Composite resection with mandibulectomy in the treatment of posterolateral oral cavity and lateral oropharynx squamous cell carcinoma

Treatment of Cancer of the Base of the Tongue and Glosso-Epiglottic Region: A Multicenter Italian Survey

BACKGROUND

The current treatment options for cancer of the base of the tongue and glosso-epiglottic region are surgery, radiotherapy, or a combination of both modalities. Comparisons between different modalities are not common in the literature, and a real standard of treatment has not yet been established. The purpose of our study was to evaluate the results of treatment in a large series of patients from 18 Italian institutions in relation to the main treatment adopted.

METHODS

The present study is a retrospective survey. The series was divided into a combined surgery group and a radiotherapy group. The Kaplan-Meier method and the log-rank test were used for survival calculations and comparisons.

RESULTS

Eight hundred patients were registered (25.7% stage III and 62% stage IV), 336 in the surgery and 372 in the radiotherapy group. Conventional fractionation was adopted in almost all cases. The five-year overall and disease free survival of the whole series was 32% and 38%, respectively. Survival was slightly better for patients with tumors of the glosso-epiglottic region than for those with a tumor of the base of the tongue. Five-year disease-free survival was 55% for patients treated with surgery +/- radiochemotherapy and 26% for those submitted to radiotherapy alone or in combination with chemotherapy. As far as the total dose and the treatment duration were concerned, only 26% of the patients of the radiotherapy group met the established criteria of adequacy, but in patients with adequate radiation the control rate was better only for small tumors (T1-T2).

CONCLUSIONS

The results in patients treated with surgery +/- postoperative radiotherapy were similar to or better than those reported in the best series in the literature. By contrast, the survival rate of irradiated patients was lower than those reported by other centers.

Lip-splitting in transmandibular resections: Is it really necessary?

Mandibular resection approach (Commando or Composite resection) is one of the fundamental techniques for oral and oropharyngeal large tumour resection. We reviewed the charts of patients who underwent a transmandibular resection for an oral and/or oropharyngeal cancer between 1980 and 2002. Of 700 patients who underwent a mandibular resection for cancer, 332 had been operated without lower lip splitting. A mono or bilateral en-block neck dissection was always performed, except in cases of relapses after a prior surgical treatment with neck dissection. We repaired 307 patients with flaps (pedicled or free flaps, with or without bone). Unsplitting of the lip never complicated resection and reconstruction. Furthermore the procedure was time sparing, as we avoided haemostasis and suture of the lip. The cosmetic results were better than those obtained by traditional technique. We used a non-lip-splitting technique also for pull-through, marginal mandibulectomy and, sometimes, for mandibular-swing approaches. In the latter case, the technique has some advantages and disadvantages and must be applied according to circumstances. We can conclude that lip-splitting in transmandibular resection for oral and oropharyngeal tumours is not necessary.

Cancer of the oropharynx

Oropharyngeal cancer is a rare tumour. Tobacco use and alcohol consumption are recognised as major risk factors. Several carcinogens, occupational exposures and vitamin deficiencies represent the most significant predisposing factors. A varying host susceptibility to carcinogens can be inferred. Carcinoma of the oropharynx has to be suspected whenever sore throat, odynophagia, and ear-ache are described by the patient. Biopsy is mandatory for the definitive diagnosis. TNM classification is crucial for treatment decision-making, while stage grouping is less important. Prognostic factors are treatment-related. Standard treatment of T1-T2 tumours is radiation therapy, for T3 and T4 tumour treatment options are controversial. More advanced tumours can be treated either with surgery followed by conventional radiotherapy or by combined chemo-radiation. Non-conventional fractionation radiotherapy in combination with chemotherapy may represent a third option. Acute toxicity needs to be managed promptly. Late sequelae are less known. Treatment of such tumours requires a multidisciplinary approach within experienced centres.

Resection of cancer of the tongue base and tonsil via the transhyoid approach

OBJECTIVE

To assess whether transhyoid resection of the tongue base and tonsil lesions is an effective approach to tumors involving this region compared with more traditional anterior surgical approaches that arbitrarily involve either segmental resection or division of the mandible.

STUDY DESIGN

Retrospective review.

METHODS

Since 1988, we have used a combined transhyoid and transoral approach to resect lesions involving the tongue base, tonsil, or both. Forty-one patients were identified who underwent surgical resection of lesions involving this region via this combined approach during this period. A stage-matched group of 41 patients was also identified in which patients underwent resection via traditional composite or mandibulotomy approaches and was used as a basis for comparison. Factors assessed included status of surgical margins, postoperative complications, degree of postoperative dysphagia, and long-term outcome.

RESULTS

Comparison between the two groups revealed similar rates of negative surgical margins. Levels of postoperative dysphagia, notably severe primarily in patients with either T4 or recurrent disease, were also similar between groups. Complication rates, especially with regard to fistula occurrence and mandible-healing problems, were significantly lower in the transhyoid group. Analysis of long-term outcome revealed similar patterns with regard to disease status in both groups.

CONCLUSIONS

The combined transhyoid and transoral approach is an effective surgical option for a number of lesions affecting the tongue base, tonsil, or both. Although similar to other approaches with regard to postoperative function and disease outcome, the transhyoid approach is associated with decreased postoperative morbidity. However, tumors that extend to involve the mandible or pterygoid musculature or skull base are probably best suited for traditional approaches that involve division of the mandible.

Surgical management of head and neck cancer

Head and neck cancer surgery continues to evolve through the years and undergo improvement and refinement. In this article, the current state of head and neck cancer surgery is summarized in a site-by-site basis. The most important developments include organ-sparing surgery and microvascular free-tissue transfer for reconstruction.

Transpharyngeal approach to base of tongue tumors: a comparative study

Tumors of the tongue base have been traditionally removed by resecting the mandible or using a translabial transmandibular approach. These procedures involve significant morbidity including lip and chin scars, malocclusion, compromised deglutition, chronic aspiration, and altered speech articulation. Therefore alternative techniques have been described to minimize the morbidity associated with transmandibular tongue resection. A retrospective analysis of patients with base of tongue tumors treated at the University of California, Los Angeles, Medical Center between 1981 and 1994 was undertaken. Thirteen patients were treated using a transpharyngeal approach compared with 18 patients who underwent a transmandibular resection. There was no difference in terms of survival or tumor-free margins. However, there was a significant difference in function (P < .05). Patients who underwent transpharyngeal resection had significantly better speech and swallowing and less aspiration compared with those who underwent transmandibular resection of tumors.

Indications, techniques and results of postoperative brachytherapy in cancer of the oral cavity

PURPOSE/OBJECTIVE

We tried to reduce the number of local recurrences after surgery and external beam irradiation (EBI) in carcinoma of the oral cavity, when margins were positive or close.

MATERIAL AND METHODS

From 1980 to 1992, we treated 97 cases of carcinomas of the oral cavity by postoperative brachytherapy. Surgery was combined with EBI+brachytherapy in 51 cases and with brachytherapy alone in 46 cases. We treated 29 T1, 34 T2, 30 T3T4 and four Tx (73% were N0 at first examination and 23% had positive nodes). The type of surgery is analysed. Brachytherapy was performed in one or two planes along the surgical scar. If the mandibular rim was resected, especially when the tongue or the remaining floor were sutured to the internal face of the inferior lip or to the buccal mucosa, the bridge technique was used. To decrease the dose to the inferior part of the mandible, the bridge was modified thanks to experimental dosimetry.

RESULTS

At 5 years, the local control (LC) is 89%, the locoregional control (LRC) 82%, the specific survival (SS) 74% and the overall survival (OS) 67%.

COMPLICATIONS

We noted 19% of grade 1 (minor), 12% of grade 2 (moderate) and 6% of grade 3 (major) complications.

CONCLUSION

Compared with the results of the literature, we think that postoperative brachytherapy can improve classical radiosurgical results in selected cases with a risk of local recurrence.