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National Journal of Maxillofacial Surgery
 
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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 13  |  Issue : 1  |  Page : 114-116  

High-power laser for oral excisional biopsy in an oncologic patient with pancytopenia


1 Department of Dentistry, School of Dentistry, University of Santo Amaro, São Paulo, SP, Brazil
2 Unit of Bone Marrow Transplantation, Brazilian Cancer Control Institute, São Paulo, SP, Brazil
3 Department of Dentistry, Ibirapuera University, São Paulo, SP, Brazil
4 Department of Biomaterials and Oral Biology, School of Dentistry, University of São Paulo, São Paulo, SP, Brazil

Date of Submission18-Jul-2021
Date of Acceptance21-Dec-2021
Date of Web Publication20-Apr-2022

Correspondence Address:
Dr. Luana Campos
School of Dentistry, University of Santo Amaro, Rua Prof. Enéas de Siqueira Neto, 340 - Jardim Das Imbuias, São Paulo 04829-300
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njms.njms_439_21

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   Abstract 


Oral surgical procedures are a great challenge in cancer patients, especially those with pancytopenia, given the risk of both hemorrhage and opportunistic infection. Thus, we report herein a case of a patient with refractory acute myeloid leukemia, severe pancytopenia, and some episodes of febrile neutropenia, who presented asymptomatic, bilateral lesions on the tongue, requiring excisional biopsy. Considering the high risk of bleeding, surgical intervention was proposed with a high-power laser (HPL) at the bedside. There was no considerable bleeding and stitches were not needed. Within 48 h postoperatively, the patient reported neither pain nor further bleeding and her tongue presented normal function. The patient was under a follow-up period of about 8 months, with no lesion relapse. The HPL seems to be of great value for preventing excessive bleeding and late infection in patients with pancytopenia submitted to minor oral surgeries.

Keywords: Case report, laser therapy, oral surgical procedures, pancytopenia


How to cite this article:
Campos L, Rezende SB, Palma LF, Simões A, Tateno RY, da Silva RL, Macedo MC. High-power laser for oral excisional biopsy in an oncologic patient with pancytopenia. Natl J Maxillofac Surg 2022;13:114-6

How to cite this URL:
Campos L, Rezende SB, Palma LF, Simões A, Tateno RY, da Silva RL, Macedo MC. High-power laser for oral excisional biopsy in an oncologic patient with pancytopenia. Natl J Maxillofac Surg [serial online] 2022 [cited 2022 Aug 11];13:114-6. Available from: https://www.njms.in/text.asp?2022/13/1/114/343488




   Introduction Top


Pancytopenia, an unspecific laboratory finding present in several diseases, is characterized by a reduction in the number of red and white blood cells and platelets.[1] The etiology of pancytopenia is multifactorial, including aplastic anemia, megaloblastic anemia, leukemia,[2] splenomegaly, sepsis, lymphoma, multiple myeloma, myelodysplastic syndromes, alcoholic diseases, viral infection, autoimmune diseases, and endocrine diseases.[1] Immune dysregulation following allogeneic stem cell transplantation is another important cause of immune-mediated pancytopenia.[3]

Patients with pancytopenia generally present a weak response to microorganisms, poor healing, and prolonged bleeding time due to the reduction in the major cellular elements of the blood.[4] In severe cases, life-threatening infections and bleeding may occur,[5] the main reasons why invasive dental procedures can be challenging in these patients.

Considering this complicated background, the present study reports a case in which a diode high-power laser (HPL) was used for oral excisional biopsy in a patient with pancytopenia.


   Case Report Top


A 17-year-old female patient diagnosed with refractory acute myeloid leukemia was admitted to the Brazilian Cancer Control Institute (São Paulo, Brazil) for a second allogeneic stem cell transplantation. The patient presented pancytopenia and some episodes of febrile neutropenia while inpatient and, therefore, it, was empirically administered meropenem, vancomycin, polymyxin B, voriconazole, amphotericin B, and daptomycin.

Before the second transplantation, she complained of difficulty chewing and speaking because of two growths on her tongue. Intraoral examination revealed the presence of two bilateral tumor-like pedunculated lesions, with normal color, measuring approximately 1 cm2, and protruding from both lateral surfaces of the tongue [Figure 1]a and [Figure 1]b. A complete blood count analysis indicated platelet counts at 54,000/mm3, erythrocyte counts at 3,06 million/mm3, and leukocyte counts at 2,170/mm3.
Figure 1: (a) Initial clinical presentation – left side; (b) Initial clinical presentation – right side; (c) Immediate postoperative presentation – left side; (d) Immediate postoperative presentation – right side; (e) Postoperative presentation after 48 h – left side; (f) Postoperative presentation after 48 h – right side; (g) Postoperative presentation after 1 week – left side; (h) Postoperative presentation after one week – right side

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Based on the diagnostic hypothesis of fibroma (differential diagnosis: pyogenic granuloma) and considering the patient's systemic health status, an 808-nm-diode laser (Thera Lase Surgery™, DMC Ltda, São Carlos, Brazil) was used instead of the conventional scalpel technique for excisional biopsy procedures. At the bedside, after local anesthetic infiltration with lidocaine in association with epinephrine, both lesions were grasped with Allis clamps, and then the HPL was delivered in continuous-wave mode with a 400-μm optical fiber and an output power of 1W [Table 1]. There was no need for sutures, the surgical time did not exceed 10 min, and bleeding was controlled adequately [Figure 1]c and [Figure 1]d. The histopathological examination confirmed that the lesions were granulomas; however, the prognosis and treatment planning were not modified.
Table 1: Laser parameters

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Forty-eight hours postoperatively, the patient reported neither pain nor bleeding [Figure 1]e and [Figure 1]f and her tongue presented normal function Within a week, wound healing was at an advanced stage [Figure 1]g and [Figure 1]h. The patient was followed up for approximately 8 months and had no relapse.

Informed consent was obtained from the patient for the collection, analysis, and publication of personal and clinical data. This manuscript was written in accordance with the CARE guidelines.[6]


   Discussion Top


In the past two decades, HPLs have been gaining popularity in oral surgery as they provide shorter operating timing, fewer postoperative complications, and reduced intraoperative bleeding. These advantages are especially relevant for the care of patients suffering from dental anxiety and those with vascular lesions or under anticoagulant therapy.[7] Moreover, laser devices have seemed to be effective for local disinfection[8] and reducing the risk of cross-infection during surgical procedures.[7]

The current paper reports a successful case in which a diode HPL was used for oral excisional biopsy procedures at the bedside in a patient with leukemia-related pancytopenia. Several studies have shown excellent results using HPLs for oral lesions under different conditions.[7],[8],[9],[10],[11],[12] However, to the best of our knowledge, this is the first report of oral surgery in a patient with pancytopenia with no need for a surgical center setting.

Patients with pancytopenia commonly experience anemia, thrombocytopenia, and leukopenia, with hemorrhage and infection being the major threats to them.[4] The rationale for selecting the technique reported herein was based on the photothermal properties of HPLs, which were proven to have antibacterial (evaporation/destruction/denaturation of microorganisms or elimination/inactivation of microbial toxic substances)[13],[14] and hemostatic effects.[14] Moreover, some authors have reasoned that the postoperative pain following HPL-assisted surgeries is less intense because of the photobiomodulation effect on adjacent tissues of the laser light scattering.[15]

Regarding the study limitations, case reports are ranked at the lowest levels of scientific evidence since they may quite be affected by the publication bias.[16] This kind of study, however, is still highly desirable for conditions poorly addressed in the literature as well as novel therapeutic approaches, as reported herein.

To sum up, based on the current case report, diode HPL seems to be of great value for preventing excessive bleeding and late infection in patients with pancytopenia submitted to minor oral surgeries. Moreover, further systemic medications or therapies can be avoided in the perioperative management of these patients.

Ethics statement

Patient anonymity was assured.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Yokuş O, Gedik H. Etiological causes of pancytopenia: A report of 137 cases. Avicenna J Med 2016;6:109-12.  Back to cited text no. 1
    
2.
Jalaeikhoo H, Kashfi SM, Azimzadeh P, Narimani A, Gouhari Moghadam K, Rajaienejad M, et al. Acute myeloid leukemia as the main cause of pancytopenia in Iranian population. Iran J Pathol 2017;12:265-71.  Back to cited text no. 2
    
3.
Tsirigotis PD, Resnick IB, Or R, Elad S, Zilberman I, Yoffe L, et al. Post-hematopoietic stem cell transplantion immune-mediated cytopenias. Immunotherapy 2009;1:39-47.  Back to cited text no. 3
    
4.
Valdez IH, Patton LL. Aplastic anemia: Current concepts and dental management. Spec Care Dentist 1990;10:185-9.  Back to cited text no. 4
    
5.
Dasgupta S, Mandal PK, Chakrabarti S. Etiology of pancytopenia: An observation from a referral medical institution of eastern region of India. J Lab Physicians 2015;7:90-5.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Riley DS, Barber MS, Kienle GS, Aronson JK, von Schoen-Angerer T, Tugwell P, et al. CARE guidelines for case reports: Explanation and elaboration document. J Clin Epidemiol 2017;89:218-35.  Back to cited text no. 6
    
7.
Dell'Olio F, De Falco D, Di Nanna S, Casorelli A, Favia G. Diode laser photocoagulation of oral venous malformations in patients on anticoagulant therapy without drug discontinuation. Cureus 2020;12:e7340.  Back to cited text no. 7
    
8.
Campos L, Gallottini M, Pallos D, Simões A, Martins F. High-power diode laser on management of drug-induced gingival overgrowth: Report of two cases and long-term follow-up. J Cosmet Laser Ther 2018;20:215-9.  Back to cited text no. 8
    
9.
Błochowiak K, Andrysiak P, Sidorowicz K, Witmanowski H, Hędzelek W, Sokalski J. Selected applications of Er: YAG and CO2 lasers for treatment of benign neoplasms and tumorous lesions in the mouth. Postepy Dermatol Alergol 2015;32:337-43.  Back to cited text no. 9
    
10.
Frame JW. Removal of oral soft tissue pathology with the CO2 laser. J Oral Maxillofac Surg 1985;43:850-5.  Back to cited text no. 10
    
11.
Monteiro LS, Mouzinho J, Azevedo A, Câmara MI, Martins MA, La Fuente JM. Treatment of epulis fissuratum with carbon dioxide laser in a patient with antithrombotic medication. Braz Dent J 2012;23:77-81.  Back to cited text no. 11
    
12.
White JM, Chaudhry SI, Kudler JJ, Sekandari N, Schoelch ML, Silverman S Jr. Nd: YAG and CO2 laser therapy of oral mucosal lesions. J Clin Laser Med Surg 1998;16:299-304.  Back to cited text no. 12
    
13.
Akiyama F, Aoki A, Miura-Uchiyama M, Sasaki KM, Ichinose S, Umeda M, et al. In vitro studies of the ablation mechanism of periodontopathic bacteria and decontamination effect on periodontally diseased root surfaces by erbium: Yttrium-aluminum-garnet laser. Lasers Med Sci 2011;26:193-204.  Back to cited text no. 13
    
14.
Aoki A, Mizutani K, Schwarz F, Sculean A, Yukna RA, Takasaki AA, et al. Periodontal and peri-implant wound healing following laser therapy. Periodontol 2000 2015;68:217-69.  Back to cited text no. 14
    
15.
Simões A, Eduardo FP, Luiz AC, Campos L, Sá PH, Cristófaro M, et al. Laser phototherapy as topical prophylaxis against head and neck cancer radiotherapy-induced oral mucositis: Comparison between low and high/low power lasers. Lasers Surg Med 2009;41:264-70.  Back to cited text no. 15
    
16.
Nakamura T, Igarashi H, Ito T, Jensen RT. Important of case-reports/series, in rare diseases: Using neuroendocrine tumors as an example. World J Clin Cases 2014;2:608-13.  Back to cited text no. 16
    


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