New techniques and recommendations in the management of free flap surgery for head and neck defects in cancer patients

Correlation during the extent of surgical resection, oral function and quality of life after tongue cancer surgery: Single-institution study

INTRODUCTION

The extent of surgical resection for tongue tumors is determined by tumor size, potentially affecting oral function and quality of life (QoL). However, the relationship between oral dysfunction and QoL decline due to glossectomy extent remains unexplored. Therefore, these correlations and their predictive value for postoperative QoL decline were elucidated.

METHODS

Patients treated for tongue cancer at our hospital between 2018 and 2022 were categorized by partial, hemi, or subtotal/total glossectomy. Assessments included swallowing function (RSST), articulation (Oral Diadochokinesis (ODK)), mastication, tongue pressure, and oral moisture. QoL was measured using the Oral Health Impact Profile-14 (OHIP-14). Differences within parameters were assessed using Kruskal-Wallis tests, and between-group comparisons via Mann-Whitney U tests. Spearman's correlation analysis examined parameter relationship.

RESULTS

35 patients were evaluated. Significant differences were found in ODK [ta] (p = 0.015), [ka] (p = 0.0006), tongue pressure (p = 0.0001), moisture levels (p = 0.031), OHIP-14 domains: physical disability (p = 0.014) and social disability (p = 0.046). ODK [ta] (PG: 5.95, HG: 5.38, TG: 4.03 times), [ka] (PG: 5.56, HG: 4.78, TG: 3.23 times), and tongue pressure (PG: 32.9, HG: 21.2, TG: 10.3 mmHg) decreased with glossectomy extent, while physical (PG: 0.27, HG: 2.38, TG: 2.00) and social disability (PG: 0.18, HG: 0.94, TG: 1.43) worsened. A significant negative correlation was observed between tongue pressure and social disability (p = 0.013, r = -0.36).

CONCLUSION

Expanding resection significantly impacted postoperative oral function and QoL. Tongue pressure assessment may predict long-term social disability in patient QoL.

Assessment of quality of life after soft tissue resection of head and neck carcinoma and reconstruction with double-paddle peroneal artery perforator free flap

We aimed to assess the quality of life for head and neck carcinoma (HNC) patients who underwent soft tissue resection and reconstruction with double-paddle peroneal artery perforator (DPAP) free flap. The quality of life was assessed by means of the University of Washington quality of life (UW-QOL) and the 14-item Oral Health Impact Profile (OHIP-14) questionnaires at 12 months postoperatively. Data from 57 patients were retrospectively analysed. Out of these, 51 patients were at TNM stage III or IV. Finally, 48 patients finished and returned the two questionnaires. In the UW-QOL questionnaire, the mean (SD) higher scores were pain 76.5 (6.4), shoulder 74.3 (9.6), and activity 71.6 (6.1), whereas the lower scores were chewing 49.7 (5.2), taste 51.1 (7.7), and saliva (56.7 (7.4). In the OHIP-14 questionnaire, the higher-scoring domains were psychological discomfort (69.3 (9.6) and psychological disability 65.2 (5.8), whereas the lower-scoring domains were handicap 28.7 (4.3) and physical pain 30.4 (8.1). The DPAP free flap significantly improved appearance, activity, shoulder, mood, psychological discomfort, and handicap compared with pedicled pectoralis major myocutaneous flap reconstruction. In conclusion, DPAP free flap for reconstruction of tissue defects after soft tissue resection of HNC significantly improved the patients' QOL compared to pedicled pectoralis major myocutaneous flap reconstruction.

Shedding of the Endothelial Glycocalyx Independent of Systemic Tryptase Release during Oncologic Oral Surgery: An Observational Study

The endothelial glycocalyx and endothelial surface layer are crucial for several functions of the vasculature. Damage to the glycocalyx (“shedding”) occurs during diverse clinical conditions, including major surgery. Mast cell tryptase has been proposed as one possible “sheddase”. During oncologic oral surgery, glycocalyx shedding could be detrimental due to loss of vascular barrier function and consequent oedema in the musculocutaneous flap graft. Concentrations of the glycocalyx components heparan sulphate and syndecan-1, as well as of tryptase in blood serum before and after surgery, were measured in 16 patients undergoing oncologic oral surgery. Secondary measures were the concentrations of these substances on postoperative days 1 and 2. Heparan sulphate rose from 692 (median, interquartile range: 535–845) to 810 (638–963) ng/mL during surgery. Syndecan-1 increased from 35 (22–77) ng/mL to 138 (71–192) ng/mL. Tryptase remained virtually unchanged with 4.2 (3–5.6) before and 4.2 (2.5–5.5) ng/mL after surgery. Concentrations of heparan sulphate and syndecan-1 in serum increased during surgery, indicating glycocalyx shedding. Tryptase concentration remained equal, suggesting other sheddases than systemic tryptase release to be responsible for damage to the glycocalyx. Investigating strategies to protect the glycocalyx during oncologic oral surgery might hold potential to improve flap viability and patient outcome.

Molecular Signatures of Tumour and Its Microenvironment for Precise Quantitative Diagnosis of Oral Squamous Cell Carcinoma: An International Multi-Cohort Diagnostic Validation Study

BACKGROUND

Heterogeneity in oral potentially malignant disorder (OPMD) poses a problem for accurate prognosis that impacts on treatment strategy and patient outcome. A holistic assessment based on gene expression signatures from both the tumour cells and their microenvironment is necessary to provide a more precise prognostic assessment than just tumour cell signatures alone.

METHODS

We reformulated our previously established multigene qPCR test, quantitative Malignancy Index Diagnostic System (qMIDS) with new genes involved in matrix/stroma and immune modulation of the tumour microenvironment. An algorithm calculates and converts a panel of 16 gene mRNA expression levels into a qMIDS index to quantify risk of malignancy for each sample.

RESULTS

The new qMIDS^V2 assay was validated in a UK oral squamous cell carcinoma (OSCC) cohort (n = 282) of margin and tumour core samples demonstrating significantly better diagnostic performance (AUC = 0.945) compared to previous qMIDS^V1 (AUC = 0.759). Performance of qMIDS^V2 were independently validated in Chinese (n = 35; AUC = 0.928) and Indian (n = 95; AUC = 0.932) OSCC cohorts. Further, 5-year retrospective analysis on an Indian dysplastic lesion cohort (n = 30) showed that qMIDS^V2 was able to significantly differentiate between lesions without transformation and those with malignant transformation.

CONCLUSIONS

This study validated a novel multi-gene qPCR test on a total of 535 tissue specimens from UK, China and India, demonstrating a rapid minimally invasive method that has a potential application for dysplasia risk stratification. Further study is required to establish if qMIDS^V2 could be used to improve OPMD patient management, guide treatment strategy and reduce oral cancer burden.

Impact of Goal Directed Therapy in Head and Neck Oncological Surgery with Microsurgical Reconstruction: Free Flap Viability and Complications

Simple Summary

Based on the proven benefits of goal directed therapy (GDT) in the perioperative management of different surgical procedures and in high-risk patients, we hypothesised that this approach would also be beneficial in microvascular free flap reconstruction in head and neck cancer. In this study, we investigated whether GDT would directly benefit flap viability in addition to improving morbidity and mortality. As this reconstructive technique is gradually being introduced in more specialist fields, particularly radical oncological surgery, the benefits of GDT in this context could be extended to numerous procedures.

Abstract

(1) Background: Surgical outcomes in free flap reconstruction of head and neck defects in cancer patients have improved steadily in recent years; however, correct anaesthesia management is also important. The aim of this study has been to show whether goal directed therapy can improve flap viability and morbidity and mortality in surgical patients. (2) Methods: we performed an observational case control study to analyse the impact of introducing a semi invasive device (Flo Trac^®) during anaesthesia management to optimize fluid management. Patients were divided into two groups: one received goal directed therapy (GDT group) and the other conventional fluid management (CFM group). Our objective was to compare surgical outcomes, complications, fluid management, and length of stay between groups. (3) Results: We recruited 140 patients. There were no differences between groups in terms of demographic data. Statistically significant differences were observed in colloid infusion (GDT 53.1% vs. CFM 74.1%, p = 0.023) and also in intraoperative and postoperative infusion of crystalloids (CFM 5.72 (4.2, 6.98) vs. GDT 3.04 (2.29, 4.11), p < 0.001), which reached statistical significance. Vasopressor infusion in the operating room (CFM 25.5% vs. GDT 74.5%, p < 0.001) and during the first postoperative 24h (CFM 40.6% vs. GDT 75%, p > 0.001) also differed. Differences were also found in length of stay in the intensive care unit (hours: CFM 58.5 (40, 110) vs. GDT 40.5 (36, 64.5), p = 0.005) and in the hospital (days: CFM 15.5 (12, 26) vs. GDT 12 (10, 19), p = 0.009). We found differences in free flap necrosis rate (CMF 37.1% vs. GDT 13.6%, p = 0.003). One-year survival did not differ between groups (CFM 95.6% vs. GDT 86.8%, p = 0.08). (4) Conclusions: Goal directed therapy in oncological head and neck surgery improves outcomes in free flap reconstruction and also reduces length of stay in the hospital and intensive care unit, with their corresponding costs. It also appears to reduce morbidity, although these differences were not significant. Our results have shown that optimizing intraoperative fluid therapy improves postoperative morbidity and mortality.