Extracapsular spread in oral squamous cell carcinoma.

BACKGROUND: Extracapsular spread (ECS) in the cervical lymph nodes represents the most significant adverse prognostic indicator in oral squamous cell carcinoma (OSCC). METHODS: In a consecutive cohort of OSCC treated by primary surgery, ECS was seen in 25% (101) of 400 patients. RESULTS: ECS doubled the incidence of local recurrence and distant metastases, but tripled regional failure. The recurrences occurred sooner in ECS than in non-ECS cases (206 vs 334 days, p = .04). Patients with macroscopic ECS had a 5-year overall survival (OS) of 19% compared with 31% in microscopic ECS. MRI neck staging offered poor sensitivity, especially in microscopic ECS. Age >75 years, smoking, and heavy use of alcohol were independent predictors of ECS, which may implicate a failure of immunosurveillance by the host as much as adverse biology of the tumor. CONCLUSIONS: Reporting of ECS is essential in accurate prognostication, and we advocate that all patients with OSCC and ECS should be grouped as pN3 on the basis of their prognosis. (c) 2009 Wiley Periodicals, Inc. Head Neck, 2010.

Passive versus active drainage following neck dissection: a non-randomised prospective study.

Drainage is used following neck dissection to prevent the collection of fluid and aid healing. Active drains are thought to be more effective due to their ability to assist adherence of skin flaps and the minimisation of bacterial migration. There is controversy regarding the type of drain (active or passive) which should be used due to concerns about the potential for compromise of free flap pedicles with active drains. A prospective non-randomised study was undertaken to determine if there were any differences in neck healing following neck dissection between active and passive drains. A consecutive series of patients (the majority of whom had free flap reconstruction) were included over an 8 month period and were examined for delayed healing of the neck wound, flap loss, infection, haematoma and fistula. A total of 60 patients underwent 72 neck dissections during the study period (passive: 13, active: 47). The delayed healing rate in patients with passive drains was 54% compared with 6% for active drains (P < 0.001). This difference remained significant irrespective of surgeon grade, nodal status and whether or not a free flap was performed. There was no patient in whom the drain was thought to contribute to free flap loss. This non-randomised study has shown a significant difference in neck healing depending on the type of drain used following neck dissection. Despite the numerical differences between the groups the patients were relatively well matched for the parameters described. This difference in neck healing, combined with the lack of evidence for a contribution to flap loss, suggests active drains should be used following neck dissection in both free flap and non-free flap cases.

APACHE II scoring for the prediction of immediate surgical complications in head and neck cancer patients.

BACKGROUND: Aggressive surgical treatment of oral and oropharyngeal cancers may be compromised by significant surgical complications. Early identification of patients at risk for postoperative complications may assist in clinical decision-making. The objective of this study was to assess the value of the Acute Physiology and Chronic Health Evaluation (APACHE II) score in predicting early postoperative surgical complications. METHODS: There were 510 cases of free tissue transfer surgery identified on the Liverpool Oncology Head and Neck Database for 1995 to 2002. APACHE II data were collected independently from critical care records and by case note retrieval. The authors' main a priori outcomes were total flap failure and any immediate complication requiring further surgery (including any from hemorrhage, hematoma, partial flap failure, airways, and anastomosis exploration). RESULTS: Overall total flap loss and immediate complication rates were 6.2 percent (30 of 485) and 13.6 percent (66 of 485), respectively. APACHE II data were known for 399 operations (82 percent) and, of these, 90 percent (360 of 399) were managed postoperatively in the critical care unit. There were clear correlations between APACHE II scores with total flap loss and with other immediate complications. CONCLUSIONS: The APACHE II score is associated with immediate postoperative surgical complications involving flap compromise and thus may be a useful tool in postoperative decision-making.

Oral rehabilitation after treatment for head and neck malignancy.

BACKGROUND: Advances in the management of oral malignancy have resulted in significant improvements in survival and functional outcome. Ablation of oral tissues and radiotherapy render many patients unable to wear conventional prostheses, and these patients are, thus, candidates for oral rehabilitation with osseointegrated implants. We aim to present outcomes and complications of such treatment over a 14-year period in a single unit. METHODS: Data were collected for 81 consecutive patients, most of whom had received microvascular free flap reconstruction after surgical ablation of oral squamous cell carcinoma. Three hundred eighty-six implants were placed after a delay of 12 months after surgery. Sixty-five percent of implants were placed in the anterior mandible. Radiotherapy was used in 47% of the patients, and hyperbaric oxygen treatment was routinely used in irradiated subjects during the latter half of the series. Retrospective analysis of implants and prostheses was made by use of case notes, radiographs, and a computerized database. RESULTS: Data are presented for 364 of the 386 implants in 77 of the 81 patients after a median follow-up of 4 years. Two hundred sixty-five (73%) of the implants were in function supporting prostheses, 56 (15%) had been lost, and 43 (12%) were present but not loaded (ie, "sleepers"). Implant loss seemed patient specific and was also correlated with host bone type. Thirteen percent of patients in whom implants were placed in the mandible lost at least one implant, and the equivalent values for the maxilla was 40%. Thirty-six percent of patients in whom implants were placed in bone graft or flap lost at least one implant. The effects of implant manufacture, dimensions, radiotherapy, and hyperbaric oxygen did not reach statistical significance in this series. Cases of a second primary malignancy were noteworthy; however, the impact of recurrence was minimized by the delay between resection and rehabilitation. Of the 42 fixed and 29 removable prostheses fitted, 12 (17%) failed. CONCLUSIONS: Implants placed in mandible were reliable, but failure rates in vascularized bone graft and maxilla were higher. Radiotherapy did not seem to prejudice implant survival, and hyperbaric oxygen had no demonstrable benefit in this series. Despite some persistent soft tissue problems and implant loss, most patients reached a successful prosthetic and functional outcome.

The influence of the pattern of mandibular invasion on recurrence and survival in oral squamous cell carcinoma.

BACKGROUND: Controversy exists over the predictive value of the presence and pattern of tumor invasion of the mandible in oral squamous cell carcinoma (SCC). Many authors have questioned increasing the classification of small tumors to T4 on the basis of mandibular invasion alone. There are little data on the influence of the pattern of invasion on prognosis. METHODS: We prospectively reviewed 100 consecutive mandibular resections for previously untreated oral SCC. Clinical and pathologic data collected included details of soft and hard tissue histologic findings. Outcomes included recurrence (local, regional, and distant metastases), disease-specific survival, and death from other causes. The median follow-up for survivors was 65 months. RESULTS: Of 100 cases, 65 involved segmental and 35 involved marginal resections. Sixty-two percent of mandibles were invaded by tumor. Local recurrence occurred in 21% and was strongly correlated with tumor size, nodal involvement, and pattern of soft tissue invasion. The 5-year disease-specific survival was 68%, and the crude survival was 50%. Mandibular invasion predicted for recurrence and disease-specific survival, even after correcting for the effects of other variables. The pattern of mandibular invasion (erosive/infiltrative) was also predicted for recurrence and disease-specific survival. CONCLUSIONS: Even in the presence of mandibular invasion, soft tissue factors are the most important determinants of prognosis. Upstaging tumors on the basis of mandibular invasion is justified. An infiltrative pattern of bone invasion is a marker of aggressive tumor biology and should be included in the pTNM classification.

Comparison of miniplates and reconstruction plates in mandibular reconstruction.

BACKGROUND: The aim of this study is to compare complication rates of miniplates versus reconstruction plates in the fixation of vascularized grafts into segmental mandibular defects. METHODS: Retrospective analysis of 143 consecutive successful microvascular composite flaps performed between 1993 and 2001 was performed. Data were gathered from a computerized database, case notes and pathology reports. Complications were classified as dehiscence, infection, plate or bone removal. RESULTS: In the series, 49% of patients received miniplates, and 51% received plates. No significant differences in complication rates were found between those grafts fixed with miniplates (27%) and those with reconstruction plates (30%). Plate choice was primarily determined by consultant preference. No significant differences were found in patient, defect, treatment, or follow-up characteristics between the plate groups. Twenty-nine percent of patients had at least one late complication at the reconstructed site, and this was higher (39%) in those who had postoperative radiotherapy. CONCLUSIONS: No evidence was found in this study that the increased rigidity offered by reconstruction plates influences the rate of plate or bone removal, infection, or plate exposure. Thus, the decision to use reconstruction or miniplates is not dependent on the rate of plate complications.

The impact of neck dissection on health-related quality of life.

OBJECTIVE: To compare health-related quality of life in patients having no neck dissection and those having a selective dissection, with particular reference to shoulder dysfunction. DESIGN: Prospective study. SETTING: Regional Maxillofacial Unit, University Hospital Aintree, Liverpool, England. PATIENTS: Two hundred seventy-eight consecutive patients undergoing primary surgery for previously untreated oral and oropharyngeal squamous cell carcinoma between January 1, 1995, and December 31, 1999. MAIN OUTCOME MEASURE: The University of Washington Quality of Life questionnaire, administered on the day before surgery and at 6 months, at 12 months, and more than 18 months after surgery. RESULTS: No neck dissection was performed in 58 patients (21%), a unilateral dissection in 181 (65%), and a bilateral dissection in 39 (14%). Patients with no neck dissection and those with unilateral level III or IV dissections had similar mean scores for shoulder dysfunction, whereas patients with unilateral level V and bilateral level III and IV dissections recorded much worse scores on average. CONCLUSIONS: There is little subjective morbidity associated with shoulder dysfunction after a unilateral level III or IV neck dissection compared with patients undergoing primary surgery without a neck dissection. More extensive surgery in the neck, whether bilaterally removing levels I to III or IV or extending posteriorly to include level V, is associated with statistically significantly worse shoulder dysfunction.

A comparison of the long-term morbidity following deep circumflex iliac and fibula free flaps for reconstruction following head and neck cancer.

Composite free tissue transfer has an established role in head and neck oncology for the reconstruction of the bony defect following tumor ablation, and while donor-site morbidity is variably reported, there is little consensus on the most favorable donor site. The fibula and deep circumflex iliac artery have distinct advantages in terms of the volume and length of bone in mandibular reconstruction. Few studies have compared their donor-site morbidity. The aim of this study was to compare the fibula and deep circumflex iliac artery flaps using a review of the case notes and cross-sectional review of patients attending a research clinic for validated orthopedic examination and completion of health-related quality-of-life questionnaires. Between February of 1993 and May of 2001, 44 fibula free flaps and 73 deep circumflex iliac artery free flaps were performed. Ninety-nine case notes and 36 patients were available for review of donor-site morbidity. Sixteen patients with fibula flaps and 20 patients with deep circumflex iliac artery flaps took part in the clinical examination component of the study, which was composed of a clinical examination by an orthopedic surgeon using the American Orthopedic Foot and Ankle Society ankle scoring system and the Harris hip scoring system, and two patient-completed questionnaires, the University of Washington Questionnaire and the Hospital Anxiety and Depression Scale. Subjective and objective markers of morbidity related to both flaps were similar in most parameters. However, fibula flaps were associated with more problems with donor-site healing, reduced power, and sensation. Poor orthopedic scores for both flaps were associated with notably poor scores on the University of Washington Questionnaire and the Hospital Anxiety and Depression Scale. The study would suggest that both deep circumflex iliac artery and fibula donor sites result in an acceptable and comparable morbidity for most patients, but in cases in which significant donor-site morbidity is encountered, health-related quality of life is significantly compromised.

Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap.

PURPOSE: The purpose of this cross sectional study was to evaluate the health-related quality of life of patients following maxillectomy and to compare obturation and free flap reconstruction. PATIENTS AND METHODS: At the Regional Maxillofacial Unit in Liverpool, United Kingdom, between 1992 to 1996, 39 patients underwent maxillectomy for malignant pathology. Of these patients, 28 (10 underwent obturation and 18 underwent free tissue reconstruction) completed a postoperative semi-structured interview. Eight questionnaires were used to test aspects of health-related quality of life and function. RESULTS: The main findings were the associations between the size of maxillectomy defect and the University of Washington activity (-0.53; P =.005) and recreation (-0.70; P <.001) domains, and with the physical functioning (-0.58; P =.001) and quality of life (-0.51; P =.007) domains of the European Organization for Research and Treatment of Cancer questionnaire. No statistically significant differences were seen between the obturator and free flap groups. Borderline trends were for obturator patients to be more concerned about their appearance, to have more pain and soreness in their mouths, to be more aware of their upper teeth, more self-conscious and less satisfied with their upper dentures, and less satisfied with function. CONCLUSION: Similar subjective outcomes were found for both groups, and a larger longitudinal study is needed to test these relationships more rigorously.