Biomedical subjects
Publications and source records attributed to R A Ord.
A case of polymorphous low-grade adenocarcinoma occurring in the sublingual gland is described, followed by a brief discussion on the differential diagnosis. This is the first case ever reported of this entity occurring in the sublingual gland. This paper brings into question the early belief that this tumor is restricted to intraoral minor salivary glands.
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PURPOSE: It has been well documented that patients with a diagnosis of cancer are at an increased risk of committing suicide. However, there is a paucity of literature on the risk of suicide in the head and neck cancer patient. The purpose of this investigation was to determine the incidence of suicide and expressed suicidal intent in a series of such cancer patients. PATIENTS AND METHODS: A retrospective chart review of 241 patients who were diagnosed with head and neck cancer at the University of Maryland Oral and Maxillofacial Surgery Oncology Division was done. RESULTS: Three patients were identified who committed suicide, 1.2% of the series. Two patients expressed suicidal intent, and four patients refused all treatment and counseling, preferring to die of their disease. CONCLUSIONS: Head and neck cancer patients have many of the same risk factors for suicide as patients with other forms of cancer. To reduce this risk, it is essential that the surgeon maintain good rapport with the patient, because this serves as a foundation for all other aspects of their therapy. In addition, these patients need to be fully evaluated for depression, hopelessness, pain, and other factors important in raising the possibility of suicide, and appropriate, aggressive management must be provided.
PURPOSE: This study examined the accuracy of frozen section diagnosis of tissue samples from surgical margins compared with the final histologic diagnosis of the same tissue. The total resection specimen was also examined to see whether frozen sections were helpful in predicting negative margins for the entire cancer. The nature of positive and negative margins and their implications for the surgeon are discussed. PATIENTS AND METHODS: The records of 49 consecutive patients with previously untreated squamous carcinoma of the mouth were reviewed. All frozen and permanent sections were evaluated by one pathologist. Margins involved by carcinoma, carcinoma in situ, dysplasia, or with carcinoma within 5 mm were defined as positive. Histologic findings were compared with the patient's clinical course to define the relationship between positive margins and local recurrence. Patients were followed for 17 to 45 months or until death. RESULTS: Three hundred four of 307 frozen sections showed concordance with the permanent section of the same tissue sample (two false negative and one false positive), an accuracy rate of 99%. When the final margins of the resected surgical specimen were compared with the frozen section diagnoses, ten patients had positive final margins. In three patients, these were diagnosed by frozen section. Seven patients had final margins that were positive when the surgical resection specimen was examined but were not diagnosed by frozen section. A greater local recurrence note was found in patients with invasive carcinoma at the margin, dysplastic margins, and margins within 5 mm of the cancer. CONCLUSIONS: Although frozen sections are extremely accurate, they are not as reliable in eliminating positive margins in the final specimen as the surgeon might hope.
PURPOSE: This study reviews the accuracy of preopertive diagnosis of mandibular invasion by oral squamous cell carcinoma and assesses the role of marginal resection of the mandible in its treatment. PATIENTS AND METHODS: A retrospective study of a 5-year cohort of 46 patients who underwent mandibular resection for previously untreated oral squamous cell carcinoma was done. Data evaluated included age; sex; site and stage of cancer; preoperative clinical, panoramic, and computed tomography (CT) evaluations; and histologic findings on the resection specimen. The type of mandibular resection (segmental vs marginal) and treatment outcome also were compared. RESULTS: Clinical examination, panoramic radiographs, and CT scans were 78.5% to 82.6% accurate in diagnosing mandibular invasion by squamous carcinoma. Clinical examination and panoramic radiographs are more sensitive than CT scans (86.6% vs 53%), but CT scans were more specific (92.5% vs 80%). The mandible was involved in 65% of patients with segmental resection and 7.6% of patients who had a marginal resection. Nineteen percent of the patients in the marginal resection group died of their oral cancer, two of five patients with local recurrence. Ten percent of patients in the segmental resection group died of oral cancer; no local recurrences were seen. CONCLUSION: There is no completely accurate method of diagnosing bony invasion of the mandible by oral squamous cell carcinoma. A combination of clinical examination, plain radiographs, and computed tomography (CT) scans may improve the diagnosis. Marginal resection is best reserved for cancers close to the bone with no invasion, minimal cortical invasion, or with early "arrosive" invasion. It is best in the symphysis region. Careful case selection will allow a favorable oncologic outcome with preservation of the mandibular contour.
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Combined chemoradiotherapy is superior to radiotherapy alone for stage III and IV squamous cell carcinoma of the head and neck, and concurrent use of both offers the advantage of synergistic interactions. Our prior trial demonstrated the ease and convenience of administering carboplatin during radiotherapy. Since paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) has activity in squamous cell carcinoma of the head and neck and can act synergistically with both radiotherapy and platinum drugs, we initially added paclitaxel at 45 mg/m2/wk to carboplatin given at 100 mg/m2 during radiotherapy given at conventional fractions. The initial dose of paclitaxel was subsequently reduced to 40 mg/m2/wk. Thirteen of 18 patients entered so far have sufficient follow-up data; 12 are assessable for toxicity and 11 are assessable for response. One died early of progressive disease, two achieved a complete response, six achieved a partial response, and two had stable disease. Toxicities have so far been manageable for the 76 weekly doses administered. Chemotherapy dose reduction was needed in 10 patients. For the planned 100 doses of chemotherapy, 53 (53%) were administered as planned, 23 (23%) were reduced, and 24 (24%) were withheld due to neutropenia or mucositis. There were no toxic deaths, and no patient stopped therapy for toxicity. Paclitaxel/carboplatin can be administered during radiotherapy for squamous cell carcinoma of the head and neck with acceptable toxicities, and further accrual is needed to evaluate the effect of this combination.
Significant clinical and biological differences are found between invasive squamous cell carcinoma (SCCA) and verrucous carcinoma (VC) of the oral cavity. The correct diagnosis of these tumors has important therapeutic implications. Immunoperoxidase stains for bcl-2, p53, and Her-2/neu, and in situ end-labeling of DNA to identify apoptosis were performed in eight VC and eight SCCA matched for age, sex, and stage. Marked differences were identified in the pattern of expression of oncogenes and the indexes of cell turnover in these two types of tumors. VC displayed minimal apoptosis in rare keratinizing cells (0 to 3%); p53-positive cells (4/8) and Ki-67 (8/8) were confined to the nuclei of the basal proliferating layers; and bcl-2 (4/8) was expressed only in the cytoplasm of rare tumor cells. In contrast, SCCA displayed higher apoptosis rates (5 to 10%), whereas p53- (5/8) and Ki-67- (8/8) positive nuclei were distributed randomly throughout the tumor. Very well differentiated areas in one SCCA case had a pattern of staining for p53 and Ki-67 similar to the one seen in VC. In SCCA bcl-2 showed patchy cytoplasmic staining (4/8) or strong cytoplasmic and nuclear positivity (2/8) in the less differentiated tumors. Her-2/neu was negative in all VC and SCCA cases. The different levels and patterns of gene expression and cell turnover between SCCA and VC undoubtedly correlate with the different biology and prognosis of these tumors.
PURPOSE: Floor-of-mouth cancers frequently involve the submandibular duct. When neck dissection, which removes the submandibular gland, is not planned, the duct requires repositioning and cannulation to avoid obstructive sialoadenitis caused by scarring and stricture after excision of the primary lesion. A swollen submandibular salivary gland may be difficult to differentiate from a metastatic node and complicate subsequent oncologic management. This study reviews the clinical course and complications after repositioning and cannulation of the submandibular duct. PATIENTS AND METHODS: Thirteen patients who underwent 21 duct cannulations over a 25-month period were reviewed for assessment of submandibular gland function and complications of the procedure. RESULTS: Only two patients (15%) had episodes of postoperative neck swelling during follow-up. The commonest complication was early loss of the cannula in 7 of 21 patients (33%). There were no cases of local recurrence of the tumor, and only 1 patient of 10 with carcinomas had later cervical metastasis. CONCLUSIONS: Repositioning and cannulation of the submandibular duct is a sound procedure that does not compromise the cancer resection. The problem of later chronic swelling of the salivary gland is avoided. Fixation of the catheter has been inadequate in one third of patients.
PURPOSE: This article retrospectively reviews 50 consecutive pectoralis major flaps used in oral and maxillofacial reconstruction with respect to reliability and complications. PATIENTS AND METHODS: Fifty patients had reconstruction of postcancer resection defects of the oral cavity and maxillofacial region. The age and sex of the patients and site of defect were analyzed. The design of the pectoralis major flap and complications encountered were documented. RESULTS: There were three cases (6%) of flap failure and an additional three cases (6%) in which 40% or more of the skin paddle sloughed. Orocutaneous fistula was rare. The use of an osteomyocutaneous flap with a rib gave poor results for mandibular reconstruction. CONCLUSION: The pectoralis major flap is reliable, and the complications seen in this series were comparable to other large series in the literature. Despite the increased use of microvascular flaps, the pectoralis major flap remains an excellent reconstructive choice for large soft tissue defects in the oral cavity.
Squamous cell carcinoma of the oral cavity and oropharynx may be amenable to chemoprevention. This review focuses on current concepts of mechanisms in oral carcinogenesis, as well as the evidence that retinoids have a role in the primary and secondary prevention of this malignancy.
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PURPOSE: Baseball bats, although meant for recreational use, are also frequently used as assault weapons, resulting in multiple types of injuries including those in the maxillofacial region. This report reviews the patients admitted to the Maryland Institute of Emergency Medical Service with maxillofacial injuries caused by blunt trauma from assault with a baseball bat between July 1989 and January 1994. PATIENTS AND METHODS: Records of 29 patients were reviewed for age, sex, race, Glasgow Coma Scale, associated drug or alcohol use, type of injury, and associated injuries. RESULTS: In this inner city hospital study it was found that 18 of the patients (62%) were African-American and that 74% of the victims had associated alcohol abuse and 38% had associated drug abuse. Of the 29 patients, 27 (93%) were men and 23 (79%) were between the ages of 21 and 40 years. The majority of fractures involved the midface region and nearly half the patients had concomitant neurologic injury. Two patients died as a result of their injuries. CONCLUSION: Assaults with a baseball bat can result in significant morbidity and even mortality.