Cervical metastasis from squamous cell carcinoma of the maxillary alveolus and hard palate.

OBJECTIVES: Squamous cell carcinoma has a predilection for regional lymphatic metastasis. The occurrence of occult cervical metastases from squamous cell carcinoma of the hard palate and maxillary alveolar ridge has not been studied systematically. We have observed many patients who have returned after resection of a primary cancer in these sites with a delayed cervical metastasis. Some of these patients have died of regional or distant metastasis despite control of their primary cancer. METHODS: We have studied 26 patients with squamous cell carcinoma of the maxillary alveolar ridge and hard palate to define incidence of cervical metastasis. RESULTS: Overall incidence of cervical metastasis was: clinical 2 of 26 (7.6%) and occult 7 of 26 (27%) for a total of 9 of 26 (34.6%). The 5-year disease-specific survival was 13 of 22 (59%). Surgery for regional failure was successful in 66% (6 of 9). Radiation was administered after surgery in eight of nine patients. CONCLUSION: Cervical metastasis from cancer of the palate and alveolar ridge is significant. Regional surgery for recurrent disease usually requires radical or modified radical neck dissection. Selective elective neck dissection should be offered to patients with cancer of the hard palate and alveolar ridge. It affords the patient and the treatment team valuable histologic information, which may help to guide therapy and reduce the potential need for future hospitalization, chemoradiation, and more radical surgery.

Reconstruction of the lateral mandibulectomy defect: management based on prognosis and location and volume of soft tissue resection.

OBJECTIVE: To examine how the accompanying soft tissue resection of the oral cavity, oropharynx, neck, or face affects the reconstructive management of the lateral mandibulectomy defect. STUDY DESIGN: Retrospective review of 76 consecutive patients. METHODS: Patient and tumor variables were extracted from the medical records. Outcomes that were examined included method of reconstruction, medical complications, flap complications, and survival. RESULTS: Age greater than 70 years (P = .03), moderate or severe comorbidity (P = .01), and tumor involvement of the base of tongue (P = .03) were significantly associated with decreased use of a free flap and with decreased 3-year survival rates. For choice of free (osteocutaneous radial forearm free flap or fibula vs. rectus abdominis) and regional flaps (pectoralis or cervicodeltopectoral), lateral defects could be classified into one of three types: type 1 (n = 60), lateral defect with a soft tissue resection limited to the oral cavity and oropharynx; type 2 (n = 11), lateral defect with a through and through defect of the lower one third of the face (skin overlying the mandible) or neck; and type 3 (n = 5), lateral defect with an associated large-volume resection of the midface, parotid, or cheek skin. CONCLUSION: When the lateral mandible is resected with an accompanying large soft tissue defect of the neck or face (type 2 or type 3 defect), the reconstructive challenge becomes the determination of how best to cover the planned bony reconstruction or whether to perform only a soft tissue reconstruction. When placed in the context of expected prognosis, the proposed classification system based on the location and volume of the associated soft tissue resection can help guide the reconstructive options for these decisions.

Oncologic outcomes of surgically treated early-stage oropharyngeal squamous cell carcinoma.

BACKGROUND: The purpose of this study was to characterize oncologic outcomes in early (T1-T2, N0) and intermediate (T1-T2, N1) oropharyngeal squamous cell carcinoma (SCC) after surgery. METHODS: Patients with oropharyngeal SCC treated with surgery were identified from 2 academic institutions. RESULTS: Of 188 patients, 143 met the inclusion criteria. Eighty-six (60%) had T1 to T2 N0 and 57 (40%) had T1 to T2 N1 disease. Sixty-five patients (45%) underwent a robotic-assisted resection, whereas the remaining had transoral (n = 60; 42%), mandible-splitting (n = 11; 8%), or transhyoid approaches (n = 7; 5%). Human papillomavirus (HPV) status was known for 97 patients (68%), and 54 (55%) were HPV positive. Three-year recurrence-free survival (RFS) was 82% (95% confidence interval [CI] = 0.75-0.89). Since 2008, HPV infection was protective of recurrence (log-rank p = .0334). A single node did not increase the risk of recurrence (p = .467) or chance of a second primary (p = .175). CONCLUSION: Complete surgical resection is effective therapy for early and intermediate oropharyngeal SCC. HPV-negative patients were at increased risk for locoregional recurrence or second primary disease. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1471, 2016.

Radiation following surgery for oral cancer: impact on local control.

OBJECTIVES: The use of postoperative radiation therapy (RT) is commonly used in the treatment of patients with high-risk squamous cell carcinoma of the head and neck. However, few data exist that quantitate the incremental benefit of RT when administered following surgery. The retrospective study was designed to measure the incremental benefit of adjuvant RT after surgery on control of the primary lesion when compared with patients undergoing surgical therapy alone for squamous cell carcinoma of the oral cavity. STUDY DESIGN: Retrospective chart. METHODS: Previously untreated patients with squamous cell carcinoma of the floor of mouth or oral tongue who were treated between 1974 and 1998 were eligible for study. A minimum follow-up of 2 years was required. Tumor site, stage, and RT data were correlated with local control. RESULTS: Patients with missing or incomplete data and those lost to follow-up or dead as a result of intercurrent disease with follow-up of less than 2 years were censored. A group of 211 patients who could be evaluated was available for the study. Radiation therapy was administered postoperatively to 58 patients, and 153 patients were treated with surgery alone. In the group treated with combined therapy, the average irradiation dose was 5850 cGy; this group included 35 patients who received more than and 16 who received less than 5700 cGy. CONCLUSIONS: The incremental benefit in terms of control of tumor at the primary site for patients receiving postoperative RT was between 0% and 7%. Surgery alone controlled 80% to 85% of primary tumors. The dose of postoperative RT did not correlate with local control.

Salivary duct carcinoma.

Salivary duct carcinoma (SDC) is a highly malignant tumor that is histologically similar to ductal carcinoma of the breast. This article presents the clinicopathologic features of 15 patients with SDC arising in the salivary glands. The majority of patients were male and aged 65 years or older. The tumor was most often located in the parotid gland. Pain, facial palsy, and presence of calcification in the CT scan were diagnostic features suggestive of SDC. Histologically, 27% of the tumors arose from pre-existing pleomorphic adenoma. Perineural and lymphatic invasion were common findings. There was an extensive cervical lymph node involvement (73%). Distant metastasis was the most common cause of failure. Although SDC exhibits an unpredictable clinical course, total parotidectomy with neck dissection and adjunctive radiation therapy appear to be appropriate for local and regional control of this aggressive neoplasm.

Early squamous cell carcinoma of the oral tongue: comparing margins obtained from the glossectomy specimen to margins from the tumor bed.

OBJECTIVES: To evaluate the impact of margin sampling on local recurrence in patients with pT1-2 pN0 conventional squamous cell carcinoma of the oral tongue. MATERIALS AND METHODS: Based on margin sampling, 126 cases were divided into group 1 (margins sampled from the glossectomy specimen only), group 2 (with revision of glossectomy margins), and group 3 (margins primarily sampled from the tumor bed). RESULTS: The probability of local progression-free survival at 3years was .90, .76 and .73 (p=.0389) in groups 1, 2, and 3, respectively. Groups differed by frequency of positive glossectomy specimen margins (p=<.0001) and by the average distance from carcinoma to the closest margin (4.5, 2.4, and 3.0mm for Groups 1, 2, and 3, respectively; p=.0009). Tumor bed margin status (positive vs. negative) and other parameters (e.g., pattern and depth of invasion) did not correlate with local recurrence. Status of the glossectomy specimen margins did correlate with outcome. A positive glossectomy margin conferred a relative risk of 2.5 (95% confidence interval, CI, 1 - 6.3) for local recurrence. A proportional hazards regression model for margin width found a hazard ratio of 0.67 (95% CI=.57-.98) comparable to a 33% decrease in risk of local recurrence for an increase of 1mm of margin width (p=.0271). CONCLUSIONS: Status of the glossectomy specimen margins rather than that of tumor bed margins was prognostically relevant. Reliance on tumor bed margins appears to be associated with worse local control, perhaps due to the narrower initial resection.

Incidence and patterns of regional metastasis in early oral squamous cell cancers: feasibility of submandibular gland preservation.

BACKGROUND: We aimed to study the incidence of metastasis to the submandibular gland (SMG) and to establish the oncologic basis of SMG preservation in early-stage cancer of the oral cavity (OSCC). METHODS: This was a retrospective study of 261 patients with OSCC treated primarily with surgery at a tertiary medical center. One hundred thirty-two early-stage (T1-2, N0) OSCCs were further analyzed. RESULTS: The mean age was 59 years with male-to-female sex ratio of 1.4:1. Two hundred sixty-one neck dissections were performed with SMG removal in 253 patients. One patient with an advanced floor of mouth cancer had obvious infiltration of the SMG. Only 2.5% (3 of 116) patients with early-stage OSCC had level I metastasis; none had SMG metastases. CONCLUSION: SMG preservation in early cancers (T1-2, N0) of the oral cavity should be feasible unless there is evidence of direct invasion of the gland or close proximity of the cancer to it.

Reconstruction of the marginal mandibulectomy defect: an update.

OBJECTIVE: The purpose of this study is to provide an update to the reconstructive management of the marginal mandibulectomy defect. STUDY DESIGN: Twenty-six consecutive patients were retrospectively reviewed. METHODS: Patient and tumor variables were extracted from the medical record. Outcomes that were examined included method of reconstruction, frequency of osteoradionecrosis, and resumption of an oral diet. RESULTS: Fifteen (57.7%), 8 (30.8%), and 3 (11.5%) patients were reconstructed with a skin graft, primary closure, or a radial forearm free flap, respectively. Indications for a radial forearm free flap were reconstruction of an associated subtotal glossectomy defect, a through-and-through cheek defect, and a maxillectomy defect. Five patients reconstructed with a skin graft also received postoperative radiation therapy. One (20%) developed osteoradionecrosis. Excluding patients with recurrent tumors (n = 5) or osteoradionecrosis (n = 1), all patients at last follow-up were maintaining an oral diet. CONCLUSIONS: Skin graft remains a preferred method of reconstruction for the marginal mandibular defect. A free flap is reserved for those marginal defects where additional soft tissue is needed to reconstruct subtotal glossectomy defects or defects of the midface and/or maxilla. Because of the potentially increased risk of osteoradionecrosis, reconstruction with a free flap instead of a skin graft should be considered if a patient will receive postoperative radiation therapy.

Prognosis as a determinant of free flap utilization for reconstruction of the lateral mandibular defect.

BACKGROUND: The purpose of this study was to determine whether patients with a poor prognosis for survival were more likely to undergo reconstruction with a pectoralis flap versus a free flap and whether the use of a pectoralis flap offered any perioperative advantage, such as a reduction in medical complications. METHODS: Fifty-five consecutive patients who underwent immediate reconstruction after a lateral mandibulectomy were retrospectively reviewed. RESULTS: Age >or=70 years (p = .03), moderate or severe comorbidity (p = .02), and involvement of the base of tongue by tumor (p = .04) were significantly associated with decreased utilization of a free flap (n = 36). Comorbidity was the main determinant of medical complications (p = .001) and length of hospital stay (p = .03). CONCLUSIONS: Expectations of prognosis bias the surgeon's decision regarding flap selection. Reconstruction with a pectoralis flap does not necessarily contribute toward the desired outcome of reduced medical complications. Any functional comparison between reconstructive groups needs to account for those differences in health status and prognosis that might explain any observed postoperative differences.

Metastatic adenocarcinoma of the colon presenting as a mass in the mandible.

BACKGROUND: Metastatic adenocarcinoma of the colon is a frequently encountered medical situation. Metastasis to the mandible from adenocarcinoma of the colon is very unusual and rarely reported. We report the case of a 73-year-old man with metastatic adenocarcinoma to the mandible. METHODS: The patient was referred for evaluation of a mass of 2 months' duration in the right parotid gland. He gave a history of watery bowel movements of unknown duration. Physical examination revealed a 7- x 6-cm hard mass, which seemed to be fixed to the right mandible. A CT scan revealed a destructive process involving the ramus and condyle of the right mandible that invaded the pterygopalatine fossa, pterygoid muscles, and middle cranial fossa. CT scans of the abdomen and pelvis revealed a 5-cm mass in the sigmoid colon with metastases to the liver. RESULTS: A biopsy of the mass in the mandible was performed, and metastatic adenocarcinoma of colonic origin was diagnosed. Colonoscopy and biopsy of the colonic mass substantiated that the sigmoid colon was the primary site of the cancer. Because the patient had disseminated disease, he declined treatment, and he died shortly thereafter. CONCLUSIONS: Although rare, metastatic adenocarcinoma from the colon to the mandible and parotid area should be included in the differential diagnosis of masses in this area. After analysis of our case and a review of the literature, we conclude that metastasis from adenocarcinoma of the colon is quite rare and represents incurable disseminated disease.

Effect of mandibular titanium reconstructive plates on radiation dose.

BACKGROUND: The effects of the mandibular titanium alloy plates on the radiation-tissue interactions are not clearly defined. Photon beam radiation may be modified after striking a metal plate used to reconstruct the mandible after oncologic surgery. The purpose of this study was to determine, in a human mandible model, the effects of a titanium alloy plate on the radiation dose received at the bone/titanium (plate and screws) interface and bone/soft tissue interface. METHODS: We used an adult male human head and neck ex vivo model. A medical grade titanium alloy 6-hole plate, 2.4 mm, was fixed in the midline of the mandible. The mandible was then irradiated using 6 MV photon beams. Thermoluminescent dosimeters were used to measure the radiation doses anterior and posterior to the mandible. The experiment was then repeated without the plate and screws. RESULTS: The difference between the average doses received by the mandible reconstructed with plate/screws and a mandible without plate/screws was +2.1% at the buccal aspect of the mandible and +3.0% at the lingual aspect; respective P values were.741 and .323. Thus, these differences were not statistically significant. CONCLUSION: In this study, we did not observe any significant influence of titanium alloy plate/screws on the radiation doses received by tissues anterior or posterior to the mandible.