Prostate Metastasis in Oral Malignant Melanoma - A Case Report.

ABSTRACT: Melanoma is the ninth most prevalent and the second most lethal tumour. The aetiology and pathogenesis remain uncertain. It occurs in elderly people, over the fifth decade, and is predominant in males. Clinically, they present as an asymptomatic macular or nodular growth. The prognosis is impacted by the size of the tumour and distant metastases. Patients with distant metastases have a 5-year survival rate of less than 30%, constituting metastasis as the major cause of melanoma-related fatality. Currently, the mainstay of treatment for metastatic melanoma is immunotherapy due to the inoperable state, radioresistant nature of the tumour and high chances of cytotoxicity in chemotherapy. A senile male patient, who was diagnosed with oral malignant melanoma of the maxillary buccopalatal gingiva with distant metastasis to the liver and the prostate, is reported here. Although metastasis to the liver is common among malignant melanomas, in this case metastasis to the prostate gland highlights the rarity.

A feasibility study assessing quantitative indocyanine green angiographic predictors of reconstructive complications following nipple-sparing mastectomy.

Introduction: Immediate post-mastectomy breast reconstruction offers benefits; however, complications can compromise outcomes. Intraoperative indocyanine green fluorescence angiography (ICGFA) may mitigate perfusion-related complications (PRC); however, its interpretation remains subjective. Here, we examine and develop methods for ICGFA quantification, including machine learning (ML) algorithms for predicting complications. Methods: ICGFA video recordings of flap perfusion from a previous study of patients undergoing nipple-sparing mastectomy (NSM) with either immediate or staged immediate (delayed by a week due to perfusion insufficiency) reconstructions were analysed. Fluorescence intensity time series data were extracted, and perfusion parameters were interrogated for overall/regional associations with postoperative PRC. A naïve Bayes ML model was subsequently trained on a balanced data subset to predict PRC from the extracted meta-data. Results: The analysable video dataset of 157 ICGFA featured females (average age 48 years) having oncological/risk-reducing NSM with either immediate (n=90) or staged immediate (n=26) reconstruction. For those delayed, peak brightness at initial ICGFA was lower (p<0.001) and significantly improved (both quicker-onset and brighter p=0.001) one week later. The overall PRC rate in reconstructed patients (n=116) was 11.2%, with such patients demonstrating significantly dimmer (overall, p=0.018, centrally, p=0.03, and medially, p=0.04) and slower-onset (p=0.039) fluorescent peaks with shallower slopes (p=0.012) than uncomplicated patients with ICGFA. Importantly, such relevant parameters were converted into a whole field of view heatmap potentially suitable for intraoperative display. ML predicted PRC with 84.6% sensitivity and 76.9% specificity. Conclusion: Whole breast quantitative ICGFA assessment reveals statistical associations with PRC that are potentially exploitable via ML.

Central Mucoepidermoid Carcinoma in the Mandible Mimicking Dentigerous Cyst: A Report of a Rare Case.

Mucoepidermoid carcinoma is a rare neoplasm of the salivary gland of which the intraosseous variety is commonly observed with a female predilection and the affected side is more commonly in the mandible. It is usually perceived as an asymptomatic swelling that increases in volume over a few months to a year. They more frequently present as a cortical bulging and are mostly discovered as an accidental finding in a routine radiograph as a well-defined unilocular or multilocular radiolucency resembling an odontogenic cyst. The most widely accepted treatment is radical surgical resection due to its recurrence or metastatic nature. The current case is quite unusual developing in the posterior jaw as a result of an impacted third molar in a 22-year-old female patient.

A Diagnostic Challenge of Oral Psoriasis in a Pediatric Patient: A Case Report and Review of the Literature.

Congenital psoriasis is a rare skin disease that can clinically manifest in the oral cavity in many ways. Although manifestations over the skin are frequent, oral manifestations are rare, especially in pediatric patients. A clear family history, proper examination, and investigations are essential to diagnose this condition. This case report aims to highlight the oral and systemic manifestations of a case of psoriasis in a male pediatric patient.

Capillary Hemangioma Managed With Laser Ablation: A Case Report.

Introduction: Hemangiomas are hamartomatous benign tumours of the vascular tissue, which are common among infants and adolescents and are found in the head and neck region. Oral hemangiomas are infrequently encountered in the palate. Baseline soft tissue imaging must be considered for an appropriate diagnosis and treatment approach. Case Report: A 68-year-old female presented with a painless growth in the roof of her mouth that gradually increased in its size. She was subjected to intraoral ultrasonography and was diagnosed with capillary hemangioma. In this instance, laser ablation was chosen as the preferred treatment due to the complications associated with the conventional surgery. Conclusion: This case report enlightens the systematic diagnostic approach and treatment plan.

Hemangioma of Tongue With Multiple Phleboliths Involving Multiple Spaces of the Right Side of the Head and Neck Region: A Case Report Along With the Importance of Specialized Imaging.

Hemangioma is one of the most common tumors of dilated blood vessels, which is usually present at birth and involutes over time. Although considered the most common tumor in the head and neck region, the oral cavity is less commonly affected. The occurrence of hemangioma in the tongue is very rare (14%). Changes in blood flow are dynamic within the hemangioma resulting in thrombus and phleboliths. Phleboliths are small blood clots that occur in a vein, which usually hardens over time due to calcifications. The phleboliths are also called vein stones, which tend to be oval-shaped and are generally less than 5 millimeters in diameter. This paper reports a case of hemangioma of the tongue. On routine radiographic investigation (orthopantomogram), multiple phleboliths were found extending over the right side of the jaw involving the ramus and body of the mandible, which was an incidental finding. On specialized imaging, the extent of the phleboliths turned out to involve multiple spaces, which was unexpected.

Complete mesocolic excision versus standard resection for colon cancer: a systematic review and meta-analysis of perioperative safety and an evaluation of the use of a robotic approach.

PURPOSE: Complete mesocolic excision (CME) has been associated with improved oncological outcomes in treatment of colon cancer. However, widespread adoption is limited partly because of the technical complexity and perceived risks of the approach. The aim of out study was to evaluate the safety of CME compared to standard resection and to compare robotic versus laparoscopic approaches. METHODS: Two parallel searches were undertaken in MEDLINE, Embase and Web of Science databases 12 December 2021. The first was to evaluate IDEAL stage 3 evidence to compare complication rates as a surrogate marker of perioperative safety between CME and standard resection. The second independent search compared lymph node yield and survival outcomes between minimally invasive approaches. RESULTS: There were four randomized control trials (n = 1422) comparing CME to standard resection, and three studies comparing laparoscopic (n = 164) to robotic (n = 161) approaches. Compared to standard resection, CME was associated with a reduction in Clavien-Dindo grade 3 or higher complication rates (3.56% vs. 7.24%, p = 0.002), reduced blood loss (113.1 ml vs. 137.6 ml, p < 0.0001) and greater mean lymph node harvest (25.6 vs. 20.9 nodes, p = 0.001). Between the robotic and laparoscopic groups, there were no significant differences in complication rates, blood loss, lymph node yield, 5-year disease-free survival (OR 1.05, p = 0.87) and overall survival (OR 0.83, p = 0.54). CONCLUSIONS: Our study demonstrated improved safety with CME. There was no difference in safety or survival outcomes between robotic and laparoscopic CME. The advantage of a robotic approach may lie in the reduced learning curve and an increased penetration of minimally invasive approach to CME. Further studies are required to explore this. PROSPERO ID: CRD42021287065.

Herpes Zoster: A Case Report of a Rare Ramification Leading to Secondary Infection.

The herpes virus causes herpes zoster (HZ) (shingles). It develops years later in elderly patients who were affected by the varicella-zoster virus in their childhood. The virus gets reactivated and typically localizes its symptoms to a particular dermatome. If left untreated, it can lead to dental complications, such as osteonecrosis, tooth exfoliation, periodontitis, calcified and devitalized pulps, periapical lesions, and root resorption, in addition to developmental irregularities, such as abnormally short roots and missing teeth. Here, we present the case of a 61-year-old male affected by a rare bacterial superinfection followed by an HZ infection. Our report aims at making clinicians aware of the various potential complications that can develop after an HZ infection.

Neoadjuvant chemotherapy in non-metastatic breast cancer: The surgeon's perspective.

Breast cancer is the most common non-skin cancer in Australia, affecting 1 in 7 women by the age of 85 years. Current management of early breast cancer is becoming increasingly variable and complex. The typical range of treatments include some combination of surgery, chemotherapy and targeted therapy, immunotherapy, radiotherapy, and endocrine therapy. Neoadjuvant chemotherapy (NACT) in carefully selected patients can facilitate increased rates of breast conservation therapy, and when successful, offers improved cosmesis due to less extensive resection of tissue. A neoadjuvant approach also provides biological insight into a patient's tumour, prognostication based on a patient's response to therapy, as well as enabling their treating oncologist to personalise adjuvant strategies based on the presence or absence of residual cancer at surgery. Neoadjuvant chemotherapy has become an integral element in the provision of breast conserving surgery to selected early-stage breast cancer patients. Appreciating the indications and understanding the likely outcomes from NACT in select situations, can result in significant improvements in patient tailored care.

Atypical presentation of maxillary osteomyelitis in an immunocompromised patient.

Maxillary osteomyelitis is a relatively rare presentation. This condition is more often associated with underlying immunocompromised systemic conditions. Thorough clinical examination coupled with meticulous investigative protocol is needed to prevent the dreaded complications associated with the disease. With the emergence of new antibiotics and the use of advanced imaging modalities, the management of such patients has been better over the recent years. Oral physicians play a major role by providing primary care in the early diagnosis of such lesions, especially in immunocompromised patients, thereby improving the patient's quality of life. The present report highlights an atypical presentation of maxillary osteomyelitis in a newly diagnosed diabetic patient, with the importance of appropriate diagnostic workup, and prompt institution of treatment resulting in complete recovery.

Oral Pemphigus Vulgaris.

Pemphigus is a chronic mucocutaneous autoimmune disease with the clinical feature of blisters that initially appear in the oral cavity and later in the skin. The dental professionals play an important role in diagnosing the disease. Early diagnosis and treatment determine the course and prognosis of the disease. Systemic corticosteroids continue to be the standard therapy for pemphigus vulgaris (PV). Management of PV involves prolonged use of steroids to control the disease and prevent relapses, but associated adverse events constantly remain a great challenge. Regular periodic clinical evaluation of patients with pemphigus on steroids is mandatory. This article describes a case of a 50-year-old woman with multiple chronic ulcers in the oral cavity in whom the diagnosis of PV was made and treated. The case study is followed by a review of the literature including etiology, pathogenesis, clinical features, as well as the various diagnostic criteria and the therapeutic options of PV.

Superficial Mucocele: A Rare Presentation.

Superficial mucoceles are benign, small, translucent vesicles occurring in any part of the oral cavity, due to extravasation of saliva due to ruptured minor salivary gland ducts. This distinct entity presents as single or multiple asymptomatic vesicles. The etiology is unclear; however, these are not associated with a history of trauma, unlike the conventional mucoceles. These lesions tend to be recurrent and are occasionally associated with discomfort to the patients. Since they clinically mimic various vesiculobullous lesions such as pemphigoid, bullous lichen planus, or herpes virus infection, they are often misdiagnosed. Asymptomatic superficial mucoceles or lesions in multiple locations do not require treatment. Nevertheless, the treatment for lesions causing discomfort includes surgical excision, cryosurgery, and carbon dioxide (CO2) laser. This case report describes a rare presentation of superficial mucocele along the midline of the hard palate in a 30-year-old male patient, which was histopathologically confirmed post-surgical excision; the patient is currently disease free with no recurrence for six months.

Complete pathological response in rectal cancer utilising novel treatment strategies for neo-adjuvant therapy: A systematic review.

BACKGROUND: Locally advanced rectal cancer is routinely treated with neo-adjuvant long course chemoradiotherapy or short course radiotherapy, followed by total mesorectal excision. Not all patients respond to this treatment and there has been an emergence of novel treatment strategies designed to improve outcomes for these patients. This systematic review aims to assess the current novel neo-adjuvant treatment strategies being utilised in the treatment of patients with rectal cancer and how these impact pathological complete response (pCR) rates. METHODS: A systematic review of the literature was performed to evaluate pathological response in patients with rectal cancer receiving novel neo-adjuvant therapy. EMBASE and Medline electronic databases were searched for relevant articles. Articles published between January 2008 and February 2019 were retrieved. Included studies underwent critical appraisal and complete pathological response rates were recorded. RESULTS: Of the initial 1074 articles identified, 217 articles fulfilled the inclusion criteria, of these 60 articles (4359 patients) were included. Neo-adjuvant therapy delivered included novel long course chemoradiation therapy, neoadjuvant chemotherapy alone, addition of a biological agent, total neo-adjuvant therapy, novel short course radiation therapy and studies utilising biomarkers to select patients for therapy. Complete pathological response rates ranged from 0 to 60%. CONCLUSION: A validated novel neo-adjuvant therapy that significantly increases pCR rates in patients with rectal cancer has not been identified.

Transanal mesorectal excision: early outcomes in Australia and New Zealand.

BACKGROUND: Transanal total mesorectal excision (taTME) aims to overcome some of the technical challenges faced when operating on mid and low rectal cancers. Specimen quality has been confirmed previously, but recent concerns have been raised about oncological safety. This multicentre prospective study aimed to evaluate the safety of taTME among early adopters in Australia and New Zealand. METHODS: Data from all consecutive patients who had taTME for rectal cancer from July 2014 to February 2020 at six tertiary referral centres in Australasia were recorded and analysed. RESULTS: A total of 308 patients of median age of 64 years underwent taTME. Some 75.6 per cent of patients were men, and the median BMI was 26.8 kg/m2. The median distance of tumour from anal verge was 7 cm. Neoadjuvant chemoradiotherapy was administered to 57.8 per cent of patients. The anastomotic leak rate was 8.1 per cent and there was no mortality within 30 days of surgery. Pathological examination found a complete mesorectum in 295 patients (95.8 per cent), a near-complete mesorectum in seven patients (2.3 per cent), and an incomplete mesorectum in six patients (1.9 per cent). The circumferential resection margin and distal resection margin was involved in nine patients (2.9 per cent), and two patients (0.6 per cent) respectively. Over a median follow-up of 22 months, the local recurrence rate was 1.9 per cent and median time to local recurrence was 30.5 months. CONCLUSION: This study showed that, with appropriate training and supervision, skilled minimally invasive rectal cancer surgeons can perform taTME with similar pathological and oncological results to open and laparoscopic surgery.

Abdominoperineal excision in Australasia: clinical outcomes, predictive factors and recent trends of nonrestorative rectal cancer surgery.

AIM: The decision to perform an abdominoperineal excision (APR) rather than restorative bowel resection relies on a number of clinical factors. There remains great variability in APR rates internationally. The aim of this study was to demonstrate trends of APR surgery in low rectal cancer (< 6 cm from the anal verge) in Australasia and identify predictors of nonrestoration. METHOD: This study reviewed a prospectively maintained colorectal registry - the Binational Colorectal Cancer Audit (BCCA) - from general/colorectal surgical units across Australia and New Zealand. Data were analysed to determine factors predictive of nonrestorative resection. Patients were analysed based on the presence (control) or absence (comparison) of a primary anastomosis. RESULTS: Of 3628 patients with rectal cancer, 2096 were diagnosed with low rectal cancer between 2007 and 2017. The incidence of APR remained constant over the study period, with 58% of all resections of low rectal cancer being APR. The majority of resections were performed by consultants in urban hospitals (86% vs 14%). Tumours ≤ 3 cm from the anal verge, T4, M1 disease and neoadjuvant therapy were the greatest predictors of APR (P < 0.001). A significantly increased rate of restorative surgery was observed in public hospital settings (59% vs 41%, P < 0.05). The rate of positive circumferential resection margin (CRM) was 7.95%, with significantly increased rates in patients undergoing APR (12.2% vs 6.2%, P < 0.001). CRM positivity was increased in open approaches, T4, N2 and M1 staged disease and in an emergency/urgent setting (P < 0.001 and P < 0.045, respectively). Significantly increased wound and pulmonary complications were observed in the APR cohort (P < 0.01). CONCLUSION: The rates of APR in Australia and New Zealand remain high but are comparable to international figures, with one-third of rectal cancers being treated by APR. The main determinants of APR are tumour height, T stage and neoadjuvant therapy requirement. CRM positivity was higher in APR patients.

Robotic multivisceral pelvic resection: experience from an exenteration unit.

BACKGROUND: Pelvic exenteration remains a viable and effective treatment option for the management of locally advanced or recurrent pelvic malignancy. The aim of this study was to present an early experience of robotic multivisceral resection of pelvic malignancy, and to compare this experience with similar series through a systematic review of the literature. METHODS: A retrospective study was performed on patients who had robotic-assisted multi-visceral resection for pelvic malignancy at a single Colorectal Surgical unit based between two tertiary academic hospitals. Primary outcomes observed included operation type, operation time, perioperative complications, and hospital length of stay. Secondary outcomes included R0 resection status, lymph node harvest, and rate of recurrence at clinical follow-up. RESULTS: Eight cases of robotic multivisceral resection were performed for primary locally advanced pelvic malignancy involving a rectal resection as part of their operative management. The median age of patients undergoing resection was 56 years (range 29-83 years). The male:female ratio was 6:2. The mean total operating time was 8.3 h (range 6-10 h). Perioperative blood transfusion requirements were minimal. Mean hospital length of stay was 15 days (range 7-26 days). No patients experienced any serious postoperative morbidity or mortality. All patients had clear margins on histological assessment and no patients have recurrence at 12-month follow-up. CONCLUSIONS: Robotic multivisceral resection for malignant disease of the pelvis is a safe and feasible minimally invasive approach in highly selected cases.