Gorlin-Goltz Syndrome - A Rare Case Entity in Young Child

Gorlin-Goltz syndrome (GGS) is an infrequent multisystemic disease with an autosomal dominant trait, which depicted presence of numerous basal cell carcinoma in conjunction with multiorgan abnormalities. This syndrome may be diagnosed early by a dentist by routine radiographic exams in the first decade of life, since the keratocystic odontogenic tumour are usually one of the first manifestations of the syndrome. This article includes a case report of the GGS with regard to its history, incidence, etiology, features, investigations, diagnostic criteria, keratocystic odontogenic tumour and treatment modalities.

Assessing Conservative Treatment Options for Odontogenic Keratocyst in a 12-Year-Old Patient, with 1-Year Follow-up

The odontogenic keratocyst (OKC) is a frequently developing odontogenic cyst that accounts for 10%-14% of all jaw cysts. Due to the high recurrence rate, aggressive therapeutic techniques such as jaw resection and marsupialization are indicated. Following a conservative marsupialization procedure in which Carnoy's solution and an iodoform packing were used, the clinical, radiological, and histological evaluation of OKC in a 12-year-old female patient revealed no evidence of recurrence over the subsequent year of follow-up.

Modified Carnoy's Versus Carnoy's Solution in the Management of Odontogenic Keratocysts-A Single Center Experience

To date, few studies have been conducted to test the effectiveness of Carnoy's (CS) versus modified Carnoy's (MC) solution for preventing the recurrence of odontogenic keratocysts, which are potentially aggressive lesions. To evaluate the efficacy of MC application, we conducted a retrospective cohort study over an 18-year period, from October 2004 to October 2022, in 122 patients treated surgically with adjunctive chemical cautery, with either CS (n = 73; median age: 30 years) or MC (n = 49; median age: 42 years), by a single surgeon. The primary outcome variables were observed recurrence and interval to recurrence. Independent variables were demographics, location, clinical presentation at baseline, adjacent tooth extraction, and bone grafting. Males predominated in both groups. No statistically significant differences were observed between the two arms in terms of recurrences in particular months, with six patients (8.2%) in the CS arm and 5 (10.2%) in the MC arm. Of the 11 recurrences, 10 were observed within the first 2 years post-surgery, with only one occurring in the 7th year of follow-up. Thus, when used as adjunctive therapy, the application of MC has an efficiency comparable to that of CS for lowering the recurrence rate of odontogenic keratocysts.

Effectiveness of different treatments for odontogenic keratocyst: a network meta-analysis

Odontogenic keratocysts (OKC) are benign but aggressive lesions. As there is a lack of well randomized clinical studies assessing the effectiveness of the different treatment options for OKC, a network meta-analysis (NMA) was performed to identify the best treatment option with the lowest recurrence rate. An electronic search was performed following the PRISMA guidelines to identify all clinical studies comparing treatment options against enucleation alone. The outcome variable was recurrence. The predictor variables were treatments. The eight included treatments were: enucleation with peripheral ostectomy/curettage (E + PO/curettage); enucleation with cryotherapy (E + CRYO); enucleation with/without PO followed by modified Carnoy's solution (E ± PO+MCS); enucleation with PO and with topical 5-fluorouracil (E + PO+5FU); enucleation with/without PO followed by original Carnoy's solution (E ± PO+CS); marsupialization alone (MARS); marsupialization followed by secondary enucleation with/without PO (MARS+2°E ± PO); and resection. The odds ratio was used to estimate the recurrence rate. A frequentist NMA was performed using Stata software. A total of 2989 patients in 40 studies were included. Both direct pairwise meta-analysis and NMA showed that E + 5FU+PO was significantly superior to E ± PO+MCS. However, no statistically significant difference was found between E ± PO+CS vs E + 5FU+PO, E ± PO+MCS, and resection, respectively (all very low quality evidence). The three most effective treatments in reducing the recurrence rate were E + PO+ 5FU (98.1%; very low quality evidence), resection (83.5%; very low quality evidence), and E ± PO+CS (63.8%; moderate quality evidence). The findings from this study suggest that CS remains the most effective fixative agent after enucleation and PO until proven otherwise. Additionally, 5FU appears to be an effective method with promising results that needs further research. Finally, the efficacy of MCS remains controversial; further in vivo and in vitro studies are required to determine new protocols. As this NMA included retrospective studies, the results should be interpreted with great caution (level of evidence: type III).

Unicystic ameloblastoma: analysis of surgical management and recurrence risk factors

Unicystic ameloblastoma is a distinct pathological variant with varying evidence published about its behaviour and surgical management. Due to a paucity of large studies in the literature with long-term follow up, the aim of this study was to analyse its surgical management and identify clinicopathological features associated with recurrences. All histopathologically confirmed lesions diagnosed at two referral centres between 1995 and 2020 were retrospectively analysed. Demographic, clinical, radiological, and histopathological features were analysed along with surgical methods and follow-up data. Univariate regression analyses were performed to identify risk factors for recurrence. Sixty-three patients were included in the study with mean age of 26.3 years and a male to female ratio of 1:0.75. The majority of lesions occurred in the posterior mandible (57.1%) and were unilocular (88.9%). Most lesions were managed with enucleation followed by application of Carnoy's solution (ferric chloride: 1g; chloroform: 3 mL; glacial acetic acid: 1 mL; ethyl alcohol 96%: 6 mL) and burring of the peripheral bone margin which resulted in the lowest recurrences (9.1%) besides resection. Significantly associated clinicopathological features with recurrences included patients who were male, large lesions (>90 mm), presence of root resorption, cortical perforation, mural subtype, and retention of associated teeth. In conclusion, decision making in the management of unicystic ameloblastoma should be based on the clinicopathological features and not be solely based on the histopathological subtype. Enucleation followed by application of Carnoy's solution and burring of the peripheral bone margin was demonstrated to be the least invasive method with an acceptable low recurrence rate.

Fixation Using Carnoy's Solution Enables Detection of More Lymph Nodes After Gastrectomy for Gastric Cancer

BACKGROUND

To compare the number of lymph nodes (LNs) detected when using Carnoy's solution (CS) versus 10% neutral buffered formalin (NBF) to fix specimens after radical gastrectomy for gastric cancer.

PATIENTS AND METHODS

LNs were routinely detected using NBF until 2020, since then, for the fixation procedure, residual fat was fixed in CS for 24 hours and dissected again for the detection of further LNs. Of 143 specimens, 117 were included in the NBF group and 26 in the CS group.

RESULTS

The mean numbers of LNs examined were 27.85±14.89 and 36.30±12.41 in the NBF and CS groups, respectively (p=0.008). The mean number of additional LNs detected using CS was 8.07±2.91, of which 0.38±1.02 were metastatic. Additional LNs were found in all patients of the CS group, and all were ≤3 mm. Of the 26 patients in the CS group, metastatic LNs were detected in four, disease in two of whom was up-staged.

CONCLUSION

CS is an appropriate alternative to NBF for the fixation of gastric cancer specimens, and more LNs were detected in the resected specimens fixed when using CS compared with NBF.

Conservative management with Carnoy's solution in ameloblastoma involving two unerupted teeth: a report of two cases

Marsupialization is widely used as a primary treatment modality for reducing size of large cysts. However, there is no recommendation for specific duration of marsupialization. In addition, Carnoy’s solution usually is applied at the time of enucleation as a fixative agent. In this report, we present an appropriate marsupialization duration of ameloblastoma involving two unerupted teeth. In this present study, marsupialization using a Foley catheter was performed in two cases of ameloblastoma of the mandible involving two adjacent impacted teeth. Carnoy’s solution was applied for 3-5 minutes after enucleation in both patients. Periodically during marsupialization, the size of the radiolucency was measured in panoramic view, and clinical examination was performed. No remarkable paresthesia or soft tissue injury was observed after application of Carnoy’s solution or during follow-up. We recommend 12 to 16 weeks as an adequate marsupialization duration for a large ameloblastoma involving two impacted teeth based on increased radiopacity along the margins of the lesions. Poor oral hygiene was an issue after 12 weeks of marsupialization in one case. There were no remarkable complications with Carnoy’s solution in either case. The Foley tube has a two-way system that is more effective for irrigating the cavity than is the conventional one-way system.

A clinical study of inferior alveolar nerve damage caused by Carnoy's solution used as a complementary therapeutic agent in a cystic lesion

Background

Cyst enucleation, which extracts only the tumor with the application of Carnoy’s solution (CS), has been suggested as a conservative treatment with a low recurrence rate and morbidity. However, there has been a concern that CS’s contact with inferior alveolar nerve (IAN) can cause neurons to degenerate and cause sensory dysfunction. The purpose of this retrospective cohort study aimed to investigate the neurosensory function after surgical treatment with or without the application of CS.

Methods

While controlling the effects of sex, age, follow-up period, and invasion size of the tumor, we performed the binary logistic regression analysis to examine whether or not the sensory function of the patients who were treated with CS (n = 19) for the cyst enucleation procedure was significantly different from those who were not treated with CS (n = 58) at the end of the follow-up period.

Results

The logistic regression result showed that the use of CS was not significantly related to the normalness of sensory function at the end of the follow-up period. Rather, the invasion size of the cyst was significantly associated with sensory dysfunction.

Conclusions

CS may be used for patients who are diagnosed with OKC and UAM without much fear of its impact on sensory dysfunction. However, a small number of patients who were treated with CS experienced severe sensory damage and did not recover at the end of the follow-up period, suggesting the need for further analysis of these patients.

Laser-capture microdissection of murine lung for differential cellular RNA analysis

The lung tissue contains a heterogeneous milieu of bronchioles, epithelial, airway smooth muscle (ASM), alveolar, and immune cell types. Healthy bronchiole comprises epithelial cells surrounded by ASM cells and helps in normal respiration. In contrast, airway remodeling, or plasticity, increases surrounding of bronchial epithelium during inflammation, especially in asthmatic condition. Given the profound functional difference between ASM, epithelial, and other cell types in the lung, it is imperative to separate and isolate different cell types of lungs for genomics, proteomics, and molecular analysis, which will improve the diagnostic and therapeutic approach to treat cell-specific lung disorders. Laser capture microdissection (LCM) is the technique generally used for the isolation of specific cell populations under direct visual inspection, which plays a crucial role to evaluate cell-specific effect in clinical and preclinical setup. However, maintenance of tissue RNA quality and integrity in LCM studies are very challenging tasks. It is obvious to believe that the major factor affecting the RNA quality is tissue-fixation method. The prime focus of this study was to address the RNA quality factors within the lung tissue using the different solvent system to fix tissue sample to obtain high-quality RNA. Paraformaldehyde and Carnoy's solutions were used for fixing the lung tissue and compared RNA integrity in LCM captured lung tissue samples. To further confirm the quality of RNA, we measured cellular marker genes in collected lung tissue samples from control and mixed allergen (MA)-induced asthmatic mouse model using qRT-PCR technique. RNA integrity number showed a significantly better quality of RNA in lung tissue samples fixed with Carnoy's solution compared to paraformaldehyde solution. Isolated RNA from MA-induced asthmatic murine lung epithelium, smooth muscle, and granulomatous foci using LCM showed a significant increase in remodeling gene expression compared to control which confirm the quality and integrity of isolated RNA. Overall, the study concludes tissue fixation solvent can alter the quality of RNA in the lung and the outcome of the results.

Ameloblastoma Management: "Horses for Courses" Protocol

Purpose

The purpose of the article is to review 45 cases of ameloblastoma treated in a tertiary care centre depending on the extent of the pathology, in terms of recurrence and morbidity of the patients.

Materials and method

This was a retrospective study of patients who underwent treatment for ameloblastoma between 2009 and 2018 at Vydehi Institute of Dental Sciences, Bangalore. During the first phase of 4 years, the focus of the treatment was on avoiding any recurrence, and therefore, resection followed by reconstruction with reconstruction plates was the only modality used in ten patients. However, from 2014, it was decided to treat each patient based on the extent of the lesion and decide on either conservative management in the form of enucleation followed by peripheral ostectomy and chemical cauterisation or resection with safe margins and reconstruction with reconstruction plates.

Results

The study sample consisted of 45 patients, and the ages ranged from 12 to 65 years with an average of 36. There were 30 males and 15 females. In the first phase of treatment protocol adopted, ten patients underwent resection. In the later period, 18 patients were treated by conservative methods and 16 patients were treated by radical management. There were only three recurrences over a period of 3-year follow-up in the group treated conservatively.

Conclusion

Considering the benign nature of the tumour and the morbidity after resection, patients, most of whom are in the younger age group, can still be subjected to conservative treatment provided they are followed up for a long period thus assuring them of a better quality of life.

Basal cell nevus syndrome (Gorlin syndrome): genetic insights, diagnostic challenges, and unmet milestones

In this article, we present three clinical case reports on Basal Cell Nevus Syndrome (Gorlin Syndrome). Gorlin syndrome is an inherited medical condition with challenges that manifest in multiple body systems and complicate early diagnosis. We examine the epidemiology of the disease and benefits of genetic testing, molecular pathophysiology, and advancement in the molecular-based therapy of Basal Cell Nevus syndrome. The goal of this paper is to shed light on both unmet challenges and advancements in the management of Gorlin syndrome and to provide a new clinical perspective and guidance for future research. Furthermore, the FDA approved Hedgehog pathway inhibitors Vismodegib and Sonidegib designed for advanced basal cell carcinoma have opened a new door for treatment that may ultimately decrease the number of surgeries for a patient with Gorlin syndrome. The role of these agents in syndromic odontogenic keratocyst has not been studied extensively, but one study found that hedgehog pathway inhibitors decrease the size of syndromic odontogenic keratocyst. Ideal surgical treatment that balances low recurrence rates with low impact on one's quality of life for syndromic odontogenic keratocyst is another unanswered question for oral and maxillofacial surgeons. Per survey studies, treatment options practiced for syndromic odontogenic keratocyst range from marsupialization to segmental osteotomy. Future studies performed should take a comprehensive long-term approach with at least three years of follow-up in order to determine the most appropriate treatment.

Evaluation of Histomorphometric Changes in Tissue Architecture in Relation to Alteration in Fixation Protocol - An Invitro Study

INTRODUCTION

Preparation of good tissue specimens for microscopy requires complete fixation. No ideal fixative has been found till date, with every fixative showing advantages and disadvantages. Appropriate fixation is required to maintain clear and consistent morphologic features for histologic examination. Pathologists mostly examine formalin fixed tissue sections and are less used to the morphologic changes induced by other fixatives. Underfixed and overfixed tissue in various fixatives can lead to tissue architectural changes which can affect its diagnostic value.

AIM

To assess sectioning ability, staining intensity and microscopic details of tissues kept in different fixatives at different time intervals.

MATERIALS AND METHODS

Fresh tissue specimen i.e., goat tongue was collected and its middle-third portion was used for the study purpose. The tissue was grossed into 10 equal pieces and kept in various fixatives (10% Buffered formalin, Carnoy's solution, Absolute ethyl alcohol, Bouin's fluid) for five different time intervals (6, 12, 18, 24 and 30 hours) and normal tissue processing steps were carried out followed by sectioning and staining. During sectioning, sectioning parameter was assessed. Following sectioning, sections were observed under light microscope and were histologically evaluated for staining and microscopic details. To calculate the sectioning parameter Fisher's exact test was used and to assess parameters for staining and microscopic details Mann-Whitney U test was used.

RESULTS

According to the study, 10% buffered formaldehyde is considered as a superior fixative under all parameters followed by Bouin's fluid, Carnoy's solution and Absolute alcohol.

CONCLUSION

In our study, it was concluded that 10% buffered formaldehyde should be continued as a routine fixative however, other fixatives can be used depending upon the non-availability of required fixative or in case of emergencies. Pathologist should be accustomed to histologic and morphologic changes of underfixed and overfixed tissue which can affect its diagnostic value.

Carnoy's solution increases the number of examined lymph nodes following gastrectomy for adenocarcinoma: a randomized trial

BACKGROUND

Pathological examination of a minimum of 16 lymph nodes is recommended following surgery for gastric adenocarcinoma, despite this a longer survival is expected when 30 or more lymph nodes are examined. Small lymph nodes are difficult to identify, and fat-clearing solutions have been proposed to improve this, but there is no evidence of their clinical benefit.

METHODS

Fifty D2 subtotal gastrectomy specimens were randomized for fixation in Carnoy's solution (CS) or 10% neutral buffered formalin (NBF), with subsequent fat dissection. After dissection, the residual fat from the NBF group, instead of being discarded, was immersed in CS and dissected again. Data from 25 D2 subtotal gastrectomies performed before the study were also analyzed.

RESULTS

The mean number of examined lymph nodes was 50.4 and 34.8 for CS and NBF, respectively (p < 0.001). Missing lymph nodes were found in all cases from the residual fat group (mean of 16.9), and in eight of them (32%) metastatic lymph nodes were present; this allowed the upstaging of two patients. Lymph nodes in the CS group were smaller than those in the NBF group (p = 0.01). The number of retrieved lymph nodes was similar among the NBF and Retrospective groups (p = 0.802).

CONCLUSIONS

Compared with NBF, CS increases lymph node detection following gastrectomy and allows a more accurate pathological staging. No influence of the research protocol on the number of examined lymph nodes was observed.

Keratocystic Odontogenic Tumour with Extraosseal Spread: Evaluation of the Effect Carnoy's Solution

Keratocystic odontogenic tumour is relatively rare benign tumour. It is characterized by its fast aggressive growth and high risk of recurrence. Treatment is always surgical: conservative (enucleation, marsupialization) or aggressive (enucleation followed by application of Carnoy's solution, cryotherapy; peripheral ostectomy or en block resection of the jaw). Authors analysed retrospectively 22 patients who fulfilled inclusion criteria, i.e. had odontogenic keratocystic tumour of mandible, wherein antero-posterior dimension was at least 30 mm, and the tumour penetrated into the surrounding soft tissues. All patients underwent tumour enucleation, in 11 patients Carnoy's solution was given into the bone cavity after enucleation. The recurrence rate in the evaluation at least 36 months after surgery was both patient groups the same: 45.4%.

Odontogenic Keratocysts in Gorlin-Goltz Syndrome: A Case Report

Gorlin-Goltz syndrome is an autosomal dominant inherited condition comprising the principle triad of basal cell carcinomas, multiple jaw keratocysts, and skeletal anomalies. The presence of jaw cysts are the early diagnostic feature of this syndrome, and this can be incidentally identified by routine radiographs. A patient presented with signs and symptoms of Gorlin-Goltz syndrome to us in her early stages.

Bilateral glandular odontogenic cyst of mandible: a rare occurrence

Glandular odontogenic cysts (GOCs) of the jaw are rare with well-defined limits radiologically, unusual histopathological features and a high recurrence rate. The radiographic appearance of GOCs vary and are not pathognomonic. Definitive diagnosis of the GOC is established only by histopathological examinations. Histologically, GOC is characterized by a thin nonkeratinized squamous epithelial lining, with papillary projections, nodular thickenings, mucous (goblet) cells with intraepithelial mucous pools and intraepithelial glandular, microcystic or duct-like structures. We present an unusual case of a bilateral GOC in the mandible. This case report is also the first documented case of bilateral GOC in the mandible.

Importance of Different Modalities of Treatment For the Management of Keratocystic Odontogenic Tumour with Five year follow-up

BACKGROUND

The keratocystic odontogenic tumors is a benign but one of most aggressive developmental cyst with many distinguishing clinical and histologic features and high recurrence rate. In the given study, authors have studied and presented their experience of managing Keratocystic odontogenic tumour. The aim of the study was to define an appropriate treatment protocol for the management of KCOT.

MATERIALS AND METHODS

Total 8 patients, whose histopathological reports confirmed Gorlin - Goltz syndrome and KCOT, with age between 10 - 50 years, were selected from cases being treated at Sree Balaji Dental College, Chennai, India. Enucleation and resection were the surgical techniques employed. Modality of treatment was based on parameters like age , size, aggressiveness and extent of the lesion. All the patients were operated under general anaesthesia. Cases were studied, reviewed and followed up for five years between 2007-2012.

RESULTS

The study included 8 cases in which three cases were opted for resection and five cases for enucleation followed by application of Carnoy's solution.

CONCLUSION

Treatment modality should be decided on age, extent, aggressiveness and nature of the tumour.

The Use of Enucleation and Chemical Cauterization (Carnoy's) in the Management of Odontogenic Keratocyst of the Jaws

The purpose of this study was to evaluate the use of enucleation and chemical cauterization in the management of odontogenic keratocyst (OKC) of the jaw. This study involves the retrospective review of 32 patients (20 males and 12 females) with 34 biopsy proven odontogenic keratocysts. All patients received a combination of enucleation and chemical cauterization with every time freshly prepared Carnoy's solution (absolute alcohol 6 mL, chloroform 3 mL, glacial acetic acid 1 mL, ferric chloride 0.1 gm/mL). None of these patients were diagnosed with basal cell nevus syndrome. Four of these patients did not give the follow up and were not included in the study. A total of 30 biopsy proven OKC were resolved with this treatment method. Post-operative follow up consists of clinical and radiographic examination. Follow up time ranged from a minimum of 2 years to a maximum of 5 years. Mean follow up was of 2.8 years. Recurrence rate of 5.8% was observed. Hence, concluded that the combination of enucleation and chemical cauterization may offer patients improved therapy in the management of odontogenic keratocysts of the jaws.

Primary intraosseous squamous cell carcinoma arising from an odontogenic keratocyst: a case report and literature review

Primary intraosseous squamous cell carcinoma (PIOSCC) derived from an odontogenic keratocyst (OKC) is a rare malignant neoplasm of the jaws, which is locally aggressive with quite poor prognosis. The incidence of carcinomas arising in odontogenic cysts was reported to be approximately 1-2/1000. The number of well-documented cases of PIOSCC ex OKC is extremely small; hence, no sufficient incidence data are available in the literature. Overall, the survival rate of an individual, which is a period of two years, is very poor, and this can be attributed to the delayed diagnosis. But knowledge of the histopathological and immunohistological features of PIOSCC allows accurate and early diagnosis of the lesion so that an early and appropriate treatment can be instituted for better prognosis. The following report describes an extremely rare case of PIOSCC of the mandible derived from an OKC in a 20-year-old female patient.

Carnoy's in Aggressive Lesions: Our Experience

Carnoy's solution is used in the treatment of various aggressive cysts and tumors in the maxillofacial region as a chemical cauterizing agent. Its use has been extensively studied in case of odontogenic keratocysts. It is used in the management of unicystic ameloblastomas and ossifying fibromas. In our institution from 2006 to 2010 we have treated 14 cases of maxillofacial lesions using carnoy's solution. Among these cases 7 were of odontogenic keratocyst, 4 cases were of amelobalstoma and one case was of juvenile ossifying fibroma. So here we share our experience of treating these lesions with the carnoy's solution.

Surgical management of recurrent odontogenic keratocyst

The odontogenic keratocyst is a distinct entity arising from odontogenic epithelium. The unique histopathological appearance and the propensity for recurrence has made it management controversial in terms of the conservatism to be followed. This article describes the management of a case of recurrent odontogenic keratocyst with an aggressive therapy being adopted due to the nature of the pathology.