Tumor-positive resection margins are a major problem in oral cancer surgery. High-wavenumber Raman spectroscopy is a reliable technique to determine the water content of tissues, which may contribute to differentiate between tumor and healthy tissue. The aim of this study was to examine the use of Raman spectroscopy to differentiate tumor from surrounding healthy tissue in oral squamous cell carcinoma. From 14 patients undergoing tongue resection for squamous cell carcinoma, the water content was determined at 170 locations on freshly excised tongue specimens using the Raman bands of the OH-stretching vibrations (3350-3550 cm(-1)) and of the CH-stretching vibrations (2910-2965 cm(-1)). The results were correlated with histopathological assessment of hematoxylin and eosin stained thin tissue sections obtained from the Raman measurement locations. The water content values from squamous cell carcinoma measurements were significantly higher than from surrounding healthy tissue (p-value < 0.0001). Tumor tissue could be detected with a sensitivity of 99% and a specificity of 92% using a cutoff water content value of 69%. Because the Raman measurements are fast and can be carried out on freshly excised tissue without any tissue preparation, this finding signifies an important step toward the development of an intraoperative tool for tumor resection guidance with the aim of enabling oncological radical surgery and improvement of patient outcome.

The incidence of leprosy in the Netherlands is now low, which can lead to incorrect diagnosis by the clinician. When this happens, leprosy can become very incapacitating. We describe a case of a young woman with hypopigmented and insensitive macules on the skin; she also suffered from pain and loss of strength in her legs. She consulted a neurologist, a rehabilitation specialist and a dermatologist, but it was many years before a diagnosis was made. In the meantime, this woman had become unemployed and the disease was still progressive. When leprosy was confirmed, she was treated with multibacillary multidrug therapy. The combination of hypopigmented macules on the skin and loss of sensitivity is a very important clue in reaching a diagnosis of leprosy. It is important to draw attention to the symptoms of this disease to ensure that the right diagnosis is made on time.

The prognosis of sentinel node (SN)-positive melanoma patients is predicted by a number of characteristics such as size and site of the metastases in the SN. The pathway and prognosis of strong pigmentation of melanoma metastases in the SN is unclear. The aim of this study is to evaluate the role of pigmentation and growth pattern of metastases in the SN with respect to survival. A total of 389 patients underwent an SN procedure (1997–2011). Ninety-five patients had a positive SN and material from 75 patients was available for review. The median follow-up time was 75 months (range 6–164). Pigmentation was scored from 0 to 2 using the following scale: 0=absent, 1=slight, and 2=strong. Growth pattern was scored as either eccentric (1) or infiltrative (2). SN tumor burden was measured according to the Rotterdam criteria. The primary melanoma had a median Breslow thickness of 2.90 mm (0.8–12.00 mm). Ulceration was present in 34 patients (45.3%). There was a median SN tumor burden of 0.5 mm (0.05–7.00 mm). In a total of 75 patients, 59 patients (79%) had no pigmentation, 13 patients (17%) had slight pigmentation, and three patients (4%) had strong pigmentation in the SN. Because of the small numbers, the classification was modified to either absent 59 (79%) or present 16 (21%) pigmentation, respectively. The SN tumor burden was significantly higher (P=0.031) for patients with pigmentation. Patients with pigmentation had a 5-year melanoma-specific survival (MSS) of 47% and a 10-year MSS of 33%. Patients without pigmentation had a 5-year MSS of 70% and a 10-year MSS of 59% (P=0.06). There was no difference in MSS for patients with an eccentric or an infiltrative growth pattern, nor did it correlate with other prognostic factors. Multivariate analysis for MSS showed five significant factors associated with worse prognosis: male sex (P=0.036), nodular melanoma (P=0.001), truncal site (P=0.0001), SN tumor burden more than 1.0 mm (P=0.022), and positive completion lymph node dissection (P=0.004). The 5-year MSS for SN tumor burden is 94% for 0.1 mm or less, 66% for 0.1–1.0 mm, and 41% for more than >1.0 mm (P<0.001). The 10-year MSS for SN tumor burden is, respectively, 94, 51, and 35% (P<0.001). This preliminary exploratory retrospective study showed that pigmentation within the SN seems to correlate with increased SN tumor burden.

BACKGROUND The presence of human papillomavirus (HPV)-infection in oropharyngeal squamous cell carcinoma (OPSCC) is a major determinant in prognostic risk modeling. However, most risk models are based on clinical trials which only include a selected patient population. The clinical significance of HPV and other prognostic factors in patients with OPSCC remains to be evaluated in a large, unselected cohort, which also includes patients with stage I/II disease and patients with severe comorbidity. PATIENTS AND METHODS All patients diagnosed with OPSCC in 2000-2006 in two Dutch university hospitals were included. The presence of an oncogenic HPV infection was determined by p16-immunostaining, followed by a high-risk HPV general primer 5+/6+ DNA PCR on the p16-positive cases. Cox regression analysis was carried out to compare survival rates between HPV-positive and HPV-negative patients and a prognostic model was generated by recursive partitioning. RESULTS In total, 163 of 841 (19.4%) tumors were HPV-positive. Patients with HPV-positive OPSCC had a more favorable overall survival [73.5% versus 40.9% after 5 years; P < 0.001; hazard ratio = 0.34, 95% confidence interval (CI) 0.25-0.48] compared with patients with HPV-negative OPSCC. Patients with p16-positive but HPV DNA-negative tumors showed a significantly less favorable survival than patients with p16-positive and HPV DNA-positive tumors (P < 0.001). A prognostic model was developed in which patients were classified into three risk groups according to HPV status, nodal stage and comorbidity. [Harrell's concordance index of 0.68 (95% CI 0.65-0.71)]. CONCLUSIONS Tumor HPV status is a strong and independent prognostic factor for survival among patients with OPSCC. A prognostic risk model was proposed, based on our large, unselected cohort of patients with HPV status, comorbidity and nodal stage being the important prognostic factors. In addition, this study emphasizes the importance of performing an HPV DNA-specific test besides p16-immunostaining.

An earlier and more accurate detection of (small) cancerous and precancerous lesions in the oral cavity is essential to improve the prognosis of oral squamous cell carcinomas. Raman spectroscopy is being pursued as a potential method to realize this improvement, since the technique provides objective information on a biochemical level and can be used for real-time guidance of the diagnostic procedure. Since oral mucosal tissue is inhomogeneous and comprises different layers and histological structures, a good understanding of the signal contributions of the individual layers and structures is required for an accurate interpretation of in vivo tissue spectra measurement volumes. The aim of this study was to create a standardized method to collect and analyse the spectral contributions of individual histopathological structures in oral mucosa. The method is based on Raman microspectroscopic mapping of unstained frozen tissue sections and subsequent histopathological annotation of the features in the resulting Raman images. The obtained annotated reference spectra were used as input in an unsupervised hierarchical cluster analysis in order to determine the spectral characteristics and variance within one histo(patho)logical structure. The described method resulted in an annotated database of Raman spectral characteristics of individual histopathological structures encountered in oral tissue. This database can be used as input for the development of classification and quantification algorithms, in order to achieve a high specificity and sensitivity for clinical diagnostic instruments. Additionally, this database can be used to optimize the exact location and measurement volume of in vivo measurements. Copyright © 2013 John Wiley & Sons, Ltd.

Background  Population‐based basal cell carcinoma (BCC) incidences are based on cancer registry data; however, these only include histologically diagnosed tumours.

Paroxysmal nocturnal haemoglobinuria (PNH) is characterized by chronic intravascular haemolysis and a high risk of thrombosis, on a background of variable pancytopenia. The disease is caused by an acquired mutation of the PIGA gene in the haematopoietic stem cell, resulting in deficiency of glycosyl phosphatidyl inositol (GPI) anchors. The lack of GPIanchored complement inhibitors on erythrocytes renders them susceptible to complement-mediated haemolysis. Thrombosis frequently complicates PNH with high morbidity and mortality (de Latour et al, 2008). Thrombotic risk is correlated to the size of the PNH clone (Hall et al, 2003). Prophylaxis with coumarins does not offer full protection, particularly in patients with prior thrombosis (de Latour et al, 2008). Proposed mechanisms include shedding of procoagulant microparticles by complement-damaged platelets and deficiencies of GPI-anchored urokinase plasminogen activator receptor (uPAR) and tissue factor pathway inhibitor (TFPI) (reviewed in van Bijnen et al, 2011). Additionally, depletion of nitric oxide by free haemoglobin may promote platelet activation (Rother et al, 2005). Eculizumab, a monoclonal antibody to complement factor C5, effectively blocks intravascular haemolysis, improves anemia and reduces thrombotic risk (Hillmen et al, 2006, 2007; Schubert et al, 2008). Treatment must be continued lifelong to maintain terminal complement inhibition. During treatment, prolonged survival of GPI-deficient PNH erythrocytes increases their number (Hillmen et al, 2006). Consequently, in the first weeks after stopping eculizumab, significant haemolysis may be anticipated. Thrombotic risk is expected to return to pre-treatment levels; rebound thrombosis however has not been described. Here, we report a patient with a first thrombotic event shortly after stopping eculizumab. While on anticoagulant prophylaxis, this female patient suffered from a fatal arteriovenous thrombosis of the small bowel 3 weeks after her last eculizumab dose. The patient was diagnosed with classic PNH (granulocyte clone size 70%) at the age of 32 years. Initial treatment included erythrocyte transfusions (1–2 units/month) and anticoagulant prophylaxis with fenprocoumon. She never suffered from thrombosis. Three years after diagnosis, the PNH clone size had increased to 92%. She started eculizumab treatment, which normalized lactate dehydrogenase (LDH) levels, rendered her transfusion-independent and improved her quality of life. In 2007, 1 year after starting eculizumab, she developed progressive pancytopenia and transfusion dependency. LDH levels remained normal, and PNH clone size was still 98%. Underdosing of eculizumab was excluded. Bone marrow histology suggested the development of aplastic anaemia. At that time, the high transfusion requirements masked the clinical benefit of eculizumab. Though unlikely, a role for eculizumab in developing aplastic anaemia could not be excluded and eculizumab was stopped. PNH erythrocytes were undetectable at that time and significant haemolysis did not occur. Three weeks after her last eculizumab dose, while on therapeutically dosed fenprocoumon and severely thrombocytopenic, she reported abdominal pain and feculent vomiting. Explorative surgery revealed segmental necrosis of the small bowel. Histology showed extensive arteriovenous thrombosis (Fig 1). Anticoagulant treatment was switched to argatroban. Nine weeks later, she again developed abdominal pain and

Background  The incidence of multiple basal cell carcinomas (BCCs) is not well documented.

OBJECTIVE To calculate the cumulative risks and incidence rates for the development of multiple (two or more) basal cell carcinomas (BCC). DESIGN A retrospective cohort study with data from PALGA, the nationwide network and registry of histopathology and cytopathology in the Netherlands. METHOD Using pathology reports, the first 2483 patients diagnosed with a first histologically confirmed BCC in the year 2004 were retrospectively followed for 5 years. The Andersen-Gill survival analysis was used to study whether gender or age affected the risk of developing multiple BCCs. RESULTS In total, 2483 patients developed 3793 BCCs. The five-year cumulative risk of developing multiple BCCs was 29.2%. The incidence rate for the development of two or more BCCs was 25,318 per 100,000 person-years in the first half year after first BCC diagnosis, decreasing to 6953 per 100,000 person-years after 5 years of follow-up. Compared with women men had a 30% (adjusted HR 1.30; 95% CI 1.11-1.53) higher risk of developing multiple BCCs and those aged 65-79 years had an 80% (adjusted HR 1.81; 95% CI 1.37-2.41) higher risk of having two or more BCCs compared with patients younger than 50 years. CONCLUSION Almost one third of the patients with a BCC developed two or more BCCs, most frequently in the period shortly after the first BCC. At diagnosis of BCC a full body skin examination should be performed and repeated annually for at least three years.