James A. McCaul

How should we manage oral leukoplakia

The aim of this article is to review the management of oral leukoplakia. The topics of interest are clinical diagnosis, methods of management and their outcome, factors associated with malignant transformation, prognosis, and clinical follow-up. Global prevalence is estimated to range from 0.5 to 3.4%. The point prevalence is estimated to be 2.6% (95% CI 1.72-2.74) with a reported rate of malignant transformation ranging from 0.13 to 17.5%. Incisional biopsy with scalpel and histopathological examination of the suspicious tissue is still the gold standard for diagnosis. A number of factors such as age, type of lesion, site and size, dysplasia, and DNA content have been associated with increased risk of malignant transformation, but no single reliable biomarker has been shown to be predictive. Various non-surgical and surgical treatments have been reported, but currently there is no consensus on the most appropriate one. Randomised controlled trials for non-surgical treatment show no evidence of effective prevention of malignant transformation and recurrence. Conventional surgery has its own limitations with respect to the size and site of the lesion but laser surgery has shown some encouraging results. There is no universal consensus on the duration or interval of follow-up of patients with the condition.

Use of Lugol's iodine in the resection of oral and oropharyngeal squamous cell carcinoma

We evaluated the use of Lugols iodine in achieving surgical margins free from dysplasia, carcinoma in situ, and invasive carcinoma by an observational study of two series of 50 consecutive patients having resection of oral and oropharyngeal squamous cell carcinoma (SCC) between November 2004 and March 2007. The standard group had resection of the primary tumour with a macroscopic 1cm margin and removal of adjacent visibly abnormal mucosa. The Lugols iodine group had identical treatment with resection of any adjacent mucosa that did not stain after the application of Lugols iodine (where this was feasible). In the standard group 16 patients (32%) had dysplasia, carcinoma in situ, or invasive SCC at a surgical margin. In the Lugols iodine group two patients (4%) had dysplasia or carcinoma in situ; none had invasive SCC. Lugols iodine is a simple, inexpensive, and apparently effective means of reducing the likelihood of unsatisfactory surgical margins in the resection of oral and oropharyngeal SCC.

Sirtuins, Bioageing, and Cancer

The Sirtuins are a family of orthologues of yeast Sir2 found in a wide range of organisms from bacteria to man. They display a high degree of conservation between species, in both sequence and function, indicative of their key biochemical roles. Sirtuins are heavily implicated in cell cycle, cell division, transcription regulation, and metabolism, which places the various family members at critical junctures in cellular metabolism. Typically, Sirtuins have been implicated in the preservation of genomic stability and in the prolongation of lifespan though many of their target interactions remain unknown. Sirtuins play key roles in tumourigenesis, as some have tumour-suppressor functions and others influence tumours through their control of the metabolic state of the cell. Their links to ageing have also highlighted involvement in various age-related and degenerative diseases. Here, we discuss the current understanding of the role of Sirtuins in age-related diseases while taking a closer look at their roles and functions in maintaining genomic stability and their influence on telomerase and telomere function.

Evidence based management of Bell's palsy

Bells palsy (idiopathic facial paralysis) is caused by the acute onset of lower motor neurone weakness of the facial nerve with no detectable cause. With a lifetime risk of 1 in 60 and an annual incidence of 11-40/100,000 population, the condition resolves completely in around 71% of untreated cases. In the remainder facial nerve function will be impaired in the long term. We summarise current published articles regarding early management strategies to maximise recovery of facial nerve function and minimise long-term sequelae in the condition.

Use of digastric branch of the facial nerve for identification of the facial nerve itself in parotidectomy: technical note.

a s d t p t p reservation of the facial nerve is an essential part of any rocedure planned on the parotid gland, and with the excepion of extracapsular dissection, its identification is key to its reservation. The approach to the nerve may be antegrade or etrograde. The retrograde approach uses the retromandibuar or superficial temporal veins in exposing the marginal andibular branch and temporal branches of the facial nerve, espectively. Where the antegrade approach is planned, many oft tissue and bony anatomical landmarks have been proosed for its early identification.1,2 They include surface andmarks, the mastoid process, and the cartilaginous tragal ointer. Two deep anatomical landmarks are the posterior superior dge of the posterior belly of the digastric muscle and the tymanomastoid suture. There is still some debate about the most ffective way of locating the nerve, and experienced surgeons se many anatomical landmarks to identify and preserve it. he retrograde technique in which the buccal branch of the acial nerve is identified and dissected in a retrograde direcion to its main trunk has previously been compared with the ntegrade technique, and the advantages and disadvantages resented.3,4 We add recognition of the digastric branch of the facial erve to the armamentarium of the surgeon as a further eans by which its main trunk can be safely identified. After

Dynamic reanimation for facial palsy: an overview

Facial paralysis can have a profound effect on the patient from both an aesthetic and functional point of view. The symptoms depend on which branch of the nerve has been damaged and the severity of the injury. The purpose of this paper is to review currently available treatments for dynamic reanimation of a damaged facial nerve, and the goals are a symmetrical and coordinated smile. Careful selection of patients and use of the appropriate surgical technique can have excellent results.

Small cell neuroendocrine tumour of the anterior tongue: A case report

INTRODUCTION Neuroendocrine carcinomas (NECs) are rare in the oral cavity. There is ambiguity regarding the classification of these tumours, but their aggressive nature is recognised throughout the literature. Merkel cell carcinoma (MCC) is rare and more frequent in skin, though it has also been described intra-orally. High grade neuroendocrine tumours (HGNEC) and MCCs behave aggressively and aggressive treatment strategies have been advocated. We describe the first small cell HGNEC on the anterior tongue. PRESENTATION OF CASE We present the first report of a pT1pN1M0 small cell HGNEC in a 75 year old man on the left lateral anterior tongue. This was widely resected with 20mm peripheral and deep margins to achieve disease clearance. Selective neck dissection of levels 1-4 was also carried out. DISCUSSION Histological analysis of the tumour confirmed a primary poorly differentiated neuroendocrine tumour of small cell type (small cell HGNEC). Resected node bearing tissue from levels 1-4 confirmed metastasis to a level III node with no extra capsular spread giving a pT1pN1M0 classification. Margins of 11.7mm from the invasive tumour to mucosal margin medially and 7.0mm for the deep margin despite surgical 20mm margin resection. To the best of our knowledge small cell neuroendocrine carcinoma has not been described in the anterior tongue. CONCLUSION The aggressive nature of this tumour type mandates aggressive surgical resection with margins similar to those now recommended for skin Merkel cell carcinomas. We advocate a wide excision margin of 20mm to give adequate clearance, with neck dissection in order to pathologically stage this cancer type.

The role of effective communication in achieving informed consent for clinical trials.

Informed consent is fundamental to the protection of the rights, safety and wellbeing of patients in clinical research. For consent to be valid, patients must first be given all the information they need about the proposed research to be able to decide whether they would like to take part. This material should be presented in a way that is easy for them to understand. This article explores the importance of communication in clinical research, and how more effective communication with patients during the informed consent process can ensure they are fully informed.

Lugol's iodine identifies synchronous invasive carcinoma—time for a clinical trial

Lugols iodine is currently under investigation as a technique to detect dysplasia, carcinoma in situ and invasive carcinoma at resection margins, plus further afield. Lugols iodine is inexpensive and easy to use. We present two cases where the technique revealed abnormal mucosa (one carcinoma, one squamous cell carcinoma in situ) at distant sites from the tumour being treated within oral cavity and oropharynx.

Management of tumour spillage during parotid surgery for pleomorphic adenoma

Over the decades parotid surgery for benign tumours has developed into a reproducible, conservative operation with low morbidity. Despite the advances tumour spillage can still occur, and its management remains controversial. Since no universal consensus exists the aim of this article is to review the approach to tumour spillage and derive a protocol for its management based on existing evidence.