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Tumors: Patients and surgeons
EDITORIAL J Oral Maxillofac Surg 60:727-728, 2002
Tumors: Patients and Surgeons our expertise in the diagnosis and treatment of tumors must be used in the treatment of all of our patients, and it must be valued. The simple universal act of the head and neck examination for every oral and maxillofacial surgery patient, along with a verbal report to the patient on its findings, engenders many appreciative smiles and relieved sighs. Our patients know that, like all of us, they are at risk for disease and that early diagnosis is the key to a favorable outcome. This examination says much about us as surgeons. It demonstrates that we are first thinking about our patient’s welfare and only next about the immediate tasks at hand. Although only a few surgeons devote the majority of their caseload to the treatment of tumors, pathology is seen daily in all of our practices. Because of the essential need for all oral and maxillofacial surgeons to maintain and upgrade their understanding of these individually uncommon lesions, JOMS strives to maintain a strong presence in tumor diagnosis, treatment, and reconstruction strategies. In 2001 we received 160 submissions of articles on tumors and 44 articles on tumor reconstruction, comprising 43% of our 477 submissions. Tumors and their consequences remain the number one area of endeavor in the scientific contribution of our specialty. This month’s JOMS is a typical issue that expands our expertise for the oral and maxillofacial surgery tumor patient. Ord et al1 indicate that ameloblastoma in children has a different distribution and behavior than it does in adults. Bataineh et al2 have shown that resection of the central giant cell granuloma can be successful with a uniform technique that usually preserves jaw continuity. Godden et al3 show that squamous cell carcinoma recurrence at level II nodes indicates the need for careful dissection and observation of this area. Gellrich et al4 show that functional disorders after tumor ablation have the greatest effect on quality of life. These studies in JOMS have important features in common. They are case series or observational studies designed to help answer important questions about tumor biology and tumor patients. Case series draw experience across decades and multiple centers to show optimal therapy, problems, and modes of rehabilitation. Along with advances in applied research, careful, scientifically valid observation is the best way to improve the outcome of tumor patients. Case-controlled studies are prospectively designed to
In my first year of practice, an acquaintance presented in our office for evaluation and asked to see my senior partner. I knew she had recently had breast cancer and appeared to be doing well. While writing our charts later that morning, Joe remarked that she had appeared quite concerned about a swelling of her lower lip. He felt sure it was minor trauma with mucous retention phenomena, and that it would disappear in the coming days. He reassured the patient, instructed her to return if the lesion persisted, and did not charge her because, as he said, “I didn’t DO anything.” That statement shook me then as it does now because it implies we are valued only for our performance and not for our cognitive expertise. It was all the more compelling in this case because I know how much that patient had just benefited from Joe’s knowledge and experience. She remained healthy and avoided unnecessary surgery and anxiety. Since that time, many patients have appeared in ways that persist in my memory. I suspect these clinical experiences reflect the experience of all practicing surgeons. Two cases are presented here (with intentional changes made to protect patient confidentiality) to show the vigilance necessary to uncover true pathology rather than accept the usual diagnoses. A middle-aged medical technician noted a mildly tender submandibular mass. A pulpless molar had been treated but the finding persisted. His evaluation revealed a greater than 2 cm, non-tender submandibular node that appeared rubbery and fixed to the underlying gland. Fine-needle aspiration demonstrated Hodgkin’s lymphoma. For years afterward, we continued to see each other in the hospital corridor and exchange “high fives” in celebration of his stage I diagnosis and successful treatment. An 11-year-old child appeared in my office for a second opinion after prolonged care elsewhere for a temporomandibular disorder characterized by pain and limitation of motion. He had been treated with a flat plane splint. On examination he exhibited a mass in the lateral pharyngeal wall that, after biopsy, proved to be fibrosarcoma. He underwent successful surgery, chemotherapy, and radiation, and I recently heard he was in high school and participating in sports. These experiences illustrate the essential role all clinicians have in the diagnosis and care of tumor patients. They also demonstrate that rare pathology is, in the aggregate, seen commonly. They show us that 727
728 address well-defined questions. Although case-controlled studies offer much more valid information, they are best designed for common lesions such as squamous cell carcinoma. Case-controlled studies are practically impossible to develop for rare valid subsets of lesions, such as ameloblastoma in children. As such, we must rely on descriptive retrospective information, as seen in case reports and case series, to gain an understanding of the optimal approach for the broad category of uncommon oral tumors. Although this may bring the validity of our contributions into question, I believe case series and case reports demonstrate our commitment to patients and extend our wisdom in improving their therapy. Oral and maxillofacial surgeons are experts in the management of head and neck tumors. We are capable of integrating our knowledge of odontogenic disease, oral pathology, differential diagnosis of facial pain, tumor biology, anatomy, and function into our interaction with each patient. Our devotion to knowledge, experience, careful diagnosis, and meticulous surgery must be continuously reinforced, and we must value our individual efforts to be indispensable and tireless bulwarks for our patients’ benefit.
EDITORIAL
Vigilance and attention to diagnosis, upgrading our knowledge of pathology, and continued commitment toward the successful treatment of tumor patients will remain a centerpiece of oral and maxillofacial surgery practice. Attached to every tumor is a patient that will always make the practice of oral and maxillofacial surgery all the more meaningful and valuable. LEON A. ASSAEL
References 1. Ord RA, Blanchaert Jr RH, Nikitakis NG, et al: Ameloblastoma in children. J Oral Maxillofac Surg 60:762, 2002 2. Bataineh AB, Al-Khateeb T, Rawashdeh MA: The surgical treatment of central giant cell granuloma of the mandible. J Oral Maxillofac Surg 60:756, 2002 3. Godden DRP, Ribeiro NFF, Hassanein K, et al: Recurrent neck disease in oral cancer. J Oral Maxillofac Surg 60:748, 2002 4. Gellrich N-C, Schimming R, Schramm A, et al: Pain, function, and psychologic outcome before, during, and after intraoral tumor resection. J Oral Maxillofac Surg 60:772, 2002
© 2002 American Association of Oral and Maxillofacial Surgeons doi:10.1053/joms.2002.34321
Tumors: Patients and Surgeons our expertise in the diagnosis and treatment of tumors must be used in the treatment of all of our patients, and it must be valued. The simple universal act of the head and neck examination for every oral and maxillofacial surgery patient, along with a verbal report to the patient on its findings, engenders many appreciative smiles and relieved sighs. Our patients know that, like all of us, they are at risk for disease and that early diagnosis is the key to a favorable outcome. This examination says much about us as surgeons. It demonstrates that we are first thinking about our patient’s welfare and only next about the immediate tasks at hand. Although only a few surgeons devote the majority of their caseload to the treatment of tumors, pathology is seen daily in all of our practices. Because of the essential need for all oral and maxillofacial surgeons to maintain and upgrade their understanding of these individually uncommon lesions, JOMS strives to maintain a strong presence in tumor diagnosis, treatment, and reconstruction strategies. In 2001 we received 160 submissions of articles on tumors and 44 articles on tumor reconstruction, comprising 43% of our 477 submissions. Tumors and their consequences remain the number one area of endeavor in the scientific contribution of our specialty. This month’s JOMS is a typical issue that expands our expertise for the oral and maxillofacial surgery tumor patient. Ord et al1 indicate that ameloblastoma in children has a different distribution and behavior than it does in adults. Bataineh et al2 have shown that resection of the central giant cell granuloma can be successful with a uniform technique that usually preserves jaw continuity. Godden et al3 show that squamous cell carcinoma recurrence at level II nodes indicates the need for careful dissection and observation of this area. Gellrich et al4 show that functional disorders after tumor ablation have the greatest effect on quality of life. These studies in JOMS have important features in common. They are case series or observational studies designed to help answer important questions about tumor biology and tumor patients. Case series draw experience across decades and multiple centers to show optimal therapy, problems, and modes of rehabilitation. Along with advances in applied research, careful, scientifically valid observation is the best way to improve the outcome of tumor patients. Case-controlled studies are prospectively designed to
In my first year of practice, an acquaintance presented in our office for evaluation and asked to see my senior partner. I knew she had recently had breast cancer and appeared to be doing well. While writing our charts later that morning, Joe remarked that she had appeared quite concerned about a swelling of her lower lip. He felt sure it was minor trauma with mucous retention phenomena, and that it would disappear in the coming days. He reassured the patient, instructed her to return if the lesion persisted, and did not charge her because, as he said, “I didn’t DO anything.” That statement shook me then as it does now because it implies we are valued only for our performance and not for our cognitive expertise. It was all the more compelling in this case because I know how much that patient had just benefited from Joe’s knowledge and experience. She remained healthy and avoided unnecessary surgery and anxiety. Since that time, many patients have appeared in ways that persist in my memory. I suspect these clinical experiences reflect the experience of all practicing surgeons. Two cases are presented here (with intentional changes made to protect patient confidentiality) to show the vigilance necessary to uncover true pathology rather than accept the usual diagnoses. A middle-aged medical technician noted a mildly tender submandibular mass. A pulpless molar had been treated but the finding persisted. His evaluation revealed a greater than 2 cm, non-tender submandibular node that appeared rubbery and fixed to the underlying gland. Fine-needle aspiration demonstrated Hodgkin’s lymphoma. For years afterward, we continued to see each other in the hospital corridor and exchange “high fives” in celebration of his stage I diagnosis and successful treatment. An 11-year-old child appeared in my office for a second opinion after prolonged care elsewhere for a temporomandibular disorder characterized by pain and limitation of motion. He had been treated with a flat plane splint. On examination he exhibited a mass in the lateral pharyngeal wall that, after biopsy, proved to be fibrosarcoma. He underwent successful surgery, chemotherapy, and radiation, and I recently heard he was in high school and participating in sports. These experiences illustrate the essential role all clinicians have in the diagnosis and care of tumor patients. They also demonstrate that rare pathology is, in the aggregate, seen commonly. They show us that 727
728 address well-defined questions. Although case-controlled studies offer much more valid information, they are best designed for common lesions such as squamous cell carcinoma. Case-controlled studies are practically impossible to develop for rare valid subsets of lesions, such as ameloblastoma in children. As such, we must rely on descriptive retrospective information, as seen in case reports and case series, to gain an understanding of the optimal approach for the broad category of uncommon oral tumors. Although this may bring the validity of our contributions into question, I believe case series and case reports demonstrate our commitment to patients and extend our wisdom in improving their therapy. Oral and maxillofacial surgeons are experts in the management of head and neck tumors. We are capable of integrating our knowledge of odontogenic disease, oral pathology, differential diagnosis of facial pain, tumor biology, anatomy, and function into our interaction with each patient. Our devotion to knowledge, experience, careful diagnosis, and meticulous surgery must be continuously reinforced, and we must value our individual efforts to be indispensable and tireless bulwarks for our patients’ benefit.
EDITORIAL
Vigilance and attention to diagnosis, upgrading our knowledge of pathology, and continued commitment toward the successful treatment of tumor patients will remain a centerpiece of oral and maxillofacial surgery practice. Attached to every tumor is a patient that will always make the practice of oral and maxillofacial surgery all the more meaningful and valuable. LEON A. ASSAEL
References 1. Ord RA, Blanchaert Jr RH, Nikitakis NG, et al: Ameloblastoma in children. J Oral Maxillofac Surg 60:762, 2002 2. Bataineh AB, Al-Khateeb T, Rawashdeh MA: The surgical treatment of central giant cell granuloma of the mandible. J Oral Maxillofac Surg 60:756, 2002 3. Godden DRP, Ribeiro NFF, Hassanein K, et al: Recurrent neck disease in oral cancer. J Oral Maxillofac Surg 60:748, 2002 4. Gellrich N-C, Schimming R, Schramm A, et al: Pain, function, and psychologic outcome before, during, and after intraoral tumor resection. J Oral Maxillofac Surg 60:772, 2002
© 2002 American Association of Oral and Maxillofacial Surgeons doi:10.1053/joms.2002.34321