The anatomically complex and often spatially restricted conditions of anastomosis in the head and neck region cannot be adequately reproduced by training exercises on current ex vivo or small animal ...models. With the development of a Realistic Anatomical Condition Experience (RACE) model, complex spatial-anatomical surgical areas and the associated intraoperative complexities could be transferred into a realistic training situation in head and neck surgery. The RACE model is based on a stereolithography file generated by intraoperative use of a three-dimensional surface scanner after neck dissection and before microvascular anastomosis. Modelling of the acquired STL file using three-dimensional processing software led to the model's final design. As a result, we have successfully created an economical, sustainable and realistic model for microsurgical education and provide a step-by-step workflow that can be used in surgical and general medical education to replicate and establish comparable models. We provide an open source stereolithography file of the head-and-neck RACE model for printing for educational purposes. Once implemented in other fields of surgery and general medicine, RACE models could mark a shift in medical education as a whole, away from traditional teaching principles and towards the use of realistic and individualised simulators.
We aimed to validate the metric accuracy of a 3-dimensional (3D) facial scanner (FS) and an intraoral scanner (IOS) in capturing the nasolabial region in ex vivo unilateral cleft lip and palate ...(UCLP) models. The nasolabial region of 10 UCLP models was scanned using a 3D FS as well as an IOS and a previously validated stationary 3D scanner as a reference. Intraoral scan was performed directly on the UCLP models. In order to apply the FS on the models, they were embedded in a 3D printed sample face. Both test groups were aligned to the reference by applying a section-based best-fit algorithm. Subsequent analysis of the metric deviation from the reference was performed with a 3D analysis tool. Mean distance and integrated distance served as main parameters for surface and volume comparison. Point comparison served as an additional parameter. Statistical analysis was carried out using t-test for unconnected samples. Considering mean distance and integrated distance as main parameters for 3D evaluation of the scanner's accuracy, FS and IOS differ significantly in their metric precision in scanning the cleft model compared to the reference. The IOS proved to be significantly more accurate than the FS compared to the previously described stationary 3D scanner as reference and validated baseline. Further validation of the tested IOS and FS for 3D assessment of the nasolabial region is presented by adding the previously validated ATOS III Triple Scan blue light scanner as a reference. The IOS shows, compared to a validated baseline scan, significantly higher metric precision in experimental cleft model scanning. The collected data provides a basis for clinical application of the IOS for 3D assessment of the nasolabial region.
TIMP-2 and IGFBP7 have been identified and validated for the early detection of renal injury in critically ill patients, but data on recovery of allograft function after kidney transplantation (KTx) ...are scarce. In a prospective observational multicenter cohort study of renal transplant recipients, urinary TIMP-2 × IGFBP7 was evaluated daily from day 1 to 7 after KTx. Different stages of early graft function were defined: immediate graft function (IGF) (decrease ≥ 10% in serum creatinine (s-crea) within 24 h post KTx); slow graft function (SGF) (decrease in s-crea < 10% within 24 h post KTx); and delayed graft function (DGF) (any dialysis needed within the first week after KTx). A total of 186 patients were analyzed. TIMP-2 × IGFBP7 was significantly elevated as early as day 1 in patients with DGF compared to SGF and IGF. ROC analysis of TIMP-2 × IGFBP7 at day 1 post-transplant for event "Non-DGF" revealed a cut-off value of 0.9 (ng/mL)
/1000 with a sensitivity of 87% and a specificity of 71%. The positive predictive value for non-DGF was 93%. TIMP-2 × IGFBP7 measured at day 1 after KTx can predict early recovery of transplant function and is therefore a valuable biomarker for clinical decision making.
Objectives
Fibula free flaps (FFF) are the standard approach to mandibular reconstruction after partial resection, with the goal of restoring aesthetics and masticatory function. The graft position ...affects both and must be carefully selected. Correlations between sagittal positioning and upper airway anatomy are known from orthognathic surgery. This study aims to evaluate changes in mandibular position and upper airway anatomy after reconstructive surgery with FFF and corresponding correlations.
Materials and methods
Mandibular position after reconstruction was evaluated using three-dimensional datasets of pre- and postoperative computed tomography scans of patients treated between 2020 and 2022. Three-dimensional measurements were performed on both condyles and the symphyseal region. Changes in upper airway volume and minimum cross-sectional area (minCSA) were analysed. Intra-rater reliability was assessed. Correlations between changes in upper airway anatomy and sagittal mandibular position were tested.
Results
The analysis included 35 patients. Intra-rater reliability was good to excellent. Condylar deviations and rotations were mostly rated as small. Changes in symphyseal position were considerably greater. Median airway volume decreased in the oropharynx and hypopharynx. Posterior deviation of the symphysis was associated with a decreasing minCSA in the hypopharynx and vice versa.
Conclusions
The overall accuracy of mandibular reconstructions with FFF is high, but there is room for optimization. The focus of research should be extended from masticatory to respiratory rehabilitation.
Clinical relevance
Effects on respiratory function should be considered prior to graft positioning. The clinical relevance of upper airway changes within the complex rehabilitation of reconstructive surgery patients needs to be further investigated.
Objectives
Mandibular reconstruction after segmental mandibulectomy can be challenging without virtual surgical planning and osteotomy guides. The purpose of this study was to analyze anatomic ...parameters to facilitate the evaluation of ideal fibula wedge osteotomies to reconstruct the neomandibula in a simple and cost-effective manner without the need for preoperative virtual planning.
Materials and methods
Computed tomography scans were acquired from randomly selected patients, and all images were obtained from routine clinical diagnostics, e.g., tumor staging, or preoperatively before reconstruction. Data was used to calculate stereolithographic models of the mandible for length and angle measurements. Statistical analysis was performed (
p
< 0.05).
Results
CT scans of 100 patients were analyzed: 39 were female and 61 were male patients, mean age was 59.08a. The mandibular arch angle proved to be constant with 241.07 ± 2.39°. The outside B-segment length was 80.05 ± 5.16 mm; the anterior S-segment length was 27.69 ± 3.16 mm. The angle of the mandibular arch showed differences in means (
p
= 0.004) between age groups, but effect was proved low. No relevant statistical significances were detected.
Conclusions
The development of a mandible reconstruction template tool would benefit the majority of head and neck patients, which is due to a constant mandibular arch angle and symphysis segment length throughout the general patient population, allowing the mimicking of a harmonic mandibular arch with up to three fibula segments.
Clinical relevance
The developed mandible reconstruction template tool can facilitate the fibula wedge osteotomies necessary for reconstruction of an ideal neomandibula providing a novel approach which is simple and cost-effective.
The authors developed a semi-standardised resection and cutting guide for mandibular reconstruction with free fibula flap based on data of mandible sizes and angles.
After analyzing the angles and ...lengths of mandibular angles and segments on computer tomography, a partly-adjustable resection guide for the mandible and cutting guide for the fibula were designed.
After testing and optimizing the guides on plastic models and cadavers, the guides were successfully used for mandible resection and reconstruction with free fibula flap in 8 patients with segmental mandibulectomy. Application of the cutting and resection guides and functional results like occlusion and aesthetic appearence were satisfactory in all cases.
The developed semi-standardised device is a helpful instrument for facilitating reconstruction of segmental mandibular defects with free fibula flaps. No extensive preoperative preparation and 3D printing is necessary which can avoid additional costs for virtual planning. Especially for lower budget health systems this can be an alternative to virtual planning.
Prognosis of patients with recurrent or metastatic head and neck cancer is generally poor. Adjuvant immunotherapy (IT) featuring immune checkpoint inhibition (ICI) is standard of care in advanced ...stage head and neck squamous cell carcinoma (HNSCC) and cutaneous squamous cell carcinoma (CSCC). ICI response rates in CSCC are described as higher than in HNSCC. IT is constantly shifting into earlier disease stages which confronts the surgeon with immunotherapeutically pre-treated patients. It is therefore becoming increasingly difficult to assess which patients with symptomatic tumor disease and a lack of curative surgical option might benefit from salvage surgery.
The following 6 cases describe therapeutic decision-making regarding ICI and (salvage) surgery in patients with advanced stage HNSCC or CSCC.
focus on neoadjuvant ICI followed by salvage surgery. In
salvage surgery was performed after short-term stabilization with partial response to ICI. The last two cases (
) address the surgical approach after failure of ICI. All cases are discussed in the context of the current study landscape and with focus on individual decision-making. For better understanding, a timetable of the clinical course is given for each case.
ICI is rapidly expanding its frontiers into the neoadjuvant setting, frequently confronting the surgeon with heavily pretreated patients. Salvage surgery is a viable therapeutic concept despite the rise of systemic treatment options. Decision-making on surgical intervention in case of a salvage surgery remains an individual choice. For neoadjuvant ICI monitoring regarding pathological tumor response or tumor necrosis rate, we suggest correlation between the initial biopsy and the definite tumor resectate in order to increase its significance as a surrogate marker. Scheduling of neoadjuvant ICI should be further investigated, as recent studies indicate better outcomes with shorter time frames.
Head and Neck Salivary Gland Carcinomas—Elective Neck Dissection, Yes or No? Nobis, Christopher-Philipp, Cand.Med; Rohleder, Nils H., MD, DDS; Wolff, Klaus-Dietrich, MD, DDS, PhD ...
Journal of oral and maxillofacial surgery,
2014, January 2014, 2014-Jan, 2014-1-00, 20140101, Letnik:
72, Številka:
1
Journal Article
Recenzirano
Purpose Surgical resection and subsequent neck dissection (ND) in cases of clinically positive lymph nodes is an accepted primary treatment strategy for salivary gland carcinomas. Because of ...uncertainty in the extent of lymphogenic metastasis, the authors advocate a strategy of surgical resection and elective ND (END) for all patients. The authors evaluated their treatment by estimating the frequency of metastatic disease and identifying factors associated with an increased risk for metastatic disease. Materials and Methods A retrospective cohort study was implemented using patient data obtained from the university's interdisciplinary board for head and neck tumors. Data were screened for age, gender, tumor entity, localization, grade, and TNM Classification of Malignant Tumors (by UICC, International Union Against Cancer) status. Statistical analysis was performed to identify possible predictors of lymph node metastasis. Nodal status groups (N+ and N0) were compared with respect to age by t tests; other comparisons involved χ2 tests. Results Ninety-four patients (50% female, 50% male; mean age, 59.12 yr) were identified, of whom 87 had an indication for END. On postsurgical histopathologic examination, 34 (39%; 17 male, 17 female) were diagnosed with N+ . Statistical analysis for nodal status produced explorative P values (age, P = .001; gender, P = .792; anatomic region, P = .114; tumor entity, P = .854; tumor status, P = .263; grade, P = .000). Conclusion All studied malignancies were capable of lymph node dissemination. Therefore, no reliable preoperative predictors for lymphogenic metastasis are currently identifiable. Because of difficulties in safely predicting lymphogenic metastasis and the high rate of N+ results on postoperative examination, the authors strongly advise END for all patients with salivary gland carcinoma.
The involvement of immune cell infiltration and immune regulation in the progression of oral squamous cell carcinoma (OSCC) is shown. Anti-PD-1 therapy is approved for the treatment of advanced OSCC ...cases, but not all patients respond to immune checkpoint inhibitors. Hence, further targets for therapeutic approaches are needed. The number of identified cellular receptors with immune checkpoint function is constantly increasing. This study aimed to perform a comparative analysis of a large number of immune checkpoints in OSCC in order to identify possible targets for therapeutic application.
A NanoString mRNA analysis was performed to assess the expression levels of 21 immune regulatory checkpoint molecules in OSCC tissue (
= 98) and healthy oral mucosa (NOM;
= 41). The expression rates were compared between the two groups, and their association with prognostic parameters was determined. Additionally, relevant correlations between the expression levels of different checkpoints were examined.
In OSCC tissue, significantly increased expression of CD115, CD163, CD68, CD86, CD96, GITRL, CD28 and PD-L1 was detected. Additionally, a marginally significant increase in CD8 expression was observed. BTLA and PD-1 levels were substantially increased, but the differential expression was not statistically significant. The expression of CD137L was significantly downregulated in OSCC compared to NOM. Correlations between immune checkpoint expression levels were demonstrated, and some occurred specifically in OSCC tissue.
The upregulation of inhibitory receptors and ligands and the downregulation of activators could contribute to reduced effector T-cell function and could induce local immunosuppression in OSCC. Increased expression of activating actors of the immune system could be explained by the increased infiltration of myeloid cells and T-cells in OSCC tissue. The analysis contributes to the understanding of immune escape in OSCC and reveals potential targets for oral cancer immunotherapy.
Objectives
Confocal laser endomicroscopy (CLE) is an optical method that enables microscopic visualization of oral mucosa. Previous studies have shown that it is possible to differentiate between ...physiological and malignant oral mucosa. However, differences in mucosal architecture were not taken into account. The objective was to map the different oral mucosal morphologies and to establish a “CLE map” of physiological mucosa as baseline for further application of this powerful technology.
Materials and methods
The CLE database consisted of 27 patients. The following spots were examined: (1) upper lip (intraoral) (2) alveolar ridge (3) lateral tongue (4) floor of the mouth (5) hard palate (6) intercalary line. All sequences were examined by two CLE experts for morphological differences and video quality.
Results
Analysis revealed clear differences in image quality and possibility of depicting tissue morphologies between the various localizations of oral mucosa: imaging of the alveolar ridge and hard palate showed visually most discriminative tissue morphology. Labial mucosa was also visualized well using CLE. Here, typical morphological features such as uniform cells with regular intercellular gaps and vessels could be clearly depicted. Image generation and evaluation was particularly difficult in the area of the buccal mucosa, the lateral tongue and the floor of the mouth.
Conclusion
A physiological “CLE map” for the entire oral cavity could be created for the first time.
Clinical relevance
This will make it possible to take into account the existing physiological morphological features when differentiating between normal mucosa and oral squamous cell carcinoma in future work.
PDF
