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Elective versus Therapeutic Neck Dissection in Node-Negative Oral Cancer
Patients with early-stage, node-negative oral cancer who had elective lymph-node dissection at the time of resection of the primary tumor had better overall survival than those who waited for node resection until clinical recurrence.
The treatment of patients with early-stage, clinically node-negative oral squamous-cell cancer has been a contentious issue spanning five decades. Such patients are usually treated with oral surgical excision of the primary tumor. Surgical options for addressing the neck include elective neck dissection at the time of the excision of the primary tumor or watchful waiting with therapeutic neck dissection for nodal relapse. Proponents of elective neck dissection cite decreased relapse rates and better survival rates.
1
–
7
However, others consider the evidence not to be definitive.
8
,
9
Data from prospective trials have also produced conflicting evidence.
10
–
13
The watchful-waiting approach has . . .
Journal Article
Oral cavity and lip cancer: United Kingdom National Multidisciplinary Guidelines
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It provides recommendations on the assessment and management of patients with cancer of the oral cavity and the lip.
Journal Article
Nationwide randomised trial evaluating elective neck dissection for early stage oral cancer (SEND study) with meta-analysis and concurrent real-world cohort
Background
Guidelines remain unclear over whether patients with early stage oral cancer without overt neck disease benefit from upfront elective neck dissection (END), particularly those with the smallest tumours.
Methods
We conducted a randomised trial of patients with stage T1/T2 N0 disease, who had their mouth tumour resected either with or without END. Data were also collected from a concurrent cohort of patients who had their preferred surgery. Endpoints included overall survival (OS) and disease-free survival (DFS). We conducted a meta-analysis of all six randomised trials.
Results
Two hundred fifty randomised and 346 observational cohort patients were studied (27 hospitals). Occult neck disease was found in 19.1% (T1) and 34.7% (T2) patients respectively. Five-year intention-to-treat hazard ratios (HR) were: OS HR = 0.71 (
p
= 0.18), and DFS HR = 0.66 (
p
= 0.04). Corresponding per-protocol results were: OS HR = 0.59 (
p
= 0.054), and DFS HR = 0.56 (
p
= 0.007). END was effective for small tumours. END patients experienced more facial/neck nerve damage; QoL was largely unaffected. The observational cohort supported the randomised findings. The meta-analysis produced HR OS 0.64 and DFS 0.54 (
p
< 0.001).
Conclusion
SEND and the cumulative evidence show that within a generalisable setting oral cancer patients who have an upfront END have a lower risk of death/recurrence, even with small tumours.
Clinical Trial Registration
NIHR UK Clinical Research Network database ID number: UKCRN 2069 (registered on 17/02/2006), ISCRTN number: 65018995, ClinicalTrials.gov Identifier: NCT00571883.
Journal Article
Things Jolie needs to do before she bites it
\"Jolie's a lot of things, but she knows that pretty isn't one of them. She has mandibular prognathism, which is the medical term for underbite. Chewing is a pain, headaches are a common occurrence, and she's never been kissed. She's months out from having a procedure to correct her underbite, and she cannot wait to be fixed. Jolie becomes paralyzed with the fear that she could die under the knife. She and her best friends, Evelyn and Derek, decide to make a \"Things Jolie Needs to Do Before She Bites It (Which Is Super Unlikely, but Still, It Could Happen)\" list. Things like: eat every appetizer on the Applebee's menu and kiss her crush Noah Reed. But since when did everything ever go exactly to plan? Filled with humor, heart--and an honest look at today's beauty standards--Jolie's journey is a true feel-good story\"--Jacket flap.
Book
Modified bolster dressing with continuous suction improves skin graft survival for an oral cavity wound
Background
Skin engraftment of intraoral defects is known to be inconsistent due to mobility of the oral structure, uneven wounds, and accumulation of saliva under the skin graft. To improve the success rate of oral skin graft, we proposed a novel and simple dressing technique for intraoral skin graft to control saliva accumulation, in comparison with the conventional bolster dressing.
Methods
We retrospectively reviewed 31 patients reconstructed with skin graft in their intraoral defect. The patients were divided into two groups; conventional bolster group (
n
= 21) and modified bolster group (
n
= 10). In the modified bolster group, a polyvinyl alcohol sponge was designed to fit the skin graft and a suction drain was inserted with tagging suture to apply continuous suction. We analyzed the success rate, the size of the skin grafts and clinical variables of each method.
Results
The overall success rate of oral skin graft was not different between the two groups (90.0 and 90.5%). However, partial necrosis in the engrafted skin was observed frequently in the control group (57.1% versus 20.0%). The relative engrafted area was significantly higher in the modified bolster group (55.0 ± 11.6% versus 23.0 ± 18.7%,
p
= 0.015). The duration of bolster dressing and the time to start an oral diet were shorter in the modified bolster group.
Conclusions
Our modified method could be easily applied for removing saliva accumulation under a skin graft and for enhancing skin engraftment of an oral cavity wound.
Journal Article
Current status of oral cancer treatment strategies: surgical treatments for oral squamous cell carcinoma
The primary treatment modality of oral cancer is generally determined according to the stage of the disease, with surgical treatment remaining the mainstay of multimodal treatment. When selecting the treatment, many factors are taken into consideration, and the treatment should be tailored individually to the patient’s needs and consider the quality of life as well as the survival of the patient. Early-stage disease is primarily managed with surgery or brachytherapy without functional morbidity, whereas for advanced-stage disease multidisciplinary treatment is recommended, not only for enhanced survival but also for improved quality of life. After resection of large primary tumors, reconstructive surgery is required. Free tissue transfer currently represents one of the most popular and reliable techniques for oral reconstruction. For cN0 neck, elective neck dissection is recommended when the risk of occult metastases is >20 %, when the neck is entered either for resection of the primary tumor or for reconstruction, or when the patient is unlikely to return for a close follow-up. Sentinel node biopsy is performed investigationally. Modified radical neck dissection is the gold standard for cN+ neck. For patients with multiple node metastases or extracapsular spread, postoperative radiotherapy or chemoradiotherapy is recommended, with the lymph nodes situated outside the confines of the radical neck dissection, such as the lingual and retropharyngeal nodes, receiving considerable attention. Targeted therapy for oral cancer is still a relatively new concept, and more studies are needed to confirm the clinical effectiveness of these drugs.
Journal Article
LIHNCS - Lugol’s iodine in head and neck cancer surgery: a multicentre, randomised controlled trial assessing the effectiveness of Lugol’s iodine to assist excision of moderate dysplasia, severe dysplasia and carcinoma in situ at mucosal resection margins of oral and oropharyngeal squamous cell carcinoma: study protocol for a randomised controlled trial
Background
Oral cavity and oropharynx cancer are increasing in incidence worldwide but survival outcomes have not significantly improved over the last three decades. The presence of dysplasia or carcinoma in situ at surgical margins following resection of squamous carcinoma of the mucosal surfaces of the head and neck has been shown to be associated with a higher incidence of local recurrence and reduced survival. While invasive carcinoma in mucosal surfaces can usually be distinguished from adjacent normal mucous membrane, pre-malignant disease is much less readily distinguished at operation. We describe a protocol for a randomised, controlled trial in which we will assess the effectiveness of Lugol’s iodine staining in allowing visualisation and excision of cancer margin dysplasia at time of primary surgery.
Methods/Design
We will recruit 300 patients diagnosed with oral cavity or oropharynx squamous cell carcinoma. All participants will be planned for primary surgery with curative intent. After completion of baseline assessment participants will be randomised into either a standard surgical treatment arm or surgical treatment including Lugol’s iodine staining.
Discussion
This paper describes the rationale and design of a unique trial in head and neck surgical oncology. If margin dysplasia visualisation with Lugol’s iodine allows complete excision of high-risk, pre-cancer mucosa at time of primary surgery, this may lead to a reduction in local recurrence and improved survival.
Trial registration
Current Controlled Trials
ISRCTN03712770
.
Journal Article