatest stage migration and apparent improvement in OS and DFS (P < .09). Discordance was noted between the presurgical (clinico-radiologic) and postsurgical (pathological) nodal status in 40.3% (88/218; 54 pathologically upstaged;34 downstaged). Pathological downstaging was particularly significant with advanced stage Gingivo-Buccal Cancers (25/73-34.7%). Stage-I-II early cancers had 3 years. OS-86.7% and DFS-78.8%; Stage-III-IV advanced cancers had 3 years. OS-56.7% and DFS-46.6%. Multivariate analysis identified poorer OS and DFS for age < 40 years (HR-1.8; 2.0), skin involvement (HR-2.1; 2.6) and pN+ status (HR-2.4; 3.5). Bone involvement did not compromise survival in this surgically treated set of patients.

CONCLUSION

Age < 45 is newly identified as significantly compromising DFS and OS in Oral Cancer. Established factors of skin involvement and pN+ are confirmed as impacting DFS-OS. An apparent improvement in survival in Stage II Cancers is noted as consequent to adoption of AJCC 8th edition staging.

LEVEL OF EVIDENCE

II (OCEBM 2011-Inception Cohort Study for Prognosis) Laryngoscope, 2021.

Surgical outcomes in oral cancer involving the central arch of the mandible in elderly patients: An institutional experience

BACKGROUNDS

Oral squamous cell cancer (SCC) is one of the most common cancers. The most common age of presentation is fifth to sixth decade. Management of this disease is dictated by stage, age, and related comorbidities. Elderly patients have their own set of limitations as far as their management is concerned. Carcinoma involving central mandibular arch is a challenging disease for surgeons, especially in the elderly. This article describes our experience with the surgical treatment of oral cancer involving the central arch of the mandible in elderly patients.

METHODS

Forty elderly (≥60 years) patients with histologically proven SCC of the oral cavity in which disease was involving the central arch of the mandible, were included in our study. Demographic, clinical, and treatment-related factors were recorded. The outcome was assessed in terms of postoperative complications, recurrence, and patient survival.

RESULTS

The median age of the patients was 63 years. The male:female ratio was 7:3. A history of oral tobacco use was present in 95% of patients. The most common site of disease was lower alveolus (80%) followed by carcinoma of the lower lip (20%). Majority of our patients (77.3% [30]) were having Stage IV disease. Mandibulectomy was either segmental (62.5%) or marginal (37.5%). Bilateral neck dissection (37/40, 92.5%) was done in most patients. Among all patients, 62.5% (25) received adjuvant radiotherapy. The local recurrence rate after a median follow-up of 30 months was 15% (6). Two-year disease-free survival and overall survival were 89% and 90%, respectively.

CONCLUSION

Central arch of the mandible is a difficult disease to treat. It needs a complex and lengthy reconstructive procedure. Comorbidities such as extreme age, diabetes, and pulmonary and cardiac illnesses make it more challenging to manage. With the proper evaluation of comorbidities and avoiding long, cumbersome procedures, we can provide patients a fairly good chance of survival.

Marginal Mandibulectomy Defect Reconstruction with Pectoralis Major Myocutaneous (PMMC) Flap in Cases of Carcinoma Buccal Mucosa: Experience from a Tertiary Cancer Institute

Patients with carcinoma buccal mucosa requiring marginal mandibulectomy pose various key challenges with regard to reconstruction. To study the role and feasibility of the PMMC flap reconstruction in patients of carcinoma buccal mucosa with intact mandible. Study design: retrospective analysis of prospectively maintained data at a tertiary cancer institute in India. Inclusion criteria: all patients of carcinoma buccal mucosa undergoing marginal mandibulectomy at our institute from 1st Jan 2015 to 31st March 2018 with reconstruction done by the PMMC flap. The retrospective analysis showed 82 patients satisfied the inclusion criteria. Median age of the patients was 46 years. Seventy-seven (93.90%) patients were male while 5 (6.09%) patients were female. Median Ryle's tube dependency was 13 days. Median follow-up period was 28 months. All the patients had acceptable cosmesis and mouth opening with minimal morbidity. PMMC flap reconstruction after marginal mandibulectomy in patients with carcinoma buccal mucosa is a robust, cosmetically, and functionally acceptable option.

A Study on Neck Nodes in Oral Cancers, with Special Reference to Skip Metastasis

To analyse the distribution of Neck metastases (NM) and to study frequency of skip metastases in oral squamous cell carcinoma (SCC) of oral cavity. From September 2012 to April 2013, 30 previously untreated patients with SCC of oral cavity underwent primary surgical treatment in our institution. From pathological report of Neck dissection specimen prevalence and distribution of NM were ascertained. All patients were classified according to American Joint Committee on Cancer 2005 TNM classification. Overall frequency of NM was 36.7%. Frequency of occult metastases was 33.3%. N+ metastases found in 37% cases. The overall frequency of NM in level IV and V was 9.5%. Isolated level III involvement was found in 3.3%. No isolated level IV and V involvement was found. Skip metastases to level III LN was 6.7%. We did not find any skip metastases to level IV in our study. Neck nodes at greater risk for metastases were level I and II (50 and 28.6%). Level III (11.9%), IV (7.14%), V (2.38%). The risk of skip metastases to level IV was nil in our study.

Tongue Flap Reconstruction in Carcinoma of Oral Cavity: An Institutional Experience

Introduction

Abundant blood supply of tongue permits various flap designs and makes it a good choice for reconstructing defects following resection of oral cancer.

Aim

We aim to evaluate the reliability of tongue flap for small- and medium-size defects after resection of oral cancer in terms of viability, complications, and functional outcome.

Methods

In this retrospective analysis, patients reconstructed with lateral tongue flaps after resection of oral cavity carcinoma from May 2011 to December 2017 were included.

Results

Forty-two patients underwent tongue flap reconstruction during the study period. Median size of defect was 3.5 cm. Out of 42 patients, 27 had carcinoma of buccal mucosa and 8 had carcinoma of lower alveolus. Mandibular resection was performed in 30 patients. Neck was addressed in all 42 patients. Supraomohyoid neck dissection was done in 12 patients, while others had comprehensive neck dissection. Average time to harvest flap was 25 min. There was no flap loss in the postoperative period. Three patients each developed flap tip necrosis and minor orocutaneous fistula that were managed conservatively. Subjective functional outcome was good to satisfactory in most patients (88%).

Conclusion

Lateral tongue flap is a simple reliable flap for reconstruction of small- and medium-sized defects following resection of oral cavity cancers in terms of low morbidity and satisfactory functional outcomes. It obviates the need of distant tissue transfer.

Retrospective Outcome Analysis of Buccal Mucosal and Lower Alveolar Squamous Cell Carcinoma from a High-Volume Tertiary Cancer Centre

To evaluate treatment outcome and factors affecting locoregional control and distant metastasis in buccal mucosal and lower alveolar squamous cell carcinoma. A retrospective analysis of all diagnosed cases of buccal mucosal and lower alveolar squamous cell carcinoma in patients who underwent surgical treatment in 2011 was included from the data base. The patients were analysed for their habits, trismus, skin and bone involvement, neck nodes, type of surgery for primary and nodes, differentiation of tumour, pathological nodal status, recurrence site, and duration after completion of treatment and follow-up. A total of 114 patients were included in the study. The mean duration of follow-up was 23.8 months. On follow-up, 30 patients had recurrence (26.32%) either locoregional or distant metastasis. Age less than 45 years, nodal positivity, presence of perineural invasion, extracapsular spread, and degree of differentiation were found to be statistically significant by univariate analysis (p < 0.05). On multivariate analysis, node positivity and presence of perineural invasion emerged as independent predictors of recurrence. Cox regression analysis showed trismus, node positivity, and perineural invasion are significantly associated with recurrence. Aggressive multimodality treatment achieves good local control rates even in locally advanced disease, and the intent of treatment should be curative. Node positivity, presence of perineural invasion, and presence of trismus are found as independent predictors of recurrence. Clinically, presence of trismus is associated with poorer outcomes in view of higher stage.

"SKILL TO KILL" - Oral cancer and potentially premalignant oral epithelial lesions (PPOELs): A survey approach. Emerging of a new system and professionals

Background:

Oral cancer is said to be the 6th most common cancer in men and 12th in women. Potentially malignant disorders/potentially premalignant oral epithelial lesion (PMDs/PPOELs) have shown an increased risk of progressing to cancer. In this regard, lack of awareness about identification of oral PMDs among healthcare providers in general and oral pathologists in particular is said to be responsible for the diagnostic delay. Oral cancer is said to be the most common cancer in men and 3rd most common in women in the Indian subcontinent. PMDs have shown an increased risk of progressing to cancer. The various rates of conversion include 14%–51% for erythroplakia, 60%–100% for proliferative verrucous leukoplakia and 7%–26% for oral submucous fibrosis (OSMF). In this regard, early detection at PPOEL level will lead to prevention of malignant transformation.

Aims and Objectives:

The purpose of this survey was: 1. To determine if awareness among professionals is essential/key to challenge the progression of PMDs of the oral cavity. 2. To examine and/ordiscern if oral pathologists felt enough was being done to address the issue of early detection and prevention and how the scenario could be improved further.

Materials and Methods:

A survey was designed to assess the interest, zeal, knowledge and skill of healthcare providers in general and oral pathologists in particular in careful examination of the oral cavity and early detection of PMDs. A questionnaire with 18 questions was designed to address these issues/points and distributed among post-graduate students and practicing oral pathologists on online platforms.

Results:

The results of the esurvey were collected, analyzed and the results discussed question wise. The validity and reliability of the questionnaire was assessed and confirmed with Aiken's index for validity and Cronbach's alpha for reliability. Inferential statistical analysis was performed using Chi square test with P = 0.05 being statistically significant.

Conclusion:

On evaluation of the survey, we found that 85% of the surveyees are on agreement that PPOELs should be registered in a standard format and should be included in the list of recognizable diseases. 89.2% and 87.8% of the respondents would like to be part of an active body for early detection and diagnosis and for Cancer screening in our country respectively. In conclusion, the oral pathology fraternity is eager to work for and tackle these PPOELs head on, provided the right opportunities and training are meted out to them.

Cis-3-O-p-hydroxycinnamoyl Ursolic Acid Induced ROS-Dependent p53-Mediated Mitochondrial Apoptosis in Oral Cancer Cells

Cis-3-O-p-hydroxycinnamoyl ursolic acid (HCUA), a triterpenoid compound, was purified from Elaeagnus oldhamii Maxim. This traditional medicinal plant has been used for treating rheumatoid arthritis and lung disorders as well as for its anti-inflammation and anticancer activities. This study aimed to investigate the anti-proliferative and apoptotic-inducing activities of HCUA in oral cancer cells. HCUA exhibited anti-proliferative activity in oral cancer cell lines (Ca9-22 and SAS cells), but not in normal oral fibroblasts. The inhibitory concentration of HCUA that resulted in 50% viability was 24.0 µM and 17.8 µM for Ca9-22 and SAS cells, respectively. Moreover, HCUA increased the number of cells in the sub-G1 arrest phase and apoptosis in a concentration-dependent manner in both oral cancer cell lines, but not in normal oral fibroblasts. Importantly, HCUA induced p53-mediated transcriptional regulation of pro-apoptotic proteins (Bax, Bak, Bim, Noxa, and PUMA), which are associated with mitochondrial apoptosis in oral cancer cells via the loss of mitochondrial membrane potential. HCUA triggered the production of intracellular reactive oxygen species (ROS) that was ascertained to be involved in HCUA-induced apoptosis by the ROS inhibitors YCG063 and N-acetyl-L-cysteine. As a result, HCUA had potential antitumor activity to oral cancer cells through eliciting ROS-dependent and p53-mediated mitochondrial apoptosis. Overall, HCUA could be applicable for the development of anticancer agents against human oral cancer.

Oral squamous cell carcinoma masquerading as gingival overgrowth

Gingival enlargements are frequently encountered in dental practice. There are different types of gingival enlargements and they vary according to the etiologic factors and pathologic processes that produce them. The exact diagnosis of the enlargement is important as some gingival enlargements can cause extensive morbidity or even mortality. Oral cancers especially squamous cell carcinomas present with variations in clinical presentation and the sites affected. A detailed medical history, clinical examination and radiographic evaluation will help identify the lesion. A biopsy will help provide a definitive diagnosis. An early diagnosis and treatment of squamous cell carcinomas is important as these tumours have a propensity for invasion of adjacent tissues and distant lymphatic metastasis which leads to a worsened prognosis. In this case report, the diagnosis and management of squamous cell carcinoma masquerading as a gingival overgrowth in the mandibular anterior region in a renal patient is reported. Dentists need to be aware and alert of the possibility of squamous cell carcinoma presenting on sites such as gingiva thereby preventing extensive morbidity and even mortality in these patients.

Accuracy of MRI in Prediction of Tumour Thickness and Nodal Stage in Oral Tongue and Gingivobuccal Cancer With Clinical Correlation and Staging

INTRODUCTION

Squamous cell carcinoma of lower gingivo-buccal complex and tongue are the most common cancer in the Indian sub-continent. The value of imaging in the staging of Oral Squamous Cell Carcinoma (OSCC) is in judging operability, assessment of the prognostic characteristics and dimensions of the primary tumour, depth of tumour invasion, the presence of cervical metastasis and detection of bone infiltration.

AIM

This study evaluated squamous cell carcinomas of the oral cavity (tongue and gingivo-buccal complex) on the basis of their appearance, soft tissue extent, depth of tumour invasion and staging. Further, this study assessed the accuracy of MRI in the detection of cervical lymph nodal metastasis on the basis of ADC values on diffusion weighted MR sequence.

MATERIALS AND METHODS

T1- and T2-weighted MR, diffusion-weighted sequences and post contrast T1W sequences were performed in various planes on biopsy proven squamous cell carcinomas (61 cases) involving tongue and/or gingivo-buccal region. Depth of tumour invasion was calculated on axial images of post contrast T1W images. The Apparent Diffusion Coefficient (ADC) was measured by using two b factors (500 and 1000 s/mm(2)). MRI findings were compared clinically and histopathologically.

RESULTS

Average depth of invasion calculated on MRI was 8.47mm and by histopathology was 6.85mm. Pearson's correlation coefficient was 0.988. Shrinkage factor was 0.8. A 71% of patients with depth of invasion greater than 9mm showed evidence of cervical lymph nodal metastasis at one or another levels. Cut-off value to discriminate between malignant and benign lymph nodes was 1.038 x10-3 mm(2)/s in the present study.

CONCLUSION

Depth of tumour invasion in oral malignancies can be measured reliably on MRI which helps in predicting cervical lymph node metastasis. Benign or malignant cervical lymph nodes can be differentiated on diffusion-weighted imaging of MRI on the basis of their ADC values.

Gingival squamous cell carcinoma mimicking as a desquamative lesion

Oral squamous cell carcinoma (SCC) is the most frequently encountered neoplasm in the oral cavity, which accounts for more than 90% of all cancers. Except for carcinoma of the lip vermilion, the most common sites of oral SCC are the tongue and floor of mouth, followed at a lower frequency by the soft palate, gingiva, and buccal mucosa. Clinically, it may be misdiagnosed because of its variable appearances. This case report presents a case of well-differentiated SCC of gingiva. A 48-year-old male patient reported to the Department of Periodontology, School of Dental Sciences, Karad, with a 1-year history of burning sensation and painful lesion on the gingiva from 35 to 37 (mandibular) regions. On clinical examination, desquamated gingival lesion was seen with no purulent exudation. Clinical characteristics and differential diagnosis indicated the lesion for an excisional biopsy. Histopathological examination confirmed the lesion to be a well-differentiated SCC. The patient was referred for the treatment consisting of surgical excision of the lesion. Since an early diagnosis and treatment was possible in this case, it resulted in a good prognosis. In these instances, dentist plays an important role in early detection of gingival SCC.

Clinical profile and epidemiological factors of oral cancer patients from North India

INTRODUCTION

Tobacco chewing, smoking, and alcohol consumption are major contributing factors in the development of oral carcinoma. India has world's highest number of oral cancers (almost 20%) and approximately 1% of the Indian population has oral premalignant lesions.

AIM

The purpose of the study was to evaluate the epidemiological factors and clinical profile of oral cancer cases in our hospital.

SETTINGS

Department of Surgical Oncology, King George's Medical University, Lucknow, India.

MATERIALS AND METHODS

A retrospective study was conducted from January 2010 to December 2012 on 479 cases with histopathologically confirmed oral carcinoma. Subjects' details of age, sex, occupation, tobacco consumption, site of carcinoma, and stage at presentation were recorded.

RESULTS

Mean age in this study was 47.84 years with male to female ratio of 3.1:1.0. Buccal mucosa and alveolus were the most affected sites. The majority of cases were from socially and economically weaker section, with 93.72% cases being tobacco users. The majority of cases were advance stage (Stage III and IV) with Stage IV being the predominant stage at presentation followed by Stage III.

CONCLUSION

The findings of the study reveal that tobacco consumption is one of the major contributors in the development of cancer of oral cavity with the majority of cases presenting in advance stages posing a big therapeutic challenge.

Clinico-epidemiological study of oral squamous cell carcinoma: A tertiary care centre study in North India

INTRODUCTION

Oral squamous cell carcinoma (OSCC) ranks 12th most common cancer in the world.

OBJECTIVE

The aim of this study was to retrospectively evaluate the OSCC.

METHODS

A retrospective study of 611 OSCC patients from January 2010 to December 2013 was carried out in Department of Surgical Oncology, King George's Medical University, Lucknow, India. Details of patient's sex, age, tobacco habit and site of cancer were noted. Data were analyzed by Student's t test and chi-squire (χ (2)) test.

RESULTS

The prevalence of OSCC was significantly (p < 0.001) higher in males (75.9%) than females (24.1%). The mean age of female patients was higher than males (p < 0.001). In both the genders, the buccal mucosa and gingivobuccal sulcus were found to be the most affected sites. Moreover, the smokeless form of tobacco was found to be significantly associated with OSCC, especially in females.

CONCLUSION

The study concluded that OSCC is more common in men as compared to women, probably due to habit of tobacco consumption. Smokeless tobacco use is an important risk factor, especially in females.

Pathways involved in the spread of buccal carcinoma on contrast-enhanced multislice CT

OBJECTIVES

To explore how buccal carcinoma spread, using contrast-enhanced multislice CT (CEMSCT).

METHODS

We retrospectively analysed the extent of lesions in 56 patients with primary buccal squamous cell carcinoma (SCCA). Abnormal manifestations on CEMSCT at oral subsites and involved adjacent structures were documented and evaluated, which were compared with the results of surgery and histopathology.

RESULTS

Infiltration and spread to oral subsites and/or adjacent structures was confirmed in 33 patients (58.9%). The opening of the Stensen duct was the most commonly invaded oral subsite (72.7%); other sites included the gingivobuccal sulcus (60.6%), pterygomandibular raphe (54.5%), gingiva (24.2%), retromolar trigone (24.2%), orbicularis oris (18.2%) and the floor of mouth (15.2%). Of the involved adjacent structures, the buccal space was the most common site of spread (69.7%), followed by the masticatory muscles and spaces (57.6%), bone (54.5%), skin and subcutaneous fat (39.4%), pharynx (30.3%), investing fascia (15.2%) and the base of the skull (6.1%). CEMSCT manifestations of the involvement in buccal SCCAs had correlations with pathological findings (p < 0.05). The sensitivities, specificities and accuracies of two radiologists' evaluation on buccal carcinoma involvement were 50.00%, 23.21% and 73.21%; and 51.79%, 32.14% and 83.93%, respectively.

CONCLUSIONS

Buccal SCCAs could superficially and deeply spread to multiple oral subsites and/or adjacent structures. CEMSCT could delineate their spread pathways and extents.

Squamous cell carcinoma of the superior gingivobuccal sulcus: an 11-year institutional experience of 203 cases

OBJECTIVE

The report presents an 11-year Institutional experience of 203 cases with superior gingivobuccal sulcus tumours receiving surgical intervention at a comprehensive tertiary cancer care centre.

METHODS

A retrospective chart review of patients with a confirmed diagnosis of squamous cell carcinoma of superior gingivobuccal sulcus was done and data related to patient demographic profile; details of surgical procedure, follow-up and survival were collected.

RESULTS

Infratemporal fossa clearance was performed in 56 patients. The 10-year overall survival and disease-free survival was observed to be 39 and 52%, respectively, with a median follow-up of 15 months. The overall survival was 40 and 36%, respectively, in cases with and without infratemporal fossa clearance. Similarly, the disease-free survival was found to be 58 and 49%, respectively, in cases with and without infratemporal fossa clearance.

CONCLUSION

Patients with higher stage tumours who underwent infratemporal fossa clearance showed better overall and disease-free survival than those who did not undergo infratemporal fossa clearance.

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.

Gingival squamous cell carcinoma: a case report

Background

Squamous cell carcinoma is a malignant epithelial neoplasm characterized by variable clinical manifestations. When located in the gingiva, this neoplasm may mimic common inflammatory lesions. The aim of this study was to report a case of atypical squamous cell carcinoma, in which the patient had no risk factors for the development of this neoplasm.

Methods

A 61 year old Caucasian female was seen with a 3 month history of a rapidly growing, painful nodule in the gingiva adjacent to tooth #11. Clinical examination revealed a proliferative lesion in the vestibular marginal gingiva of teeth #11 and #12, presenting with purulent exudation. Thus, in view of the clinical symptoms and differential diagnosis of an infectious granulomatous process and malignant neoplasm, an incisional biopsy was obtained from the lesion.

Results

The diagnosis of squamous cell carcinoma was made and fourteen days after incisional biopsy, healing was found to be unsatisfactory. The patient was referred for treatment consisting of surgical excision of the tumour. A removable partial denture was fabricated for rehabilitation, one month after surgery of the maxilla; the patient was submitted to dissection of the regional lymph nodes and radiotherapy for an additional 3 months. Three years after the end of treatment, the patient continues to be followed-up and does not show any sign of recurrence.

Conclusions

Gingival squamous cell carcinoma is a condition which chance of cure is higher when carcinomatous lesions are diagnosed and treated early. In this instance dentists play an important role in early detection of gingival squamous cell carcinoma.