BackgroundGuidelines 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.MethodsWe 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.ResultsTwo 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).ConclusionSEND 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 RegistrationNIHR UK Clinical Research Network database ID number: UKCRN 2069 (registered on 17/02/2006), ISCRTN number: 65018995, ClinicalTrials.gov Identifier: NCT00571883.
The histological features of the flexor tendon sheath in the spontaneous carpal tunnel syndrome were studied. The main differences between our findings and previous studies were twofold. Firstly a striking absence of inflammation in our material and secondly the diversity of the pathological changes encountered--alterations in the connective tissue especially the collagen; proliferation with thickening of the tissues of the tendon sheath; fibrosis; amyloid deposition; oedema; vascular lesions including thickening of vessels walls, intimal hyperplasia, and thrombosis; and a foreign body giant cell reaction. Although the lesions described here may not be significant in every case in which they are encountered, they do appear to support the view that pressure in the carpal tunnel and ischaemia are the important factors in a majority of cases of the spontaneous carpal tunnel syndrome.
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