High Rate Of Malignant Transformation Research Articles

Oral submucous fibrosis in Asian countries.

Oral submucous fibrosis (OSF) is a chronic, insidious, and progressive oral mucosal disease that affects entire oral cavity and sometimes pharynx. This oral potentially malignant disorder has a high rate of malignant transformation (7%-30%) to oral squamous cell carcinoma (OSCC), posing global problems for public health. Due to enormous efforts dedicated to this disease in the past decades, there have been significant advances in identification of its etiology and pathogenesis as well as development of corresponding therapeutic approaches, in spite of several challenges. This study reviewed the existing literature concerning OSF in Asian countries, encompassing its etiology, histopathology, pathogenesis, clinical manifestations, diagnosis and differential diagnosis, and treatments. For improving treatment of OSF, the multifactorial etiology analysis, incorporation of effective molecular pathways, cytokines and cells for mechanism illustration, and integration of multidisciplinary modalities were also expounded to guide future research and clinical practice.

Oral submucous fibrosis: A global challenge. Rising incidence, risk factors, management, and research priorities.

Oral submucous fibrosis is a potentially malignant disorder of the oral cavity, with a high rate of malignant transformation. It is very common among habitual areca nut chewers. The pathogenesis of oral submucous fibrosis is not well established, but it is believed to be a disease of multifactorial origin, including areca nut chewing, ingestion of chilies, genetic factors, immunologic processes and nutritional deficiencies. Genetically susceptible individuals when exposed to areca nut chewing develop this disease over a variable period of time. Oral submucous fibrosis is considered to be a disease of collagen metabolism. Several genetic factors are reported but there is no consensus about the exact mechanism of disease initiation. Variations in histopathological presentation are noted among oral submucous fibrosis patients with habitual areca nut chewing in different forms and other additive agents, eg betel quid, pan masala and gutkha, together with a variety of tobacco habits. The role of epigenetic modifications, such as miRNA regulation, and DNA methylation is also being reported as part of the pathogenesis of oral submucous fibrosis. A combined approach, including analysis of genetic and epigenetic regulations with different habits, might be helpful to better understand the contributory factors and pathogenesis of this serious disorder.

Quantifying the Immense Burden of OPMDS and of Oral Cancer in South Asia: Time for Action

Background: Cancer of head and neck is sixth most common malignancy worldwide https://www.ncbi.nlm.nih.gov/pubmed/27245686 . ∼90% are squamous cell carcinomas [HNSCC]. Of H&N sites, mouth is most common [∼300,373 cases pa, cf oropharynx ∼142,387; larynx ∼156,877; nasopharynx 86,691]. Across south Asia, cancer of lip & mouth [oral cancer: OSCC] is a serious public health problem. In many, it is the most common cancer among men, 5th/6th in women, second overall. Five year survival rates are < 50%. Treatment is devastating. It is difficult to get authorities and public to recognize the problem: this is not a “glamorous” cancer. Yet we know the major causes so most disease is preventable. In south Asia, the major causes are tobacco - mostly chewed, areca [erroneously called betel] nut, mostly as component of betel quid, and heavy alcohol use in a background of diets lacking adequate antioxidant vitamins/minerals. To this is added the global epidemic of human papillomavirus [HPV]-driven nonkeratinising squamous epithelial head/neck cancer, particularly in lymphoid tissues of Waldyer's ring. Though data vary by country, high-risk [hr]HPVs are likely associated with up to 30% of OSCC too. We need detailed local information, especially as hrHPV-driven SCC respond well to radio/chemotherapy. Next-generation molecular methods are now examining roles for fungi and bacterial consortia. Across Asia, most OSCC arise from long-standing changes in oral mucosa: oral potentially malignant disorders [OPMD]. Leukoplakia is commonest, though with lowest risk. Risk is greater in red or mixed red/white lesions. Oral submucous fibrosis is prevalent and devastating. It has a high rate of malignant transformation and causes immense suffering: burning mouth, taste disturbances and severe sclerosis of soft tissues resulting in restricted mouth opening. The major etiology is areca nut. There is genetic and inherited propensity: very young children encouraged to chew areca can be seriously affected. There are no truly successful treatments, be it surgery to relieve trismus, physiotherapy to improve mouth opening and dietary supplements with numerous antioxidants, most commonly curcumin. Strategy: Primary prevention is possible. Improve diet; no tobacco; no areca nut [we need a WHO Framework Convention on areca]: to nip in the bud a serious epidemic of HPV-related cancers, sexual hygiene and widespread vaccination of girls - in my opinion also of boys. Public education is key. Legal controls on tobacco, areca & alcohol are needed - a tremendous challenge especially for areca, given the ancient cultural importance of this masticatory in myriad forms. It is time for effective action. Outcomes: In India and Sri Lanka we have made great progress with public awareness and with regulations on advertising and sale of smokeless tobacco and some areca products. Southeast Asia lags behind. HPV vaccination requires greater uptake across the region. What was learned: Both top-down and bottom-up approaches are needed.

Assessment of Betel Quid Habits and Risk of Precancerous Oral Lesions Among Paniya Tribes of Wayanad, India - A Cross-Sectional Study

Background: Betel quid habits in India is widely prevalent and responsible for increased incidence of head and neck cancer in the country. Head and neck cancer is a major public health problem among Paniya tribes, a marginalized tribal group in Kerala state, India. Previous studies among Paniya tribals in Wayanad have documented a high prevalence of betel quid habit. Oral leukoplakia (OL) and oral submucous fibrosis (OSF) are the most common oral mucosal diseases that have a very high malignant transformation rate. Aim: Aim of this study was to evaluate the risks imposed by betel quid habits in the development of oral leukoplakia and oral submucous fibrosis among Paniya tribes of Wayanad. Methods: A cross-sectional study was carried out in 300 residents between September 01, 2009 and March 31, 2017 using a structured questionnaire containing details of betel quid habits and socio-demographic details. Descriptive statistics and testing of hypothesis were used for the analysis using EPI INFO and SPSS 16 software. Results: In the 300 subjects, the mean age was 32.4 ±SD 11.4 years, gender distribution (57.5% males vs. 42.5% females). 32.5% out of the study population were betel quid chewers (46.5% of males and 14.6% of females). The prevalence of OL and OSF was 12.9% and 13.02%, respectively among betel quid chewers. Conclusion: Awareness of head and neck cancer by betel quid habits varied with socioeconomic status among Paniya tribes of Wayanad. Despite their awareness of tobacco chewing as a risk factor for head and neck cancer, most of them still continue to chew. There is an urgent need to develop and implement culturally appropriate awareness-raising activities to target betel quid habit.

Assessment of Oral Lesions and Its Association With Smoking Habits in Paniya Tribes of India

Background: The tribal populations throughout India have remained socially and culturally alienated from mainstream Indian society until developmental and conservation activities in tribal areas forced interactions between them. Oral health remains far neglected especially among the underprivileged tribal populations in India. Oral leukoplakia and oral submucous fibrosis are the most common oral mucosal diseases that have a very high malignant transformation rate. Aim: The aim of this study was to assess the oral lesions among smoking habits in Paniya tribes of Wayanad, India. Methods: A cross-sectional survey was done among 170 nonsmoking and 145 smoking Paniya tribal populations of Wayanad district from January 2016 after approval from the institutional ethical committee. A pretested structured questionnaire was used to collect data regarding study variables. Results: In this study oral lesions was found to be far more prevalent among smoking Paniya tribes than among the non smoking ( P < 0.0001). The prevalence of oral lesions was found to be 48% among smokers. This was much higher than the 7% found among the nonsmokers. Among smokers gingivitis (82%) and periodontitis (68%) is the common lesions followed by oral pigmentation (33%), angular cheilitis (16%), oral submucous fibrosis (12%), leukoplakia (8%) and oral candidiasis (4%). Among the smokers a statistically significant relationship was observed between oral lesions and poor access to oral health care ( P < 0.001). Conclusion: The current study demonstrates gross disparities in oral lesions among smoking and nonsmoking Paniya tribes. Oral health problems due to tobacco use are highly prevalent in the tribal community of Wayanad. Hence attention should be focused on improving the oral health status of this unprivileged group.

Abstract IA13: Extrinsic control of the breast cancer spectrum

Abstract Breast cancer consists of multiple subtypes characterized by genetic, transcriptional, histologic, and clinical differences that confer distinct prognoses. While epidemiology associates distinct classes with certain groups of women, it is unclear what aspects of biology determine the spectrum of breast cancer observed in different populations. Ionizing radiation is a well-established human carcinogen, particularly of breast. Of particular concern is that girls who have been successfully treated with radiation for childhood cancers have a relative risk of subsequently developing breast cancer similar to that conferred by BRCA1 germline mutation. Moreover, recent studies specifically found that the invasive breast cancer arising in previously irradiated breast tissue is more likely to be triple-negative (TNBC, i.e., negative for hormone receptors and HER2 amplification) compared with age-matched sporadic invasive breast cancer (1). Cancer risk following radiation exposure is often considered exclusively through the prism of the cell-intrinsic effects of DNA damage and mutations that might initiate transformation in long-lived cells. For example, a model proposed by Vogelstein and Tomasetti attributes cancer risk to the frequency of tissue stem cells and the 3 factors that increase their mutation load, hereditary defects, environmental mutagens, and replication; the latter that occur stochastically have been dubbed the bad luck mutations (2). Although radiation is a mutagen, the cell-intrinsic paradigm cannot explain the high rate of TNBC in radiation-preceded breast cancer. Over the last decade, research has “zoomed out” to not only include intrinsic genetic and epigenetic alterations of cancer cells, but to also incorporate tumor microenvironment constituents as essential partners in cancer development (3). We postulated that the effect of ionizing radiation on tumor type and age dependence could act through local and systemic effects. To test how host biology shapes the course of carcinogenesis, we used a genetic-mammary chimera in which Trp53 null epithelium is transplanted to wild-type syngeneic hosts. The Trp53 null epithelium gives rise to an apparently normal ductal outgrowth with a high rate of malignant transformation that generates carcinomas over the course of 12-18 months. These murine mammary cancers are biologically and genomically diverse in a manner very like that of human breast cancer (4, 5). To assess the contribution of radiation effects on stromal-epithelial-immune interactions during carcinogenesis, we irradiated mice prior to Trp53 fragment transplantation (i.e., a radiation-genetic chimera). These experiments show that radiation exposure acts via the microenvironment to promote fast-growing, estrogen receptor (ER)-negative cancers (6, 7). Notably, the signature of Trp53 null tumors arising in irradiated mice clusters cancers obtained from irradiated people and sporadic TNBC (4). Our recent focus is the basis for the increased growth rate of tumors arising in irradiated mice. New studies show that aggressive, rapidly growing ER-negative tumors arising in irradiated mice are enriched in immunosuppressive myeloid cells and depleted of tumor-infiltrating cytotoxic T cells compared to matched cancers arising in nonirradiated mice. Treating irradiated mice with a nontoxic compound that reduces inflammation eliminates these effects of host irradiation but has no evident effect on nonirradiated mice, suggesting that low-grade chronic inflammation may be a target for preventing or delaying breast cancer in women post-irradiation. Our extensive transcriptomic and histologic characterization of Trp53 null mammary cancers show that the distribution of subtypes is modulated by host genetic background, prior radiation exposure, type of radiation, and age. These studies lead us to propose that the breast cancer spectrum results from dominant extrinsic processes that likely influence selection of sporadic genomic mutations.

Diode laser surgery in the treatment of oral proliferative verrucous leukoplakia associated with HPV-16 infection

BackgroundProliferative verrucous leukoplakia (PVL) is an oral potentially malignant disorder, characterized by multifocal expression, progressive clinical evolution, and a high rate of malignant transformation. Evidence-based information regarding optimal PVL management is lacking, due to the paucity of data. The present report describes a case of PVL associated with HPV-16 infection and epithelial dysplasia treated by diode laser surgery, and the outcome of disease clinical remission over a 2-year follow-up period.Case reportA 61-year-old Caucasian male with oral verrucous hyperkeratosis presented for diagnosis. The lesions were localized on the maxillary gingiva and palatal alveolar ridge. Multiple biopsy specimens have been taken by mapping the keratotic lesion area. Microscopic examination was compatible with a diagnosis of PVL with focal mild dysplasia, localized in the right maxillary gingiva. Polymerase chain reaction (PCR) was done for human papillomavirus (HPV) detection which revealed presence of HPV DNA, and the genotype revealed HPV 16 in the sample. The PVL in the right gingival area was treated on an outpatient basis by excision with a diode laser. This approach resulted in good clinical response and decreased morbidity over a 2-year follow-up period.ConclusionsThis case illustrates the benefit of a conservative approach by diode laser treatment than wide surgical excision for management of the PVL lesions associated with mild dysplasia and HPV-16 infection.

Inverted Papilloma of the Middle Ear presenting as an Aural Polyp

Objective: To present a rare case of inverted papilloma of the middle ear in a 77-year old man presenting with an external auditory canal polyp of the right ear.
 Methods
 Study Design: Case Report
 Setting: Tertiary Private Hospital
 Patient: One (1)
 Results: A 77-year old man presenting with external auditory canal mass underwent tympanoplasty with canal wall down mastoidectomy. Histopathologic examination revealed inverted papilloma.
 Conclusion: With only 30 cases reported in the literature, inverted papilloma of the middle ear is a rare disease entity that may mimic other benign conditions such as cholesteatoma. It requires further investigation to devise a rational approach to diagnosis and management. Regular post-operative monitoring is essential due to high recurrence and malignant transformation rate, while post-operative radiotherapy remains controversial and requires further investigation.
 
 Keywords: Inverted papilloma, cholesteatoma, middle ear

Management of atypical polypoid adenomyoma of the uterus: A single center's experience.

Atypical polypoid adenomyoma (APA) is a rare uterine lesion, which has a high rate of recurrence and malignant transformation. How to treat this disease is crucial for the prognosis, but there are few reports on it.We retrospectively reviewed the clinical records of all the patients diagnosed with APA after surgical therapy in our hospital. All the clinical information, pathological results, treatment, and outcome were retrieved from the clinical records.A total of 43 patients were diagnosed with APA. The median age was 56.0 years (range: 17–71 years). Primary treatments included hysteroscopic transcervical resection (TCR) of the lesions in 34 patients (79.1%), hysterectomy and bilateral salping-oophenrectomy in 5 (11.6%), hysterectomy in 1 (2.3%), and primary cytoreductive surgery for ovary cancer in 3. A total of 42 patients were followed up for a mean period of 26.9 months (range 2–57 months). Three of them recurred. One patient underwent hysterectomy after recurrence, and TCR was performed for the other 2. High-dose progestogen was given to the 2 recurrent patients after TCR.Hysterectomy is the primary therapeutic choice for postmenopausal patients with APA. Conservative treatment of APA with TCR is safe and efficient.

Gastrointestinal stromal tumors: a comprehensive review.

Gastrointestinal stromal tumors (GISTs) are rare neoplasms of the gastrointestinal tract associated with high rates of malignant transformation. Most GISTs present asymptomatically. They are best identified by computed tomography (CT) scan and most stain positive for CD117 (C-Kit), CD34, and/or DOG-1. There have been many risk stratification classifications systems which are calculated based on tumor size, mitotic rate, location, and perforation. The approaches to treating GISTs are to resect primary low-risk tumors, resect high-risk primary or metastatic tumors with imatinib 400 mg daily for 12 months, or if the tumor is unresectable, neoadjuvant imatinib 400 mg daily followed by surgical resection is recommended. Sunitinib is required for KIT exon 9, 13, and 14 mutations, while ponatinib is used for exon 17 mutations and regorafenib for highly refractory tumors. High-risk tumors should be monitored for recurrence with serial abdominal CT scans. Radiofrequency ablation has shown to be effective when surgery is not suitable. Newer therapies of ipilimumab, nivolumab, and endoscopic ultrasound alcohol ablation have shown promising results. This report addresses the epidemiology, clinical presentation, diagnostic imaging, histologic diagnosis, classification and risk stratification, staging and grading, surgical treatment, adjuvant treatment, and metastasis of GISTs.

Management of Proliferative Verrucous Leukoplakia: justification for a conservative approach

Introduction/Aims: Proliferative verrucous leukoplakia (PVL) is a progressive, multifocal, exophytic form of leukoplakia with high rates of malignant transformation. The aim of this study is to evaluate a cohort of PVL in a single tertiary referral clinic.

Oral leukoplakia and proliferative verrucous leukoplakia: a review for dental practitioners.

Objectives To provide an overview of the current thinking in terms of the diagnosis and management of oral leukoplakia and proliferative verrucous leukoplakia as relevant to general dental practitioners.Data sources, data selection, data extraction, data synthesis We searched the MEDLINE Ovid, EMBASE databases and the Cochrane Library, (1990 to 16 April 2017), restricting our search to English language with the following key words: leukoplakia, white patch, proliferative verrucous leukoplakia, precancerous lesion, premalignant lesions, potentially malignant oral conditions and potentially malignant oral disorders. The two authors selected key papers and engaged in collaborative data extraction and synthesis of the selected reference material.Conclusions General dental practitioners (GDPs) are likely to encounter patients with a known or yet undiagnosed oral leukoplakia in their clinical practice. The diagnosis is clinically based as there are no pathognomonic histopathological features. The definition of leukoplakia has evolved over the years. The importance of recognition and appropriate management relating to this condition is described particularly as it is one of the oral potentially malignant lesions. The inferred increased risk of malignant transformation is well documented however controversy still persists in terms of the appropriate management for these lesions. Proliferative verrucous leukoplakia is a recalcitrant, often widespread and multifocal distinct type of leukoplakia. It is considered to have a high rate of malignant transformation with implications in terms of lifelong monitoring both clinically and histopathologically. A high index of suspicion is important for general dental practitioners in order to identify such lesions that would require onward referral for further investigation and management.

Prophylactic chemotherapy for hydatidiform mole to prevent gestational trophoblastic neoplasia.

This is an update of the original Cochrane Review published in Cochrane Library, Issue 10, 2012.Hydatidiform mole (HM), also called a molar pregnancy, is characterised by an overgrowth of foetal chorionic tissue within the uterus. HMs may be partial (PM) or complete (CM) depending on their gross appearance, histopathology and karyotype. PMs usually have a triploid karyotype, derived from maternal and paternal origins, whereas CMs are diploid and have paternal origins only. Most women with HM can be cured by evacuation of retained products of conception (ERPC) and their fertility preserved. However, in some women the growth persists and develops into gestational trophoblastic neoplasia (GTN), a malignant form of the disease that requires treatment with chemotherapy. CMs have a higher rate of malignant transformation than PMs. It may be possible to reduce the risk of GTN in women with HM by administering prophylactic chemotherapy (P-Chem). However, P-Chem given before or after evacuation of HM to prevent malignant sequelae remains controversial, as the risks and benefits of this practice are unclear. To evaluate the effectiveness and safety of P-Chem to prevent GTN in women with a molar pregnancy. To investigate whether any subgroup of women with HM may benefit more from P-Chem than others. For the original review we performed electronic searches in the Cochrane Gynaecological Cancer Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, 2012), MEDLINE (1946 to February week 4, 2012) and Embase (1980 to 2012, week 9). We developed the search strategy using free text and MeSH. For this update we searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 5, 2017), MEDLINE (February 2012 to June week 1, 2017) and Embase (February 2012 to 2017, week 23). We also handsearched reference lists of relevant literature to identify additional studies and searched trial registries. We included randomised controlled trials (RCTs) of P-Chem for HM. Two review authors independently assessed studies for inclusion in the review and extracted data using a specifically designed data collection form. Meta-analyses were performed by pooling data from individual trials using Review Manager 5 (RevMan 5) software in line with standard methodological procedures expected by Cochrane methodology. The searches identified 161 records; after de-duplication and title and abstract screening 90 full-text articles were retrieved. From these we included three RCTs with a combined total of 613 participants. One study compared prophylactic dactinomycin to no prophylaxis (60 participants); the other two studies compared prophylactic methotrexate to no prophylaxis (420 and 133 participants). All participants were diagnosed with CMs. We considered the latter two studies to be of poor methodological quality.P-Chem reduced the risk of GTN occurring in women following a CM (3 studies, 550 participants; risk ratio (RR) 0.37, 95% confidence interval (CI) 0.24 to 0.57; I² = 0%; P < 0.00001; low-quality evidence). However, owing to the poor quality (high risk of bias) of two of the included studies, we performed sensitivity analyses excluding these two studies. This left only one small study of high-risk women to contribute data for this primary outcome (59 participants; RR 0.28, 95% CI 0.10 to 0.73; P = 0.01); therefore we consider this evidence to be of low quality.The time to diagnosis was longer in the P-Chem group than the control group (2 studies, 33 participants; mean difference (MD) 28.72, 95% CI 13.19 to 44.24; P = 0.0003; low-quality evidence); and the P-Chem group required more courses to cure subsequent GTN (1 poor-quality study, 14 participants; MD 1.10, 95% CI 0.52 to 1.68; P = 0.0002; very low quality evidence).There were insufficient data to perform meta-analyses for toxicity, overall survival, drug resistance and reproductive outcomes. P-Chem may reduce the risk of progression to GTN in women with CMs who are at a high risk of malignant transformation; however, current evidence in favour of P-Chem is limited by the poor methodological quality and small size of the included studies. As P-Chem may increase drug resistance, delays treatment of GTN and may expose women toxic side effects, this practice cannot currently be recommended.

MiR-127 and miR-376a act as tumor suppressors by in vivo targeting of COA1 and PDIA6 in giant cell tumor of bone

Giant cell tumors of bone (GCTB) are generally benign bone tumors associated with expansive osteolytic defects, a high rate of recurrence and potential malignant transformation. We recently observed silencing of miR-127-3p and miR-376a-3p in GCTB and identified COA1 and PDIA6 as their target genes. Here, we investigate the impact of these microRNAs and their target genes on tumor engraftment and progression of giant cell tumor stromal cells (GCTSC) in vivo by xenotransplantation on the chorioallantoic membrane of chicken eggs. Prior to transplantation, the neoplastic GCTSCs were transfected with miRNA mimics or siRNAs directed against their target genes. Restoration of miR-127-3p and miR-376a-3p reduced the tumor take rate to 17% and 47% compared to 95% in the controls. The tumor volumes were significantly reduced to 29% by both miRNAs. Silencing of COA1 and PDIA6 significantly decreased the tumor volumes to 37.7% and 42.7%, while the tumor take rates remained stable. Our results indicate that re-expression of miR-127-3p and miR-376a-3p induces a strong tumor suppressor effect in GCTSC, which is partially mediated via COA1 and PDIA6.

Hospital-based epidemiological and clinical characterisation of the malignant transformation of oral leukoplakia in a Chinese population

The aim of this review was to analyse, systematically, hospital-based epidemiological information concerning the malignant transformation rate (MTR) of oral leukoplakia (OL) in a Chinese population, as well as the associated risk factors. Four electronic databases were searched for studies dealing with OL and related risk factors, including age, gender, type of lesion, site, and smoking and drinking habits. The MTR of OL in the hospital-based Chinese population ranged from 4% to 13%, based on the studies analysed. Regarding risk factors, we found that female patients had a higher MTR than male patients, and that patients older than 50years of age also had a higher MTR. Patients who smoked had a lower MTR, while alcohol consumption seemed to have no association with MTR. Malignant transformation occurred most commonly on the tongue. Regarding lesion type, non-homogeneous OL had a higher MTR, with the granular type having the highest MTR. Our results regarding the epidemiology of OL showed a similar trend to those reported in western populations and provided preliminary epidemiological information on the Chinese population. Our findings show that female gender, age >50years and non-homogeneous OL are risk factors for malignant transformation. It is important to develop clinical strategies to educate, diagnose and treat patients with OL and to minimise the MTR of OL.

Management of proliferative verrucous leukoplakia: Justification for a conservative approach.

Proliferative verrucous leukoplakia (PVL) is a progressive, multifocal, exophytic form of leukoplakia with high rates of malignant transformation. The purpose of this study was to evaluate a cohort of patients with PVL in a single tertiary referral clinic. Cases meeting accepted diagnostic criteria were reviewed with regard to their pathology, demographic characteristics, management, and outcomes. Human papillomavirus (HPV) testing was undertaken on a subset. Almost half of the 48 patients with PVL (48%; n = 23) underwent malignant transformation after a median 23.4 months. The characteristics of this cohort were similar to those previously described, but management was notably more conservative. Conservative management of PVL was used in 92% of our patients, but the clinical outcomes seem comparable with previously described cohorts in which PVL was predominantly treated by surgical excision. All HPV testing was negative. Aggressive surgical intervention in the premalignant phase of PVL may not influence the rate of malignant transformation.

Safety and efficacy of cap-assisted EMR for sporadic nonampullary duodenal adenomas

Eradication of sporadic nonampullary duodenal adenomas (SNADAs) is essential because of their high rate of malignant transformation. EMR techniques are the alternative to the traditional surgical treatments of SNADAs. There are very limited data on the safety and efficacy of cap-assisted EMR (C-EMR) in the treatment of SNADA. The medical records of patients who underwent C-EMR for SNADAs between July 2002 and April 2013 were retrospectively reviewed. Eradication was defined as no residual adenoma on follow-up or en bloc resection on pathology. Recurrence was defined as finding adenoma after a negative follow-up. Fifty-nine C-EMR sessions were performed on 49 SNADAs (flat, 46; sessile, 3); 39 polyps were treated in piecemeal fashion and 10 polyps with en bloc resection. The polyp histology was tubular adenoma (63.3%) and tubulovillous adenoma (36.7%), with 16.3% of lesions showing high-grade dysplasia. Initial eradication rate was 90.5%; residual adenomas were successfully treated with repeat C-EMR/snare, resulting in 100% ultimate eradication rate without any recurrences (median follow-up of 17 months). The overall adverse events rate was 16.9%: intraprocedural bleeding (10.2%), delayed GI bleeding (5.1%), and perforation (1.7%). Among large polyps (≥15mm), the initial and ultimate eradication rates were 87.9% and 100%, respectively, and the adverse event rate was 17%. Initial eradication rate for small polyps was higher than in large polyps (100% vs 87.9%, respectively; P= .02). C-EMR is a highly efficient and safe method for the treatment of SNADAs. We recommend that endoscopists should learn C-EMR on esophageal, gastric, rectal, or left-sided colonic lesions before attempting C-EMR in the duodenum.

Endoscopic surgery of a sinonasal inverted papilloma: Surgical strategy, follow-up, and recurrence rate.

Sinonasal inverted papilloma (SNIP) is noted for its high rate of recurrence and malignant transformation. Although many clinical studies have demonstrated the effectiveness of the endoscopic approach for SNIP, the surgical strategy has been the subject of much debate. To evaluate the effectiveness of the endoscopic endonasal approach in SNIP. A systematic review of patients with a diagnosis of SNIP and who had surgery at our institution from June 2005 to March 2013 was performed. All the patients who had postoperative follow-up for >2 years were enrolled. Each case was categorized into one of four stages as reported by Krouse. Demographic and tumor date, operative approach, complications, and recurrence rates were collected. A total of 125 patients were included in this study. There were 17 patients in stage 1, 40 in stage 2, 57 in stage 3, and 11 in stage 4. The overall recurrence rate was 8.0%. There was no significant difference in recurrence among the stages (all p > 0.05). Recurrence after endoscopic endonasal approach (8.4%) and a combined endoscopic and open exposure procedure (5.6%) were not significantly different (p > 0.05). The recurrence rate was significantly (p < 0.05) higher in patients with revision (15.6%) than in patients in the primary cases (3.8%). A common site of tumor origin was recorded to be from the maxillary sinus (40.2%). Twenty percent of recurrences were observed up to 5 years after surgery. Endoscopic surgery may be preferred for treating SNIP. The elevated recurrence rate after revision emphasized the significance of the first surgery. We encourage a follow-up period of at least 5 years.

Early detection and treatment of Speckled leukoplakia

Background: Leukoplakia is one of potentially malignant disorders that can be found on oral mucosa. Speckled leukoplakia is a rare type of leukoplakia with a very high risk of premalignant growth. Approximately 3 % of worldwide population has suffered from leukoplakia, 5-25% of which tend to be malignant leukoplakia. Purpose: This case report was aimed to discuss about early detection of speckled leukoplakia as one of potentially malignant disorders. Case: A 62 year old male patient came with chief complaint of bald and painful tongue since one month ago. The patient has a history of allergic reaction, hypertension, uric acid, and hepatitis B. He had been a heavy smoker since young until 10 years ago. Intra oral examination showed a firm, rough, non scrapable white plaque lesion with a size of 1 x 1.5 cm, surrounded by painful erosion with diffuse boundary. Case Management: Based on cytology examination, the patient was reffered to oncologist to get an excisional biopsy. Next, the patient succesfully underwent the excisional biopsy and came for control. The results showed the healing process of the lesion with a minimal complaint of bald tongue, especially when eating spicy or hot meal. To improve healing process, the patient then was given an antibacterial mouth rinse containing zinc and mulvitamin. Conclusion: Speckled leukoplakia could show high malignant transformation rate, therefore, early detection and treatment are necessary.

PROLIFERATIVE ERYTHRO-LEUKOPLAKIA: A VARIANT OF PROLIFERATIVE VERRUCOUS LEUKOPLAKIA?

Oral proliferative verrucous leukoplakia (PVL) is a rare form of progressive multifocal leukoplakia with a high rate of malignant transformation (MT). However, not all PVLs are entirely white/keratotic or fissured. This study aims to characterize PVL from a clinical and histopathologic standpoint.