Cutaneous Head and Neck Squamous Cell Carcinoma with Regional Metastases: The Prognostic Importance of Soft Tissue Metastases and Extranodal Spread

Extranodal spread (ENS) is an established adverse prognostic factor in metastatic cutaneous squamous cell carcinoma (cSCC); however, the clinical significance of soft tissue metastases (STM) is unknown. The aim of this study was to evaluate the prognosis of patients with STM from head and neck cSCC, and to compare this with that of node metastases with and without ENS. Patients with cSCC metastatic to the parotid and/or neck treated by primary surgical resection between 1987 and 2007 were included. Metastatic nodes > 3 cm in size were an exclusion criterion. A Cox proportional hazard model was used to determine the effect of STM adjusting for other relevant prognostic factors. The population included 164 patients with a median follow-up of 26 months. There were 8 distant and 37 regional recurrences. There were 22 were cancer-specific deaths, and 29 patients died. STM was a significant predictor of reduced overall (hazard ratio 3.3; 95% confidence interval 1.6-6.4; P = 0.001) and disease-free survival (hazard ratio 2.4; 95% confidence interval 1.4-4.1; P = 0.001) when compared to patients with node disease with or without ENS. After adjusting for covariates, STM and number of involved nodes were significant independent predictors of overall and disease-free survival. In metastatic cSCC of the head and neck, the presence of STM is an independent predictor of reduced survival and is associated with a greater adverse effect than ENS alone

Cortical Gray Matter Injury in Encephalopathy of Prematurity: Link to Neurodevelopmental Disorders

Preterm-born infants frequently suffer from an array of neurological damage, collectively termed encephalopathy of prematurity (EoP). They also have an increased risk of presenting with a neurodevelopmental disorder (e.g., autism spectrum disorder; attention deficit hyperactivity disorder) later in life. It is hypothesized that it is the gray matter injury to the cortex, in addition to white matter injury, in EoP that is responsible for the altered behavior and cognition in these individuals. However, although it is established that gray matter injury occurs in infants following preterm birth, the exact nature of these changes is not fully elucidated. Here we will review the current state of knowledge in this field, amalgamating data from both clinical and preclinical studies. This will be placed in the context of normal processes of developmental biology and the known pathophysiology of neurodevelopmental disorders. Novel diagnostic and therapeutic tactics required integration of this information so that in the future we can combine mechanism-based approaches with patient stratification to ensure the most efficacious and cost-effective clinical practice

Barbarians at the British Museum: Anglo-Saxon Art, Race and Religion

A critical historiographical overview of art historical approaches to early medieval material culture, with a focus on the British Museum collections and their connections to religion

Representation of a Framework for Determining Emergency Muster Points in Process Industries Using Integrated FAHP-FTOPSIS Methods

Background and Objective: Emergency evacuation planning is one of the most central protective measures in emergency situations. Determination of the emergency muster points is one of the principal requirements of emergency evacuation planning. In this regard, this study aimed to represent a framework for determining emergency muster points in process industries. Materials and Methods: After examining various texts, the effective criteria for determining emergency muster points were identified, and the relative weight of each criterion was calculated using the fuzzy analytic hierarchy process (FAHP) method. Finally, the fuzzy technique for order preference by the similarity of an ideal solution (FTOPSIS) method was utilized to prioritize and determine optimal emergency muster points. Results: According to the calculations by the FAHP method, from the total 12 criteria surveyed in this study, the first eight criteria from any factors with the highest weight were introduced as the most significant factors. The criteria of external factors affected relative weights, dis-tances from the hazard centers, prevailing wind conditions, nature of probable scenarios, and the presence of vulnerable groups. On the other hand, the criteria of internal factors included the potential impact of the accident, easy accessibility, visibility, and monitoring, as well as travel time. Conclusion: Identification and evaluation of emergency muster points shall be made based on distances from the hazard centers, prevailing wind conditions, nature of probable scenarios, presence of vulnerable groups, the potential impact of the accident, easy accessibility, visibility, and monitoring, as well as travel time

Social perception of morbidity in facial nerve paralysis

Background: There are many patient-based and clinician-based scales measuring the severity of facial nerve paralysis and the impact on quality of life, however, the social perception of facial palsy has received little attention. The purpose of this pilot study was to measure the consequences of facial paralysis on selected domains of social perception and compare the social impact of paralysis of the different components. Method: Four patients with typical facial palsies (global, marginal mandibular, zygomatic/buccal, and frontal) and 1 control were photographed. These images were each shown to 100 participants who subsequently rated variables of normality, perceived distress, trustworthiness, intelligence, interaction, symmetry, and disability. Statistical analysis was performed to compare the results among each palsy. Results: Paralyzed faces were considered less normal compared to the control on a scale of 0 to 10 (mean, 8.6; 95% confidence interval [CI] = 8.30–8.86) with global paralysis (mean, 3.4; 95% CI = 3.08–3.80) rated as the most disfiguring, followed by the zygomatic/buccal (mean, 6.0; 95% CI = 5.68–6.37), marginal (mean, 6.5; 95% CI = 6.08–6.86), and then temporal palsies (mean, 6.9; 95% CI = 6.57–7.21). Similar trends were seen when analyzing these palsies for perceived distress, intelligence, and trustworthiness, using a random effects regression model. Conclusion: Our sample suggests that society views paralyzed faces as less normal, less trustworthy, and more distressed. Different components of facial paralysis are worse than others and surgical correction may need to be prioritized in an evidence-based manner with social morbidity in mind.6 page(s

Contralateral neck failure in lateralized oral squamous cell carcinoma

Background: Elective treatment of the contralateral clinically node-negative (cN0) neck is not routinely recommended for lateralized oral cavity squamous cell carcinoma (SCC). We sought to determine the failure rate in the untreated contralateral neck in patients with lateralized oral SCC undergoing treatment of the primary and ipsilateral neck and to identify any features placing patients at sufficient risk of contralateral regional failure to justify elective treatment. Methods: We identified 688 patients with oral SCC undergoing curative surgery ± adjuvant therapy between 1985 and 2012 from a prospectively collected database. Patients with midline primaries and those undergoing bilateral neck treatment were excluded. The primary endpoint was isolated contralateral neck failure. Results: Of 481 patients, 14 (2.9%) developed isolated contralateral neck recurrence, with median time to recurrence of 8 months. Patients with poorly differentiated tumours or pathologically proven ipsilateral nodal metastases were at significantly higher risk of contralateral failure (hazard ratio (HR) 3.6, 95% confidence interval (CI) 1.1–11.9, P = 0.037 and HR 4.6, 95% CI 1.5–13.8, P = 0.006 respectively). Presence of both of these factors conferred a 10% risk of contralateral failure. Conclusion: Patients with lateralized oral SCC undergoing treatment of the primary tumour and ipsilateral neck have a low rate of isolated contralateral neck failure. Although poorly differentiated primaries and ipsilateral nodal metastases were predictors of contralateral recurrence, the risk remains relatively modest in this subset of patients suggesting close observation may be more appropriate than elective treatment. Our results support current recommendations for observation of the cN0 contralateral neck in lateralized oral SCC.5 page(s

Evolution of Head and Neck Cutaneous Squamous Cell Carcinoma Nodal Staging—An Australian Perspective

Cutaneous squamous cell carcinoma of the head and neck (HNcSCC) is one of the commonest malignancies. When patients present with regional metastatic disease, treatment escalation results in considerable morbidity and survival is markedly reduced. Owing to the high incidence, Australian institutions have been at the forefront of advocating for reliable, accurate, and clinically useful staging systems that recognise the distinct biological characteristics of HNcSCC. As a result, an extensive body of literature has been produced over the past two decades, which has defined critical prognostic factors, critiqued existing staging systems, and proposed alternative staging models. Notwithstanding, a suitable staging system has proved elusive. The goal of cancer staging is to group patients according to cancer characteristics for which survival differs between groups (distinctiveness), consistently decreases with increasing stage (monotonicity), and is similar within a group (homogeneity). Despite implementing major changes based on published data, the latest edition of the American Joint Committee on Cancer (AJCC) staging manual fails to satisfy these fundamental requirements. This review chronologically explores and summarises the Australian contribution to prognostication and nodal staging of HNcSCC and highlights the ongoing challenges

Perineural invasion in oral squamous cell carcinoma : quantitative subcategorisation of perineural invasion and prognostication

Background: Evidence regarding the prognostic value of perineural invasion (PNI) in oral squamous cell carcinoma (OSCC) and whether PNI alone warrants consideration of adjuvant therapy is controversial. We evaluated whether histopathological sub-categorization of PNI improves risk stratification. Methods: PNI was evaluated for nerve size, number of foci, and distance from the tumor in 318 OSCC patients. Univariable and multivariable analyses were performed, with local failure (LF) and disease-specific survival (DSS) as the primary endpoints. Results: PNI did not influence prognosis when classified as absent versus present. In contrast, multifocal PNI was associated with LF (P = 0.049) and decreased DSS (P = 0.043) on multivariable analyses. The size of the involved nerve separated those with multifocal PNI into intermediate (<1 mm) and high-risk (≥1 mm) groups. Unifocal PNI and distance from the tumor did not influence prognosis. Multifocal PNI was associated with worse prognosis irrespective of post-operative radiotherapy (PORT). Conclusions: Multifocal PNI is associated with poor outcomes even with PORT suggesting consideration of therapeutic escalation, particularly with involved nerves ≥1 mm. Unifocal PNI did not affect prognosis even in the absence of PORT, which may not be required if this is the sole risk factor. Prospective validation and testing of these hypotheses is essential before implementation.7 page(s