Double-barrel fibula vascularized free flap with dental rehabilitation for mandibular reconstruction.

PURPOSE: The vascularized free fibula flap has become the most popular reconstruction method after mandibular resection because of adequate bone graft length and acceptance of dental implants. However, using 1 fibula bone may produce a height discrepancy between the native mandible and the grafted fibula that results in subsequent difficulty in wearing conventional dentures or osteointegrated implants. Several options can be used to resolve this problem such as delayed onlay bone graft, iliac bone reconstruction, fibula distraction, and double-barrel fibula flap graft. This article describes the reconstruction of segmental mandible defects with the double-barrel fibula flap and denture rehabilitation. MATERIALS AND METHODS: This procedure was used in 7 patients. A donor site fibula corresponding to at least twice the length of the mandibular defect was harvested. Double-barrel free fibula grafting was performed in 6 patients for primary reconstruction and 1 patient for secondary reconstruction, including 3 cases of osteocutaneous flap with skin islands in the reconstruction of a composite defect from a malignant tumor. Prosthodontic treatment was completed in all 7 patients. Four patients received secondary implant-supported dental reconstruction, and 3 patients who received radiation (6,000 cGy) after graft surgery had conventional removable partial dentures. RESULTS: Microvascular fibula transfers were completely successful, and all skin paddles survived without necrosis. The original mandibular contour was maintained by a reconstruction plate; the reconstruction mandibular length was 6.5 to 10 cm, the reconstruction height of the double-barrel fibula was 3.0 to 3.8 cm, and all patients were satisfied with the postoperative facial esthetics and chewing function from the implant-supported denture and removable partial prostheses. CONCLUSIONS: Mandibular segmental defects can be esthetically and functionally reconstructed by a double-barrel vascularized fibula flap that not only matches the height of the native mandible but also allows osteointegrated dental implantation for dental rehabilitation.

Clinical management of peripheral ameloblastoma.

Peripheral ameloblastoma is a rare epithelial odontogenic tumor, limited to the soft tissues of the gingiva or oral mucosa. Peripheral ameloblastoma represents approximately 2% to 10% of all ameloblastomas. It is always considered to be benign, but occasionally it may be locally aggressive or with malignant potential. In this article, we report 3 new cases of benign peripheral ameloblastoma and further discuss the clinical management of this disease.

Schwannoma arising from intramasseteric region.

Schwannoma in the head and neck is usually arising in the parapharyngeal space, but intramasseteric schwannoma is very rare. We report a schwannoma arising from masseter muscle in a middle-aged woman, who presented with a history of a painless right cheek mass for 3 years. Computed tomography scan suggested that the mass was located within the masseter muscle. Fine-needle aspiration was performed and showed spindle neoplastic cells, which were suspected to be of mesenchymal tissue origin. The mass was completely resected under general anesthesia. It was a well-circumscribed and lobulated mass, 4 × 3 × 2 cm in size. Histological examination gave the diagnosis of schwannoma, which was also confirmed by immunohistochemical stainings for S-100 and vimentin. Neurologic sequelae and recurrence were not found at 2 years after surgery.

Free fibula osteocutaneous flap for primary reconstruction of T3-T4 gingival carcinoma.

Lower gingival squamous cell carcinoma (SCC) frequently invades the mandibular bone and buccal or lingual oral mucosa. In the concept of en bloc surgery of malignant tumors, it is advisable to prefer segmental mandibulectomy for T3-T4 lower gingival carcinoma that had radiologic bone involvement and resection of soft tissue on the buccal or lingual side with negative border of margin. Consequential defects of oral mucosa and mandible need immediate reconstruction to provide the maximum probability of cure and quality of life with minimal donor site morbidity. The aim of this study was to evaluate the fibula osteocutaneous flap with skin island as a means to meet both hard and soft tissue reconstructions needed in a one-stage procedure of gingival SCC. Data of 17 patients, with gingival SCC pathologically and who underwent en bloc operations including segmental mandibulectomy and reconstruction of mandible and intraoral mucosa with fibular flap, were retrospectively analyzed. The segmental mandibular defects ranged from 8 to 17 cm, and intraoral soft tissue defects ranged from 4 degrees at 2.5 cm to 8.5 degrees at 4 cm. The flaps survived in all 17 patients including 9 patients who received postoperative radiotherapy with good final function of the lower leg. Of 17 patients, 11 had with no evidence of disease with a mean follow-up period of 25 months. Our study results, together with literature findings, revealed that the fibula that had a long length of good-quality bone and sufficient blood supply were suitable for stable osteosynthesis, with the overlying skin suitable in thickness and without limitation of skin flap size for intraoral reconstruction especially after ablative surgery. This method provides oral and maxillofacial surgeons with a means to meet both hard and soft tissue needs in a one-stage procedure for extensive resection of gingival SCC.

Intralesional injection of Pingyangmycin may be an effective treatment for epulis.

Gingival epulis represents a family of benign tumors and tumorlike masses of the gingiva. A spectrum of inflammatory and other reactive changes can be observed pathologically as granulation, fibrous or vascular tissue. It may occur at any age, but most commonly found in patients at their twenties and sixties. Women are more frequently affected than men. Surgical excision or removal is the treatment of choice, and wider resection including extraction of the involved teeth and adjacent tissues is often required in order to prevent recurrence. However, wider resection may result in cosmetic and functional problems. Epulis bears some similarities with hemangioma both clinically and histopathologically. Therefore, we hypothesize that intralesional injection of Pingyangmycin may be a safe and effective treatment for epulis. The efficacy of this treatment modality is worthy of further investigation.

A new mutation of PTCH gene in a Chinese family with nevoid basal cell carcinoma syndrome.

BACKGROUND: Nevoid basal cell carcinoma syndrome (NBCCS) is a rare autosomal dominant disease characterized by a combination of development anomalies and a predisposition to tumour formation. Mutation of patched gene (PTCH), considered the molecular defect of NBCCS, in a Chinese NBCCS family was investigated in this study. METHODS: Genomic DNA was isolated from blood samples of all 12 members of this family. The mutated PTCH gene was screened by polymerase chain reaction amplification and direct sequencing. RESULTS: A new mutation of 3 bp (GAT deletion) was found in all seven affected members of this family. This mutation caused one aspartate deletion in the fourth transmembrane domain of the PTCH protein located within the sterol sensing domain (SSD). This deletion was not found in any unaffected members of this family nor in 200 control samples. CONCLUSIONS: Our findings suggest that one 3-bp deletion in PTCH gene was the cause of nevoid basal cell carcinoma in a Chinese family through affecting the conformation and function of PTCH protein.

Occult cervical lymph node metastases in 100 consecutive patients with cN0 tongue cancer.

BACKGROUND: Squamous cell carcinoma (SCC) of the tongue is one of the most common cancers in the oral and maxillofacial region. To provide clinical evidence for selective neck dissection in management of cN0 patients by analyzing the characteristics and correlation of factors of occult cervical lymph node metastases (OCLNM) in patients with SCC of the tongue. METHODS: From 2002 to 2006, 100 consecutive patients with SCC of the tongue were reviewed by analyzing the characteristics of OCLNM, diameter of the tumor, T classifications, depth of invasion, forms of growth, pathological grade and degree of differentiation. RESULTS: The rate of OCLNM in 100 patients with SCC of the tongue was 22%. The most common region with OCLNM was level II in the ipsilateral neck, followed by levels I and III. There were 51.61% (16/31) of OCLNM in level II and 87.10% (27/31) of OCLNM in levels I - III. There was no significant correlation between the diameter of tumor and OCLNM (P > 0.05). OCLNM was statistically significantly correlated with the depth of invasion, forms of growth, pathological grade and degree of differentiation (P < 0.05). The rate of occult metastases increased with the increased pathological grade, the decreased degree of differentiation and the increased depth of invasion. CONCLUSIONS: The most common regions with OCLNM in cN0 patients with SCC of the tongue were levels I - III in the ipsilateral neck. Supraomohyoid neck dissection should be the elective treatment to the neck in patients with cN0 SCC of the tongue by consideration of the clinical and pathological factors for the depth of invasion, forms of growth, pathological grade, and degree of differentiation.

Expression of E-cadherin in cervical lymph nodes from primary oral squamous cell carcinoma patients.

BACKGROUND: Oral squamous cell carcinoma (OSCC) is the most common malignant tumor in oral and maxillofacial region with poor prognosis. E-cadherin plays a key role in cell-to-cell adhesion. E-cadherin expression in the metastatic cervical lymph node, especially in the micrometastatic cervical lymph node has seldom been reported in OSCC patients. OBJECTIVE: To investigate the E-cadherin expression in cervical lymph nodes from OSCC patients as well as its clinical significance. DESIGN: Thirty-three OSCC patients were involved in this study; among them, there were 28 males and 5 females, the age ranged from 34 to 78 years (mean 58.8 years). The most suspicious metastatic cervical lymph node (total 99 lymph nodes) from three cervical regions of each OSCC patient was selected for detection of E-cadherin using routine pathological examination and immunohistochemistry. RESULTS: Increased E-cadherin expression in the metastatic cervical lymph nodes was detected, which was diagnosed by routine pathological examination using HE staining. However, in the micrometastatic cervical lymph node, E-cadherin expression was negative. The survival rate of OSCC patients correlated with decreased E-cadherin expression (P=0.001), N stage (P=0.024) and tumor recurrence (P<0.001). Tumor recurrence is the only independent factor on the prognosis (RR=20.83 and P=0.014). CONCLUSIONS: Decreased E-cadherin expression in cancerous tissue correlates with the poor prognosis of OSCC patients. Detection of E-cadherin expression is useful to confirm the cervical lymph node metastasis and maybe useless to detect the cervical lymph node micrometastasis; further studies are encouraged to reveal the detail mechanism of E-cadherin expression in formation of lymph node metastatic focus.

Long-term results of a randomized phase III trial of TPF induction chemotherapy followed by surgery and radiation in locally advanced oral squamous cell carcinoma.

Previously, we conducted a randomized phase III trial of TPF (docetaxel, cisplatin, and 5-fluorouracil) induction chemotherapy in surgically managed locally advanced oral squamous cell carcinoma (OSCC) and found no improvement in overall survival. This study reports long-term follow-up results from our initial trial. All patients had clinical stage III or IVA locally advanced OSCC. In the experimental group, patients received two cycles of TPF induction chemotherapy (75mg/m2 docetaxel d1, 75mg/m2 cisplatin d1, and 750mg/m2/day 5-fluorouracil d1-5) followed by radical surgery and post-operative radiotherapy; in the control group, patients received upfront radical surgery and post-operative radiotherapy. The primary endpoint was overall survival. Among 256 enrolled patients with a median follow-up of 70 months, estimated 5-year overall survival, disease-free survival, locoregional recurrence-free survival, and distant metastasis-free survival rates were 61.1%, 52.7%, 55.2%, and 60.4%, respectively. There were no significant differences in survival rates between experimental and control groups. However, patients with favorable pathologic responses had improved outcomes compared to those with unfavorable pathologic responses and to those in the control group. Although TPF induction chemotherapy did not improve long-term survival compared to surgery upfront in patients with stage III and IVA OSCC, a favorable pathologic response after induction chemotherapy may be used as a major endpoint and prognosticator in future studies. Furthermore, the negative results observed in this trial may be represent type II error from an underpowered study. Future larger scale phase III trials are warranted to investigate whether a significant benefit exists for TPF induction chemotherapy in surgically managed OSCC.

Tricholemmal carcinoma of the head and neck region: A report of 15 cases.

Tricholemmal carcinoma is an extremely rare malignancy of the skin, and its biological behavior and management is controversial. The objective of the present study was to investigate the clinicopathological characteristics and management of tricholemmal carcinoma of the head and neck region. The study analyzed 15 patients with tricholemmal carcinoma. Demographic and clinical data were collected, and features associated with the management and prognosis of tricholemmal carcinoma were analyzed. Two of the 15 patients were lost to follow-up. The results showed that, during the follow-up period, 5 of the 13 available patients succumbed to the causes of recurrence (n=3), neck lymph node metastasis (n=1) and Parkinson's disease (n=1). No patients developed distant metastasis. The disease-free survival (DFS) and overall survival (OS) were 31.1±7.8 and 32.9±7.4 months (mean ± SE), respectively, and the DFS and OS rates were 69.2 and 61.5%, respectively. In conclusion, the biological behavior of tricholemmal carcinoma is locoregionally aggressive. The recommended management for head and neck tricholemmal carcinoma is radical resection and neck dissection, and post-operative radiotherapy may be considered for high-risk patients.

[Polymorphous low-grade adenocarcinoma of the palate with cervical lymph node and distant metastasis: report of one case and review of the literature].

Polymorphous low-grade adenocarcinoma is a rare salivary gland tumor with lower rate of local and regional metastasis and rare distant metastasis. The prognosis is relatively good. This paper reported a case of palatal polymorphous low-grade adenocarcinoma with cervical lymph node and distant metastasis, and discussed clinical characteristics, differential diagnosis, treatment, prognosis based on literature review.

Randomized phase III trial of induction chemotherapy with docetaxel, cisplatin, and fluorouracil followed by surgery versus up-front surgery in locally advanced resectable oral squamous cell carcinoma.

PURPOSE: To evaluate induction chemotherapy with docetaxel, cisplatin, and fluorouracil (TPF) followed by surgery and postoperative radiotherapy versus up-front surgery and postoperative radiotherapy in patients with locally advanced resectable oral squamous cell carcinoma (OSCC). PATIENTS AND METHODS: A prospective open-label phase III trial was conducted. Eligibility criteria included untreated stage III or IVA locally advanced resectable OSCC. Patients received two cycles of TPF induction chemotherapy (docetaxel 75 mg/m(2) on day 1, cisplatin 75 mg/m(2) on day 1, and fluorouracil 750 mg/m(2) on days 1 to 5) followed by radical surgery and postoperative radiotherapy (54 to 66 Gy) versus up-front radical surgery and postoperative radiotherapy. The primary end point was overall survival (OS). Secondary end points included local control and safety. RESULTS: Of the 256 patients enrolled onto this trial, 222 completed the full treatment protocol. There were no unexpected toxicities, and induction chemotherapy did not increase perioperative morbidity. The clinical response rate to induction chemotherapy was 80.6%. After a median follow-up of 30 months, there was no significant difference in OS (hazard ratio [HR], 0.977; 95% CI, 0.634 to 1.507; P = .918) or disease-free survival (HR, 0.974; 95% CI, 0.654 to 1.45; P = .897) between patients treated with and without TPF induction. Patients in the induction chemotherapy arm with a clinical response or favorable pathologic response (≤ 10% viable tumor cells) had superior OS and locoregional and distant control. CONCLUSION: Our study failed to demonstrate that TPF induction chemotherapy improves survival compared with up-front surgery in patients with resectable stage III or IVA OSCC.

[Inhibition effects of tumor necrosis factor-alpha gene transduced tumor drainage node of lymphocytes from tongue cancer on SCID mice transplanted tumor established with human tongue carcinoma cell lines].

OBJECTIVE: To observe the in vivo inhibition effects of tumor necrosis factor-alpha (TNF-alpha) gene transduced tumor drainage node of lymphocytes (DNL) from tongue cancer on SCID mice transplanted tumor. METHODS: 15 human tongue carcinoma models were established in SCID mice by subcutaneously injection of squamous cell carcinoma line Tca8113. TNF-alpha gene introduced DNL, combined with low dose Pinyancin (PYC), were locally injected into tumor site. The inhibition rate was determined by the weights at the 8th week after tumor dissection and fresh specimens were prepared and subject to histopathologic examination under transmission electron microscope, and in situ TUNEL was used to detect apoptosis. RESULTS: The TNF/DNL and rIL-2 group, and the TNF/DNL and rIL-2 and PYC group both exerted a strong inhibition effect on the implanted tumor. Treated tumors of the TNF/DNL and rIL-2 and PYC group were significantly reduced in comparison with those of the TNF/DNL and rIL-2 group (P < 0.05). The apoptosis of tumor in the TNF/DNL and rIL -2 group was evidenced based on transmission electron microscope and TUNEL analysis, and the apoptosis index was higher than that of control group (P < 0.05). CONCLUSION: Local injection of DNL modified with TNF-alpha gene, combined with low dose PYC, exert a synergistic antitumor effect. Apoptosis may be an important mechanism of squamous cell carcinoma killed by TNF/DNL.

Clinical analysis of Castleman disease (hyaline vascular type) in parotid and neck region.

OBJECTIVE: The aim of this study was to analyze a single institution's experience in clinical diagnosis, treatment, and prognosis of Castleman disease (hyaline vascular type) in the parotid and neck region. STUDY DESIGN: From 2004 to 2008, a total of 10 consecutive patients with Castleman disease (hyaline vascular type) in the parotid and neck region underwent surgery were included in this retrospective study. The preoperative examinations, clinical diagnosis, surgical treatment, and prognosis were recorded and analyzed. RESULTS: Of the 10 patients, 4 were males and 6 female; their age ranged from 13 to 54 years with a mean of 26.6 years. The lesion occurred in the parotid region in 3 patients, in the neck region in 5 patients, and in both the parotid and neck regions in 2 patients. Their course of disease ranged from 3 months to 48 months with a mean of 12.5 months; 70% of the patients (7 out of 10) had a course of disease of <12 months. The patients always had no obvious complaint, and the laboratory examinations were almost within the normal limits. Magnetic resonance imaging/angiography were valuable on clinical diagnosis and differential diagnosis. All patients underwent surgical removal of the masses completely. During the follow-up period, which ranged from 9 months to 60 months with a mean of 38.9 months, no recurrence of the lesion occurred, and the quality of life of each patient was good. CONCLUSIONS: Castleman disease (hyaline vascular type) in the parotid and neck region is rare, with clinical manifestation and physical examination the same as benign lesions. There is no specific indication in the laboratory tests and imaging examinations; however, magnetic resonance imaging/angiography has potential value on clinical diagnosis and differential diagnosis. Surgical resection is the choice of treatment with good prognosis.

Three-dimensional model simulation and reconstruction of composite total maxillectomy defects with fibula osteomyocutaneous flap flow-through from radial forearm flap.

OBJECTIVE: A total maxillectomy always causes composite defects of maxilla, zygomatic bone, orbital floor or rim, and palatal and nasal mucosa lining. This leads to significant functional and cosmetic consequences after ablative surgery. The purpose of this clinical study was to preliminarily 3-dimensionally reconstruct the defect of total maxillectomy with sufficient bone support and soft tissue lining. STUDY DESIGN: Three-dimensional model simulation technique and free fibula osteomyocutaneous flap flow-through from radial forearm flap were used to reconstruct a total maxillectomy defect for a 21-year-old female patient. Preoperatively, the 3-dimensional (3D) simulated resin models of skeleton and fibula were used to design the osteotomies and bone segment replacement. At surgery, a 22-cm-length free fibula was divided into 4 segments to make 1 maxilla skeletal framework in the schedule of the preoperative model surgical planning with a radial forearm flap flow-through for the free fibula flap with skin paddle to repair the palatal and nasal region. RESULTS: Free fibula and radial forearm flap were alive, and the patient was satisfied with the results both esthetically and functionally after dental rehabilitation which was carried out 6 months after surgery. CONCLUSION: This preliminarily clinical study and case demonstrated that: the fibula osteomyocutaneous flap is an ideal donor site in 3D total maxillectomy defect reconstruction, because of its thickness, length, and bone uniformity which makes ideal support for dental rehabilitation; the flow-through forearm radial flap not only serves as the vascular bridge to midface reconstruction, but also provides sufficient soft tissue cover for the intraoral defect; and the 3D model simulation and preoperative surgical planning are effective methods to refine reconstruction surgery, shorten the surgical time, and predict the outcome after operation.

Spontaneous thoracic duct cyst presenting as a left supraclavicular mass - report of a case and review of literature.

Spontaneous and asymptomatic supraclavicular thoracic duct cysts occurring in the neck are the rarest. We report a case of a huge thoracic duct cyst occurring in the supraclavicular fossa with a review of the literature and management options. A 28-year-old female had a left supraclavicular mass with a 10-year history. A cervical thoracic duct cyst was diagnosed after chemical analysis of the milky fluid obtained by preoperative fine-needle aspiration. Treatment was achieved by surgical excision of the cyst and thoracic duct ligation. Pathological analysis of the cyst after excision confirmed the diagnosis. In the case of left supraclavicular masses, the rare differential diagnosis of thoracic duct cysts must be considered as a possibility. Magnetic resonance imaging as the imaging method of choice and chemical analysis of the milky fluid obtained by preoperative fine-needle aspiration are sufficient for primary diagnosis. The treatment of this disease consists of simple excision.