Cancer of Oral Cavity Abutting the Mandible; Predictors of Loco-regional Failure.

AIM OF WORK: : The purpose of this study is to analyze the causes of Loco-regional failure in 51 patients with tumors of the oral cavity abutting the mandible. PATIENTS AND METHODS: This cross-sectional study (27 patients were operated upon in the retrospective section and 24 patients in the prospective section of the study) was done in the department of Surgical Oncology, National Cancer Institute, Cairo University, from January 2003 to January 2008. Fifty-one patients, with oral cavity cancerous lesions abutting the mandible, were operated upon by segmental mandibulectomy en-bloc with primary tumor resection in addition to modified radical or selective neck dissection according to the status of the cervical lymph nodes. RESULTS: During a median follow-up of 2 years, 29 patients (56.8%) had local recurrences, the incidence of nodal recurrence after neck dissection was detected in 4 patients (7.8%). On multivariate analysis, tumor depth, tumor grade, oral mucosa, soft tissue and bone surgical margins in addition to metastatic lymphadenopathy were independent prognostic factors of loco-regional failure and disease-free survival. CONCLUSION: Oral cavity cancers abutting the mandible should be treated with great caution by a multidisciplinary oncology team (resection and reconstruction surgeons) as it has a very aggressive biologic behavior. Negative intraoperative pathological margins should be attempted since this is the critical point for patients with cancers abutting the mandible? Further research on the biologic margin and genetic study is required. KEY WORDS: Oral cavity cancer abutting the mandible - Predictors of loco-regional failure.

Hyperparathyroidism with bone tumor-like presentation, approach for diagnosis and surgical intervention.

AIM OF WORK: This work aims to find out a clinical approach for diagnosis of cases with hyperparathyroidism presented with bone tumor like condition as first and main presentation in order to differentiate primary bone tumors or secondary bone metastases from different types of hyperparathyroidism and to clear out the indications and type of surgery in such cases. PATIENTS AND METHODS: It is a prospective case series study done in the National Cancer Institute from April 2000 to May 2009. During this period we followed 45 cases of hyperparathyroidism (HPT) presented with a main complaint of bone tumor-like lesion. We started by clinical evaluation, laboratory investigationsincluding: Parathormone hormone, total and ionic calcium, renal function tests, alkaline phosphatase, 24h urine calcium, C-AMP in urine or inappropriate parathormne like peptide if needed and radiological investigations for preoperative localization including neck ultrasound, Tc99m Sestamibi scan, C-T neck and superior mediastinum or M.R.I. Intraoperative ultrasound was used in some cases. Postoperative bone desimetry and plain-X ray to follow bone mineral deposition were done. RESULTS: Preoperative diagnosis was: 80% cases of primary hyperparathyroidism (pHPT), 15.5% cases of secondary hyperparathyroidism (sHPT), 4.5% tertiary hyperparathyroidism (tHPT), benign adenoma in 73.3%, diffuse hyperplasia in 8.8% and one case of parathyroid carcinoma. Neck ultrasound localized 29/38 adenoma (sensitivity = 73.3%), sestamibi localized 23/38 including another 2 cases of diffuse hyperplasia not detected by ultrasound (sensitivity = 63.8%), C-T scan detected adenoma in upper mediastinum. Total preoperative localization was 84.2%. We used unilateral exploration in 27 cases, and bilateral in 11 cases. Intraoperative ultrasound was useful in detection of 2 additional cases in the thyroid lobe tissue. Intraoperative parathormone hormone after 10 minutes dropped in all of cases. Recurrence of the disease occurred in 2 cases during follow-up (5.2%). Postoperative sever hypocalcemia occurred in 4 cases necessitating longer hospitalization and longer period of oral calcium. Healing in cortical bone was faster than cancellous bone. CONCLUSION: Hyperparathyroidism should be suspected in all cases with bone tumor-like presentation or even in earlier disease complain of bony or muscle aches. Intact P.T.H and calcium (total &ionic), renal functions, 24 hours urine calcium, neck ultrasonography, and Tc 99m pertechnitate/Tc99m sestsmibi subtraction scan can establish the diagnosis. Surgical treatment with unilateral approach or bilateral when indicated with intraoperative ultrasound localization, frozen section examination and assessment of intraoperative 10 minutes-P.T.H is very successful with minimal rate of recurrence and complications. KEY WORDS: Hyperparathyroidism - Bone tumor-like presentation - Diagnosis - Surgical approach.

Paravertebral neurogenic tumors with intraspinal extension: preoperative evaluation and surgical approach.

AIM OF WORK: To achieve adequate excision of paravertebral neurogenic tumors with intra spinal extension, safe decompression of spinal cord and preservation of spine stability. PATIENTS AND METHODS: From Nov. 2000 till July 2009 sixteen patients of paravertebral neurogenic tumors with intraspinal extension (dumbbell tumors) were operated upon by combined team work of surgical oncology and neurosurgery at the National Cancer Institute and at Kasr- Al Einy Hospitals, Cairo University. All patients had CT with guided biopsy and MRI to evaluate extent of tumor bone invasion, intraspinal component, to decide surgical approach and the need for spine fixation. Patients were referred postoperatively to I.C.U for stabilization of general condition. Follow-up with radiology was done for a period from 3-36 month. RESULTS: The group of patients were 9 males and 7 females with age range 1.5-47 year, 8 patients had tumors in post. Mediastinum, 7 in the retroperitoneal space and one in the cervicothoracic inlet. Benign schwannoma were diagnosed in 5 cases, malignant schwannoma in 3, neurofibromatosis in one case, neuroblastoma in 3 cases, ganglioneuroblastoma in 2 cases and ganglioneuroma in 2 cases. Anterior transthoracic resection through posterolateral thoracotomy was used in 6 cases, anterior transabdominal resection was done in 6 cases through midline or transverse incisions. Combined anterior and posterior approach was used in 3 cases while Posterior approach was done in one case using medial para scapular incision. Delivery of the tumor was done in 8 cases, widening of the intervertebral foramina in 3 cases, costotransversectomy with lateral laminectomy in 3 cases while posterior laminectomy and total vertebrectomy was done in one case. We fixed the spine in 3 cases using Z-plate and screws, lateral plates and screws with either iliac crest or isobone graft. All cord compression manifestations improved postoperatively with perfect spine stability. Morbidity was detected in 3 cases in the form of (graft and plate infection in posterior approach case, and limited spine mobility in 2 cases) while mortality of local and distant recurrence within 16-19 month was registered in 3 cases. CONCLUSION: Para vertebral neurogenic tumors with intra spinal extension could be diagnosed and evaluated with very high accuracy using C-T in adjunct with MRI. C-T guided biopsy can select patients with pathological diagnosis that could be sensitive to pre operative chemotherapy and/or radiotherapy to facilitate surgery. Adequate surgical resection is feasible in a combined team work with different surgical approaches and possible spine fixation. KEY WORDS: Para vertebral - Neurogenic tumors - Intra spinal extension - Surgical approach.

Role of pectoralis major myocutanuos flap in salvage laryngeal surgery for prophylaxis of pharyngocutaneuos fistula and reconstruction of skin defect.

AIM OF WORK: This study was carried out to minimize the incidence of pharyngocutaneous fistula (PCF) following salvage laryngeal surgery using vascularized pedicle pectoralis major myocutaneous flap (PMMC) for enhancing wound healing, rapid intake of oral feeding, reconstruction of desqauamated irradiated skin, achieving short hospital stay and protection against catastrophic blow out mortality. PATIENTS AND METHODS: This case series study of sixteen patients carried out from May 2005 to July 2009, at the National Cancer Institute, Cairo University where we applied PMMC flap in salvage laryngeal surgery for those with high risk to develop complications: Patients of poor general conditions (anemia, hypoproteinemia, diabetics) and/or poor local conditions for healing (irradiated neck, extensive local or nodal recurrence with skin desquamation, infiltration or tumor fungation which need extensive resection). Five cases had been treated with primary cobalt radiotherapy laryngeal field only and 4 cases laryngeal field with draining neck nodes, while photon therapy was given in 4 cases as laryngeal field only and 3 cases laryngeal field with draining neck nodes. All cases were squamous cell carcinoma (13 cases grade 2, 2 cases grade 3 and one case grade 1) proved before radiotherapy. Supraglottic recurrence was detected in 7 cases (43.75%) and glottis in 9 cases (56.25%). Following salvage surgery, 11 cases were staged T3 N0, N1 and N2, 3 cases were T2 N0 or N1 and 2 cases were T4 N2 with skin infiltration. Tracheostomy was there in 4 cases. RESULTS: The study included fifteen males (93.75%) and one female (6.25%), age was between 38-73 years (mean=55.5 years). Five cases were operated on as total laryngectomy with excision of skin flaps + PMMC flap, 4 cases as total laryngectomy with skin flap excision + functional block neck dissection + PMMC flap and 7 cases as total laryngectomy + block neck dissection with skin excision (modified radical in 4 cases &radical in 3 cases) + PMMC flap reconstruction. Flaps survived in all cases, PCF developed in 2 cases (12.5%) with wound infection but healed conservatively within 2 weeks. Dropped shoulder occurred in 3 cases (18.75%) treated by physiotherapy. Mild postoperative chest infection developed in 7 cases (36.84%) improved by broad spectrum antibiotics and chest physiotherapy. CONCLUSION: Routine use of pectoralis major myocutaneous flap in salvage laryngeal surgery is of great help in such high risk patients to minimize incidence of pharyngocutaneous fistula and to allow primary skin wound healing. This flap will give the patient the advantage of early oral feeding, good tracheostomy care, short hospital stay and protection against catastrophic vascular blow out mortality. KEY WORDS: Pectoralis major myocutaneous flap - Prevention of pharyngocutaneous fistula - Salvage laryngectomy.

Critical appraisal of nasolabial flap for reconstruction of oral cavity defects in cancer patients.

PURPOSE: Re-evaluation of nasolabial flap in lip and oral cavity reconstruction and role of each of its variants in reconstructing various intermediate size defects was addressed. PATIENTS AND METHODS: Case-series study was conducted in National Cancer Institute, Cairo University over the period from July 2005 - January 2009 which included 23 patients with clinically T-1 N0, T-2 N0 invasive squamous cell carcinoma of buccal mucosa and the vermilion border of the lower lip. Immediately after surgical excision, one stage reconstruction of the defect was done using a type of nasolabial flap. All patients were followed and the median follow-up period was 7.5 month. RESULTS: Twelve patients with the lower lip carcinoma and 11 patients with the carcinoma of buccal mucosa underwent surgical excision under frozen section control. 19 fasciocutaneous nasolabial flap and 4 facial artery musculomucosal flaps were used for reconstruction. Minor wound complications occurred in 2 flaps and one patient required secondary suture. Flap viability was reliable and was not affected by performance of a synchronous neck dissection. Functional results were satisfactory, cosmetic results were good in most of the patients and excellent when facial artery musculomucosal flap was used. CONCLUSIONS: The nasolabial flap is a reliable and minimally traumatic local flap for one stage reconstruction of medium size defects in the oral cavity. The abundant blood supply allowed its modification in order to cover larger defects or to obtain better cosmetic results. This versatility makes it more widely used thus minimizing the use of local tongue flaps and split thickness grafts for covering these medium size defects in cases of buccal mucosa cancer or affecting the other lip or commissure in cases of lip cancer. It has a high viability rate, low complication rate; it is quick and easy to perform in addition to its satisfactory functional and cosmetic results. KEY WORDS: Nasolabial flap (NLF) - Facial artery musculomucosal (FAMM) flap - Reconstruction of oral cavity - Squamous cell carcinoma (SCC) - Buccal mucosa - Lower lip reconstruction.