The feasibility of visualizing and quantifying muscle changes in postoperative oral cancer patients using Quantitative Muscle Ultrasound (QMUS).

PURPOSE: Quantitative muscle ultrasound (QMUS) is a patient friendly tool for examining orofacial muscles. Resection of tissue can have an effect on the architecture and function of these muscles. The aim of this study is to investigate the feasibility of visualizing and quantifying muscle changes in postoperative oral cancer patients and to relate the findings to tumor and patient characteristics. METHODS: Adult patients with a resected first primary pT1 or T2 oral squamous cell carcinoma, at least one year post operatively, where included. Ultrasound data were collected of the geniohyoid muscle, digastric muscles, masseter muscle, transverse muscle and genioglossus muscle. Ultrasound images were labeled as clearly visible, questionable or unclear. Of the clear muscles, echogenicity and muscle thickness were measured. RESULTS: 37 patients were included. The masseter muscle was clearly visible in all ultrasound images, both intrinsic tongue muscles had the lowest visibility (45.9%). There was a significant correlation between visibility and tumor localization for the genioglossus (p = 0.029). Age correlated with the visibility of the genioglossus muscle, BMI with the genioglossus and transverse muscles. Echogenicity and muscle thickness of the clearly identified muscles did not differ from normative values. CONCLUSION: QMUS of orofacial muscles is feasible in postoperative oral cancer patients with relatively small tumor sizes. Tongue resections negatively affected the visibility of the two intrinsic tongue muscles. These preliminary results for particular muscles indicate that the use of ultrasound might be promising in oral cancer patients to help determine targeted goals in post-operative rehabilitation.

Visor flap: A solution for the reconstruction of large skin defects on the frontal and parietal parts of the skull.

BACKGROUND: Reconstruction of skin defects after oncological surgery for a cutaneous squamous cell carcinoma is often mandatory to facilitate adjuvant treatment and/or to prevent chronic wound problems. Some of the most challenging regions to reconstruct after resection of a skin tumor are the frontal and parietal parts of the skull. METHODS: This article describes three patients with large skin defects after oncological surgery that were reconstructed with the use of a (hemi) visor flap. RESULTS: The (hemi) visor flap is easy to harvest, resulting in a concise procedure and short hospitalization with maximum wound control. CONCLUSION: The (hemi) visor flap is a safe and reliable option for the closure of large skin defects on the skull. Especially in the older and frail patient group.

Variation in Integrated Head and Neck Cancer Care: Impact of Patient and Hospital Characteristics.

Background: Monitoring and effectively improving oncologic integrated care requires dashboard information based on quality registrations. The dashboard includes evidence-based quality indicators (QIs) that measure quality of care. This study aimed to assess the quality of current integrated head and neck cancer care with QIs, the variation between Dutch hospitals, and the influence of patient and hospital characteristics. Methods: Previously, 39 QIs were developed with input from medical specialists, allied health professionals, and patients' perspectives. QI scores were calculated with data from 1,667 curatively treated patients in 8 hospitals. QIs with a sample size of >400 patients were included to calculate reliable QI scores. We used multilevel analysis to explain the variation. Results: Current care varied from 29% for the QI about a case manager being present to discuss the treatment plan to 100% for the QI about the availability of a treatment plan. Variation between hospitals was small for the QI about patients discussed in multidisciplinary team meetings (adherence: 95%, range 88%-98%), but large for the QI about malnutrition screening (adherence: 50%, range 2%-100%). Higher QI scores were associated with lower performance status, advanced tumor stage, and tumor in the oral cavity or oropharynx at the patient level, and with more curatively treated patients (volume) at hospital level. Conclusions: Although the quality registration was only recently launched, it already visualizes hospital variation in current care. Four determinants were found to be influential: tumor stage, performance status, tumor site, and volume. More data are needed to assure stable results for use in quality improvement.

The value of histological grading of biopsy and resection specimens in early stage oral squamous cell carcinomas.

INTRODUCTION: In oral squamous cell carcinoma (OSCC) the differentiation grade of the tumor is determined on the biopsy and the resection specimen. The relation between tumor grade, nodal metastasis and survival is debatable. The aims of this study were to determine the correlation between differentiation grade of the biopsy and the resection specimen. Furthermore, we wanted to correlate tumor differentiation grade with nodal stage and survival. PATIENTS AND METHODS: One-hundred and forty-five patients with OSCC staged as T1-2, N0 of the tongue, floor of mouth or cheek with primary resection of the tumor were examined. Biopsy and resection specimen were histologically re-assessed with regard to differentiation grade, as well as infiltrative, peri-neural and vascular invasive growth. RESULTS: This study showed a poor correlation between differentiation grade in the incisional biopsy and the resection specimen of the same tumor. No significant relation between differentiation grade of the resection specimen and nodal involvement, as well as overall and disease-specific survival was found. CONCLUSION: In early OSCC the differentiation grade determined by biopsy is of little predictive value for the grading of the resection specimen. Poor differentiation grade could not be related to the presence of nodal metastasis or survival and seems not to have any prognostic value concerning outcome. Treatment planning must be related to these findings.

Poor Correlation of Histologic Parameters Between Biopsy and Resection Specimen in Early Stage Oral Squamous Cell Carcinoma.

OBJECTIVES: Infiltration depth, perineural growth (PG), vascular invasive growth (VG), and infiltrative growth (IG) are associated with regional metastases in oral squamous cell carcinomas (OSCCs). Preoperative knowledge of these parameters could facilitate the treatment planning of the neck. The aim of this study was to evaluate if the biopsy specimen correlates with the resection specimen. METHODS: In total, 149 patients with a pT1-2cN0 OSCC were included. Biopsy thickness and tumor thickness were analyzed. Occurrence of PG, VG, and IG was determined on biopsy and resection specimens and correlated with the N status and survival. Sensitivity, specificity, positive and negative predictive value, and diagnostic gain of the biopsy specimen were calculated. RESULTS: N+ patients showed PG, VG, and IG significantly more often in the resection specimen compared with N- patients (P = .02, P = .001, and P = .001, respectively). Histologic parameters in the biopsy specimens did not correlate with N status or survival. The positive diagnostic gain for biopsy specimens with PG, VG, and IG was 57%, 40%, and 19%, respectively. The negative diagnostic gain was 2%, 0%, and 22%, respectively. CONCLUSIONS: Histologic parameters in biopsy specimens do not represent the resection specimen. Determination of histologic parameters in routinely taken biopsy specimens of OSCC is not helpful in deciding whether to treat the neck.

Resection of early oral squamous cell carcinoma with positive or close margins: relevance of adjuvant treatment in relation to local recurrence: margins of 3 mm as safe as 5 mm.

OBJECTIVES: The treatment strategy of early stage oral squamous cell carcinoma's (OSCC) resected with close or involved margins is a returning point of discussion. In this study we reviewed the consequences of re-resection (RR), postoperative radiotherapy (PORT) or watchful waiting (WW). PATIENTS AND METHODS: Two-hundred patients with a primary resected Stage 1-2 OSCC of the tongue, floor of the mouth and cheek were included and retrospectively analysed. Local recurrence ratio was related to margin status, unfavourable histological parameters (spidery infiltrative, peri-neural and vascular-invasive growth) and postoperative treatment modality. 3-year overall survival (OS) and disease-specific survival (DSS) was calculated in relation to margin status. RESULTS: Twenty-two of 200 (11%) patients had pathological positive margins (PM), 126 (63%) close margins (CM), and 52 (26%) free margins (FM). OS and DSS were not significantly different between these groups. Nine of 200 (4.5%) patients developed local recurrent disease. Two (9.1%) had a PM, five (4.0%) a CM and two (3.8%) a FM. Of the nine recurrences, five patients had undergone PORT, one a RR, and three follow-up. Watchful waiting for CM ⩾3 mm with ⩽2 unfavourable histological parameters showed, besides margin status no significant differences with the FM group. CONCLUSION: With this treatment strategy, the local recurrence rate was 4.5%. No evidence was found for local adjuvant treatment in case of close margins ⩾3 mm with ⩽2 unfavourable histological parameters. Current data do not support the use of one treatment modality above any other.

Micro-structured calcium phosphate ceramic for donor site repair after harvesting chin bone for grafting alveolar clefts in children.

OBJECTIVES: The purpose of this study was to evaluate the use of synthetic bone graft material as a filling material at the mandibular symphysis donor site of autologous bone in children. MATERIALS AND METHODS: A blinded patient group comprised 20 patients with unilateral (UCLP) or bilateral (BCLP) cleft of lip and palate, all with an indication for alveolar cleft repair. The study took the form of a prospective randomized clinical trial. We used lateral cephalograms for the measurement of the symphyseal donor area defect both peroperatively and at 12 months postoperatively. The data obtained were digitalized and the treatment outcome expressed in numbers. Comparisons with a previous study were made. Histology of biopsies and CT scans were used for visualising bone formation. RESULTS: This study demonstrates that the micro-structured, resorbable calcium phosphate ceramic provides good regeneration properties for the repair of a critical size bony defect in children. One year postoperatively, the measurements taken from lateral cephalograms show that there is scarcely any visible residual defect. Histological investigations of the bone biopsies show solid, induced bone formation and almost complete resorption of the micro-structured calcium phosphate. CONCLUSIONS: The findings of this study (novel in children) indicate that micro-structured resorbable calcium phosphate is an excellent alternative to autologous bone. The digital findings showed a restored donor site defect significantly indicating the efficacy (i.e., osteoconductivity and resorbability) of this bone substitute. The biopsy histology demonstrated the overall presence of newly formed vital bone and the resorption of the bone substitute. Its use for grafting the alveolar cleft is currently researched and it may become the new standard. CLINICAL RELEVANCE: As co-morbidity and prolonged operation time at the donor operation site are inherent to the alveolar cleft repair procedure, the use of the described bone substitute is winning progress.

The modifications of the sagittal ramus split osteotomy: a literature review.

BACKGROUND: In 1953, the sagittal ramus split osteotomy was introduced by Obwegeser. For many years, and in some countries still, this technique has defined the term oral and maxillofacial surgery. METHODS: The basic design of the sagittal ramus split surgical procedure evolved very quickly. The original operation technique by Obwegeser was shortly after improved by Dal Pont's modification. The second major improvement of the basic technique was added by Hunsuck in 1967. Since then, the technical and biological procedure has been well defined. Resolution of the problems many surgeons encountered has, however, taken longer. Some of these problems, such as the unfavorable split or the damage of the inferior alveolar nerve, have not been satisfactorily resolved. RESULTS: Further modifications, with or without the application of new instruments, have been introduced by Epker and Wolford, whose modification was recently elaborated by Böckmann. The addition of a fourth osteotomy at the inferior mandibular border in an in vitro experiment led to a significant reduction of the torque forces required for the mandibular split. CONCLUSIONS: The literature was reviewed, and the last modifications of the successful traditional splitting procedure are presented narrowly. It indicates the better the split is preformatted by osteotomies, the less torque force is needed while splitting, giving more controle, a better predictability of the lingual fracture and maybe less neurosensory disturbances of the inferior alveolar nerve.