Do predetermined surgical margins compromise oncological safety in computer-assisted head and neck reconstruction?

OBJECTIVES: Computer assisted head and neck reconstruction has gained popularity over the past few years. In computer assisted surgery (CAS), surgical margins are predetermined in virtual surgery and resection guides are designed to be fitted intra-operatively. However, concerns have been raised regarding the oncological safety of predetermined surgical margins. Therefore, the aim of this study was to compare surgical margins, recurrence and survival outcomes in patients underwent CAS and non-CAS in head and neck reconstruction. METHODS: We retrospectively reviewed the patients underwent oral and maxillofacial malignancies surgical excision and free flap reconstruction from October 2014 to December 2019 by the same chief surgeon. Patients were divided into two groups depending on whether CAS and predetermined surgical margins were adopted. The primary outcome was surgical resection margin and the secondary outcomes included recurrence and survival. RESULTS: A total of 66 subjects were recruited with 37 in the CAS group and 29 in the non-CAS group. The follow-up rate was 100%. The average follow-up time was 24.5 months. No significant difference in resection margin was identified between the groups (p = 0.387). Tumor staging, margin status, perineural invasion, lymphovascular invasion and extranodal extension were identified as significant factors influencing survival. Both before and after adjustment for these prognostic factors identified, CAS and non-CAS group showed no significant difference in survival outcome. CONCLUSION: Predetermined surgical margins do not compromise oncological safety in terms of resection margin, disease recurrence and patient survival.

Elective neck dissection (END) and cN0 hard palate and upper gingival cancers: A National Cancer Database analysis of factors predictive of END and impact on survival.

BACKGROUND AND OBJECTIVES: The reported risk of nodal metastasis in hard palate and upper gingival squamous cell carcinoma (SCC) has been inconsistent with inadequate consensus regarding the utility of neck dissection in the clinically negative (cN0) neck. MATERIALS AND METHODS: Using the National Cancer Database, cN0 patients diagnosed with SCC of the head and neck with the subsites of the hard palate and upper gingiva were identified from 2004 to 2014. RESULTS: A total of 1830 patients were identified, and END was performed on 422 patients with cN0 tumors. Pathologically positive nodes occurred in 14% (59/422) of patients in this cohort. Higher tumor stage, academic hospital type, and large hospital volume (>28 cancer-specific cases/year) were associated with a higher likelihood of END both in univariate and multivariate analyses (P < .05). Patients >80 years of age were less likely to receive END on multivariate analysis (OR 0.52, 0.32-0.84). No variables, including advanced T stage, predicted occult metastases. Cox proportional hazards regression analysis showed that patients who underwent END demonstrated improved OS over an 11-year period (hazard ratio 0.75, P = .002). On subgroup analysis, this improvement was significant in patients with both stage T1 and T4 tumors. CONCLUSIONS: Tumor stage, hospital type, and hospital volume were associated with higher rates of END for patients with cN0 hard palate SCC and after controlling for clinical factors, END was associated with improved overall survival.

Ameloblastic carcinoma: Clinicopathological analysis of 18 cases and a systematic review.

OBJECTIVES: Exploring the clinicopathological features of ameloblastic carcinoma (AC) and reviewing the literature to improve the diagnosis and treatment of the disease. MATERIALS AND METHODS: Clinical data and pathological features of 18 cases of AC were retrospectively analyzed. A systematic review was carried out by searching PubMed and Medline databases using the MeSH terms "ameloblastic" and "carcinoma." RESULTS: In the systematic analysis, 125 cases of AC from 81 eligible original studies and 18 cases of AC from this research were included. The male-to-female ratio was 2.58:1, and the mandible-to-maxilla ratio was 1.80:1. Mean age of patients was 45.3 years. Thirty-seven cases of recurrence and 27 cases of metastasis were recorded. CONCLUSION: AC is a rare neoplasm of the odontogenic epithelium. A systematic review indicates that diagnoses at the early phase and a close periodic assessment for recurrence and metastasis are necessary.

Lack of efficacy of neoadjuvant chemotherapy in adult patients with maxillo-facial high-grade osteosarcomas: A French experience in two reference centers.

INTRODUCTION: Neoadjuvant chemotherapy (neo-CT) for osteosarcomas is the standard of care. Management of maxillo-facial osteosarcomas (MFOS) is challenging. In this rare disease, we collected a large cohort of patients with the aim to report the histological and radiological local response rates to neo-CT. PATIENTS AND METHODS: All consecutive adult patients treated between 2001 and 2016 in two French sarcoma referral centers (Pitié-Salpêtrière Hospital, APHP, RESAP France and Gustave Roussy Institute France), for a histologically proved MFOS were included. Clinical, histological and radiological data were independently reviewed. Tumor response to neo-CT was assessed clinically, radiologically with independent review using RECIST v1.1 criterion and pathologically (percentage of necrosis). Multivariate analysis was done for outcomes, tumor response and disease-free survival (DFS). RESULTS: A total of 35 high grade MFOS were collected. The clinical tumor response was 4% (1/24 receiving neo-CT), the radiological response was 0% (0/18 with available data) and the pathological response was 5% (1/20 with available data). Three patients (12.5%) initially resectable became unresectable due to clinical and radiological progression during neo-CT. Tumor size and R0 (clear margins) surgical resections were significantly associated with DFS. CONCLUSION: MFOS is a rare disease. This large retrospective cohort of MFOS indicates the lack of benefit and potentially deleterious effects of neo-CT. We suggest privileging primary surgery in initially localized resectable MFOS. The benefit of adjuvant chemotherapy should be prospectively studied.

Predicting individualized mortality probabilities for patients with squamous cell carcinoma of the maxilla: Novel models with clinical and histopathological predictors.

BACKGROUND: The aim of this article was to develop prediction models that calculate postoperative 2- and 5-year mortality probabilities of patients with squamous cell carcinoma of the maxilla (MSCC). METHODS: Data were collected from the medical records of patients who had been operated between 2000 and 2015 for MSCC. Potential clinical and histopathological predictors were identified. Confounding-(un)adjusted multivariate Cox and logistic regression models were computed with stepwise backward selection. Internal validation was performed to assess calibration and discriminatory ability. RESULTS: Ninety-five patients with MSCC were included. Two-year follow-up was complete, and 85 patients had 5-year follow-up. Age, neck treatment, surgical margins, bone invasion, spindle growth, and vasoinvasive growth were associated with mortality. Models were adjusted for confounding with Charlson's comorbidities index. C-indexes were .841 and .770 respectively, and .838 and .749 after bootstrapping. CONCLUSION: The MSCC-specific mortality probability can be calculated with new prediction models.

Quality of life and problems associated with obturators of patients with maxillectomies.

BACKGROUND: Maxillary defects predispose patients to different undesirable effects. The aim of this study was to assess the quality of life (QoL) of patients with maxillary defects (acquired/congenital) wearing obturators. METHODS: The study comprised 30 patients aged between 16 and 78 years. Interviews were conducted to collect information pertaining to patients; sociodemographic, self-reported function of obturator using Obturator Functioning Scale (OFS), self-evaluation of general health using Visual Analogue Scale (VAS), radiotherapy treatment, salivary gland removal, reconstructive surgery, neck dissection and length of time obturators were worn. Clinical examination included type of maxillectomy, Aramany classification of the defect, and evaluation of obturator function using the Kapur retention and stability scoring system. RESULT: Quality of life was affected significantly by marital status (P = 0.026). Married patients had better quality of life 61.3%, followed by divorced patients 38.8%, widowed 37.3% and the least QoL was detected in single patients 36.5%. Significant association between the type of maxillectomy and QoL was detected (P = 0.002). Retention of obturator prosthesis had a highly significant association with QoL (P < 0.001). Type of maxillectomy had a significant relation with obturator retention (P = 0.005). Stability had a significant correlation with QoL (P = 0.022). Obturator wearers who were treated with radiotherapy had lower QoL than those who were not treated with radiotherapy. CONCLUSION: Rehabilitation of patients with maxillary defects using obturator prosthesis is an appropriate and not invasive treatment modality. Results support that good obturators contribute to a better life quality.

Prognostic value of computed tomography characteristics for overall survival in patients with maxillary cancer.

BACKGROUND: Our aim was to identify the preoperative computed tomographic (CT) characteristics most efficient in predicting overall survival (OS) of patients with maxillary cancer (MC). METHODS: A retrospective review of CT images was performed in 115 patients with histopathologically confirmed primary MC from January 2005 to December 2013, who were classified into 2 subtypes (epithelial and non-epithelial) according to tissue of origin. The prognostic value of CT characteristics for OS was determined firstly through univariate Kaplan-Meier survival estimates with log-rank tests. Significant predictors were further tested with multivariable Cox proportional hazard models. RESULTS: CT characteristics predictive of OS in univariate survival analysis were long and short diameter of the mass, long and short diameter of the largest cervical lymph node and adjacent soft tissue infiltration (P < 0.05). In the multivariable Cox analyses, the significantly independent predictors were long diameter of mass ≥ 4.2 cm (hazard ratio [HR] 1.8; 95 % confidence interval [CI] 1.1-3.0) and short diameter of the largest lymph node ≥ 7 mm (HR 1.9; 95 % CI 1.0-3.6) for all MC patients, as well as for non-epithelial MC patients (HR 3.1; 95 % CI 1.2-8.0; HR 3.3; 95 % CI 1.3-8.7, respectively). CONCLUSIONS: Preoperative CT characteristics of tumor size, lymph node size and adjacent structure infiltration are predictive of the OS time of MC patients. The information brought up in this study could be used in clinical practice to inform about the possible prognosis, and be beneficial to clinical decision making.

Management of the clinically N0 neck in squamous cell carcinoma of the maxillary alveolus and hard palate.

BACKGROUND: The purpose of this study was to evaluate active surveillance strategy in the clinically negative neck in maxillary squamous cell carcinoma (SCC). METHODS: One hundred fourteen consecutive patients diagnosed with oral maxillary SCC were analyzed retrospectively from 3 centers in The Netherlands. Analysis parameters included regional disease-free survival of N0 patients stratified for T classification, elective radiotherapy (RT) of the neck; and overall survival of the whole cohort, stratified by N classification; salvage neck surgery rates. RESULTS: Within the N0 cohort, 26.0% of the patients developed neck metastasis in the follow-up visits. Regional recurrence was not related to T classification or postoperative RT of the neck. Regional and locoregional recurrence were associated with diminished overall survival (p < .05). Regional metastasis was operable in 22 of 26 cases (85%). Only 1 patient presented with inoperable neck metastasis without local recurrence. CONCLUSION: Watchful waiting was feasible in this cohort. If meticulous follow-up is not available, elective neck dissection is recommended. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1794-1798, 2016.

Clinicopathological Study of Primary Intraosseous Squamous Cell Carcinoma of the Jaw and a Review of the Literature.

PURPOSE: Primary intraosseous squamous cell carcinoma (PIOSCC) is a rare malignant odontogenic tumor that originates from odontogenic epithelial remnants. It is often difficult to diagnose PIOSCC definitively; hence, extraction or surgical treatment is performed before the initial diagnosis in most cases. The present study examined new insights into and prognostic factors of patients with PIOSCC admitted to the authors' department. MATERIALS AND METHODS: An extensive record review was conducted of patients who underwent radical surgery for PIOSCC from January 2001 through December 2014. RESULTS: Of all cases of OSCC, the frequency of PIOSCC was 1.45%. The 2-year relapse-free survival (RFS) and overall survival (OS) rates were 50.0 and 41.6% in all cases, respectively. Three patients underwent surgery or tooth extraction before the initial diagnosis; in fact, intervention before initial diagnosis was found to be an important poor prognostic factor for RFS and OS. In contrast, patients who were not treated before the initial diagnosis was made did not exhibit any locoregional recurrence. CONCLUSIONS: The treatment of PIOSCC should be similar to that for oral cancer with at least clinical stage T3N0 in the National Comprehensive Cancer Network clinical practice guidelines. In addition, cases of PIOSCC that are not treated before the initial diagnosis are more likely to obtain a good prognosis.

Local therapy in non-metastatic primary Ewing sarcoma of the mandible and maxilla in children.

Ewing sarcoma (ES) of the jaw bones comprises a small fraction of ES at all sites. Due to their rarity, a specific policy for local treatment is lacking. The aim of this study was to evaluate the local therapy for ES and recommend measures to individualize treatment options. Patients with primary non-metastatic ES of the jaw bones treated between August 2005 and February 2015 were analyzed. All patients received primary induction chemotherapy, following which lesions amenable to resection based on specific radiological criteria were resected; those with unresectable lesions were offered definitive radiotherapy. The maxilla was the primary site in 13 patients and the mandible in eight. The median age of patients was 11.6 years (range 5-17 years). Overall, surgery was performed in 17 patients and definitive radiotherapy was used in four patients. Postoperative radiotherapy was administered to 12 patients and was avoided in five patients with 100% tumour necrosis. The 3-year overall survival, event-free survival, and local control were 68.1%, 63.6%, and 80.2%, respectively. Mandible primary and a histological response to chemotherapy were significant prognostic factors. The stratification of patients based on radiological criteria aids in selecting local therapy. In eligible patients, surgery with contemporary reconstruction results in optimal oncological and functional outcomes. Surgery also has the added advantage of identifying patients who may not need radiotherapy.

Pediatric maxillary and mandibular tumors.

Pediatric maxillary and mandibular tumors offer considerable challenges to otolaryngologists, oral surgeons, pathologists, and radiologists alike. Because of the close proximity to vital structures, appropriate steps toward a definitive diagnosis and treatment plan are of paramount importance. This article reviews the most common causes of pediatric jaw masses and discusses diagnostic and therapeutic considerations and recommendations.

Primary non-metastatic Ewing sarcoma of the jaw in children: results of surgical resection and primary reconstruction.

BACKGROUND AND OBJECTIVE: The rarity of Ewing sarcoma (ES) of the jaw coupled with the technical challenge of resection and associated functional and cosmetic impairment has resulted in deficient data on surgical management of these tumors. The purpose of this study is to describe the results of surgical excision and reconstruction of primary non-metastatic ES of the mandible and maxilla in children. METHODS: Consecutive patients (mandible = 6, maxilla = 5) treated with surgery from August 2005 to January 2013 were selected. All patients received induction chemotherapy and were selected for surgical resection based on the presence of specific criteria for operability. RESULTS: The median age was 11.5 years (range 5-16 years). Free fibular osteocutaneous flap was commonly used for reconstruction. There were no complications related to microvascular anastomosis or flap loss. Five patients had 100% tumor necrosis and did not receive radiotherapy. Teeth alignment, chewing, swallowing, and speech were normal in all and donor site morbidity occurred in one. The 5-year overall, event-free survival, and local control are 87.5%, 72.9%, and 90%, respectively. CONCLUSION: In eligible patients, surgery with contemporary reconstruction results in optimal oncological and functional outcome. Surgery also has the added advantage of identifying patients who may not need radiotherapy.

Cervical metastases from squamous cell carcinoma of hard palate and maxillary alveolus: a retrospective study of 10 years.

BACKGROUND: The purpose of this study was to investigate the incidence of cervical metastasis in squamous cell carcinoma (SCC) of hard palate and maxillary alveolus and to define its impact factors. METHODS: We conducted a retrospective study of patients surgically treated for SCC of hard palate and maxillary alveolus from 2002 to 2011. In situ hybridization was performed to detect high-risk human papillomavirus (HPV) infection. RESULTS: The incidences of cervical metastasis and occult metastasis were 17.2% (11/64) and 9.8% (5/51), respectively. The pT classification and vascular invasion were correlated with cervical metastasis. Occult metastatic risk was significantly higher among patients with pT4. Presence of positive nodes impaired prognosis significantly. CONCLUSION: SCC of hard palate and maxillary alveolus has nonnegligible incidences of both overall and occult metastasis, which were highly associated with pT classification. We recommend routine, synchronous elective neck dissection for T4 lesions, whereas observation is an alternative for T1 to T3 lesions.

Usefulness of the anterolateral thigh flap with vascularized fascia lata for reconstruction of orbital floor and nasal surface after total maxillectomy.

OBJECTIVES/HYPOTHESIS: The aim of this study was to describe a technique using the fascia lata (FL) component of the anterolateral thigh (ALT) flap to re-create the orbital floor and lateral nasal wall after total maxillectomy. STUDY DESIGN: Retrospective analysis of medical records. METHODS: A total of 22 patients underwent maxillary reconstruction using a composite ALT-FL flap following cancer resection. All patients underwent total maxillectomies via the Weber-Ferguson approach. The ALT flap was harvested with the deep fascia of the thigh with the aim of using it for lining of the orbital floor and lateral nasal cavity. The FL was sutured to the palatine bone inferiorly, nasal bone and zygomatic bone superiorly, and nasopharyngeal mucosa posteriorly to provide an orbital floor and make a neonasal cavity. RESULTS: There was 100% free flap survival. Speech was normal in eight (36%) patients, near normal in 10 (46%), and intelligible in four (18%). Seventeen (77%) patients gained a good facial appearance, and five (23%) a fair appearance. Sixteen (73%) patients complained of mild nasal crust formation, and the rest (27%) developed moderate crust. CONCLUSIONS: Microvascular reconstruction using a composite ALT-FL flap provided a reliable fascial component for orbital floor and nasal surface reconstruction of total maxillectomy defects.

Survival in patients with oral and maxillofacial diffuse large B-cell lymphoma

The purpose of this study was to determine the survival and prognostic factors of patients with diffuse large B-cell lymphoma (DLBCL) of the oral cavity and maxillofacial region. Retrospectively, the clinical records of patients with a primary diagnosis of DLBCL of the oral cavity and maxillofacial region treated at the A.C. Camargo Hospital for Cancer, São Paulo, Brazil, between January 1980 and December 2005 were evaluated to determine (A) overall survival (OS) at 2 and 5 years and the individual survival percentage for each possible prognostic factor by means of the actuarial technique (also known as mortality tables), and the Kaplan Meier product limit method (which provided the survival value curves for each possible prognostic factor); (B) prognostic factors subject to univariate evaluation with the log-rank test (also known as Mantel-Cox), and multivariate analysis with Cox's regression model (all the variables together). The data were considered significant at p ≤ 0.05. From 1980 to 2005, 3513 new cases of lymphomas were treated, of which 151 (4.3%) occurred in the oral cavity and maxillofacial region. Of these 151 lesions, 48 were diffuse large B-cell lymphoma, with 64% for OS at 2 years and 45% for OS at 5 years. Of the variables studied as possible prognostic factors, multivariate analysis found the following variables have statistically significant values: age (p = 0.042), clinical stage (p = 0.007) and performance status (p = 0.031). These data suggest that patients have a higher risk of mortality if they are older, at a later clinical stage, and have a higher performance status.

Survival in patients with oral and maxillofacial diffuse large B-cell lymphoma.

The purpose of this study was to determine the survival and prognostic factors of patients with diffuse large B-cell lymphoma (DLBCL) of the oral cavity and maxillofacial region. Retrospectively, the clinical records of patients with a primary diagnosis of DLBCL of the oral cavity and maxillofacial region treated at the A.C. Camargo Hospital for Cancer, São Paulo, Brazil, between January 1980 and December 2005 were evaluated to determine (A) overall survival (OS) at 2 and 5 years and the individual survival percentage for each possible prognostic factor by means of the actuarial technique (also known as mortality tables), and the Kaplan Meier product limit method (which provided the survival value curves for each possible prognostic factor); (B) prognostic factors subject to univariate evaluation with the log-rank test (also known as Mantel-Cox), and multivariate analysis with Cox's regression model (all the variables together). The data were considered significant at p≤0.05. From 1980 to 2005, 3513 new cases of lymphomas were treated, of which 151 (4.3%) occurred in the oral cavity and maxillofacial region. Of these 151 lesions, 48 were diffuse large B-cell lymphoma, with 64% for OS at 2 years and 45% for OS at 5 years. Of the variables studied as possible prognostic factors, multivariate analysis found the following variables have statistically significant values: age (p=0.042), clinical stage (p=0.007) and performance status (p=0.031). These data suggest that patients have a higher risk of mortality if they are older, at a later clinical stage, and have a higher performance status.

Malignant lymphoma of the oral cavity and the maxillofacial region: overall survival prognostic factors.

OBJECTIVE: To identify the overall survival and prognostic factors of malignant lymphoma of the oral cavity and the maxillofacial region. STUDY DESIGN: Clinical records data were obtained in order to determine overall survival at 2 and 5 years, the individual survival percentage of each possible prognostic factor with the actuarial technique, and the survival regarding the possible prognostic factors with the actuarial technique and the Log-rank and Cox's regression tests. RESULTS: Of 151 subjects, an overall survival was 60% at 2 years, and 45% at 5 years. The multivariate analysis demonstrated statistically significant differences for clinical stage (p=0.002), extranodal involvement (p=0.030), presence of human immunodeficiency virus (p=0.032), and presence of Epstein-Barr virus (p=0.010). CONCLUSION: The advanced clinical stage and the larger number of involved extranodular sites are related to a lower overall survival, as well as, the presence of previous infections such as the human immunodeficiency and the Epstein-Barr virus.

Outcome predictors in squamous cell carcinoma of the maxillary alveolus and hard palate.

OBJECTIVES/HYPOTHESIS: Hard palate and maxillary alveolus are two commonly grouped oral cavity subsites due to their anatomic contiguity and oncologic disease behavior. Few studies have been conducted investigating clinical presentation, staging, prevalence of cervical metastases, and outcomes in this population. The primary objective of this study was to analyze predictors of disease-free survival (DFS) in surgically treated patients, particularly as it relates to the role of neck dissection. STUDY DESIGN: Cohort study with planned data collection. METHODS: This cohort study used planned data collection over 15 years (1994-2008) at a large tertiary care cancer center to study all patients presenting with squamous cell carcinoma of the maxillary alveolus and hard palate treated surgically. Univariate and multivariate Cox regression analyses were used to identify predictors of DFS. RESULTS: Ninety-seven patients met the inclusion criteria (54 male, 56%). The majority of patients (54, 56%) presented with locally advanced disease (cT3, cT4). Occult nodal metastases were noted in 26% (17 of 65) of patients clinically staged as N0. The 3-year DFS was 70% (95% confidence interval = 59%-78%) with a median time to failure of 1.1 years (range = 0.3-9.7 years). Cox regression multivariate model demonstrated that advanced pathologic T stage, hard palate tumor site, and poorly differentiated tumor grade were each independent predictors of DFS. CONCLUSIONS: A significant portion of the patients with hard palate and maxillary alveolus tumors harbor occult cervical metastases. Elective neck dissection in the high-risk patients may potentially be beneficial in providing more accurate staging and improving DFS. LEVEL OF EVIDENCE: 2b.

Orbitomaxillary reconstruction using the layered fibula osteocutaneous flap.

OBJECTIVE: To describe a surgical technique for total palatomaxillary and orbital reconstruction using a fibula osteocutaneous free flap in a layered fashion. METHODS: Case series from a tertiary care facial plastic and reconstructive surgical practice including patients with postextirpative Brown 3a and 3b orbitopalatomaxillary defects undergoing immediate microvascular reconstruction. Application of the layered fibula free flap to composite maxillary defects permits single-stage, optimal reconstruction of contiguous orbitomaxillary defects, reconstitution of midface 3-dimensional contour, and restoration of the anterior alveolar arch with robust bone, thereby providing for potential sequential dental rehabilitation with osseointegrated implants. RESULTS: This technique demonstrates excellent long-term symmetry, support, function, and aesthetic contour. Although patients may need minor, adjunctive procedures, this technique is flexible in design and offers reliable outcomes with a minimum of morbidity. CONCLUSION: The fibula osteocutaneous free flap, because of its design flexibility and ability to provide structural support, is an excellent reconstructive option for total maxillary defects, including those that involve the orbit.

Outcomes of patients with maxillofacial osteosarcoma: a review of 15 cases.

PURPOSE: To assess clinical behavior, response to treatment, and factors affecting survival in maxillofacial osteosarcoma treated at a tertiary referral center. PATIENTS AND METHODS: Ethics-approved retrospective review of clinical and pathological records was undertaken for 15 patients managed by the Royal Melbourne Hospital Head and Neck Oncology Tumor Stream. RESULTS: Treatment was a combination of surgery and chemotherapy. Chemotherapy was given as adjuvant, neoadjuvant, or in combination. The overall 2-, 5-, and 15-year disease-free survival rates in this study were 92%, 74%, and 74%, respectively. Using Kaplan-Meier analysis with log rank tests, increasing T stage (P = .01) and positive margins (P = .003) were found to affect survival significantly. Neoadjuvant chemotherapy was not significantly associated with tumor necrosis or improved survival. CONCLUSIONS: Tumor size and adequacy of local control were found to be the most important predictors of outcome.