Sentinel lymph node biopsy for early oral cancer - accuracy and considerations in patient selection

Sentinel lymph node biopsy (SLNB) for staging oral squamous cell carcinoma (OSCC) patients presenting with early (T1 and T2 N0) disease in preference to elective neck dissection (END) remains controversial worldwide. A retrospective analysis of 145 patients who underwent sentinel lymph node biopsy for a previously untreated early oral cancer between 2010 and 2020 was performed. The primary outcome measures were predictors of occult metastases, accuracy of SLNB and disease specific plus overall survival. The negative predictive value, the false negative rate, and sensitivity for SLNB were 97%, 7.8%, and 92%, respectively. Depth of invasion (DOI) was a significant predictor of N status, overall survival, and disease specific survival. There was a significant difference in the incidence of the neck node metastasis in patients with DOI <5mm compared to those with DOI >5mm. For tumours >5mm there was a moderate to good correlation between radiological depth on contrast enhanced computed tomography (CECT) and histopathological DOI. Preoperative estimation of DOI may be a useful tool in the counselling of patients in the selection of either SLNB or END for N staging purposes in early OSCC.

Temporal Bone Adenoma: A Comprehensive Analysis of Clinical Aspects and Surgical Outcome on a Very Rare Entity

Objective The aim of this study is to present our experience in dealing with middle ear adenomas (MEAs), very rare tumors of the middle ear.

Methods The medical notes of individuals with MEAs treated in tertiary referral; academic settings were retrospectively reviewed. We recorded the presenting symptoms, imaging findings, and pathology results. We additionally examined our surgical outcomes, follow-up period, recurrence, and morbidity.

Results We identified four patients with MEAs: two males and two females with an average age of 36.25 years (range = 27–51 years). Despite the detailed imaging studies, including computed tomography and magnetic resonance imaging with intravenous contrast administration, a biopsy was essential in setting the diagnosis. Total surgical resection was achieved in all patients without any recurrence over an average of 6 years (range = 3–10 years). Complete ipsilateral deafness was the commonest surgical morbidity due to footplate infiltration by the tumor.

Conclusion Total surgical resection is the treatment of choice in MEAs to minimize the risk for recurrence; this can come with morbidity, mostly sensorineural deafness. Given the very limited literature, long-term follow-up is recommended.

Droplet digital PCR quantification suggests that higher viral load correlates with improved survival in HPV-positive oropharyngeal tumours

BACKGROUND

Although HPV-positive oropharyngeal cancer (OPC) patients have improved prognosis compared to HPV negative patients; there remains an HPV-positive group who have poor outcomes. Biomarkers to stratify discrete patient outcomes are thus desirable. Our objective was to analyse viral load (VL) by droplet digital PCR (ddPCR), in HPV-positive patients with OPC on whom clinical outcome data were available.

METHODS

In a cohort of patients that had previously tested HPV positive via conventional PCR, VL was determined using ddPCR assays for HPV16 L1 and E6 genes. VL was classed as "medium/high" if more than 5.57 copies or 8.68 copies of the HPV 16 L1 or E6 gene were detected respectively. Effect of VL on overall survival and hazard of death & disease progression was performed with adjustments made for sex, age, deprivation, smoking, alcohol consumption and stage.

RESULTS

L1 VL ranged from 0.0014-304 gene copies per cell with a mean of 30.9; comparatively E6 VL ranged from 0.0012-356 copies per cell with a mean of 37.9. Univariate analysis showed those with a medium/high VL had a lower hazard of death; this was significant for L1 (p = 0.02) but not for E6 (p = 0.67). The ratio of E6 to L1 deviated from n = 1 in most samples but had no influence on clinical outcomes.

CONCLUSIONS

HPV viral load may be informative for the further stratification of clinical outcomes in HPV positive OPC patients.

Postoperative risk stratification in oral squamous cell carcinoma

Postoperative prognostic stratification using the Union for International Cancer Control (UICC) TNM 8th edition staging rules (UICC 8) may identify additional groups of patients who could benefit from adjuvant radiotherapy. Currently, selection for such treatment is not based on all known prognostic factors, and their relative importance may vary depending on the overall risk category. The objective of this study therefore was to evaluate these possibilities. We retrospectively studied 644 patients who had surgery with curative intent for oral squamous cell carcinoma (OSCC) between March 2006 and February 2017. The outcomes of interest were disease-specific survival (DSS) and locoregional recurrence (LRR). Patients were re-staged according to the UICC 8 staging rules. Putative clinical and pathological prognostic variables were evaluated and hazard ratios estimated. Regression analysis was done to identify independent prognostic factors, and iterative analyses identified clinically-relevant risk categories with a minimum of residual prognostic variables. The significance of recognised pathological prognostic factors differed according to the overall risk category. An intermediate risk group comprising patients with pN1 disease as well those with pT3 disease solely on the basis of a depth of invasion (DOI) of more than 10 mm, was identified. A trial to evaluate the benefit or otherwise of adjuvant radiotherapy in this group is now required. Individual prognostic risk factors should be considered within the context of the overall risk category in patients with OSCC.

Organized labor, public health, and tobacco control policy: a dialogue toward action

An action-oriented conference, Organized Labor, Public Health, and Tobacco Control Policy, was held in September 2000 in Boston, Massachusetts. Labor union leaders, tobacco control and public health activists, researchers, and practitioners met for two days to: 1) learn about existing labor-based tobacco control initiatives; 2) educate one another about resources, barriers, and opportunities for labor-public health joint action on tobacco policy; 3) and identify where agendas overlap and form the basis for specific next steps in collaborative efforts in tobacco-related research, training, and advocacy. This report summarizes presentations and participant discussions to inform readers of the information exchanged and of the enthusiasm shared by conference participants translated into a set of joint recommendations for increased labor-based and joint labor-public health action to reduce the burden of tobacco on working people.

Use and limitations of imatinib mesylate (Glivec), a selective inhibitor of the tyrosine kinase Abl transcript in the treatment of chronic myeloid leukaemia

Chronic myeloid leukaemia is associated with a specific translocation between chromosomes 9 and 22 that results in the formation of a chimaeric gene. This gene, when transcribed, produces the BCR-Abl oncoprotein which has tyrosine kinase activity and the ability to prevent apoptosis, but has no effect on cellular proliferation. Imatinib mesylate, an inhibitor of the BCR-Abl transcript modelled on the ATP binding pocket of the Abl oncoprotein, prevents phosphorylation of effector molecules and induces apoptosis. Imatinib has limited effectiveness when BCR-Abl cells are in the quiescent cell-cycle state of G0. A life-long regimen of imatinib should reduce the risk of relapse from cells leaving G0. Up-regulation of BCR-Abl expression, ATP binding pocket mutations, up-regulation of MDR1 and over-expression of Pgp are all thought to limit the effectiveness of imatinib. Advanced BCR-Abl positivity is associated with complex mutations, which are thought to have a cumulative effect on the BCR-Abl oncoprotein in disrupting normal signal transduction, making these cells refractory to monotherapy alone. Combination therapy is thought to overcome this. Research studies have identified imatinib as a potential treatment option for a diverse range of malignancies associated with BCR-Abl, platelet-derived growth factor receptor (PDGFr) and c-Kit pathways. This may extend the application of this special therapy in the future.

Assessing and intervening on OSH programmes: effectiveness evaluation of the Wellworks-2 intervention in 15 manufacturing worksites

AIMS

(1) To develop a transparent and broadly applicable method for assessing occupational safety and health (OSH) programmes or management systems; (2) to assess OSH programmes in a sample of manufacturing worksites; and (3) to determine whether a management focused occupational health intervention results in greater improvement in OSH programmes compared to minimal intervention controls.

METHODS

OSH programmes were assessed using an adaptation of the US Occupational Safety & Health Administration's 1995 Program Evaluation Profile. Scores were generated from 91 binary indicator variables grouped under four "Essential Elements". Essential Element scores were weighted to contribute to an overall programme score on a 100 point scale. Seventeen large manufacturing worksites were assessed at baseline; 15 sites completed the 16 month intervention and follow up assessments.

RESULTS

There was considerable variation in Essential Element scores across sites at baseline as judged by our instrument, particularly in "management commitment and employee participation" and "workplace analysis". Most sites scored highly on "hazard prevention and control" and "training and education". For overall OSH programme scores, most sites scored in the 60-80% range at baseline, with four sites scoring below 60%, suggesting weak programmes. Intervention sites showed greater improvements than controls in the four programme elements and in overall programme scores, with significantly greater improvements in "management commitment and employee participation".

CONCLUSIONS

The OSH programme assessment method used is broadly applicable to manufacturing work settings, and baseline profiles suggest needs for improvement in OSH programmes in most such worksites. Despite a small sample size, results showed that sustained management focused intervention can result in improvement in these OSH programme measures.

Inferior turbinate reduction in children using Holmium YAG laser-a clinical and histological study

BACKGROUND AND OBJECTIVES

To compare the efficacy and safety of inferior turbinate reduction in children using Holmium:YAG (Ho:Yag) laser and diathermy. Histological effects of these treatments on turbinate tissue are also studied.

STUDY DESIGN/MATERIALS AND METHODS

A retrospective review and structured telephone interview of paediatric cases treated with Ho:Yag laser and diathermy to inferior turbinates. The complications, morbidity and efficacy were quantified. Histological sections of inferior turbinates treated with diathermy (surface and submucosal) and laser were compared.

RESULTS

Efficacy in the laser (n = 8) and diathermy group (n = 11) was similar. The complication/morbidity score was lower in the laser group, 1.92 versus 3.48, (P = 0.04, CI: 0.01, 2). Long-term benefit was 50 and 36% in the laser and diathermy group respectively. Histology showed very limited tissue damage in all methods of treatment.

CONCLUSIONS

Ho:Yag laser treatment is equally efficacious, but causes less complications and morbidity compared to surface diathermy. Both treatment methods have poor long-term efficacy, which may be related to limited tissue damage.

Human immune response to streptococcal inhibitor of complement, a serotype M1 group A Streptococcus extracellular protein involved in epidemics

Streptococcal inhibitor of complement (Sic) is a highly polymorphic extracellular protein made by serotype M1 group A Streptococcus strains that contributes to bacterial persistence in the mammalian upper respiratory tract. New variants of the Sic protein arise very rapidly by positive selection in human populations during M1 epidemics. The human antibody response to Sic was analyzed. Of 636 persons living in diverse localities, 43% had anti-Sic serum antibodies, but only 16.4% had anti-M1 protein serum antibody. Anti-Sic antibody was also present in nasal wash specimens in high frequency. Linear B cell epitope mapping showed that serum antibodies recognized epitopes located in structurally variable regions of Sic and the amino terminal hypervariable region of the M1 protein. Phage display analyses confirmed that the polymorphic regions of Sic are primary targets of host antibodies. These results support the hypothesis that selection of Sic variants occurs on mucosal surfaces by a mechanism that involves acquired host antibody.

Pediatric genitourinary tumors

Advances in our knowledge of pediatric genitourinary tumors are being made at both the basic science and clinical levels. The molecular mechanisms underlying these pediatric malignancies are being uncovered and will aid in uncovering novel treatments. Because of the high success rate in treating these tumors, treatment options are being modified to decrease both short- and long-term morbidity, while maintaining the improved survival.

Improving transfusion practices in a busy teaching hospital

A retrospective audit of blood transfusions was carried out in Cardiff Royal Infirmary (CRI) to investigate how efficiently blood was requested and used by the various clinical directorates. Excessive crossmatch/transfusion (C/T) ratios were found for a number of operations. In an attempt to improve practices, a pilot study was carried out between the Department of Haematology and the largest single requesting group, the Orthopaedic Directorate. As a result of a preliminary retrospective audit, crossmatch guidelines were revised, with more reliance on the group and antibody screen (G & S) for low-risk operations. A subsequent prospective audit showed major reductions in crossmatch requests and a general decrease in C/T ratios to very efficient levels without any patient morbidity. Blood was freed for urgent use elsewhere, and significant cost improvements resulted. This study, using the orthopaedic surgery department as a model, shows the value of inter-departmental audit and supports the experience of other centres using similar methods to make considerable savings in the amount of blood crossmatched unnecessarily.

Pulmonary infiltration after exposure to home renovation dust: histopathology and microanalysis

A subacute self-resolving illness associated with bilateral pulmonary infiltration developed in a patient following renovation in her home. This may have been related to exposure to silicaceous plaster dust which was found in an environmental sample as well as on microanalysis of a transbronchial lung biopsy specimen and bronchoalveolar lavage fluid.

Spurious rise in total carbon dioxide and chloride with negative anion gap after cystogram

We report a case of spurious hyperchloraemia, elevated total carbon dioxide and negative anion gap 9 days following a voiding cystourethrogram (VCU) in a patient with bladder exstrophy and obstructive uropathy. We believe that the spurious laboratory results were due to analytical interference of the absorbed iodine with the method of bicarbonate and chloride measurement. The absorbed iodine was retained in the circulation for an extended period because of associated renal impairment. Our patient was also on piperacillin which might have interfered with iodine clearance. Physicians and laboratory pathologists should be aware of this effect when interpreting laboratory results of patients who have undergone a VCU in association with obstructive uropathy and impaired renal function.

Hodgkin's disease at the optic chiasm

In a case of visual loss due to infiltration of the optic chiasm by Hodgkin's lymphoma in a 44-year-old man the diagnosis was supported by histology of the optic chiasm, an axillary lymph node, and bone marrow at presentation. This appears to be only the third histologically proven reported case of Hodgkin's disease in this location, and the first diagnosed during life.

Haemoglobinopathy screening in a 'low-risk' area of the United Kingdom: South Glamorgan, Wales

Figures collected over 2 1/2 years of screening of women attending the antenatal clinics of South Glamorgan, Wales, showed that the percentage of women identified as a risk for haemoglobinopathy trait (7.4%) was almost twice that estimated from the 1981 Census data (4.1%) and that the incidence of a thalassaemia trait in these women (0.38% beta; 0.68% alpha) was similar to that of an area of supposedly greater risk in London (0.46% beta; 0.42% alpha). Figures from one laboratory showed that without a scrutiny of all antenatal clinic blood counts for thalassaemic indices some thalassaemia traits will be missed. The apparent incidence of the HbS trait was 0.13%, and reasons for this being an underestimate are given.

Perspectives on occult bacteremia in children

Bacteremia in young children seen in the outpatient clinic is a reasonably frequent occurrence with occasionally serious sequelae; most patients, however, do quite well. The problem is more perplexing in infants and young children with high fever and no apparent focus of infection. Laboratory tests and clinical observations help to determine which children are at low risk of occult bacteremia and need not have blood cultured; testing and assessment are much less predictive of the child who does have occult bacteremia. Currently, it is unclear whether treating all patients at risk is warranted. In any case, very close follow-up of the patient who is sent home from the outpatient department with high fever is desirable. The prevalence of serious infections caused by pneumococcus, Hib, and meningococcus warrants continued research on the development of vaccines that effectively prevent these infections.

Subselective preoperative embolization for meningiomas. A radiological and pathological assessment

Over a 2-year period the authors have studied the effects of preoperative subselective embolization of meningiomas. Thirty-six consecutive patients shown by computerized tomography (CT) to have a meningioma underwent selective internal and external carotid artery angiography, and any significant external carotid artery feeders were embolized (27 cases). It was found that CT and dynamic radioisotope scan findings were unable to predict the degree of vascularity of the tumor or its suitability for embolization. Furthermore, these tests, repeated after embolization, were unreliable in detecting either the extent of necrosis or reduction in blood flow. The effects of embolization upon surgery were recorded, and the excised tumor specimen examined for evidence of thrombosis and infarction. Subselective embolization was determined to be a simple, safe, and effective method of producing tumor necrosis and intraoperative hemostasis in selected patients.

A double-blind controlled trial of two dose levels of factor VIII in the treatment of high risk haemarthroses in haemophilia A

One hundred and thirteen haemarthroses involving the knees, ankles and elbows of 29 severe haemophiliacs presenting with at least two of the risk factors, pain, tenderness, loss of more than 50% of movement and a delay of more than 3 h in treatment were studied. Each was given either a 20% or 40% dose of factor VIII and progress was then reviewed by medical staff unaware of the initial dosage. There was no significant effect on the retransfusion rate nor on the time to complete resolution. However, the difference between the percentage of patients showing residual movement restriction was significantly in favour of the high dose at 24, 36 and 48 h when all the bleeds were pooled and at 48 h for elbow bleeds.

The neuropathology of the vegetative state and severe disability after non-missile head injury

A full neuropathological examination was undertaken in 35 cases of head injury who survived at least one month and who were either vegetative or severely disabled. Diffuse axonal injury was found in 21 cases, extensive hypoxic damage in the neocortex in 16 and secondary damage to the brain stem in 10.

Catheter embolization: preparation of patient with pheochromocytoma

This is a case report of a patient treated at West Virginia University Medical Center that illustrates the successful use of preoperative percutaneous angiographic embolization of a pheochromocytoma in controlling a malignant hypertensive crisis.

A New Technique in the Application of Thiersch Skin Grafts

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A New Blood Transfusion Apparatus

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