Intraoral Tumors Research Articles

The Tumor Risk Score (TRS) – next level risk prediction in head and neck tumor surgery

PurposeHead and neck cancer surgery often requires postoperative monitoring in an intensive care unit (ICU) or intermediate care unit (IMC). With a variety of different risk scores, it is incumbent upon the investigator to plan a risk-adapted allocation of resources. Tumor surgery in the head and neck region itself offers a wide range of procedures in terms of resection extent and reconstruction methods, which can be stratified only vaguely by a cross-disciplinary score. Facing a variety of different risk scores we aimed to develop a new Tumor Risk Score (TRS) enabling anterograde preoperative risk evaluation, resource allocation and optimization of cost and outcome measurements in tumor surgery of the head and neck.MethodsA collective of 547 patients (2010–2021) with intraoral tumors was studied to develop the TRS by grading the preoperative tumor size and location as well as the invasiveness of the planned surgery by means of statistical modeling. Two postoperative complications were defined: (1) prolonged postoperative stay in IMC/ICU and (2) prolonged total length of stay (LOS). Each parameter was analyzed using TRS and all preoperative patient parameters (age, sex, preoperative hemoglobin, body-mass-index, preexisting medical conditions) using predictive modeling design. Established risk scores (Charlson Comorbidity Index (CCI), American Society of Anesthesiologists risk classification (ASA), Functional Comorbidity Index (FCI)) and Patient Clinical Complexity Level (PCCL) were used as benchmarks for model performance of the TRS.ResultsThe TRS is significantly correlated with surgery duration (p < 0.001) and LOS (p = 0.001). With every increase in TRS, LOS rises by 9.3% (95%CI 4.7–13.9; p < 0.001) or 1.9 days (95%CI 1.0-2.8; p < 0.001), respectively. For each increase in TRS, the LOS in IMC/ICU wards increases by 0.33 days (95%CI 0.12–0.54; p = 0.002), and the probability of an overall prolonged IMC/ICU stay increased by 32.3% per TRS class (p < 0.001). Exceeding the planned IMC/ICU LOS, overall LOS increased by 7.7 days (95%CI 5.35–10.08; p < 0.001) and increases the likelihood of also exceeding the upper limit LOS by 70.1% (95%CI 1.02–2.85; p = 0.041). In terms of predictive power of a prolonged IMC/ICU stay, the TRS performs better than previously established risk scores such as ASA or CCI (p = 0.031).ConclusionThe lack of a standardized needs assessment can lead to both under- and overutilization of the IMC/ICU and therefore increased costs and losses in total revenue. Our index helps to stratify the risk of a prolonged IMC/ICU stay preoperatively and to adjust resource allocation in major head and neck tumor surgery.

Feasibility study of ResNet-50 in the distinction of intraoral neural tumors using histopathological images.

Neural tumors are difficult to distinguish based solely on cellularity and often require immunohistochemical staining to aid in identifying the cell lineage. This article investigates the potential of a Convolutional Neural Network for the histopathological classification of the three most prevalent benign neural tumor types: neurofibroma, perineurioma, and schwannoma. A model was developed, trained, and evaluated for classification using the ResNet-50 architecture, with a database of 30 whole-slide images stained in hematoxylin and eosin (106, 782 patches were generated from and divided among the training, validation, and testing subsets, with strategies to avoid data leakage). The model achieved an accuracy of 70% (64% normalized), and showed satisfactory results for differentiating two of the three classes, reaching approximately 97% and 77% as true positives for neurofibroma and schwannoma classes, respectively, and only 7% for perineurioma class. The AUROC curves for neurofibroma and schwannoma classes was 0.83%, and 0.74% for perineurioma. However, the specificity rate for the perineurioma class was greater (83%) than in the other two classes (neurofibroma with 61%, and schwannoma with 60%). This investigation demonstrated significant potential for proficient performance with a limitation regarding the perineurioma class (the limited feature variability observed contributed to a lower performance).

Spindle cell carcinoma of the maxillary antrum presenting in the oral cavity: A case report

AbstractBackgroundSpindle cell carcinoma is a rare biphasic malignancy consisting of epithelial and mesenchymal components. It is a poorly differentiated variant of squamous cell carcinoma accounting for less than 2% of intraoral tumours, with only 69 cases reported in the literature. Clinical presentation may vary from exophytic tumours to infiltrating ulceration in the oral mucosa. Atypical presentation and erractic behaviour of these tumours mean management can be challenging, therefore prompt diagnosis and treatment are required to address the significant morbidity and mortality associated with this disease.Case PresentationA 49‐year‐old patient presented to the oral medicine clinic reporting pain affecting the left side of their palate and cheek. Prior to their attendance, they were assessed by their general medical practitioner and neurologist; however, a trial of various medications resulted in no improvement in their symptoms. Intra‐oral examination revealed an ulcer in the left hard palate with underlying visible maxillary bone. A subsequent biopsy confirmed the diagnosis of spindle cell carcinoma, and the patient received radiotherapy with adjuvant chemotherapy. Further imaging revealed distant metastasis in the right lung and treatment was changed to palliative immunotherapy. Follow‐up imaging has shown lung nodules to be stable, and the patient remains under review with the regional head and neck cancer team.ConclusionsWe report a rare case of intra‐oral spindle cell carcinoma diagnosed from a palatal lesion, which has only been reported in four cases previously at this site. Despite preceding encounters with multiple medical professionals, it is not clear whether an intra‐oral examination was carried out which may have established the diagnosis earlier. It emphasizes the importance of full head &amp; neck examination, including intraoral examination in presentations of unexplained and intractable orofacial pain.

Malignant salivary gland tumors: agreement between fine needle aspiration biopsy, incisional biopsy and final histopathological diagnostic.

Incisional biopsy is indicated for intraoral tumors, but it is a contraindicated surgical procedure for major salivary glands. To avoid complications and facilitate diagnosis, fine needle aspiration biopsy (FNAB) is a type of biopsy widely used for preoperative diagnosis in these glands. The aim of this study was to analyze the agreement between the diagnosis by FNAB (major glands), incisional biopsy (minor glands) and histopathological analysis of the surgical specimen in salivary gland tumors from a database (medical records) of patients treated in a cancer treatment reference center in the Northeast region of Brazil. The sample consisted of 110 cases, being 86 of them malignant tumors in major salivary glands (parotid gland=73; submandibular gland=13) and 24 cases in minor salivary glands (palate). The female gender was the most affected (57.3%), especially in patients over 60 years (42.7%). In the TNM classification, 41.8% of the cases were in T2 at the time of diagnosis, with most of the regional lymph nodes in N0 (85.5%) and 87.3% of the cases in M0. FNAB was able to identify malignant neoplasms in 68.6% of the cases (n=59), while incisional biopsy in palatal tumors obtained agreement of 75% of the cases (n=18). The analysis revealed that tumors classified as T3-T4 (p=0.012) showed greater agreement between pre- and post-surgical diagnosis. The results obtained in this study indicate that FNAB has similar accuracy to incisional biopsy in providing satisfactory preoperative diagnoses of malignant tumors in salivary glands.

Minor Salivary Gland Tumors a Clinicopathological Study and Management

Salivary gland tumors are uncommon and most reported series include tumors affecting both major and minor glands. Very few series have focused solely on intra-oral minor salivary gland tumors. Is to report the clinicopathological d ata of intra-oral minor salivary gland tumors in sample of patients in Baghdad, Most important characteristic features of benign and malignant tumors, different pathological behavior and the importance of pathological classification in changing the management plans. Thirty five patients with tumors of minor salivary gland were analyzed clinlcopathologically and the management of these tumors is discussed. 19 female and 16 male patients, age range from9-79years. The range of duration of tu mors was about 3 years and the size range from 1-7cm. The most commo n site was the palate followed by floor of mouth, lips, cheek, and the maxillary alveolar ridge respectively. Different methods of surgical management of minor salivary gland tumors from simple excision of tumors mass to total maxillectomy were also described.

Intraoral Minor Salivary Gland Tumors: A Retrospective, Clinicopathologic, Single-Center Study of 432 Cases in Japan and a Comparison with Epidemiological Data.

Intraoral minor salivary gland tumors are relatively rare lesions with histological subtypes not commonly found in major salivary glands. This study aimed to retrospectively evaluate the clinicopathologic features of intraoral minor salivary gland tumors from the Tokyo Dental College Hospital, Japan, and compare them with findings from other epidemiological studies. We conducted a retrospective clinicopathologic evaluation of 432 cases of intraoral minor salivary gland tumors [161 male (37.3%) and 271 female (62.7%) patients; mean age: 52.5 and 48.6years for males and females, respectively; age at diagnosis: 7-87 (mean: 50.1) years] from the Tokyo Dental College Hospital between 1975 and 2022, including 283 benign tumors (65.5%) and 149 malignant tumors (34.5%). The most common benign tumor was pleomorphic adenoma (n = 239), whereas mucoepidermoid carcinoma was the most common malignant tumor (n = 74). The mean age of patients with benign and malignant tumors was 48.4 and 53.2years, respectively, with patients with malignant tumors being significantly older (P = 0.0042). The mean age of patients with malignant tumors was significantly higher in males (56.7years) than in females (50.9years) (P = 0.0376), although the mean age of patients with benign tumors did not differ by sex. Tumors were commonly located in the palate [250 cases (57.9%)]. Benign tumors were more frequent in the palate, upper lip, and buccal mucosa, whereas malignant tumors were more frequent in the palate, floor of the mouth, buccal mucosa, and retromolar area. Understanding the features of intraoral minor salivary gland tumors is useful for diagnosis. Our study provides important epidemiological data (patient differences in age at occurrence, sex, and site of origin) that will inform clinicians and researchers.

Early prosthetic management of mandible using interim guidance appliances in hemimandibulectomy patients

Mandible is the most common site for intraoral tumors which often requires resection of large portions of the mandible depending upon the location and extent of the tumor leading to various complications such as deviation of the mandible toward the resected side and facial disfigurement. Early prosthodontic intervention during the healing period helps in training the muscles and establish an acceptable occlusal relation using guide flange prosthesis (GFP). This article aims to describe the case reports of early prosthodontic management of two patients who underwent partial resection of the mandible due to squamous cell carcinoma using two different GFP: palatal ramp prosthesis and mandibular buccal GFP using an innovative approach. Prosthodontic intervention by guidance therapy serves the purpose of reducing mandibular deviation, preventing extrusion of maxillary teeth, and improving masticatory efficiency. Guidance appliances are the simplest and most commonly used treatment modality in restoring the form and function of the mandible.

Combined approach of transnasal and transoral endoscopic surgery in a child with nasal glial heterotopia

Aim of the study: The aim of this case report is to outline the difficulties associated with managing a child with nasal glial heterotopia. Developmental midline nasal mass, especially of neurogenic origin, poses a great challenge to managing surgeons. Nasal glial heterotopia is among benign congenital midline nasal tumours with aggressive features. Case report: Herein, we report the case of a 5-month-old infant who presented earlier, at 3 months old, with respiratory distress secondary to obstructive nasal mass. Result and discussion: Imaging and bedside flexible nasopharyngolaryngoscopy showed a localised nasal mass with no intracranial tumour. Following two combined endoscopic intraoral and transnasal tumours, the diagnosis of nasal glial heterotopia was made, and the patient is under surveillance. Conclusion: Multidisciplinary team discussion along with combined endoscopic transnasal and transoral approach ought to be considered in managing challenging congenital nasal tumours in children.

Primary angiosarcoma of the ascending colon diagnosed after the discovery of intraoral tumor.

Here, we report a case of primary angiosarcoma of the ascending colon diagnosed after the discovery of an oral tumor. An 86-year-old woman presented to our hospital with severe anemia. Although she did not report any oral symptoms, an intraoral mass 15mm in size with ulceration was observed. Since colonic tumors and osteolytic tumors in the maxilla and sacra were also identified by fluorodeoxyglucose (FDG)-positron emission tomography (PET), colonoscopy was performed. A semi-peripheral tumor with ulceration from the cecum to the ascending colon was detected. Biopsies of the oral cavity and colon revealed a poorly differentiated tumor, and multiple additional immunohistochemical stains were performed to confirm the diagnosis of angiosarcoma. Angiosarcoma progresses rapidly and has a very poor prognosis. Hence, although it is rare, angiosarcoma should always be considered in the differential diagnoses of malignancy of the gastrointestinal tract.

CARCINOMA EX-PLEOMORPHIC ADENOMA: A CASE REPORT

A 37-year-old afrodescendant man presented a nodular lesion on the palate, with 2 years of evolution and history of pain and ulceration in the last 6 months. The provisional diagnosis was salivary gland neoplasia. An incisional biopsy revealed areas of typical pleomorphic adenoma (PA) associated with mucous, clear and atypical squamous cells, and cystic spaces. Immunohistochemical positivity for AE1/AE3, CK 7, CK14, CK19, p63, and Ki-67 (30%) was observed. The diagnosis was carcinoma ex-pleomorphic adenoma (CEPA). The tumor was resected, with a safety margin, and complementary chemo and radiotherapy were performed. No recurrence was observed after 1 year of follow-up. CEPA represents a malignant change in a pre-existing PA, which is extremely uncommon in minor salivary glands. Despite the rarity, this tumor must be considered in the differential diagnosis of intraoral salivary gland tumors with sudden changes in their clinical behavior.

ROLE OF THE DENTAL SURGEON ON DIAGNOSIS OF LYMPHOMAS IN HIV PATIENTS: A RARE INTRAORAL ANAPLASTIC LARGE CELL LYMPHOMA

Malignancies in patients with human immunodeficiency virus (HIV) are well documented in the literature. Although the head and neck region is rarely involved, this can signal initial HIV infection or its worsening, and the dental surgeon is the main professional for intraoral diagnoses. Some are extremely rare tumors like anaplastic large cell lymphoma. In 2020, a 49-year-old male with a 4-month diagnosis of HIV infection presented with an ulcerated lesion on the retromolar region achieving the tonsillar pillar with no malignancy on the first incisional biopsy. Because of its appearance, another biopsy was performed, confirming the anaplastic lymphoma kinase-negative anaplastic large cell lymphoma diagnosis, not hypothesized at first sight. The patient had a great response with chemotherapy and hematopoietic cell transplantation with total remission of the intraoral tumor. The early diagnosis of a rare high-morbidity tumor allowed a precocious treatment and recovery of the patient.

LARGE ORAL SQUAMOUS PAPILLOMA: CASE REPORT

Oral squamous papilloma is a benign neoplasm that rarely measures more than 1 cm. The aim of this study is to report the case of a 51-year-old asymptomatic woman who was referred to the dental clinic with a solid intraoral tumor causing facial asymmetry with a 20-year evolution. The patient presented the result of a previous incisional biopsy of squamous papilloma. On physical examination, pedicled nodular lesions were observed in the anteroposterior region of the left maxilla and in the mandible on the left, both granular, multilobulated, normochromic, respectively measuring 7.0 × 4.0 × 3.5 cm and 3.7 × 2.7 × 0.6 cm. The lesions were removed under general anesthesia and anatomopathologic exam was conclusive for oral squamous papilloma for both lesions. The patient maintains periodic follow-up without signs of recurrence.

Diagnostic Pathway of Head &amp; Neck Cancer Patients in Ireland: Audit of patterns of first attendance 1983-2019.

##Objectives: This audit explores patterns of HNC patient presentation in primary care in Ireland over four decades and reflects on the possible impact of a 10-year national HNC awareness campaign. ##Materials and Methods: Trends in patient presentation and diagnosis are presented for 920 HNC patients across three time periods: 1983-1990, 2010 and 2018-2019. Descriptive analysis was undertaken using SPSS-v27 on basic demographic details, tumour-related details and primary care referral patterns. ##Results: Patients were generally male (71%), aged 54+ (71%), and 84% were diagnosed with squamous cell carcinoma (SCC). Larynx, tongue and tonsil were the most common sub-sites. General Medical Practitioners (GPs) were the first healthcare contact for 75% cases, with only13% referred by General Dental Practitioners (GDPs). This pattern remained consistent across four decades. GDP role was higher for tongue, floor of mouth and intra-oral tumours (30-47%), with some increase seen in recent years. While symptomology varied by site, symptom burden remained high across the decades with 99.9% exhibiting 1+ NICE ‘red flag signs’ of HNC, suggesting considerable diagnostic delay, despite a 10-year national campaign to raise public and professional awareness. ##Conclusions: This audit highlights the role of GPs in HNC diagnosis, but reveals sub-optimal use of the dental pathway. The high symptom burden reported suggests considerable diagnostic delay. Increased and sustained efforts are required to raise public and professional awareness, encourage regular dental attendance, upskill HCP in opportunistic screening and ensure appropriate responses to symptomatic patients.

Mass on the Floor of the Mouth in a Teenager.

Mass on the Floor of the Mouth in a Teenager.

Ossifying fibrous epulis as an IgG4-related disease of the oral cavity: a case report and literature review

BackgroundFibrous sclerosing tumours and hypertrophic lesions in IgG4-related disease (IgG4-RD) are formed in various organs throughout the body, but disease in the oral region is not included among individual organ manifestations. We report a case of ossifying fibrous epulis that developed from the gingiva, as an instance of IgG4-RD.Case presentationA 60-year-old Japanese man visited the Department of Oral and Maxillofacial Surgery, Gunma University Hospital, with a chief complaint of swelling of the left mandibular gingiva. A 65 mm × 45 mm pedunculated tumour was observed. The bilateral submandibular lymph nodes were enlarged. The intraoperative pathological diagnosis of the enlarged cervical lymph nodes was inflammation. Based on this diagnosis, surgical excision was limited to the intraoral tumour, which was subsequently pathologically diagnosed as ossifying fibrous epulis. Histopathologically, the ossifying fibrous epulis exhibited increased levels of fibroblasts and collagen fibres, as well as infiltration by numerous plasma cells. The IgG4/IgG cell ratio was > 40%. Serologic analysis revealed hyper-IgG4-emia (> 135 mg/dL). The patient met the comprehensive clinical diagnosis criteria and the American College of Rheumatology and European League Against Rheumatism classification criteria for IgG4-RD. Based on these criteria, we diagnosed the ossifying fibrous epulis in our patient as an IgG4-related disease. A pathological diagnosis of IgG4-related lymphadenopathy was established for the cervical lymph nodes. Concomitant clinical findings were consistent with type II IgG4-related lymphadenopathy.ConclusionsA routine serological test may be needed in cases with marked fibrous changes (such as epulis) in the oral cavity and plasma cells, accompanied by tumour formation, to determine the possibility of individual-organ manifestations of IgG4-related disease.

Clinicopathological differences between lip cancers and tongue cancers

Lip cancer is closely linked to chronic exposure to solar radiation, while tongue cancer, the most common intraoral neoplasm, is mainly related to tobacco and/or alcohol consumption. Lip cancer has a much better prognosis than tongue cancer. The objective of this study was to assess the differentiating features between squamous cell carcinomas located on both the lip and the tongue. A search for studies on lip cancer and tongue cancer was performed in the following databases: PubMed (MEDLINE and Cochrane Library), Web of Science (WoS), and Scopus. The estimated prevalence of lip and tongue cancers was calculated according to the random model of DerSimonian and Laird. For categorical outcomes, Pearson's Chi-square test was used with Fisher's exact test when required. Thirty-two studies were included in this review. Considering the whole oral tumor locations, the estimated prevalence of lip cancer was 23.43% and in tongue cancer, 27.58%. A greater number of lip cancers were found in males, were classified as T1, were well-differentiated tumors, and had a higher 5-year survival rate. In contrast, a greater number of tongue cancers were observed in younger patients, tobacco and/or alcohol users, presented lymph node metastases, and more advanced tumor stages. Although both tumors are located in the mouth, lip cancers and tongue cancers have different clinicopathological features and biological behaviors.

Fostering a faster post-operative wound healing process with hyperbaric oxygen therapy in a rare case of squamous odontogenic tumor.

IntroductionThe surgical removal of an intraoral tumor and preventing intraoral wound dehiscence are constant challenges faced by surgeons today. Hyperbaric oxygen therapy (HBOT), the inhalation of 100% oxygen at a greater atmospheric pressure, is often used in cases of wounds to induce a faster wound healing process, alongside other treatment modalities. We report a rare case of squamous odontogenic tumor (SOT) treated with HBOT after being surgically removed to foster an accelerated wound recovery.Case presentationA 39-year-old Asian male presented with an intraoral 3 × 4 cm tumor, accompanied by acute pain on the maxillary region. Biopsy results showed a solid, brown parenchyma with islands of mature squamous epithelial cells, confirming the diagnosis of an SOT. An intraoral surgical approach was performed to remove the tumor. The patient was then treated with prophylactic antibiotics and 5 consecutive, daily sessions of HBOT at 2.0 ATA as an adjuvant therapy. No further complaints and no abnormalities were found at the 2-week follow-up evaluation.DiscussionIn our case of SOT, HBOT plays a role to inhibiting the bacterial growth which could lead to post-operative wound infections. A number of studies have incorporated HBOT as an adjuvant therapy for post-operative intra oral wounds which has resulted in minimal wound complications.ConclusionThe use of HBOT as an adjunctive therapy in managing possible wound complications after the resection of an intraoral tumor enables a faster angiogenesis process, reduces tissue hypoxia and minimizes the risk of post-operative wound infections; hence fostering the wound healing process.

Socioeconomic Influences on Short-term Postoperative Outcomes in Patients With Oral Cavity Cancer Undergoing Free Flap Reconstruction.

To evaluate the associations between median household income (MHI) and area deprivation index (ADI) on postoperative outcomes in oral cavity cancer. Retrospective review (2000-2019). Single-institution tertiary medical center. MHI and ADI were matched from home zip codes. Main postoperative outcomes of interest were length of tracheostomy use, length of hospital stay, return to oral intake, discharge disposition, and 60-day readmissions. Linear and logistic regression controlled for age, sex, race, body mass index, tobacco and alcohol use history, primary tumor location, disease staging at presentation, and length of surgery. A secondary outcome was clinical disease staging (I-IV) at time of presentation. The cohort (N = 681) was 91.3% White and 38.0% female, and 51.7% presented with stage IV disease. The median age at the time of surgery was 62 years (interquartile range [IQR], 53-71). The median MHI was $47,659 (IQR, $39,324-$58,917), and the median ADI was 67 (IQR, 48-79). ADI and MHI were independently associated with time to return of oral intake (β = 0.130, P = .022; β = -0.092, P = .045, respectively). Neither was associated with length of tracheostomy, hospital stay, discharge disposition, or readmissions. MHI quartiles were associated with a lower risk of presenting with more advanced disease (Q3 vs Q1: adjusted odds ratio, 0.56 [95% CI, 0.32-0.97]). MHI is associated with oral cavity cancer staging at the time of presentation. MHI and ADI are independently associated with postoperative return to oral intake following intraoral tumor resection and free flap reconstruction.

Pleomorphic Adenoma of Palate - A Case Report

The benign mixed tumor (pleomorphic adenoma) is the most common intraoral salivary gland tumor: more than 50% occurs on the hard and soft palate. Minor salivary gland tumors of the palate may pose diagnostic and therapeutic dilemmas. We present a male patient who came with the chief complaint of a swelling at the right side of the palate, which persisted for 11 years. The oral mucosa covering the lesion was intact. Occlusal radiograph revealed no bony destruction. The computed tomographic scan showed a round shaped, 3×3 cm sized mass with soft tissue density in the soft palate without invasion of the adjacent tissues. Incisional biopsy was performed on this patient. The patient was treated by wide local excision and no recurrence was observed 4 years after the surgery. Differential diagnoses of a palatal swelling was discussed.

The intraoral growth patterns of parapharyngeal tumors: A proposed classification system.

Nearly half of parapharyngeal space (PPS) tumors present as an intraoral mass, which is diagnostically challenging. In this study, we studied whether preoperative growth patterns were associated with histopathological diagnosis for planning surgery. We performed a cross-sectional study in patients with PPS tumors. A simplified classification scheme based on intraoral tumor growth patterns (patterns 1 and 2) was then proposed. In pattern 1, tumors bulge submucosally to the oropharynx from the soft palate, with the center convexity above the uvula. In pattern 2, tumors bulge submucosally to the oropharynx from the lateral oropharynx wall, with the center convexity below the uvula. The association of this classification with postoperative histopathological diagnosis and surgical-related events was studied. Twenty-two patients were enrolled in this study (12 with pattern 1, 10 with pattern 2). Of these, 91.7% (11/12) of pattern 1 tumors were salivary gland tumors (P < .001), and 90% (9/10) of pattern 2 tumors were neurogenic (P < .001). Pattern 2 tumors had fewer bleeding complications or needed external approaches when a transoral approach was chosen. This new classification of PPS tumors facilitates the prediction of salivary gland and neurogenic tumors and can improve the accuracy of preoperative radiologic diagnosis. This system will be helpful for planning surgical interventions, such as implementing transoral approaches.