Transoral resection with buccinator flap reconstruction vs. pull-through resection and free flap reconstruction for the management of T1/T2 cancer of the tongue and floor of the mouth

De-escalated surgery following neoadjuvant chemoimmunotherapy for locally advanced oral squamous cell carcinoma: A retrospective cohort study

BACKGROUND

There remains considerable debate regarding whether the extent of surgery can be reduced in oral squamous cell carcinoma (OSCC) with significant tumor shrinkage after neoadjuvant chemoimmunotherapy. This study aims to report the feasibility and oncological safety of de-escalated surgery (DES) following neoadjuvant chemoimmunotherapy in locally advanced OSCC.

MATERIALS AND METHODS

We collected clinical data of patients with locally advanced OSCC (T3-4 N0-3 M0) treated at our cancer center between November 2019 and July 2023 who received platinum-based doublet chemotherapy combined with a PD-1 inhibitor followed by DES. DES was defined as surgery performed according to the extent of residual tumor after neoadjuvant therapy. Tumor response, flap reconstruction/mandibulectomy exemption rates, event-free survival (EFS), and overall survival (OS) were assessed.

RESULTS

A total of 111 patients were included, with tumors located in the tongue (73/111, 65.8 %), buccal-lip mucosa (15/111, 13.5 %), mandibular gingiva - floor of mouth (15/111, 13.5 %), and maxillary gingiva - hard palate (8/111, 7.2 %). The objective response rate (ORR) was 77.5 %, with a pathological complete response (pCR) rate of 40.5 %. Flap reconstruction was exempted in 80 (72.1 %) of patients. Among the 96 patients initially planned for mandibulectomy, 68 patients (70.8 %) were exempted from mandibulectomy. With a median follow-up of 27 months, the estimated 1-, 2-, and 3-year EFS rates were 90.1 %, 84.4 %, and 80.9 %, respectively. The estimated 1-, 2-, and 3-year OS rates were 97.3 %, 93.1 %, and 91.3 %, respectively.

CONCLUSION

Opting for DES after neoadjuvant chemoimmunotherapy appears to be feasible, with satisfactory oncological safety in OSCC patients.

Real-Time Subcutaneous Arterial Navigation for Thinning of an Anterolateral Thigh Flap Using Photoacoustic Imaging and Projection Mapping: A Case Report

Thinning of anterolateral thigh flap is challenging. Anatomical studies have shown variations in arterial branching patterns in the subcutaneous layer, which were suspected to be the reason for the high frequency of thinning failures. We attempted to visualize subcutaneous arterial courses preoperatively and perform thinning of perforator flaps using this information appropriately. We accumulated evidence on the accuracy of noninvasive vascular visualization using photoacoustic tomography (PAT). In the present case, we applied a medical imaging projection system (MIPS), which enabled real-time surgical navigation using indocyanine green (ICG) emission signals, to use photoacoustic information intraoperatively during the flap thinning procedure. A 69-year-old woman underwent half-tongue resection using the pull-through method for right-sided tongue cancer. Preoperative PAT was performed 5 days before surgery. The 12 × 6-cm area took ~8 min to scan. We used an ICG test card containing ICG-positive control material cut into strips to show tentative artery lines by projection mapping. The transparent vascular map was laminated and sterilized. MIPS captured ICG fluorescence signals that penetrated the anterolateral thigh flap and continuously projected the purple area on the reverse side of the flap, guiding the position of the tentative arteries. A 20 × 6.5-cm anterolateral thigh flap was elevated with the distal part of the reconstructed tongue and proximal de-epithelialized part to fill the pull-thorough tunnel in the submandibular region. Active bleeding was observed when cutting marginal fat tissue near the purple line of the distal ALT flap projected by MIPS. The study protocol did not include a highly invasive trial for MIPS-guided thinning; therefore, we removed minimal marginal fat tissue. The ALT flap showed no postoperative complications while maintaining conversation and swallowing functions. We present the concept of subcutaneous arterial real-time navigation surgery using PAT and MIPS for safe, easy, and fast flap thinning procedures in the future.

Contralateral facial artery myomucosal island flap for the reconstruction of T2-T3 oncologic oral defects

Objectives

To avoid the oncologic risks of ipsilateral regional flaps, this study aimed to explore the feasibility and clinical outcomes of the contralateral-based facial artery myomucosal island flap (C-FAMMIF) for oral T2-T3 oncologic defects reconstruction.

Methods

A study of flap anatomy was conducted on 7 cadaver samples and a cohort of 24 patients who received C-FAMMIF reconstruction after malignancy resection were retrospectively researched. A balanced anterolateral thigh flap (ALT) group of 47 patients was extracted as control group using propensity score matching method. Progression-free survival (PFS), functional outcomes, and donor site complications were assessed.

Results

Consistent blood supply and drainage through facial artery and vein with median maximum pedicle length of 106 mm supported contralateral reconstruction. The superficial vein drainage pattern indicated safer flap harvest at contralateral neck under circumstances of ipsilateral neck dissections. The pedicle and marginal facial nerve formed three anatomical patterns. The surgical management of each was described. Patients with ipsilateral pN+ neck accounted for 41.7% and 40.4% in the C-FAMMIF and ALT group, respectively. The 2-year PFS rate between the C-FAMMIF and ALT groups was not significantly different (88.2% in C-FAMMIF group and 84.6% in ALT group, respectively, p = 0.6358). Promising recoveries were observed for swallowing function and tactile sensation. The donor sites healed upon primary closure without trismus or permanent facial palsy.

Conclusion

Our findings suggested that C-FAMMIF is feasible and safe for T2-T3 oral oncologic defect reconstruction in patients with ipsilateral cN+ neck.

Systematic review of minimally-invasive reconstructive options for oral cavity defects

The oral cavity is a primary site for malignant neoplasms of the head and neck region. Surgery, with or without adjuvant therapy, offers the highest probability of cure by focusing on radical tumour removal and organ function restoration. Reconstructive options are represented by local and free flaps, while small defects can be managed without reconstruction. For medium-sized defects without bone involvement, local flaps can be a good alternative to free flaps in selected patients. The purposes of this article are to analyse the main minimally-invasive reconstructive techniques in oral cancer surgery through a systematic review of the literature and develop a reconstructive algorithm based on the site and size of the defect. We defined minimally-invasive reconstruction as any reconstructive option not involving flap dissection from the neck or other distant areas from the oral cavity. Options considered include: local myo-mucosal or mucosal flaps (based on the facial or buccal arteries, and palatal flap), Bichat’s fat pad flap, and nasolabial flap. Use of biological or synthetic materials is also described. In selected patients with small to moderate-sized defects, the possibility of reconstruction with local flaps can be a viable option.

Submandibular gland involvement in oral cavity squamous cell carcinoma: a retrospective multicenter study

BACKGROUND

The submandibular gland (SMG) is routinely excised during neck dissection. Given the importance of the SMG in saliva production, it is important to understand its involvement rate by cancer tissue and the feasibility of its preservation.

METHODS

Retrospective data were collected from five academic centers in Europe. The study involved adult patients affected by primary oral cavity carcinoma (OCC) undergoing tumor excision and neck dissection. The main outcome analyzed was the SMG involvement rate. A systematic review and a meta-analysis were also conducted to provide an updated synthesis of the topic.

RESULTS

A total of 642 patients were enrolled. The SMG involvement rate was 12/642 (1.9%; 95% CI 1.0-3.2) when considered per patient, and 12/852 (1.4%; 95% CI 0.6-2.1) when considered per gland. All the glands involved were ipsilateral to the tumor. Statistical analysis showed that predictive factors for gland invasion were: advanced pT status, advanced nodal involvement, presence of extracapsular spread and perivascular invasion. The involvement of level I lymph nodes was associated with gland invasion in 9 out of 12 cases. pN0 cases were correlated with a reduced risk of SMG involvement. The review of the literature and the meta-analysis confirmed the rare involvement of the SMG: on the 4458 patients and 5037 glands analyzed, the involvement rate was 1.8% (99% CI 1.1-2.7) and 1.6% (99% CI 1.0-2.4), respectively.

CONCLUSIONS

The incidence of SMG involvement in primary OCC is rare. Therefore, exploring gland preservation as an option in selected cases would be reasonable. Future prospective studies are needed to investigate the oncological safety and the real impact on quality of life of SMG preservation.

A nomogram for predicting overall survival of patients with squamous cell carcinoma of the floor of the mouth: a population-based study

BACKGROUND

Floor of mouth squamous cell carcinoma (SCCFOM) is a rare but aggressive malignancy with 5-year overall survival (OS) rates below 40% in published studies. However, the clinicopathological predictors of the prognosis of SCCFOM remain undefined. We aimed to establish a model to predict the survival outcomes of SCCFOM.

METHODS

We searched the Surveillance, Epidemiology, and End Results (SEER) database for patients diagnosed with SCCFOM between 2000 and 2017. Data on patient demographics, treatment modalities, and survival outcomes were retrieved. Risk factors for OS were evaluated by survival and Cox regression analyses. A nomogram for OS was developed based on the multivariate model and split the patients into high- and low-risk cohorts based on cutoff values.

RESULTS

Overall, 2014 SCCFOM patients were included in this population-based study. Multivariate Cox regression showed that age, married status, grade, American Joint Committee on Cancer stage, radiotherapy, chemotherapy, and surgery were significant risk factors for survival. A nomogram was established using the regression model. The C-indices, areas under the receiver operating characteristic curves, and calibration plots demonstrated the reliable performance of the nomogram. Patients assigned to the high-risk group had a significantly lower survival rate.

CONCLUSIONS

The nomogram predicting survival outcomes of SCCFOM patients based on clinical information showed good discriminative ability and prognostic accuracy. Our nomogram could be used to predict the survival probabilities for SCCFOM patients at different timepoints.

Examination of Suprahyoid Muscle Resection and Other Factors Affecting Swallowing Function in Patients With Advanced Oral Cancer After Surgical Resection and Reconstruction

Dysphagia is one of the most common adverse effects associated with oral cancer therapy and could greatly impair postoperative quality of life. The objective of this study was to analyze postoperative swallowing outcomes and factors influencing postoperative swallowing function in patients with advanced oral cancer who underwent primary reconstruction after surgical resection to identify patients at risk of experiencing severe dysphagia after immediate reconstruction of surgical defects, and to determine an ideal approach to provide appropriate perioperative interventions. The swallowing status was evaluated at 4 week postoperatively using the Functional Oral Intake Scale. We also analyzed the effects of patient, tumor, surgical, and other factors on postoperative swallowing function. The study included 67 patients. At 4 weeks postoperatively, 11 patients showed reduced swallowing function, whereas 56 patients showed good swallowing function. The number of resected suprahyoid muscles (odds ratio, 1.55; 95% confidence interval, 1.03-2.32; P=0.035) was an independent factor influencing postoperative swallowing function. Thus, among patients who underwent radical resection of oral cancer with primary reconstruction, those with extensive resection of the suprahyoid muscles were at higher risk of developing postoperative dysphagia. These findings are expected to facilitate increased vigilance for dysphagia, better counseling, and appropriate rehabilitation interventions.

The sub-fascial pattern of the myocutaneous platysma flap - The anatomical basis and preliminary cases for oral reconstruction

To verify the feasibility of the SF-MPF for oral reconstruction, the anatomic, sonographic and histologic features of the SF-MPF were investigated and the outcome in a series of patients was evaluated. The sonographic and histologic results showed a supra-fascial arterio-venous vascular blood supply to the sub-fascial design of the MPF. The clinical course of 12 consecutive patients who underwent oral reconstruction using the SF-MPF along with ipsi- or lateral neck dissection for treatment of oral cancer showed sufficient pedicle length and reliable blood supply. The SF-MPF is a reliable and safe pedicled myocutaneous flap. Therefore, it should be considered being an additional option when a pedicled flap has to be selected.

Functional outcomes in tongue reconstruction with myomucosal buccinator flaps

OBJECTIVE

Buccal myomucosal local flaps in oral cavity reconstruction are a valid option for small-to-moderate defects. Nevertheless, few articles report about functional recovery. The purpose of the present analysis is to evaluate the impact of these flaps on function and quality of life.

STUDY DESIGN

The study, retrospectively conducted on 36 patients who were surgically treated for tongue cancer between 2012 and 2018 at the Unit of Maxillo-Facial Surgery, Foundation IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo (Italy), evaluates functional outcomes using the following 4 questionnaires: Performance Status Scale for Head and Neck Cancer Patients, M.D. Anderson Dysphagia Inventory, Speech Handicap Index, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module.

RESULTS

All patients are able to eat soft or more solid foods, and most of them eat quietly in public. Although 50% of cases reported a certain degree of dysphagia, it does not impact self-esteem and social relationships. Only 20% of patients have severe problems with speech. However, more than half of the cases (65%) report oral problems.

CONCLUSIONS

The collected data confirm the suitability of the myomucosal cheek flaps for tongue reconstruction. Most patients report a good functional recovery and satisfactory quality of life even if none of them has a recovery comparable to the presurgical state.

Health-Related Quality of Life in Oral Cancer Patients: Scoping Review and Critical Appraisal of Investigated Determinants

BACKGROUND

health-related quality of life (HRQOL) represents a secondary endpoint of medical interventions in oncological patients. Our aim was to highlight potential sources of bias that could be encountered when evaluating HRQOL in oral cancer patients.

METHODS

this review followed PRISMA-ScR recommendations.

PARTICIPANTS

patients treated for oral cancer.

CONCEPT

HRQOL assessed by EORTC QLQ-C30 and QLQ-H&N35/QLQ-H&N43. A critical appraisal of included studies was performed to evaluate the accuracy of data stratification with respect to HRQOL determinants.

RESULTS

overall, 30 studies met the inclusion criteria, totaling 1833 patients. In total, 8 sociodemographic (SDG) and 15 disease/treatment-specific (DT) HRQOL determinants (independent variables) were identified. The mean number of the independent variables was 6.1 (SD, 4.3)-5.0 (SD, 4.0) DT-related and 1.1 (SD, 1.8) SDG-related variables per article. None of the included papers considered all the identified determinants simultaneously.

CONCLUSIONS

a substantial lack of evidence regarding HRQOL determinants was demonstrated. This strongly weakens the reliability of the reported findings due to the challenging presence of baseline confounding, selection, and omitted variable biases. The proposed approach recommends the use of further evaluation tools that gather more variables in a single score together with a selection of more homogeneous, reproducible, and comparable cohorts based on the identified baseline confounding.

Functional Outcomes with Facial Artery Musculo-Mucosal (FAMM) Flap and Dental Implants for Reconstruction of Floor of the Mouth and Tongue Defects in Oncologic Patients

Optimal functional outcomes in oncologic patients with squamous cell carcinoma (SCCA) of the tongue and floor of the mouth require good lingual mobility, adequate facial competence, the cheek suction effect and dental rehabilitation with osseointegrated implants. In this study, twenty-two oncologic patients who had been diagnosed with intraoral SCCA affecting the tongue and the floor of the mouth and who had undergone wide resection of the tumor and immediate reconstruction with an inferiorly pedicled FAMM flap and immediate osseointegrated implants were assessed. Lingual mobility, speech articulation, deglutition, implant success rate, mouth opening, and aesthetic results were evaluated. All patients were staged as T2 and the defect size ranged from 3.7 × 2.1 cm to 6.3 × 4.2 cm. A selective neck dissection was performed in all patients as part of their oncologic treatment, either electively or for node positive disease. Thirteen patients (59%) were diagnosed with node positive disease and underwent adjuvant radiotherapy. A total of 101 osseointegrated implants were placed for prosthetic rehabilitation and 8 implants were lost (7.9%), of which 7 received radiotherapy (87.5%). The implant success rate was 92.1%. Mouth opening was reported as normal in 19 patients (86.3%). Tongue tip elevation was reported as excellent in 19 patients (86.3%) and good in 3 patients (13.6%). Lingual protrusion was referred to as excellent in 15 patients (68.2%) and good in 6 patients (27.2%). Lateral excursion was reported as excellent in 14 patients (63.6%) and good in 7 patients (31.8%). In terms of speech articulation, 20 patients reported normal speech (90.9%). Regarding deglutition, 19 patients (86.3%) reported a regular diet while a soft diet was reported by 3 patients (13.7%). Aesthetic results were referred to as excellent in 17 patients (77.3%). FAMM flaps, immediate implants and fixed prostheses enable the functional rehabilitation of oncologic patients, optimizing aesthetics and functional outcomes even in patients undergoing irradiation, thus returning oncologic patients to an excellent quality of life.

Effects of high-frequency speech therapy on speech-related quality of life and objective speech intelligibility of oral cancer patients

To analyze objective and subjective progression of speech intelligibility in oral cancer patients undergoing high-frequency speech therapy during early rehabilitation. Oral cancer patients in the Department of Maxillofacial Surgery, University Hospital of Schleswig-Holstein, Kiel, Germany, participated in the study from March 2016 to November 2017. Speech intelligibility was analyzed preoperatively (t1), post radiation (t2), and post speech therapy (t3). Objective measures were the Munich Intelligibility Profile (Online) and the Frenchay Dysarthria Assessment-2 (FDA-2). Subjective measures were the Speech Handicap Index (SHI), the speech subscale of the EORTC QLQ-C30&HN35, and the WHO-5 Index II. For nine patients with complete data, progression analyses showed a non-existent-to-low intelligibility impairment at t1 (means/SDs: e.g. FDA-2: 8.96/0.11, SHI: 17.5/15.15), increasing towards t2 (means/SDs/p-values for difference from t1: e.g. FDA-2: 7.40/0.80/0.000, SHI: 21.7/14.24/0.213), and then decreasing towards t3, without ever reaching the initial level (means/SDs/p-values for difference from t1: e.g. FDA-2: 8.22/0.60/0.005, SHI: 23.5/15.85/0.481). The objective changes in intelligibility were significant; the subjective changes were not. Overall, the ability to speak intelligibly after oral cancer treatment follows a typical pattern. Therefore, high-frequency speech therapy in the early rehabilitation phase might be recommendable. It might help patients to adapt to their situation after surgery, and facilitates compensating for possible functional deficits.

Maxillo-facial reconstruction following cancer ablation during COVID-19 pandemic in southern Italy

In COVID-19 pandemic era, one major concern is related to ensure optimal management to oncologic patients, even though a context of radical uncertainty. The aim of our effort is to guarantee high-quality and timely care, minimizing COVID-19 infection risk, according to our head and neck (HN) reconstructive mission, still more challenging because of the criticality of the period. Thus, our reconstructive decision algorithm is changed. Microvascular free flaps, reported to be the gold standard for surgical reconstruction, represent extremely specialized procedures necessitating an extended resource allocation not affordable in the adversities of the period. Therefore, we are obliged to define a paradigm shift in our approach, based on free-style reconstructive surgery principles of propeller flap concept. According to our experience, we believe that this viable and feasible surgical technique could represent a reconstructive landmark in this pandemic era, since any guideline is missing, besides HN reconstructive surgery is most likely heading towards a new reconstructive approach.

Clinical management of squamous cell carcinoma of the tongue: patients not eligible for free flaps, a systematic review of the literature

INTRODUCTION

The management of squamous cell carcinoma (SCC) of the tongue represents the most demanding treatment planning in head and neck surgery. Ablation followed by free flap reconstruction is considered the gold standard, but not all patients are suitable for this strategy. The aim of this review is to provide a comprehensive view of surgical reconstruction possibilities in patients not eligible for free flaps.

METHODS

Following PRISMA recommendations, a systematic literature review was conducted searching for original papers that investigated outcomes of patients treated by surgical ablation for tongue SCC followed by reconstruction with local or pedicled flaps. Selected papers were read and data extracted for qualitative analysis.

RESULTS

Twenty articles met the inclusion/exclusion criteria. The study design was case series in sixteen papers, cohort study in the remaining four. Four different local flaps (BMM, FAMM, NLIF, SMIF) and four regional flaps have been discussed in included studies (IHF, SFIF, SCM, PMMC).

CONCLUSION

The improved anatomical knowledge makes local flaps a reliable alternative to free tissue transfer in cases requiring small-/medium-sized defects. Regional flaps still represent cornerstones in reconstruction of the tongue. Ease of execution, costs-to-benefit ratio, low-rate complications, minimal donor site morbidity represent the best advantages choosing local/regional flaps.