Successful treatment of erosive lichen planus with Upadacitinib complicated by oral squamous cell carcinoma.

Erosive lichen planus is a chronic auto-inflammatory disease which affects the stratified squamous epithelia resulting in painful ulcerations of both the skin and mucosal surfaces, and has a known malignant potential. Management of erosive lichen planus has proven to be difficult; however, recent reports of treatment with Janus kinase inhibitors such as Upadacitinib, are encouraging. This report outlines the third reported case of erosive lichen planus to be successfully treated with Upadacitinib in a 70-year-old woman with treatment-resistant disease. In addition, we report the complication of oral squamous cell carcinoma which became apparent once the extensive erosive lichen planus had healed. This case report highlights the importance of monitoring for mucosal squamous cell carcinoma in areas affected by erosive lichen planus, as squamous cell carcinoma can mimic the erosions of erosive lichen planus.

Treatment of Soft-Tissue Necrosis of the Pyriform Sinus Using Pentoxyllifylline and Tocopherol.

Radiotherapy of the head and neck can often lead to complications and side effects, including osteoradionecrosis and soft tissue necrosis. One relatively well-established method of treating osteoradionecrosis includes the PENTOCLO protocol, which consists of Pentoxyllifylline, Tocopherol, and Clodronate. Despite its success in the treatment of osteoradionecrosis, the effectiveness of components of the PENTOCLO protocol in treating soft tissue necrosis of the head and neck is underexplored. This case study reviews the successful treatment of a pyriform sinus ulcer that developed after the use of radiotherapy in treating a T3N2b squamous cell carcinoma. The treatment plan used Pentoxyllifylline and Tocopherol, and omitted Clodronate, and can therefore be referred to as a PENTO protocol.

Chondroma of the Nasal Septum.

Chondromas are benign cartilaginous tumours that rarely occur in the head and neck region. Only a limited number of cases have been reported involving the nasal septum. Here we report a case of a 55-year-old male that presented with a suspicious lesion involving his nasal septum and columella. The lesion was removed under general anesthestic using a combination of both columellar and hemitransfixion incisions. The lesion consisted of firm tan-white tissue measuring 2.5 cm. Histopathologic examination revealed a low-grade chondroid neoplasm with lobulated hyaline cartilage. No signs of ischemic change, significant pleomorphism, mitoses, or necrosis were present. This was consistent with the features of a chondroma rather than a low-grade chondrosarcoma. A chondroma should be considered in the differential diagnosis of nasal septum lesions. Surgical excision of the tumour is the preferred treatment option.

Three-Dimensional Printing: A Novel Approach to the Creation of Obturator Prostheses Following Palatal Resection for Malignant Palate Tumors.

BACKGROUND: A subgroup of patients who have an oronasal fistula live in areas that have limited access to oral prosthetics. For these individuals, a temporary prosthesis, such as a palatal obturator, may be necessary in order to speak, eat, and breath properly. The creation of an obturator, which requires a highly trained prosthodontist, can take time and can be expensive. Through the current proof-of-concept study, there is an attempt to create a patient-specific palatal obturator through use of free and publicly available software, and a low-cost desktop 3-dimensional printer. The ascribed study may provide a means to increase global access to oral prosthetics if suitable biomaterials are developed. METHODS: Computerized tomography data were acquired from a patient who had an oronasal fistula. Through use of free software, these data were converted into a 3-dimensional image. The image was manipulated in order to isolate the patient's maxilla and was subsequently printed. The palatal obturator models were designed, and reformed, in correspondence with the maxilla model design. A final suitable obturator was determined and printed with 2 differing materials in order to better simulate a patient obturator. RESULTS: Creating a suitable palatal obturator for the specified patient model was possible with a low-cost printer and free software. CONCLUSIONS: With further development in biomaterials, it may be possible to design and create an oral prosthesis through use of low-cost 3-dimensional printing technology and freeware. This can empower individuals to attain good healthcare, even if they live in rural, developing, or underserviced areas.

The first Canadian experience with the Afirma® gene expression classifier test.

BACKGROUND: Thyroid nodules are common and often benign, although prove to be malignant upon surgical pathology in 5-15% of cases. When assessed with ultrasound-guided fine-needle aspiration (USFNA), 15-30% of the nodules yield an indeterminate result. The Afirma® gene expression classifier (AGEC) was developed to improve management of indeterminate thyroid nodules (ITNs) by classifying them as "benign" or "suspicious." Objectives were (1) to assess the performance of the AGEC in two Canadian academic medical centres (2), to search for inter-institutional variation and (3) to compare AGEC performance in Canadian versus American institutions. METHODS: We undertook a retrospective cohort study of patients with indeterminate cytopathology (Bethesda Class III or IV) as per USFNA who underwent AGEC testing. We reviewed patient demographics, cytopathological results, AGEC data and, if the patient underwent surgery, results from their final pathology. RESULTS: In total, we included 172 patients with Bethesda Class III or IV thyroid nodules underwent AGEC testing, 109 in Montreal, Quebec and 63 in St. John's, Newfoundland, in this study. Among the nodules sent for testing, 55% (60/109) in Montreal and 46% (29/63) in St. John's returned as "benign." None of these patients underwent surgery. On the other hand, 45% (49/109) nodules in Montreal and 54% (34/63) in St. John's were found to be "suspicious," for a total of 83 specimens. Seventy seven of these patients underwent surgery. Both in Montreal and St. John's, the final pathology yielded malignant thyroid disease in approximately 50% of the specimens categorized as "suspicious." Since 2013, no patient diagnosed with a benign nodule as per AGEC testing was found to harbor a malignant thyroid nodule on follow-up. CONCLUSIONS: Molecular analysis is increasingly used in the management of indeterminate thyroid nodules. This study highlights the experience of two Canadian centres with AGEC testing. We found inter-institutional variability in the rate of nodules returning as "benign," however we found similar rates of confirmed malignancy in nodules returning as "suspicious." According the literature, results for AGEC testing in two Canadian institutions align with results reported in American centres.

Does Size Matter? Evaluation of malignancy rate differences between small and large thyroid follicular neoplasms.

OBJECTIVE: To determine if there is a significant difference in the malignancy rates of thyroid follicular neoplasms, based on lesion size. DESIGN: Retrospective study. SETTING: Tertiary care institution. MATERIALS AND METHODS: We retrospectively reviewed charts from patients with a thyroid fine-needle biopsy diagnosis of "follicular neoplasm," who subsequently had thyroidectomy, from 2000 to 2005 at our institution. The size of the lesion was determined from pathology reports or preoperative sonograms. We divided the patients into "large nodule" and "small nodule" groups, based on the median size. MAIN OUTCOME MEASURE: Malignancy rate difference between thyroid follicular neoplasms in large nodule and small nodule size groups. RESULTS: One hundred seventeen patients were included. The median size was 2.2 cm; thus, our small nodule group included lesions < or = 2.2 cm with a malignancy rate of 16.7%. The large nodule group included lesions > 2.2 cm with a malignancy rate of 26.3%. Chi-square analysis showed no statistically significant difference between the groups (p = .20). A receiver operating characteristic (ROC) curve was generated, and all cutoff values of tumour size did not lie far from the line of no discrimination. The area under the ROC curve was 0.52 (95% confidence interval = 0.38-0.66), indicating that the use of increasing tumour size as a diagnostic tool may be worse than chance. CONCLUSION: There was no statistical difference in the malignancy rates of follicular neoplasms observed in the small nodule and large nodule groups. Our ROC curve also indicated that tumour size cannot be used to predict malignancy.

Radiotherapy for T1 and T2 laryngeal cancer: the Dalhousie University experience.

OBJECTIVE: To report outcomes of definitive radiotherapy for early-stage squamous cell carcinoma of the larynx. DESIGN: Retrospective outcome analysis. SETTING: Tertiary referral centre. PATIENTS AND METHODS: A total of 373 cases of laryngeal cancer reported in Nova Scotia from 1990 through 2001 were reviewed. All cases were classified by T stage (T1 = 137, T2 = 90, T3 = 89, T4 = 57) and affected sites (glottic = 233, supraglottic = 136, subglottic = 4). We focused on those patients with T1 and T2 cancers of both the glottis and the supraglottis who received radiotherapy as a primary modality. RESULTS: Eighty-eight percent (150 of 170) of T1/T2 glottic cancers were first treated with radiotherapy. Seventy-one percent (80 of 112) and 63.3% (24 of 38) of T1 and T2 glottic cancers, respectively, were controlled by radiation, with an average follow-up of 37 months. Of those T1 glottic cancers unsuccessfully treated by radiotherapy, 14 underwent surgical salvage, with 9 of these patients being free of disease following an average of 57 months. For T2 glottic cancers unsuccessfully treated by radiotherapy, five patients underwent surgical salvage, of whom four (68.4%) were free of disease after an average follow-up of 62 months. Seventy-five percent of T1 (3 of 4) and 70.6% (25 of 35) of T2 supraglottic cancers were successfully controlled by radiotherapy. Salvage surgery was attempted in five patients; however, all patients except one died of disease. CONCLUSION: Although radiotherapy is a standard treatment for early laryngeal cancers, the results of this review may suggest considering other modalities in the treatment of early laryngeal cancer.