SYNOPSIS PROFORMA



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,BANGALORE

KARNATAKA

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE AND ADDRESS

DR. G. SUCHITRA.

P.M.N.M DENTAL COLLEGE & HOSPITAL

BAGALKOT- 587101

KARNATAKA

2. NAME OF THE INSTITUTION

P.M.N.M DENTAL COLLEGE & HOSPITAL,

BAGALKOT-- 587101

KARNATAKA

3. COURSE OF STUDY AND SUBJECT

M.D.S (MASTER OF DENTAL SURGERY)

DEPARTMENT OF ORAL & MAXILLOFACIAL PATHOLOGY & MICROBIOLOGY

4. DATE OF ADMISSION TO COURSE

8th APRIL 2008

5. TITLE OF THE TOPIC

“HISTOPATHOLOGIC STUDY OF LYMPH NODES IN NECK DISSECTIONS OF CARCINOMAS OF THE ORAL CAVITY”

6. BRIEF RESUME OF THE INTENDED WORK

6.1. NEED FOR THE STUDY

Head and neck cancer is the sixth major prevalent neoplasm of the world, being responsible for 5% of all neoplasms in men and 2.5% in women. Squamous cell carcinoma is the most common neoplasm and comprises approximately 80% of cancers of head and neck.¹

Incidence of regional metastases in head and neck cancer is high and the presence or absence of lymph node metastases is the most important prognostic factor. An understanding of the mechanisms, whereby tumor cells are prevented from developing lymph node metastases and tumor cells establish the metastases is crucial for tumor biology.¹

The five-year survival rate of patients with squamous cell carcinoma of the upper aero-digestive tract is reduced by almost 50% with the development of cervical metastases.

Prognostic features related to the regional lymph nodes are the metastatic status, laterality of positive nodes, number of positive nodes, size of metastatic deposit, anatomical level of involvement, extracapsular spread, embolisation/permeation of perinodal lymphatics, pN stage.²

Lymph nodes have a great variety of both cellular and humoral immune responses. There is node-to-node heterogeneity of reaction. Metastatic nodes are usually larger than the tumor-free node or sometimes tumor cells may be metastasised in small nodes. ¹

The lymph nodes exhibit a wide spectrum of changes ranging from reactive changes, isolated tumor cells, micrometastasis3 to frank metastasis.

Very few studies have been undertaken to describe these histological patterns in the cervical lymph nodes from primary tumors of oropharyngeal region.

Hence this study aims at determining the various histopathological changes of excised lymph nodes in neck dissection specimens of carcinomas of oral cavity.

6.2. REVIEW OF LITERATURE

A study was conducted by Masaya Okura et al, on the morphological changes of regional lymph nodes in squamous cell carcinoma of the oral cavity and 430 lymph nodes were assessed. The gross area, germinal center area, paracortical area and tumor area were measured. Their results showed that metastatic nodes had significantly lower distribution ratio of paracortical area to grossarea than that of tumor free node. Germinal center area was not constantly associated with lymph node metastasis.1

A study was conducted by Y. Okada et al., on the analysis of cervical lymph node metastasis in oral squamous cell carcinoma. 38 cases of neck dissection were used and the relationship of degree of histological malignancy with cervical lymph node metastasis were analysed. In their study a significant relation was evident between the degree of histological malignancy and metastases in the cervical lymph nodes, indicating that the histological malignancy could be served as a predictor for metastases in the cervical lymph nodes.4

A study was conducted by Susuma Shingaki et al on: evaluation of histolopathologic parameters in predicting cervical lymph node metastases of oral and oropharyngeal carcinomas. Retrospectively 53 patients with squamous cell carcinoma of oral cavity and oropharynx were undertaken. Specimens were examined for degree of differentiation, pattern and depth of invasion and lymphoplasmacytic response in relation to metastasis. They found that the pattern and depth of stromal invasion and the presence of lymphatic-vascular invasion were important indicators of cervical lymph node metastasis.5

A study was conducted by J.A.Woolgar on the incidence, extent and distribution of nodal metastases in 152 neck dissections from patients with a No neck who underwent surgery for intraoral/oropharyngeal squamous cell carcinoma. Metastases was detected histologically in 32 No necks. Three cases showed ‘skipping’ of levels within the neck and one case showed ‘peppering’. 17 of the 32 positive No necks had ‘micrometastasis’ and hence they concluded that preoperative staging by palpation and routine magnetic resonance imaging cannot be relied upon to detect early cervical metastatic disease, and the topographic distribution of positive nodes indicates that modified neck dissections should include level IV nodes when the primary tumor involves the tongue.6

A study done by J.A. Woolgar on 439 cases of neck dissections revealed that metastases was evident in 47% of patients including bilateral metastases in 6%, extracapsular spread in 29% and matting in 7%. The typical ‘inverted-cone pattern’ was seen in 67% of patients with metastases. A single micrometastases was seen in 14%, skip metastasis(10%), peppering (2%), flushing of lymph node sinuses (1%), contralateral neck metastases(0.4%)7

6.3. OBJECTIVES OF THE STUDY

1. To study the histopathologic changes of lymph nodes in excised neck dissection specimens.

2. To correlate the histopathological findings of these lymph nodes with the staging of primary tumor.

7. MATERIAL AND METHODS

7.1. SOURCE OF DATA

Department of Oral and Maxillofacial Pathology P.M.N.M Dental College Bagalkot

Karnataka Cancer Therapy & Research Institute, Hubli.

7.2. METHOD OF COLLECTION OF DATA

Details related to clinical history, examination and staging are obtained and recorded on a proforma.

Retrospective and prospective collections of 40 neck dissection specimens will be undertaken. Careful dissection, harvesting and trimming of lymph nodes are done. Thin 4µm sections of the tumor proper and the harvested lymph nodes will be undertaken and stained with Hematoxylin & Eosin stain, and examined under a light microscope for the histopathological evaluation.

Primary tumor grading will be done according to the WHO grading system into three categories:

Grade I --Well differentiated

Grade II—Moderately differentiated

Grade III- Poorly differentiated

Lymph node sections are then observed for the histopathologic changes according to the criteria described by Tsakraklides et al 8as

1. Lymphocyte predominance

2. Germinal center predominance

3. Lymphocyte depletion

4. Unstimulated node

Correlation with the histopathologic findings of the tumor proper and the lymph nodes will be done. Histopathological study of the obtained sections from lymph nodes is done by three different pathologists and finally the results are analysed statistically using appropriate statistical methods.

Exclusion criteria

1. Patients who have received preoperative radiotherapy, chemotherapy, or previous surgery, other than routine dento-alveolar procedures and diagnostic biopsy.

7.3. DOES OUR STUDY REQUIRE ANY INVESTIGATION INTERVENTION TO BE CONDUCTED ON PATIENT OR OTHER HUMANS OR ANIMALS? IF SO, PLEASE BRIEFLY SPECIFY.

No.

7.4. HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3.

Yes

8. LIST OF REFERENCES

1. Masaya okura, et al., Morphological changes of regional lymph node in squamous cell carcinoma of the oral cavity. J Oral Pathol Med (2005) 34: 214-219.

2. Julia A.Woolgar, Histopathological prognosticators in oral and oropharyngeal squamous cell carcinoma. Oral Oncology (2006) 42;229-239.

3. Paul Hermanek et al. Classification of Isolated Tumor Cells and Micrometastasis. Cancer 1999;86:2668-2673.

4. Y. Okada et al, An analysis of cervical lymph nodes metastasis in oral squamous cell carcinoma, Int J Oral & Maxillofacial Surgery 2003;32;284-288

5. Susuma Shingaki et al, Evaluation of histopathologic parameters in predicting cervical lymph node metastasis of oral and oropharyngeal carcinomas, Oral surg Oral med Oral pathol; 1988;66;683-688

6. J. A. Woolgar Pathology of the No neck, British Journal of Oral & Maxillofacial Surgery(1999)37.205-209.

7. J. A. Woolgar The topography of cervical lymph node metastases revisited: the histological findings in 526 sides of neck dissection from 439 previously untreated patients. Int.J. Oral Maxillofacial Surg.2007;36;219-225.

8. Tsakraklides V et al Prognostic significance of regional lymph node histology in uterine cervical cancer. Cancer April 1973;vol 31;860-86810

9 . SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11.1. NAME AND DESIGNATION OF GUIDE

DR. R.S. PURANIK MDS

PROFESSOR,

DEPARTMENT OF ORAL AND MAXILLOFACIAL PATHOLOGY,

P.M.N.M DENTAL COLLEGE AND HOSPITAL,

BAGALKOT – 587101 ( KARNATAKA).

2. SIGNATURE OF THE GUIDE

3. NAME & DESIGNATION OF CO-GUIDE

DR. SHRINIVAS S. VANAKI MDS

PROFESSOR AND HEAD,

DEPARTMENT OF ORAL AND MAXILLOFACIAL PATHOLOGY,

PMNM DENTAL COLLEGE AND HOSPITAL,

BAGALKOT – 587101 ( KARNATAKA).

11.4. SIGNATURE OF THE CO-GUIDE

11.5. HEAD OF THE DEPARTMENT

DR. SHRINIVAS S. VANAKI MDS

PROFESSOR AND HEAD,

DEPARTMENT OF ORAL AND MAXILLOFACIAL PATHOLOGY,

PMNM DENTAL COLLEGE AND HOSPITAL,

BAGALKOT – 587101 ( KARNATAKA).

11.6. SIGNATURE OF THE HEAD OF THE DEPARTMENT

12.1. REMARKS OF THE PRINCIPAL

12.2. SIGNATURE OF THE PRINCIPAL

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