TAREK K. SABER, M.D.; HESHAM A. HUSSEIN, M.D.; ALI H. MEBEED, M.D.;
HESHAM I. EL SEBAI, M.D.; IHAB SAMI, M.D. and IMAN G. FARAHAT, M.D.*
The Departments of Surgical Oncology and Pathology*, National Cancer Institute, Cairo University.
Journal of the Egyptian Nat. Cancer Inst., Vol. 21, No. 3, September: 219-227, 2009
Metastasis of Neck Node with Unknown Primary Himanshu Soni
carcinoma of unknown Primary accounts for 5%-10% of all tumours. 3–5% of head and neck cancers presented as cervical squamous cell carcinomas of unknown primary
Suboccipital lymphadenectomy for patients with occipital squamous cell carcin...Dr./ Ihab Samy
F. Fouad Saleep(1), I. Fayek(1), I. Farahat(2)
(1)National Cancer Institute - Cairo University, Surgical Oncology Department, Cairo, Egypt.
(2)National Cancer Institute - Cairo University, Pathology Department, Cairo, Egypt.
Poster presentation No.3224 at the 17th European Cancer Organization conference ECCO 17, Amsterdam-Netherlands, September 2013.
Metastasis of Neck Node with Unknown Primary Himanshu Soni
carcinoma of unknown Primary accounts for 5%-10% of all tumours. 3–5% of head and neck cancers presented as cervical squamous cell carcinomas of unknown primary
Suboccipital lymphadenectomy for patients with occipital squamous cell carcin...Dr./ Ihab Samy
F. Fouad Saleep(1), I. Fayek(1), I. Farahat(2)
(1)National Cancer Institute - Cairo University, Surgical Oncology Department, Cairo, Egypt.
(2)National Cancer Institute - Cairo University, Pathology Department, Cairo, Egypt.
Poster presentation No.3224 at the 17th European Cancer Organization conference ECCO 17, Amsterdam-Netherlands, September 2013.
Management of mandibulectomy / /certified fixed orthodontic courses by Indian...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
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As per AJCC 7th Ed, a pictorial review with prediction for change in future edition.
Presented at "Oral Oncology-An update" CME conducted by Shri Mata Vaishno Devi Narayana Superspecialty Hospital, Katra at Fortune Inn Riviera Hotel, Jammu on 21st Jan, 2017.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...daranisaha
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...JohnJulie1
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...eshaasini
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...NainaAnon
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Clinics of Oncology | Oncology Journals | Open Access JournalEditorSara
Clinics of OncologyTM (ISSN 2640-1037) - Impact Factor 1.920* is a medical specialty that focuses on the use of operative techniques to investigate and resolve certain medical conditions caused by disease or traumatic injury.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
In this retrospective study we enrolled patients with upper rectal or sigmoid junction locally advanced tumors (stages II-III). At the first Institution patients received NCRT followed by surgery (study group); at the second Institution patients were referred to upfront surgery (control group). Overall survival was the main endpoint of the analysis. Local relapse and other clinical variables were also analyzed.
Radiation-Induced Angiosarcoma of the Breast: Retrospective Analysis at a Reg...semualkaira
Radiation-induced angiosarcoma (RIA) of the breast is an uncommon but morbid complication after radiotherapy for breast cancer. This retrospective study analysed the treatment and outcome of breast RIA patients at Cambridge University Hospital (CUH), a regional treatment centre in the East of England.
Radiation-Induced Angiosarcoma of the Breast: Retrospective Analysis at a Reg...semualkaira
Radiation-induced angiosarcoma (RIA) of the breast is an uncommon but morbid complication after radiotherapy for breast cancer. This retrospective study analysed the treatment and outcome of breast RIA patients at Cambridge University Hospital (CUH), a regional treatment centre in the East of England.
Transanal Endoscopic Microsurgery in Young Patients: A Retrospective Studysemualkaira
Local excision of rectal lesions is considered an acceptable choice for elderly and high-risk patients, yet data is scarce regarding its application in young adults
Gastrointestinal Stromal Tumors: A clinicopathologic study of 67 cases.Dr./ Ihab Samy
Amr H. Sleema MD; Ihab S. Fayeka MD; Hany F. Habashyb MD;Amany Saberc MD;Alfred E. Namourd MD;Nevine F. Habashye MD
a: Surgical Oncology Department – National Cancer Institute – Cairo University – Egypt.
b: Surgery Department – Fayoum teaching hospital – Fayoum University – Egypt.
c: Medical Oncology Department – Minia Cancer Center – Egypt.
d: Medical Oncology Department – National Cancer Institute – Cairo University – Egypt.
e: Surgical Pathology Department - National Cancer Institute – Cairo University – Egypt.
Kasr el-aini journal of surgery Volume 15, No.2, May 2014
F. Fouad Saleep(1), I. Fayek(1), I. Farahat(2)
(1)National Cancer Institute - Cairo University, Surgical Oncology Department, Cairo, Egypt.
(2)National Cancer Institute - Cairo University, Pathology Department, Cairo, Egypt.
Poster presentation No.3224 at the 17th European Cancer Organization conference ECCO 17, Amsterdam-Netherlands, September 2013
Impact of dead space closure and lymph vessel ligation during MRM on Post-ope...Dr./ Ihab Samy
Hany F. Habashy MD.a , Ihab S. Fayek MD b , Mohamed I.Abd el aziz MD a
a:Department of Surgery-Fayoum University Hospital-El Fayoum , Egypt.
b:Department of Surgical Oncology –National Cancer Institute – Cairo University ,Egypt.
Kasr el-aini journal of surgery Volume 14, No.2, May 2013
Poster Presentation at the 6th Breast-Gynecological international cancer conference (BGICC) at Fairmont Towers Hotel, Cairo-Egypt on the 9th-10th of January 2014
Sentinel lymph node biopsy before neoadjuvant chemotherapy for clinical axill...Dr./ Ihab Samy
Ihab S. Fayeka MD; Fouad A. Saleepa MD; Hany F. Habashyb MD; Alfred E. Namourc MD ; Iman G. Farahatd MD ;Magdy Kotbe MD
a: department of surgical oncology - national cancer institute - Cairo university - Egypt.
b: department of surgery - Fayoum university hospital - El Fayoum - Egypt.
c: department of medical oncology - national cancer institute - Cairo university - Egypt.
d: department of surgical pathology - national cancer institute - Cairo university - Egypt.
e: department of nuclear medicine - national cancer institute - Cairo university - Egypt.
For correspondance contact: drihab74@hotmail.com
Kasr el-aini journal of surgery Volume 14, No.1, January 2013
Treatment and early outcome of 11 children with hepatoblastoma.Dr./ Ihab Samy
Fouad A. Fouad saleep MD., Ihab samy Fayek MD.
Department of Surgical Oncology – National Cancer Institute – Cairo University - Egypt.
Kasr el-aini medical journal Volume 18, No.4, October 2012.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Cancer of Oral Cavity Abutting the Mandible; Predictors of Loco-regional Failure.
1. ABSTRACT
Aim of Work: The purpose of this study is to analyze
the causes of Loco-regional failure in 51 patients with
tumors of the oral cavity abutting the mandible.
Patients and Methods: This cross-sectional study (27
patients were operated upon in the retrospective section
and 24 patients in the prospective section of the study)
was done in the department of Surgical Oncology, National
Cancer Institute, Cairo University, from January 2003 to
January 2008. Fifty-one patients, with oral cavity cancerous
lesions abutting the mandible, were operated upon by
segmental mandibulectomy en-bloc with primary tumor
resection in addition to modified radical or selective neck
dissection according to the status of the cervical lymph
nodes.
Results: During a median follow-up of 2 years, 29
patients (56.8%) had local recurrences, the incidence of
nodal recurrence after neck dissection was detected in 4
patients (7.8%). On multivariate analysis, tumor depth,
tumor grade, oral mucosa, soft tissue and bone surgical
margins in addition to metastatic lymphadenopathy were
independent prognostic factors of loco-regional failure
and disease-free survival.
Conclusion: Oral cavity cancers abutting the mandible
should be treated with great caution by a multidisciplinary
oncology team (resection and reconstruction surgeons) as
it has a very aggressive biologic behavior. Negative
intraoperative pathological margins should be attempted
since this is the critical point for patients with cancers
abutting the mandible? Further research on the biologic
margin and genetic study is required.
Key Words: Oral cavity cancer abutting the mandible –
Predictors of loco-regional failure.
INTRODUCTION
Oral cancer is the sixth most common cancer
worldwide, with a high prevalence in south
Journal of the Egyptian Nat. Cancer Inst., Vol. 21, No. 3, September: 219-227, 2009
Cancer of Oral Cavity Abutting the Mandible;
Predictors of Loco-regional Failure
TAREK K. SABER, M.D.; HESHAM A. HUSSEIN, M.D.; ALI H. MEBEED, M.D.;
HESHAM I. EL SEBAI, M.D.; IHAB SAMI, M.D. and IMAN G. FARAHAT, M.D.*
The Departments of Surgical Oncology and Pathology*, National Cancer Institute, Cairo University.
219
Asia. Surgery is the most well established mode
of initial definitive treatment for a majority of
oral cancers. Primary site location, size, prox-
imity to bone, and depth of infiltration are
factors which influence a particular surgical
approach. Tumors that approach or involve the
mandible require specific understanding of the
mechanism of bone involvement. This facilitates
the employment of mandible sparing approaches
such as marginal mandibulectomy and mandib-
ulotomy [1,2].
Standard plain radiographs such as the or-
thopantomogram (OPG) are reasonably sensitive
in detecting mandibular invasion, but this should
be confirmed in doubtful cases with more sen-
sitive imaging techniques like CT and MRI [3].
It was found that a malignant tumor does
not extend directly through the intact periosteum
and cortical bone toward the cancellous part of
the mandible since the periosteum acts as a
significant protective barrier, instead the tumor
advances from the attached gingiva towards the
alveolus [4,5].
In patients with teeth, tumor extends through
the dental sockets into the cancellous part of
the bone and invades the mandible while in
edentulous patients the tumor extends up to the
alveolar crest and then infiltrates through the
dental pores in the alveolar process and extends
to the cancellous part of the mandible, Fig. (1)
shows the classification of mandible invasion
with oral cancer [6,7].
Thus in patients with very early invasion of
the alveolar process, marginal mandibulectomy
is feasible since the cortical part of the mandible
Correspondence: Dr Tarek K. Saber,
Department of Surgical Oncology, National Cancer
Institute, Cairo University, khairytarek@yahoo.com
2. 220
inferior to the roots of the teeth remains unin-
volved and can be safely spared [8,9].
In edentulous patients, the feasibility of
marginal mandibulectomy depends on the ver-
tical height of the body of the mandible which
is not visible with the age desorption process.
Segmental mandibulectomy must be performed
when there is extension of tumor to involve the
cancellous part of the mandible and may also
be required in patients who have massive pri-
mary tumors with extensive soft tissue disease
surrounding the mandible, and should not be
considered to simply gain access for resection
as mandibulotomy is a reasonable solution [10].
PATIENTS AND METHODS
This study was conducted in the National
Cancer Institute, Cairo University, a tertiary
cancer institution, from January 2003 to January
2008.
Statistical analysis was performed on 51
patients who fulfilled our inclusion criteria.
These criteria included patients with all T stages,
N0, N1 or N2 patients with exclusion of patients
with distant metastases.
The patients were staged according to the
American Joint Committee of Cancer (AJCC)
staging system.
Demographic data including clinical presen-
tation, relevant imaging findings, operative
details, histopathologic confirmation and follow-
up information is presented.
In addition to routine laboratory investiga-
tions, chest X-ray, cardiologic and anesthetic
consultations, pre-operative plain X-ray of the
mandible (Panorex) was done in 21 patients.
Pre-operative CT scan of the head and neck
was done in 38 patients.
All patients were operated upon as the pri-
mary definitive treatment (apart from two pa-
tients who received pre-operative neo-adjuvant
chemoradiation therapy due to advanced stage
of disease). Commando operation was per-
formed in the form by lateral segmental man-
dibulectomy en-bloc with excision of the pri-
mary tumor in addition to modified radical or
selective neck dissection in 45 patients. Central
mandibulectomy was performed in 4 patients
with appropriate mandibular reconstruction,
and two patients were operated upon by marginal
mandibulectomy with appropriate soft tissue
reconstruction.
In the majority of patients, a pectoralis major
myo-cutaneous flap was done for reconstruction
followed by a deltopectoral fascio-cutaneous
flap.
A free vascularized radial forearm flap was
done for three patients for reconstruction of
floor of mouth defects and a free vascularized
fibular graft was done for two patients for
mandibular reconstruction.
Pathologic examination of the resected speci-
men:
The surgical specimens submitted to the
Department of Pathology at the National Cancer
Institute, Cairo University, were processed in
standard fashion after orientation of the mucosal,
soft tissue, and bone margins of the resected
part of the mandible.
Lymph nodes were identified by visual in-
spection and palpation, and were dissected out
from the gross specimen. After fixation in 10%
neutral buffered formalin, decalcification of
bony sections was done utilizing a solution
containing 10% formic acid and 10% Hcl.
After decalcification, the specimen was sub-
sequently processed routinely for paraffin em-
bedding and staining by haematoxylin and eosin
(H&E).
After the sections were processed, slides
from each section containing the tumor were
assessed to determine the extent of mandibular
bone invasion, if present.
The sections from margins of resection,
including bone pathological margins, were eval-
uated and classified as negative if there was no
evidence of tumor at the margin, close if the
tumor was within 2mm distance from the margin
or positive if the margin was involved by tumor
tissue (microscopic cut-through).
Surgical and post-operative treatment done
to patients and their results were planned ac-
cording to the site of primary tumor and stage
of disease.
RESULTS
From a total of fifty-one patients with oral
cavity cancer, 31 (60.7%) were male patients
Cancer of Oral Cavity Abutting the Mandible
3. Tarek K. Saber, et al. 221
and 20 (39.3%) were females whose ages ranged
from 22 to 73 years. The median age of all
patients was 58 years, while the mean age was
56.3 years.
The commonest tumor was alveolar margin
carcinoma encountered in 19 patients (37.2%),
followed by 14 patients (27.4%) with retromolar
tumors, followed by other sites, as shown in
Table (1).
A.J.C .C staging is shown in Table (2), where
T3 was the commonest (31.3%), followed by
T2 (29.4%) and T4 (27.4%). Negative nodes
(N0) represented 52.94% of the cases followed
by N1 (43.13%) (Table 2).
Regarding the histology of tumors, squamous
cell carcinoma was the predominant histology
found in 47 patients (92.1%) (Table 3).
Regarding the grade of the tumor, Interme-
diate grade (grade 2) was the predominant grade
in 38 patients (80.8%) (Table 4). Table (5) shows
the number of patients at different primary sites,
their stage, tumor grade and histopathological
type.
The final pathological reports for the surgical
pathological margins in different sites came
with negative pathological margins in 9/19
patients of alveolar margin carcinoma, 7/14
patients of retromolar trigone, 3/8 buccal mucosa
patients, 2/6 patients of tongue carcinoma, 1/3
floor of mouth patient and one patient of basal
cell carcinoma.
Positive margins recorded high incidence in
9/19 patients with alveolar margin carcinoma,
3/14 patients with retromolar trigone, 4/7 in
buccal mucosa, 3/6 of tongue carcinoma patients
and 1/3 patients with floor of mouth carcinoma.
Close margins were reported in 1/19 patients
with carcinoma of the alveolar margin, 4/14 in
retromolar trigone patients, 1/8 of buccal mu-
cosa, 1/6 in tongue carcinoma and one case of
floor of mouth carcinoma. All results are sum-
marized in Table (6). Figs. (2-5) show radiolog-
ical and intraoperative photographs of oral
cavity cancer.
In this study, most cases of mandibular bone
invasion with tumor were in patients of alveolar
margin tumors, this was proved pathologically
in 14/19 patients. Bone invasion occurred next
in frequency in 8/14 patients with retromolar
tumors. Tumors of the buccal mucosa abutting
the mandible (gingivo-buccal sulcus tumors)
invaded the mandible in 2/8 patients, one of
these patients had a grade 2 squamous cell
carcinoma and the other one had muco-
epdermoid cancer of the gingivo-buccal sulcus
(GBC). Both patients had T 4 lesions, but this
was not observed in a patient with a locally
advanced GBC and another patient with grade
3 squamous cell carcinoma (Table 7).
As regards the incidence of local recurrence
in this study, the highest rate of local recurrence
was found in 5/6 patients (83.3%) with carci-
noma of the tongue (Table 8).
In this study, we had 4/50 patients (6%) who
underwent neck dissection and developed neck
recurrence in the neck dissection side. Details
of locoregional recurrence and distant metastases
according to primary site tumors are shown in
Table (9).
Results of treatment for the 51 patient with
oral cavity cancer abutting the mandible are
presented in Table (10).
Table (1): Oral cavity cancers abutting the mandible; sites
and number of cases.
Alveolar margin
Retromolar trigone
Buccal mucosa (gingivo-buccal complex)
Tongue
Floor of mouth
Skin of Chin
Total No. of cases
19 (37.25)
14 (27.45)
8 (15.6)
6 (11.7)
3 (5.8)
1 (1.9)
51
Site of primary tumor
No. of cases
(%)
Table (2): T. N. M stage of 51 patients.
T 1
T 2
T 3
T 4
Referred
recurrent
cases
Total no.
T stage
T = Tumor. N = Node. M = Metastasis.
M 0
M 0
M 0
M 0
0
M stage
27 (52.94)
22 (43.13)
2 (3.92)
0
None
51
No. of
cases (%)
N 0
N 1
N 2
N 3
Neck
Recurrence
after
treatment
N stage
3 (5.8)
15 (29.4)
16 (31.3)
14 (27.4)
3 (5.8)
51
No. of
cases (%)
4. 222 Cancer of Oral Cavity Abutting the Mandible
Table (3): Histological type of primary tumor.
1 (1.9%)
Basal cell
carcinoma
1 (1.9%)
Verrucous
carcinoma
2 (3.9%)
Muco-epedermoid
carcinoma
No. of cases
Type of
tumor
47 (92.1%)
Squamous cell
carcinoma
Table (6): Pathologic surgical margin according to the site of primary tumor.
Negative surgical margin
Positive surgical margin
Close margin
Margin status
1ry Tumor
9 (47.3%)
9 (47.3%)
1 (5.2%)
Alveolar
margin
N=19
7 (50%)
3 (21.4%)
4 (28.5%)
Retromolar
trigone
N=14
3 (37.5%)
4 (57.1%)
1 (12.5%)
Buccal mucosa
(GBC)
N=8
2 (33.3%)
3 (50%)
1 (16.6%)
Tongue
N=6
1 (33.3%)
1 33.3%
1 33.3%
Floor of mouth
N=3
1
0
0
Chin
N=1
Table (4): Grade of primary tumor.
No. of cases
Type of
tumor
4/47 (8.5%)
Squamous
cell Ca.
Grade 1
38/47 (80.8%)
Squamous
cell Ca.
Grade 2
8/47 (17%)
Squamous
cell Ca.
Grade 3
Gd1 1 case 1/51 (3.9%)
Gd3 1 case 1/51 (3.9%)
Muco-epedermoid
Grade 1,3
1/51 (1.9%)
Verrucous
carcinoma
1/51 (1.9%)
Basal cell
carcinoma
Table (5): Tumor and nodal stage, histopathology and grade in different sites of oral cavity cancer patients.
Alveolar margin (19)
31.5%
Retromolar trigone (14)
27.4%
Buccal mucosa (8)
Tongue (6)
Floor of mouth (3)
Chin mandible (1)
Primary site
G3=3
G2=14
G1=2
G3=2
G2=11
G1=1
G3=4
G2=3
G1=1
G3=1
G2=4
G1=1
G2=3
Grade
Squamous cell carcinoma.
Squamous cell
Carcinoma. (13)
Mucoepidermoid (1)
Verrucous carcinoma (1)
Squamous cell carcinoma (6)
Mucoepidermoid (1)
Squamous cell carcinoma
Squamous cell carcinoma
Basal cell carcinoma
Histopathology
N0=9
N1=8
N2=2
N0=7
N1=7
N0=4
N1=4
N0=5
N1=1
N0=3
N0=1
Node
T=0
T2=6
T3=6
T4=7
T1=1
T2=5
T3=6
T4=2
T1=0
T2=2
T3=2
T4=4
T1=0
T2=2
T3=4
T4=0
T1=2
T4=1
T4=1
Tumor
T = Tumor. N = Node. G = Grade.
5. Table (7): Incidence of mandible invasion in different sites of oral cavity cancer.
Invasion of Mandible
Percentage
Site of 1ry tumor
1/1
Chin
2/3
66.6%
F.O.M
0/6
0%
Tongue
2/8
14.2%
Buccal mucosa
(GBC)
8/14
57.1%
Retromolar trigone
14/19
73.6%
Alveolar margin
FOM: Floor of mouth.
Tarek K. Saber, et al. 223
Table (10): Results of treatment according to site of primary tumor.
11 cases
(57.8%)
7 cases
(50%)
5 cases
(62.5%)
5 cases
(83.3%)
1 case
No
29/51 cases of
locegional failure
56.8%
Local recurrence
Yes
Yes
Yes
Yes
Yes
Yes
Adjuvant
therapy
14 cases
8 cases
2 cases
No case of
mandibular
infiltration
2 cases
1 case
27/51 cases
mandibular
invasion with
tumor
52.9%
Positive invasion
of mandible
Commando
N=19 case
Commando
N=13 cases
Marg.mandibulectomy
N=1 case
Commando
N=8 cases
Commando
N=6 cases
Commando
N=2 cases
Wide excision=1 case
Central mandibulectomy
N=1 case
Primary treatment
Alveolar margin
Retromolar trigone
Buccal mucosa GBC
Tongue
Floor of mouth
Chin
Total no.
Percentage
Site of 1ry tumor
Table (8): Incidence of local recurrence in different sites of oral cavity cancer.
Local recurrence
Percentage
Site of 1ry tumor
0/1
0%
Chin
1/3
33.3%
F.O.M
5/6
83.3%
Tongue
5/8
62.5%
Buccal mucosa
(GBC)
7/14
50%
Retromolar trigone
11/19
57.8%
Alveolar margin
FOM: Floor of mouth.
Table (9): Details of loco-regional and distant metastases according to site of primary tumor.
Total cases of local recurrence
Positive mucosal margin
Positive soft tissue margin
Positive bone margin
Nodal recurrence
Distant metastases
Site of 1ry tumor
29/51 (56.8%)
16/51 (31.3%)
8/51 (15.6%)
3/51 (5.8%)
4/51 (7.8%)
1/51 (1.9%)
Total No. Local,
Nodal, Recurrence,
Distant metastases
1/3 (33.3%)
1/1
0
0
0
0
Floor of
Mouth
(F.O.M)
5/6 (83.3%)
2/5 (40%)
1/5 (20%)
0
1/5 (20%)
0
Tongue
5/8 (62.5%)
3/5 (60%)
1/5 (20%)
1/5 (20%)
0
0
Buccal
mucosa
(GBC)
7/14 (50%)
4/7 (57.1%)
2/7 (28.5%)
1/7 (14.2%)
1/7 (14.2%)
1/7 (14.2%)
Retromolar
trigone
11/19 (57.8%)
6/11 (54.5%)
4/11 (36.3%)
1/11 (9.1%)
2/11 (18.1%)
Alveolar
margin
6. No Bone
Invasion
T1
Invasion within
Alveolar Bone
T2
Invasion beyond
alveolar bone but
above the LMC
T3
Invasion including
the LMC
T4
224 Cancer of Oral Cavity Abutting the Mandible
DISCUSSION
In this study, we had considerable high rates
of loco-regional failure in patients with carci-
noma abutting the mandible in different sites
of the oral cavity. In comparison, a similar
study from Rapidis et al from the Greek Cancer
Institute in 2009 included 194 patients with
tumors abutting the mandible to whom a com-
posite mandibular resection in addition to the
appropriate type of neck dissection was carried
out.
Fig. (1): Classification of mandible invasion with oral
cancer.
T 1 No Bone Invasion.
T 2 Invasion within Alveolar Bone.
T 3 Invasion beyond alveolar bone but above the *LMC.
T 4 Invasion including the LMC.
*LMC: Level of Mandibular Canal (Alexander D.Rapidis) (12).
Fig. (2): Carcinoma of floor of mouth abutting the man-
dible.
Fig. (3): CT of tumor invading the alveolar bone on the
lt. side.
Fig. (4): Lip splitting, lower cheek flap, marginal man-
dibulectomy en-bloc with wide excision of tumor
of floor of mouth.
Fig. (5): Specimen, en- bloc resection of floor of mouth
tumor + marginal mandibulectomy + modified
radical neck dissection.
7. Tarek K. Saber, et al. 225
Local recurrence in alveolar margin carci-
noma was found in 61.9% (26/42 patients), in
50% of patients with retromolar carcinoma (5/10
patients), in 42.6% of patients with tongue
cancer (20/47 patients), in 41.9% of patients
with floor of mouth carcinoma (13/31 patients)
in a total of 64/194 patients (32.6%).
The overall rate of loco-regional failure in
our study was 29/51 patients (56.8%), where
alveolar margin cancer recurrence was detected
in 11/19 patients (57.6%), in carcinoma of the
tongue, in 5/6 patients (83.3%) with local re-
currence, retromolar trigone in 7/14 patients
(50%), carcinoma of the buccal mucosa or the
gingivo-buccal complex in 5/8 patients (62.5%),
while in floor of mouth carcinoma, we had 1/3
patient (33.3%) with local recurrence [12].
This high incidence of local recurrence in
our study could be explained by the high number
of positive resection margins which were exam-
ined pathologically after surgery, as presented
in Table (6).
Jones et al. [13], in an attempt to identify
those patients most at risk for recurrence, ret-
rospectively determined the clinical and histo-
logical factors that was associated with recur-
rence in 49 patients with stage I and II oral
cavity cancer. Multiple regression analysis re-
vealed that when various interactions between
variables were controlled for, only the presence
of a positive surgical margin or a tumor depth
greater than 5mm was significantly associated
with recurrence. Each-individually-increased
the likelihood of recurrence almost threefold
[14].
Again, this high rate of local recurrence in
our study could be explained by the high inci-
dence of positive margins, although most of
these cases were operated upon by segmental
mandibulectomy to be sure of negative margins
but results came with positive soft tissue margins
as shown in Table (6).
O`Brien et al. [15] prospectively documented
patients who were treated with marginal or
segmental resection for oral (n=110) and oropha-
ryngeal (n=17) cancers. Among patients with
bone invasion, the local control rate was higher
following segmental resection when compared
to marginal resections (87% Vs. 75%), but this
was not statistically significant. Survival was
significantly influenced by positive soft tissue
margins but not bone invasion or the type of
resection. They concluded that bone invasion
alone did not predict for local control or survival
rates among patients with oral and oropharyn-
geal cancers. Involved soft tissue margins were
highly predictive of local recurrence and de-
creased survival. Conservative resection of the
mandible is safe as long as marginal mandibulec-
tomy does not lead to compromise of soft tissue
margins. Segmental resection should be reserved
for patients with extensive bone invasion or
those with limited invasion in a thin atrophic
mandible.
The need for intra-operative frozen section
confirmation cannot be over-emphasized in
order to obtain adequate local control for these
potentially curable tumors which were inade-
quately treated.
However, despite apparently adequate local
resection of oral cancer,
recurrence rates of 25-48% have been re-
ported [16]. Recurrent oral cancer tends to appear
at the primary site, perhaps because of the
persistence of malignant cells within local lym-
phatics or field cancerization, and is usually
seen within 36 months after the initial treatment.
Surgery and radiotherapy may cause tissue
hypoxia, hypocellularity, and fibrosis, the last
of which can encase persistent malignant cells,
making detection difficult. These processes may
eventually result in local recurrence. One of the
most important causes of local recurrence is
the persistence of tumor cells at the resection
margin [17].
Slootweg et al. [18] examined the resection
margins of 394 patients who underwent tumor
resection and found a much lower incidence of
local recurrence in patients with negative (3.9%)
than positive (21.9%) margins.
Unfortunately, locally recurrent cancer de-
velops even when resection margins are histo-
logically tumor-free. It is believed that the
relatively small number of cancer cells that
remains in the patient at the margin is the main
source of local recurrence. This limited number
of cells has been designated local minimal
residual cancer (MRC) [19-22].
8. 226
Recent molecular genetic studies provide
evidence that the majority of, if not all, head
and neck squamous cell carcinomas (HNSCCs)
develop within a contiguous field of pre-
neoplastic cells and genetic alterations associ-
ated with the process of carcinogenesis. A sub-
clone in a field gives rise to an invasive carci-
noma. An important implication of this
knowledge is that, after surgery of the initial
carcinoma, part of the field may remain in the
patient.
A field with preneoplastic cells that share
genetic alterations with cells of the excised
tumor has been detected in the resection margins
of at least 25% of patients, indicating that this
frequently occurs. Fields can be much larger
than the actual carcinoma, sometimes having a
diameter >7cm [19].
Still further research is ongoing to accurately
predict and, therefore, have an implication on
early prediction and treatment of patients most
susceptible to have recurrences based on genetic
and biologic examination of the surgical margin
in patients with oral cavity squamous cell car-
cinoma.
Conclusion:
Oral cavity cancers abutting the mandible
should be treated with great caution by a mul-
tidisciplinary oncology team (resection and
reconstruction surgeons) as it has a very aggres-
sive biologic behavior. Negative intraoperative
pathological margins should be attempted since
this is the critical point for patients with cancers
abutting the mandible. Further research on the
biologic margin with genetic studies is required.
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