Complications following interventional laser surgery for oral cancer and precancerous lesions

ICI-based therapies: A new strategy for oral potentially malignant disorders

Oral potentially malignant disorders (OPMDs) are linked with an escalated risk of developing cancers, particularly oral squamous cell carcinoma (OSCC). Since prevailing therapies cannot effectively forestall the exacerbation and recurrence of OPMDs, halting their malignant progression is paramount. The immune checkpoint serves as a cardinal regulator of the immune response and the primary cause of adaptive immunological resistance. Although the exact mechanism remains elusive, elevated expression of multiple immune checkpoints in OPMDs and OSCC relative to healthy oral mucosa has been ascertained. This review delves into the immunosuppressive microenvironment of OPMDs, the expression of diverse immune checkpoints such as programmed death receptor-1 (PD-1) and programmed death receptor-1 ligand (PD-L1) in OPMDs, and the potential application of corresponding inhibitors. In addition, synergistic strategies incorporating combined immune checkpoint inhibitors, such as cGAS-STING, costimulatory molecules, cancer vaccines, and hydrogels, are discussed to gain a more comprehensive understanding of the role and application of immune checkpoint inhibitors (ICIs) in oral carcinogenesis.

Overview of Oral Potentially Malignant Disorders: From Risk Factors to Specific Therapies

Oral squamous cell carcinoma (OSCC) is a very aggressive cancer, representing one of the most common malignancies worldwide. Oral potentially malignant disorders (OPMDs) regroup a variegate set of different histological lesions, characterized by the potential capacity to transform in OSCC. Most of the risk factors associated with OSCC are present also in OPMDs' development; however, the molecular mechanisms and steps of malignant transformation are still unknown. Treatment of OSCC, including surgery, systemic therapy and radiotherapy (alone or in combination), has suffered a dramatic change in last years, especially with the introduction of immunotherapy. However, most cases are diagnosed during the advanced stage of the disease, decreasing drastically the survival rate of the patients. Hence, early diagnosis of premalignant conditions (OPMDs) is a priority in oral cancer, as well as a massive education about risk factors, the understanding of mechanisms involved in malignant progression and the development of specific and more efficient therapies. The aim of this article is to review epidemiological, clinical, morphological and molecular features of OPMDs, with the purpose to lay the foundation for an exhaustive comprehension of these lesions and their ability of malignant transformation and for the development of more effective and personalized treatments.

Managing Benign and Malignant Oral Lesions with Carbon Dioxide Laser: Indications, Techniques, and Outcomes for Outpatient Surgery

Purpose  Because of its affinity for water-based tissues, carbon dioxide (CO ₂ ) laser has become an instrument of choice for treating oral mucosa conditions, ranging from inflammatory to malignant lesions. The aim of this work is to systematically evaluate the outcomes of laser surgery over a wide range of lesions, while providing a solid and reproducible protocol for CO ₂ laser surgery in the outpatient management of oral lesion.

Methods  Seventy-eight patients underwent 92 laser outpatient procedures for treatment of a wide range of benign and malignant lesions. We performed 60 removals, 11 exeretic biopsies, 15 vaporizations, and 3 vaporization/removal combined. We analyzed laser parameters applied for each technique and provided a systematic evaluation of surgical results.

Results  No problems occurred intraoperatively in any of the patients. Five patients complained marginal pain, while 3 patients had postsurgery bleeding. All treatments were successful, with the notable exception of 3 relapsing verrucous proliferative leukoplakias and an infiltrating squamous cell carcinoma of the tongue requiring radicalization. We did not record any adverse reactions to drugs or lesions due to laser action. Concordance between clinical diagnosis and pathology results was at 94.8%.

Conclusions  Our data indicate that CO ₂ laser is a solid choice for outpatient treatment of oral lesions. This technique grants painless and almost bloodless treatment, with negligible recurrence rates. Providing a solid reference for laser settings and operative techniques could provide a foundation for further exploring this tool while offering the basis for a positive comparison between different surgical techniques and options.

Patients' experience in the early recovery phase after removal of intraoral squamous cell carcinoma with carbon dioxide laser

Laser excision of oral cancer is well established. The aim of this cross-sectional survey was to ask patients about their main symptoms and the severity of them during the first postoperative weeks. We devised a short questionnaire in collaboration with patients, and did a cross-sectional survey of 50 consecutive patients who had laser excision of T1 and T2 oral cancers over a two-year period. The response rate was 76% (38/50). Twenty patients reported that eating was "quite a bit" or "very much of a problem" and 13 reported similar for pain. The main problems were eating (n=27), pain (n=16), numbness (n=14), speech (n=13), and swallowing (n=12). It took 11 patients more than 4 weeks to recover, and 11 of the 20 who were employed needed to take time off work (modal duration 3 or 4 weeks). Thirteen patients sought advice postoperatively from the clinic, ward or secretary's office, general practitioner, or accident and emergency department (or other out-of-hours service). The survey shows that morbidity associated with laser excision is relatively high, and more studies are required to provide a better evidence base that will inform improvements in postoperative recovery and care.

Oral leukoplakia treatment with the carbon dioxide laser: A systematic review of the literature

We conducted a systematic review of the literature to evaluate treatment of oral leukoplakia with the carbon dioxide (CO2) laser. A comprehensive search of studies published between 1981 and 2015 and listed in the PubMed (National Library of Medicine, NCBI) database yielded 378 articles which were screened in detail. Relevant studies were selected according to predetermined inclusion and exclusion criteria. A total of 33 articles met the final inclusion criteria and were analysed in detail in accordance with the PRISMA-P statement. These full-text papers were classified as synopses (n = 7), recurrence and malignant transformation studies (n = 17), comparative studies between CO2 laser and cold knife surgery (n = 3) and studies evaluating the efficacy of CO2, Nd:YAG and KTP lasers. According to the literature the CO2 laser is the workhorse of oral leukoplakia treatment due to its effectiveness and low associated morbidity. However, randomized clinical trials are needed to compare CO2 laser with other lasers. The results of our systematic review showed that there is no consensus regarding the factors involved in higher recurrence and malignization rates, so further studies are needed.

Frequency and outcomes of submandibular gland obstruction following resection of squamous cell carcinomas in the vicinity of the submandibular duct

INTRODUCTION

The aim of this study was to report rates, associated factors and outcomes of submandibular gland obstruction following surgery for squamous cell carcinoma in the anterior floor of the mouth (FOM) or ventral tongue without a neck dissection where resection has involved (or has been in very close proximity to) the submandibular duct.

METHODS

A retrospective case note review was carried out for the period January 2007 to December 2011. Only patients who received primary local surgical resection for squamous cell carcinoma of the anterior FOM or ventral tongue were included.

RESULTS

Fifty-two patients were analysed. Fifteen (29%) developed submandibular gland symptoms following surgery. Symptoms resolved spontaneously for 14 (93%) and 1 patient required the submandibular duct to be repositioned. Comparatively, 2 patients (13%) developed symptoms when the duct was repositioned during primary surgery. No patients had their submandibular gland removed.

CONCLUSIONS

Resection of small tumours associated with the FOM and ventral tongue in proximity to the submandibular duct is associated with obstructive symptoms in about a quarter of patients; this is reduced by half when redirecting the duct. Symptoms are self-limiting and self-resolving. A prospective clinical trial comparing duct repositioning with subcapsular gland excision would help clarify potential benefits and best treatment modalities.

Pulsed versus continuous wave CO2 laser excisions of 100 oral fibrous hyperplasias: a randomized controlled clinical and histopathological study

BACKGROUND

In experimental animal studies, pulsing the CO2 laser beam has been shown to reduce the thermal damage zone of excised oral mucosal tissue. However, there is still controversy over whether this is borne out under clinical conditions.

OBJECTIVE

To compare the outcome following excisional biopsies of fibrous hyperplasias using a pulsed (cf) versus a continuous wave (cw) CO2 laser mode regarding the thermal damage zone, duration of surgeries, intra- and postoperative complications, postoperative pain sensation, scarring and/or relapse during the initial 6 months.

MATERIALS AND METHODS

One hundred Swiss-resident patients with a fibrous hyperplasia in their buccal mucosa were randomly assigned to the cw mode (5 W) or the cf mode (140 Hz, 400 microseconds, 33 mJ, 4.62 W) group. All excisions were performed by one single oral surgeon. Postoperative pain (2 weeks) was recorded by visual analogue scale (VAS; ranging from 0 to 100). Intake of analgesics and postoperative complications were recorded in a standardized study form. The maximum width of the collateral thermal damage zone was measured (µm) in excision specimens by one pathologist. Intraoral photographs at 6-month follow-up examinations were evaluated regarding scarring (yes/no).

RESULTS

Median duration of the excision was 65 seconds in the cw and 81 seconds in the cf group (P = 0.13). Intraoperative bleeding occurred in 16.3% of the patients in the cw and 17.7% of the cf group. The median value of the thermal damage zone was 161(±228) μm in the cw and 152(± 105) μm in the cf group (P = 0.68). The reported postoperative complications included swelling in 19% and minor bleeding in 6% without significant differences between the two laser modes. When comparing each day separately or the combined mean VAS scores of both groups between Days 1-3, 1-7, and 1-15, there were no significant differences. However, more patients of the cw group (25%) took analgesics than patients of the cf group (9.8%) resulting in a borderline significance (P = 0.04). Scarring at the excision site was found in 50.6% of 77 patients after 6 months, and more scars were identified in cases treated with the cf mode (P = 0.03).

CONCLUSIONS

Excision of fibrous hyperplasias performed with a CO2 laser demonstrated a good clinical outcome and long-term predictability with a low risk of recurrence regardless of the laser mode (cf or cw) used. Scarring after 6 months was only seen in 50.6% of the cases and was slightly more frequent in the cf mode group. Based on the findings of the present study, a safety border of 1 mm appears sufficient for both laser modes especially when performing a biopsy of a suspicious soft tissue lesion to ensure a proper histopathological examination.

The role of interventional surgery in oral potentially malignant disorders

Oral potentially malignant disorders are mucosal diseases with a significantly increased risk of squamous carcinoma development – a lethal and deforming disease with rising incidence, especially in young people. Despite the ability to recognise pre-cancer disorders in patients, clinicians remain unable to predict individual mucosal lesion behaviour or quantify the risk of malignant transformation. No clear management guidelines exist and the available scientific literature is unable to answer the fundamental question: does early diagnosis and interventional management treat pre-cancer effectively and prevent malignant transformation?