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Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018



Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018



Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018



Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018



Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018



Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata



Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018



Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018



Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018



Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011



Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2024 | Month : June | Volume : 18 | Issue : 6 | Page : ZC16 - ZC20 Full Version

Effectiveness of Lymph Node Revealing Solution in Estimation of Lymph Nodes Yield in Radical Specimen of Oral Squamous Cell Carcinoma: A Preliminary Histomorphometric Observational Study

Published: June 1, 2024 | DOI: https://doi.org/10.7860/JCDR/2024/69792.19473

S Dharini, Deepak Pandiar, Reshma Poothakulath Krishnan

1. Postgraduate Resident, Department of Oral Pathology and Microbiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India. 2. Associate Professor, Department of Oral Pathology and Microbiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India. 3. Assistant Professor, Department of Oral Pathology and Microbiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India.

Correspondence Address :
Dr. Deepak Pandiar,
Associate Professor, Department of Oral Pathology and Microbiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai-600077, Tamil Nadu, India.
E-mail: deepakpandiar1923@yahoo.com

Abstract

Introduction: Oral cancer poses a serious health challenge globally, particularly for nations undergoing economic transition. The number and size of lymph nodes obtained, along with nodal involvements, are crucial for proper diagnosis, treatment, and prognosis.

Aim: To assess the number of lymph nodes obtained before and after treating the specimens with the Lymph Node Revealing Solution (LNRS) along with staining characteristics.

Materials and Methods: The present prospective observational study was conducted at the Department of Oral Pathology and Microbiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India, over a period of six months from January 2023 to June 2023 in a tertiary oral healthcare centre in Chennai. Six histologically confirmed Oral Squamous Cell Carcinoma (OSCC) cases with neck dissection were included in the study, involving 32 lymph node levels. Lymph nodes were grossed using both routine procedures of palpation and visualisation and after treatment with LNRS for two days. The number of nodes obtained through both methods was compared along with the staining characteristics. The data were analysed using Statistical Package for Social Sciences (SPSS) software version 26.0. Chi-square and paired t-tests were used to compare the two groups, and any value less than or equal to 0.05 was considered statistically significant.

Results: Out of 134 lymph nodes, 21 were positive with conventional fixation, whereas after the application of LNRS, an additional 41 lymph nodes were retrieved. Two nodes showed metastatic deposits; fortunately, the additional positive nodes did not affect the staging. No statistically significant difference was found before and after immersion in LNRS regarding staining characteristics. The mean area of the yielded nodes was 84.71±4.85 mm2. There was a statistically significant difference between the size of lymph nodes between the manual grossing method and after immersion in LNRS (p-value <0.001).

Conclusion: The study confirmed that the LNRS technique identified very small lymph nodes in oral cancer patients, which may contain metastatic deposits. This might change the stage of the disease and influence the mode of treatment.

Keywords

Mean area, Metastatic deposits, Node size, Oral cancer

Introduction
Oral Squamous Cell Carcinoma (OSCC) constitutes 90% of all oral cancers (1),(2). According to the Indian Cancer Society, the country records more than 1,00,000 cases of oral cavity cancers every year (3). Oral cancer poses a serious health challenge to the nations undergoing economic transition (4),(5). In India, around 77,000 new cases and 52,000 deaths are reported annually, which is approximately one-fourth of global incidences (6). The prognosis of OSCC depends on various factors, including age, immune response, gender, site, habits, and genetic mutations, reflecting its multifactorial behaviour (7). Along with these, the management and prognosis of OSCC rely on tumour staging, which further includes tumour size, nodal involvement, and distant metastasis (8),(9).

According to American Joint Committee on Cancer (AJCC) 8th edition, the number and size of lymph nodes obtained and nodal involvement are crucial for proper diagnosis, treatment, and prognosis (10). Drawbacks in the manual grossing of lymph node specimens are time-consuming, missed small nodes, and a lower count following radiation; thus, micrometastasis could be missed in manual grossing and may affect staging and devising adjuvant therapy. The majority of OSCC cases reported to have regional cervical lymph node metastasis. The absence of specific molecular markers (11) and biomarkers for OSCC in diagnosis and treatment also have a crippling effect on the prognosis (12). Hence, the present study was designed to utilise LNRS to evaluate its effectiveness in cases with OSCC. The objectives of the present study were to prepare an LNRS, to assess its effectiveness regarding staining characteristics and readability, and to assess the number of lymph nodes obtained before and after treating the specimens with the prepared LNRS.
Material and Methods
The present prospective observational study was conducted at the Department of Oral Pathology and Microbiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India, from January 2023 to June 2023, after obtaining clearance from the Institutional Human Ethical Committee (IHEC/SDC/FACULTY/23/OPATH/240).

Inclusion criteria: Included six consecutive excised radical specimens of histologically confirmed OSCC cases. The radical specimen included wide local excision with selective/modified lymph node dissection.

Exclusion criteria: Recurrent OSCC cases and cases with a previous history of radiotherapy or chemotherapy were excluded from the study.

Study Procedure

The margins were obtained for clearance intraoperatively on frozen, and the remaining specimen was fixed in 10% neutral buffered formalin. Lymph nodes were grossed using the routine procedure of palpation and visualisation. The lymph nodes were processed, recorded, and sectioned. The remaining specimen was immersed in the LNRS and grossed after two days. The solution was changed every day. The LNRS (per 1 litre) was prepared by adding 650 mL of ethyl alcohol, 200 mL of Diethyl ether, and 50 mL of glacial acetic acid to 100 mL of buffered formalin.

The remaining fibrofatty tissue was re-examined after two days for additional lymph nodes. The number of newly retrieved nodes was recorded. The previously dissected nodes were not counted (Table/Fig 1). The new nodes were thereafter processed, sectioned, and stained. The data were tabulated for the number of nodes obtained through routine manual grossing versus after LNRS, number of positive nodes obtained through routine manual grossing versus after LNRS, and comparison of staining characteristics between the two groups. All the slides were compared for nuclear staining, cytoplasmic staining, cellular morphology, and uniformity of the staining, in a semi-qualitative manner, and classified into poor (score 0), intermediate (score 1), and good (score 3) as previously mentioned (13). For assessing the cellular and nuclear morphology, cell outline, cytosolic features, nuclear outline, and nucleolar characteristics were evaluated at high power magnification in all the slides. The size of the lymph nodes was estimated on the mechanical stage of the light microscope, while the mean area was estimated using Image J software (14).

Statistical Analysis

The data were entered in a Microsoft excel spreadsheet (2021). SPSS software (version 26.0, IBM Corp., Armonk, New York) was used for analysis. Chi-square and paired t-tests were used to compare the two groups, and any value less than or equal to 0.05 was considered statistically significant.
Results
Demographic profile: Six patients were included with a male-to-female ratio of 5:1 and ages ranging from 37 to 57 years. Three cases were from the tongue, two cases from the lower posterior gingivobuccal sulcus, and the remaining case involved the upper right maxillary tuberosity. Four cases were graded as Well-differentiated Squamous Cell Carcinoma (WDSCC), and the other two cases were Moderately-differentiated Squamous Cell Carcinoma (MDSCC). Modified Radical Neck Dissection (MRND) was performed for three cases, and Selective Neck Dissection (SND) for the other three cases.

Comparison of node yield by routine manual grossing vs LNRS: Routine manual grossing yielded 134 lymph nodes from 32 lymph node levels, out of which 21 were positive. After immersion in LNRS, an additional 41 lymph nodes were retrieved. Fortunately, two nodes showed metastases, but this did not upstage the tumour staging. The clinicopathological features and nodal yield are detailed in (Table/Fig 2).

Comparison of staining characteristics: All the sections after the application of LNRS showed good nuclear (p-value=0.268) and cytoplasmic staining (p-value=0.595). No statistically significant difference was found before and after immersion in LNRS. Similarly, no difference was found in the cellular morphology and uniformity of the staining (p>0.05) (Table/Fig 3)a,b,(Table/Fig 4)a-d.

Mean area and size of newly yielded nodes: Additionally, the mean area of the yielded nodes after treating with LNRS was calculated using Image J software. The mean area was 84.71±4.85 mm2 (±standard deviation) (Table/Fig 5). The mean area of the lymph nodes prior to LNRS could not be estimated as some large lymph nodes were cut into two and processed as two blocks. However, when the sizes of the lymph nodes were compared, there was a statistically significant difference between the size of the lymph node between the manual grossing method and after immersion in LNRS (p-value <0.001). The mean size of the 134 lymph nodes yielded by the manual visual and palpation method was 13.01±8.16 mm, while after immersing in LNRS, it was significantly lesser (1.99±1.001 mm; p<0.001). The detailed comparative results of staining characteristics, mean area, and size of lymph nodes before and after immersion in LNRS is shown in (Table/Fig 6).
Discussion
Postoperative adjuvant chemo and radiotherapy, based on tumour staging and histopathological diagnosis, play a crucial role in the patient’s recovery (15),(16). It has been reported that the five-year survival rate of cases with lymph node metastasis (54%) is significantly lower than those without lymph node metastasis (87%) (17). Surgical resection is the conventional treatment option for any OSCC case (18). Hence, accurate and total lymph node examinations are essential for appropriate management. According to the AJCC 8th edition, the ideal number of lymph nodes in SND and Radical/MRND (RND/MRND) is 10 or more and 15 or more, respectively (10). It is not always easy to harvest the required number, especially in patients who may have received neoadjuvant therapy, an increasingly common treatment. The use of neoadjuvant therapy is known to further decrease the number and size of identifiable lymph nodes within specimens (19).

The present study harvested new small lymph nodes after immersing them in LNRS. Similar studies were conducted previously in gastric cancer and colon cancer using LNRS, and it was found that the number of lymph nodes increased by 53.0% with LNRS, and the number of metastatic lymph nodes was 28.9% higher than that of the conventional process (19),(20). This is critically important, as node-positive patients (pN1) are considered for adjuvant chemotherapy, whereas node-negative patients (pN0) may not be. The LNRS yields much smaller nodes, which may be missed by manual examination and sometimes are metastatic in nature.

The widely used fixative for routine pathological specimens has disadvantages, such as a slow rate of fixation (21). In some instances, even after 24 hours, fixation does not provide sufficient firmness to the tissues, especially in cases of large specimens and cystic lesions, resulting in delayed diagnosis (22). Furthermore, longer exposure of tissues to formaldehyde can have adverse effects on many antigens (23). Therefore, the combination of various fixatives can mitigate these adverse effects and improve properties. Glacial acetic acid, ethanol, water, and formalin offer advantages over other revealing solutions as they are safe, cheap, easy to use, and relatively quick. The utilisation of LNRS offers many advantages, including lesser time during grossing, an inexpensive technique for detecting very small lymph nodes, ease of working, enhanced visibility, no need for an attentive process, the ability to use immunostains, and clear visibility of the lymph nodes (24).

Simental AA Jr et al., found cervical metastasis from squamous cell carcinoma of the maxillary alveolus and hard palate in 34.6% of patients (25). A high incidence (20-30%) of cervical metastasis of cancer in the tongue/floor of mouth has also been well studied and reported (26). Therefore, missing a single positive lymph node in an N0 patient may upstage the tumour staging to N1, which has a significant impact on the outcome. Fortunately, the identification of new positive nodes did not upstage pTNM in any of the present cases.

It has been repeatedly proven and reported that the presence of extranodal extension is proportionately correlated with distant metastasis, locoregional recurrences, and difficulty in obtaining clear margins (27). Missing a single lymph node with extranodal extension directly upgrades the tumour staging to N3b. Therefore, obtaining more lymph nodes may benefit patients as it allows for accurate cancer staging and appropriate use of adjuvant chemotherapy for node-positive patients. The present study included 32 lymph node levels from six patients with OSCC. Although the results and findings are preliminary, they provide significant insight into the usage of LNRS in neck dissections of head and neck cancers. Further studies with a larger sample size are required to confirm the findings.

Limitation(s)

While the results obtained were promising, there were a few limitations that need to be addressed. Firstly, the sample size was small, with only six patients prospectively recruited. However, the number of lymph node levels was adequate to provide a baseline data for future studies with a larger sample size. Secondly, the mean area of larger nodes could not be assessed for comparison due to the fact that some nodes were too large to be processed as a single block and were thus bisected for further processing.
Conclusion
The study confirmed that the LNRS technique identified very small lymph nodes that may contain metastatic deposits. This could potentially change the stage of the disease and influence the mode of treatment. Prospective studies with larger sample sizes are warranted. The authors believe that LNRS does not change the architecture of the nodes and yields a greater number, including the smallest nodes, thus it may be used in routine practice.
Reference
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Krishnan RP, Pandiar D, Ramani P, Jayaraman S. Necroptosis in human cancers with special emphasis on oral squamous cell carcinoma. J Stomatol Oral Maxillofac Surg. 2023;124(6S):101565.   [CrossRef]  [PubMed]
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Gupta B, Bray F, Kumar N, Johnson NW. Associations between oral hygiene habits, diet, tobacco and alcohol and risk of oral cancer: A case–control study from India. Cancer Epidemiol. 2017;51:07-14.   [CrossRef]  [PubMed]
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Laprise C, Shahul HP, Madathil SA, Thekkepurakkal AS, Castonguay G, Varghese I, et al. Periodontal diseases and risk of oral cancer in Southern India: Results from the HeNCe Life study. Int J Cancer. 2016;139(7):1512-19.   [CrossRef]  [PubMed]
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Krishnan RP, Ramani P, Pandiar D. Plausible mechanisms in the pathobiology of acantholytic squamous cell carcinoma: An evidence based hypothesis. Medical Hypotheses. 2022;167(9):110946.   [CrossRef]
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DOI and Others
DOI: 10.7860/JCDR/2024/69792.19473

Date of Submission: Jan 26, 2024
Date of Peer Review: Feb 21, 2024
Date of Acceptance: Mar 18, 2024
Date of Publishing: Jun 01, 2024

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 25, 2024
• Manual Googling: Feb 23, 2024
• iThenticate Software: Mar 16, 2024 (13%)

ETYMOLOGY: Author Origin

EMENDATIONS: 8
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