[Technique and clinical application of free lobed anteromedial thigh perforator flap].

Objective: To introduce the technique and clinical application of free lobed anteromedial thigh perforator flap. Methods: Between October 2017 and December 2021, 65 patients with buccal and oral cancer penetrating defects were planned to treat with free lobed anterolateral thigh flap transplantation, of which 15 cases were found that the sole anterolateral thigh perforator was actually a branch of the anteromedial thigh perforator, and then the free lobed anteromedial thigh perforator flap was harvested for repair. There were 12 males and 3 females with an average age of 34.6 years (range, 29-55 years). According to Union for International Cancer Control (UICC) TNM staging, there were 7 cases of T 4N 0M 0, 4 cases of T 4N 1M 0, 2 cases of T 3N 1M 0, and 2 cases of T 3N 2M 0. The disease duration was 1-10 months (mean, 6.3 months), and the area of secondary soft tissue defect left after radical resection of buccal and oral cancer was from 5 cm×4 cm to 10 cm×6 cm. The anterolateral thigh skin flap ranged from 5 cm×4 cm to 13 cm×6 cm, and the anteromedial thigh skin flap ranged from 5 cm×3 cm to 10 cm×6 cm. The free trilobed anteromedial thigh flap was prepared according to the actual branches of the main trunk of the anteromedial thigh perforator in 4 cases, and the vastus medialis muscle flap was used to fill the cavity defect of the floor of mouth in 7 cases. Among the 15 patients, the vessel pedicles of the anteromedial thigh perforators were derived from the main femoral artery and vein in 8 cases, from the main descending branch of the lateral femoral circumflex artery in 4 cases, and from the main lateral femoral circumflex artery in 3 cases. Results: Hematoma occurred in 2 cases after operation, which was successfully saved after emergency exploration. No vascular crisis occurred, and partial necrosis of anterolateral femoral skin island occurred in 1 case, which was healed with debridement. The remaining flaps survived successfully, and the wounds and donor site incisions healed by first intention. All the patients were followed up 12-36 months (mean, 14.6 months). The appearance of the flap was satisfactory, and no obvious swelling was found; the mouth opening and language function were satisfactory; only linear scar was left in the donor area, and the thigh function was not significantly affected. Local recurrence occurred in 3 cases, and the defect after tumor resection was repaired with pedicled pectoralis major myocutaneous flap. Four patients with neck lymph node metastasis, including ipsilateral side in 3 patients and contralateral side in the other 1 patient, all underwent neck lymph node dissection again. The 3-year survival rate was 86.7% (13/15). Conclusion: The anteromedial thigh perforator vessels distributed in the anterolateral region of the thigh can be used to prepare the anterolateral thigh split lobed flap to repair the buccal and oral cancer penetrating defects.

Second Primary Metachronous Malignancies Occurring in Oral Cavity of Young Adult-A Case Report.

The incidence of oral cancer in Japan is increasing. Interestingly, the number of young patients with oral cancer is also rising. A 19-year-old man with no history of smoking or drinking alcohol presented with a 20×15-mm elastic, hard, protruding mass with a white surface on the right-hand margin of the tongue. A biopsy resulted in a diagnosis of a well-differentiated squamous cell carcinoma of the tongue, for which a partial resection was subsequently performed. During regular follow-up, the patient demonstrated no clinical or imaging abnormalities until 4 years and 9 months later, when erosion was observed at the right palatoglossal arch. A malignant tumor of the right palatoglossal arch was diagnosed based on cytology and imaging findings, and total resection of the lesion performed. Histopathological examination of the resected lesion revealed a moderately differentiated squamous cell carcinoma. Epithelial dysplasia on the right-hand margin of the tongue was diagnosed 4 years and 9 months after the second surgery and was subsequently resected. The patient's condition has been favorable for 7 years since the diagnosis of the second cancer, with no noted recurrence. This case emphasizes the importance of follow-up after initial treatment, as even young people, who are likely to have to endure long-lasting consequences from treatment, can develop metachronous cancer in the oral cavity.

Surgical anatomy of the lingual lymph nodes: systematic literature analysis and proposition for topographic classification.

PURPOSE: Metastatic involvement of the lingual lymph nodes (LLNs) in oral cavity squamous cell cancer (SCC) has recently been proven to significantly reduce locoregional control and survival. Despite recent refinements in the detection of these lesions, the understanding of the LLN topographic anatomy among clinicians is limited. A proposition of a topographic division on LLN based on a comprehensive literature search and synthesis may be helpful in this condition. METHODS: A literature search and election based on contemporary PRISMA guidelines was performed for sources on LLN anatomy with special attention on their subdivision. RESULTS: Four topographic LLN subgroups were defined: median-between genioglossal and geniohyoid muscles; intermediate parahyoid-medial to the hyoglossal muscle, at the greater cornu of the hyoid bone; lateral sublingual (paraglandular) LLNs-at the sublingual salivary gland; lateral submandibular (paraglandular) LLNs -lateral to the hyoglossal muscle, at the deep surface of the submandibular salivary gland. CONCLUSION: The development and implementation of a unified anatomical topographic classification of LLN subgroups may be among the important conditions for improving the detection and treatment of LLN lesions.

[Combination mode and optimization strategy of harvest procedure of anterolateral thigh chimeric perforator myocutaneous flap].

Objective: To summarize the combination methods and optimization strategies of the harvest procedure of anterolateral thigh chimeric perforator myocutaneous flap. Methods: A clinical data of 359 cases of oral cancer admitted between June 2015 and December 2021 was retrospectively analyzed. There were 338 males and 21 females with an average age of 35.7 years (range, 28-59 years). There were 161 cases of tongue cancer, 132 cases of gingival cancer, and 66 cases of buccal and oral cancer. According to the Union International Center of Cancer (UICC) TNM staging, there were 137 cases of T 4N 0M 0, 166 cases of T 4N 1M 0, 43 cases of T 3N 1M 0, 13 cases of T 3N 2M 0. The disease duration was 1-12 months (mean, 6.3 months). The soft tissue defects in size of 5.0 cm×4.0 cm to 10.0 cm×7.5 cm remained after radical resection were repaired with the free anterolateral thigh chimeric perforator myocutaneous flaps. The process of harvesting the myocutaneous flap was mainly divided into 4 steps. Step 1: exposing and separating the perforator vessels, which mainly came from the oblique branch and the lateral branch of the descending branch. Step 2: isolating the main trunk of the perforator vessel pedicle and determining the origin of the vascular pedicle of muscle flap, which was came from oblique branch, lateral branch of the descending branch, or medial branch of the descending branch. Step 3: determining the source of muscle flap, including lateral thigh muscle and rectus femoris muscle. Step 4: determining the harvest form of muscle flap, which included muscle branch type, main trunk distal type, and main trunk lateral type. Results: The 359 free anterolateral thigh chimeric perforator myocutaneous flaps were harvested. In all cases, the anterolateral femoral perforator vessels existed. The perforator vascular pedicle of the flap came from the oblique branch in 127 cases and the lateral branch of the descending branch in 232 cases. The vascular pedicle of muscle flap originated from the oblique branch in 94 cases, the lateral branch of the descending branch in 187 cases, and the medial branch of the descending branch in 78 cases. The muscle flaps harvested from the lateral thigh muscle in 308 cases and the rectus femoris muscle in 51 cases. The harvest forms of muscle flaps included 154 cases of muscle branch type, 78 cases of main trunk distal type, and 127 cases of main trunk lateral type. The size of skin flaps ranged from 6.0 cm×4.0 cm to 16.0 cm×8.0 cm, and the size of muscle flaps range from 5.0 cm×4.0 cm to 9.0 cm×6.0 cm. In 316 cases, the perforating artery anastomosed with the superior thyroid artery, and the accompanying vein anastomosed with the superior thyroid vein. In 43 cases, the perforating artery anastomosed with the facial artery, and the accompanying vein anastomosed with the facial vein. After operation, the hematoma occurred in 6 cases and vascular crisis in 4 cases. Among them, 7 cases were successfully saved after emergency exploration, 1 case had partial necrosis of skin flap, which was healed after conservative dressing change, and 2 cases had complete necrosis of skin flap, which was repaired by pectoralis major myocutaneous flap. All patients were followed up 10-56 months (mean, 22.5 months). The appearance of the flap was satisfactory, and the swallowing and language functions were restored satisfactorily. Only linear scar left in the donor site with no significant effect on thigh function. During follow-up, 23 patients had local tumor recurrence and 16 patients had cervical lymph node metastasis. The 3-year survival rate was 38.2% (137/359). Conclusion: The flexible and clear classification of the key points in the harvest process of anterolateral thigh chimeric perforator myocutaneous flap can optimize the protocol to the greatest extent, increase the safety of the operation, and reduce the difficulty of the operation.

Utility of 6% hydroxyethyl starch 130/0.4 in oral cancer surgeries with a duration of over 6 hours: A retrospective case-control study.

To evaluate the utility of 6% hydroxyethyl starch (HES) 130/0.4 in oral cancer surgeries with durations over 6 hours. Using a case-control study design, the investigators enrolled patients who underwent oral cancer surgery involving osteotomy or manipulation near the major blood vessels at the Department of Orofacial Surgery in our hospital between 2017 and 2020. The predictor variable was 6% HES130/0.4. Outcomes included in-out balance and other postoperative parameters pertaining to circulatory maintenance (blood loss, urine volume, infusion volume, blood transfusion volume, albumin dose, hemoglobin levels, blood albumin levels, and doses of vasopressors used to maintain blood pressure), as well as pre- and postoperative renal function, pH, bicarbonate levels, and base excess. Changes in renal function were evaluated by assessing blood urea nitrogen and creatinine levels before surgery and at 1 and 7 days postoperatively. The Mann-Whitney U test was used for between-group comparisons, and Student t test was used for intragroup comparisons. The statistical significance was set at P < .05. A total of 65 patients underwent oral cancer surgery with a duration over 6 hours during the study period. The administration of 6% HES130/0.4 at 22.1 ± 7.5 mL/kg/day did not increase blood loss or the blood transfusion volume. Moreover, patients who were administered 6% HES130/0.4 had a significantly larger mean urine volume and infusion volume than those who were not administered 6% HES130/0.4. The infusion therapy could maintain the urine volume and did not worsen renal function. The results of this study showed that administration of 6% HES130/0.4 at a dose lower than 25 mL/kg in patients undergoing oral cancer surgery over 6 hours was effective for circulation maintenance but did not increase the intraoperative blood loss or transfusion volume. This treatment did not cause any dilutional metabolic acidosis or renal dysfunction.

Factors associated with follow-up attendance of patients with oral squamous cell carcinoma: A retrospective cohort study.

BACKGROUND: This study examined the postoperative follow-up attendance of oral squamous cell carcinoma (OSCC) patients, evaluated some of the factors associated with it, and assessed its relationship with early detection of postoperative disease progression. METHODS: An exploratory retrospective cohort study of 430 OSCC patients was conducted. We examined associations of follow-up attendance within the first year after surgery with selected demographic and clinical factors, and with early detection of disease progression. RESULTS: The mean number of follow-up visits within the first year after surgery was 3.9 out of the 12 recommended at our center; few patients were fully adherent. Age ≥70 years, unmarried status, high education level, and negative history of surgery for premalignant or malignant lesions from oral cavity or other sites were significantly associated with lower follow-up attendance. Greater follow-up attendance was significantly associated with early detection of disease progression during the first year after surgery (p = 0.025). CONCLUSIONS: Adherence to follow-up visits was poor. Several sociodemographic and clinical factors were related to follow-up attendance, greater follow-up attendance was significantly associated with early detection of disease progression, and these should be further explored in future research.

MMP14 expression levels accurately predict the presence of extranodal extensions in oral squamous cell carcinoma: a retrospective cohort study.

BACKGROUND: Extranodal extension (ENE) is an adverse prognostic factor for oral squamous cell carcinoma (OSCC), and patients with OSCC along with ENE require neck dissection. In this study, we developed a novel ENE histology-based pathological predictor using MMP14 expression patterns in small biopsy specimens. METHODS: A total of 71 surgically resected tissue, 64 dissected lymph node (LN), and 46 biopsy specimens were collected from 71 patients with OSCC. Immunohistochemical analyses of total MMP14 expression in the tumour nest and cancer-associated fibroblasts (CAFs) were performed using the MMP14 co-scoring system (high- or low-risk). The association analysis of MMP14 expression in metastatic LNs was performed with respect to the presence and absence of ENE. Clinicopathological analyses and multivariate examinations were performed to assess the risks of metastasis and ENE presence. The predictive value of ENE and the impact of ENE and MMP14 expression on 5-year overall survival were examined. RESULTS: High-risk MMP14 expression was detected in metastatic LN specimens with ENE. MMP14 expression in tumour nests and CAFs and its overexpression at the tumour-stromal interface significantly correlated with the presence of ENE. The MMP14 co-scoring system was an independent risk predictor for ENE, with sensitivity, specificity, and accuracy of over 80% in biopsy samples; patients with a high risk in the MMP14 co-scoring system had significantly worse prognoses in both resections and biopsies. CONCLUSION: The MMP14 co-scoring system accurately predicted ENE presence and poor prognosis via immunohistochemical evaluation of small biopsies. This system is a simple, accurate, and inexpensive immunohistochemical approach that can be used in routine pathological diagnosis for effective treatment planning.

Comparison of histopathological turnaround times for mandibulectomies, glossectomies, and incisional biopsies of the tongue.

Diagnostic histopathology plays a key role in the management of oral cancer and timely reports are essential. The aim of this study was to retrospectively compare the time interval between receipt of the specimen and issue of the histopathology report (the 'turnaround time', TT) of two types of oral cancer resections (mandibulectomies and glossectomies) and incisional biopsies from the tongue (n = 100 of each). The information documented included the number of days from receipt of the specimen until the sample was ready for reporting, and the number of subsequent days until the report was authorised by the pathologist. The number of days mandibulectomies required decalcification, the number of blocks processed per sample, and pathological TNM stage were also recorded. Results showed that mandibulectomies had statistically significantly longer TT than glossectomies. Incisional biopsies had the shortest TT with 87% reported in seven days and 95% in ten. There were also statistically significantly longer TT for pT3/pT4 than for pT1/pT2 glossectomies, and between the number of blocks processed for the three main groups. Decalcification and the interval whilst the slides awaited the pathologists' attention were identified as 'bottlenecks'. Dentate mandibulectomies had the longest TT of all; extraction of teeth at operation and detachment of the lower border of the mandible at macroscopic sampling are thus potential means by which the decalcification delay might be reduced. Expectations of the multidisciplinary team managing the patient should be realistic when scheduling postoperative discussion.

Oral cavity adjuvant therapy (OCAT) -a phase III, randomized controlled trial of surgery followed by conventional RT (5 fr/wk) versus concurrent CT-RT versus accelerated RT (6fr/wk) in locally advanced, resectable, squamous cell carcinoma of oral cavity.

BACKGROUND: Limited data exists regarding the impact of intensification of adjuvant therapy in resected Oral Cavity Squamous Cell Carcinomas (OCSCC) with adverse prognostic features on histopathology. PATIENTS AND METHODS: This was a three-arm phase III, randomised trial including patients with resected advanced OCSCC. Randomisation was done in a 1:1:1 ratio: Arm-A- standard adjuvant radiation therapy (RT) 60Gy/30 fractions over 6 weeks versus Arm-B-concurrent chemoradiation versus Arm-C-accelerated radiation therapy (6 d a week). The trial was powered to detect an absolute difference of 10% in 5-year Locoregional Control (LRC). RESULTS: The trial was conducted between June 2005 and March 2013. Majority of the patients were males, had T3-T4 disease, had N2-N3 nodal status and had Extra-Capsular Extension (ECE) in nodes. The median follow-up was 95.9 months. There was no difference between the three arms (A versus B versus C) for 10-year locoregional control (LRC): 60.2% versus 61.4% versus 65.7%, p = 0.57; disease free survival (DFS): 37.4% versus 43.9% versus 39.6%, p = 0.40; or Overall Survival (OS): 39.7% versus 46.6% versus 40.4%, p = 0.40. There was no benefit of intensification with either modality in patients with any single adverse pathological factor. A benefit of intensification could be seen in patients with a combination of high-risk features: T3-T4 primary tumours with N2-N3 nodes along with ECE for DFS (Arm B versus Arm A HR) = 0.53, Arm C versus Arm A HR = 0.63) and OS (Arm B versus Arm A HR = 0.58, Arm C versus Arm A HR = 0.60). CONCLUSIONS: All optimally resected OCSCC with adverse features did not benefit from intensification of adjuvant therapy. Only a cohort of patients with a combination of high-risk features are likely candidates for intensification. CLINICAL TRIAL REGISTRATION: NCT00193843.

Improved Cancer-Specific Risk Stratification by the Lymph Node Ratio-Based Nomogram: A Potential Role in Guiding Postoperative Management Decisions for Oral Cavity Carcinoma.

PURPOSE: To develop and validate a nomogram integrating lymph node ratio (LNR) to predict cancer-specific survival (CSS) and assist decision making for postoperative management in nonmetastatic oral cavity squamous cell carcinoma (OCSCC). MATERIALS AND METHODS: We retrospectively retrieved 6,760 patients with OCSCC primarily treated with surgery from surveillance, epidemiology, and end results database between 2010 and 2015. They were randomly divided into training and validation cohorts. Performance of the nomogram was evaluated by calibration curve, consistency index, area under the curve, and decision curve analysis and was compared with that of the LNR, positive lymph nodes (PLN) and tumor node metastasis (TNM) staging. According to the individualized nomogram score, patients were classified into three risk cohorts. The therapeutic efficacy of postoperative radiotherapy and chemotherapy was evaluated in each cohort. RESULTS: The nomogram incorporated six independent variables, including race, tumor site, grade, T stage, PLN, and LNR. Calibration plots demonstrated a good match between the predicted and observed CSS. C-indices for training and validation cohorts were 0.746 (95% CI, 0.740 to 0.752) and 0.726 (95% CI, 0.713 to 0.739), compared with 0.687, 0.695, and 0.669 for LNR, PLN, and TNM staging, respectively (P < .001). Decision curve analyses confirmed that nomogram showed the best performance in clinical utility. Postoperative radiotherapy presented survival benefit in medium-and high-risk groups but showed a negative effect in the low-risk group. Chemotherapy was only beneficial in the high-risk group. CONCLUSION: The LN status-incorporated nomogram demonstrated good discrimination and predictive accuracy of CSS for patients with OCSCC and could identify those most likely to benefit from adjuvant therapy.

Plasma cell-free DNA methylome profiling in pre- and post-surgery oral cavity squamous cell carcinoma.

Head and neck squamous cell carcinoma (HNSCC), a highly heterogeneous disease that involves multiple anatomic sites, is a leading cause of cancer-related mortality worldwide. Although the utility of noninvasive biomarkers based on circulating cell-free DNA (cfDNA) methylation profiling has been widely recognized, limited studies have been reported so far regarding the dynamics of cfDNA methylome in oral cavity squamous cell carcinoma (OCSCC). It is hypothesized in this study that comparison of methylation profiles in pre- and postsurgery plasma samples will reveal OCSCC-specific prognostic and diagnostic biomarkers. As a strategy to further prioritize tumor-specific targets, top differential methylated regions (DMRs) were called by reanalyzing methylation data from paired tumor and normal tissue collected in the the cancer genome atlas head-neck squamous cell carcinoma (TCGA) head and neck cancer cohort. Matched plasma samples from eight patients with OCSCC were collected at Moffitt Cancer Center before and after surgical resection. Plasma-derived cfDNA was analyzed by cfMBD-seq, which is a high-sensitive methylation profiling assay. Differential methylation analysis was then performed based on the matched samples profiled. In the top 200 HNSCC-specific DMRs detected based on the TCGA data set, a total of 23 regions reached significance in the plasma-based DMR test. The top five validated DMR regions (ranked by the significance in the plasma study) are located in the promoter regions of genes PENK, NXPH1, ZIK1, TBXT, and CDO1, respectively. The genome-wide cfDNA DMR analysis further highlighted candidate biomarkers located in genes SFRP4, SOX1, IRF4, and PCDH17. The prognostic relevance of candidate genes was confirmed by survival analysis using the TCGA data. This study supports the utility of cfDNA-based methylome profiling as a promising noninvasive biomarker source for OCSCC and HNSCC.

Application of anatomy unit resection surgery for lateral basicranial surgical approach in oral squamous carcinoma.

BACKGROUND: The basicranial region lacks definite boundaries and includes various anatomical units. We developed a novel concept of the posterior oral anatomical complex (POAC) to identify these anatomical units in the basicranial region. OSCC with POAC involvement is termed posterior oral squamous cell carcinoma (POSCC) with poor prognosis. The principal aim of this study was to evaluate the effect of anatomy unit resection surgery (AUSR) on patients with POSCC. METHODS: A total of 120 POSCC patients who underwent radical surgical treatment were recruited for this study. These POSCC patients were treated with conventional surgery or AUSR. According to the extent of primary tumor resection in the AUSR group, the lateral basicranial surgical approach can be subdivided into four types: face-lateral approach I, face-lateral approach II, face-median approach or face-median and face-lateral combined approach. Facial nerve function was evaluated according to the House-Brackmann Facial Nerve Grading System. RESULTS: The overall survival rate was 62.5% and 37.5% in the AURS group and conventional group (hazard ratio: 0.59; p < 0.0001), respectively. The disease-free survival rate was 62.5% and 34.3% in the AURS group and conventional group (hazard ratio: 0.43; p = 0.0008), respectively. The local disease control rate in the AURS group (71.4%) was significantly better than that in the conventional group (34.4%) in present study (p < 0.0001). Compared to the conventional group, all the patients undergoing AURS were classified as T4 stage and presented with more lymph node metastasis (71.4%). A total of 20 patients (face-lateral approach I and face-lateral combined approach) were temporarily disconnected from the temporofacial branch of the facial nerve. Fifteen patients exhibited slight paresis, and five patients presented with moderate or severe paresis. The survival rate of zygomatic arch disconnection was 94.6% (54 of 56 patients). CONCLUSION: This lateral basicranial surgical approach based on AUSR improves the survival rate and enhances the local control rate while also preserving a good prognosis without damaging the nerve and zygomatic bone. This surgical approach based on AUSR provides a novel and effective surgical treatment to address POSCC with better prognosis, especially for patients without metastatic lymph nodes.

[Anatomical classification of adductor magnus perforator flap and its application in head and neck reconstruction].

Objective: To investigate the anatomical classification of adductor magnus perforator flap and its application in head and neck reconstruction. Methods: From January 2017 to January 2020, Hunan Cancer Hospital treated 27 cases of oral tumor patients (15 cases of tongue cancer, 9 cases of gingival cancer and 3 cases of buccal cancer), including 24 males and 3 females, aged 31-56 years old. The course of disease was 1-12 months. Secondary soft tissue defects with the sizes of 5.0 cm × 3.5 cm to 11.0 cm × 8.0 cm were left after radical resection of the tumors, and were repaired with free adductor magnus perforator flaps. The flaps based on the origing locations of perforator vessels were divided into three categories: ① intramuscular perforator: vessel originated between the gracilis muscle and the adductor magnus or passed through a few adductor magnus muscles; ② adductor magnus middle layer perforator: vessel run between the deep and superficial layers of adductor magnus; ③ adductor magnus deep layer perforator: vessel run between the deep layer of adductor magnus and the semimembranous muscle. Descriptive analysis was used in this research. Results: Perforator vessels of adductor magnus were found in all cases, with a total of 62 perforator branches of adductor magnus. The anatomical classification of the perforator vessels was as follows: 12 branches for class ①, 31 branches for class ② and 19 branches for class ③. The vascular pedicles of the free adductor major perforator flaps included type ① for 3 cases, type ② for 16 cases and type ③ for 8 cases. All 27 flaps survived and the donor sites were closed directly. In 18 cases, the perforator arteries and the venae comitan were respectively anastomosed with the superior thyroid arteries and veins. In 9 cases, the pedicle arteries and the venae comitan were respectively anastomosed with the facial arteries and veins. Follow up for 12-40 months showed that the appearances of the flaps and the swallowing and language functions of patients were satisfactory, apart from linear scars were left in the donor sites with no significant affect on the functions of thigh. Local recurrence occurred in 3 cases and radical surgeries were performed again followed by repairs with pedicled pectoralis major myocutaneous flaps. Cervical lymph node metastasis occurred in 2 cases and cervical lymph node dissection was performed again. Conclusions: The adductor magnus perforator flap has soft texture, constant perforator vessel anatomy, flexible donor location and harvesting forms, and less damage to the donor site. It is an ideal choice for postoperative reconstruction in head and neck tumors.

Novel Local Chimeric Flap Based on Tunnelized Facial Artery Myomucosal Island Flap and Submandibular Gland Flap for Reconstructions After Oral Squamous Cell Carcinoma Surgery.

The reconstruction of oral tongue and floor of mouth defects after resections of squamous cell carcinoma is a challenging task in reconstructive surgery aiming for appropriate restoration of oral function and quality of life improvement. In this study, the authors introduce the innovative reconstruction technique of medium-sized defects consisting of tunnelized facial artery myomucosal island flap and submandibular gland flap as the local chimeric flap pedicled on facial vessels. A retrospective case series evaluation of 4 patients suffering from oral cavity cancer (stages III and IVa), who underwent transoral tumor excision with neck dissection and immediate reconstruction in the time period September 2020 to July 2021, was conducted. No flap losses or flap-related complications were identified. No recurrences occurred during the follow-up at 11.0±4.5 months (range: 6-16 mo, median=11 mo). Tunnelized facial artery myomucosal island flap and submandibular gland flap local chimeric flap expands the reconstruction options of medium-sized defects after ablative oral cancer surgery in carefully selected patients primarily not suitable for free flap reconstructions.

Prognostic Involvement of Lymph Node Density in Oral Squamous Cell Carcinoma. A New Predictive Model.

PURPOSE: Lymph node density (LND) has been reported to be a significant predictor of survival in oral squamous cell carcinoma (OSCC). The aim of this study was to analyze LND as a prognostic factor in OSCC and create a predictive model that determines the probability of death in these patients. METHODS: A retrospective cohort study was carried out with a cohort of patients who underwent cervical dissection and primary resection of OSCC between 1980 and 2020. The primary predictor variable in this study was LND, which is defined as the number of positive lymph nodes divided by the total number of lymph nodes removed. The cutoff values for prediction of disease-specific survival (DSS) were calculated by receiver operating characteristic curve analysis, which determined the best cutoff value was 0.07. Patients were divided into binary subgroups (low and high risk) using the best cutoff value of LND. The outcome variable was DSS, defined as the duration from the date of diagnosis to death due to OSCC and not due to other causes or secondary tumors. Other variables were type of neck dissection, postsurgical treatment, surgical margin, pathological T category stage, pathological N category (pN) stage, extranodal extension, perineural invasion, bone invasion, and presence of recurrence. A predictive model (score) was generated by selecting variables using a log-rank test and by using the Cox proportional-hazards regression (multivariate analysis). RESULTS: The sample consisted of 368 patients, 252 (68.5%) male and 116 (31.5%) female patients, with a mean age of 60.3 years. According to the LND cutoff value, there were 289 patients with a low LND (≤0.07) and 79 with a high LND (>0.07). The univariate analysis showed LND as a significant predictor of DSS at 5 years (67.1% in LND ≤ 0.07 vs 32.9% in LND > 0.07; P < .001). The Cox multivariate analysis identified LND (hazard ratio [HR] = 27.2; 95% confidence interval [CI], 3.18-231; P = .002), recurrence (HR = 4.45; 95% CI, 2.3-8.4; P < .001), and type of treatment (HR = 0.52; 95% CI, 0.34-0.81; P < .001) as independent predictive factors for DSS. In the predictive model, the presence of recurrence was the most important factor with 8 points, whereas LND >0.07 contributed only 1 point; however, the 2 categories resulting from this limit were statistically significant. CONCLUSIONS: Our study demonstrates that LND is an additional prognostic factor in patients with a pN+ disease. In addition, our predictive model could be useful in the therapeutic algorithm of OSCC patients, as it can predict the probability of death in these patients.

Ultrasound-guided resection for squamous cell carcinoma of the buccal mucosa: A feasibility study.

BACKGROUND: Image-guided surgery could help obtain clear (≥5.0 mm) resection margins. This feasibility study investigated ultrasound-guided resection accuracy of buccal mucosa squamous cell carcinoma (BMSCC). METHODS: MRI and ultrasound measurements of tumor thickness were compared to histology in 13 BMSCC-patients. Ultrasound measured margins (at five locations) on the specimen were compared to the corresponding histological margins. RESULTS: Accuracy of in- and ex-vivo ultrasound (mean deviation from histology: 1.6 mm) for measuring tumor thickness was comparable to MRI (mean deviation from histology: 2.6 mm). The sensitivity to detect clear margins using ex-vivo ultrasound was low (48%). If an ex-vivo ultrasound cutoff of ≥7.5 mm would be used, the sensitivity would increase to 86%. CONCLUSIONS: Ultrasound-guided resection of BMSCC's is feasible. In- and ex-vivo ultrasound measure tumor thickness in BMSCC accurately. We recommend ≥7.5 mm resection margins on ex-vivo ultrasound to obtain histological clear margins. Additional research is required to establish the effect of 7.5 mm ultrasound cutoff.

Accuracy of preoperative clinical examination and imaging for mandibular resection in oral cancer: a systematic review of diagnostic test accuracy studies.

The aim of this systematic review is not only to analyse the accuracy of clinical examination and radiological preoperative assessment of mandibular invasion reported in isolation, but to highlight those reports that have combined them. A total of 1636 titles and abstracts published between 1995 - 2000 were screened following a literature search in PubMed. Keywords were "mandible" and "squamous cell carcinoma". A total of 90 full manuscripts were reviewed with 24 meeting defined inclusion/exclusion criteria and yielding the data reported. The most sensitive test was single photon emission tomography with eight out of the 10 studies reporting sensitivity higher than 95%. Magnetic resonance imaging (MRI) demonstrated superior sensitivity but was less specific than computed tomography (CT). A single report attempted to report the combined CT and MRI scans with a separate expert reporting but did not result in more reliable detection. Periosteal stripping was not reported, and there was insufficient data to establish the value of new technologies. This review confirms that, to our knowledge, there are no reliable data on the results of combining imaging techniques with or without clinical examination. It emphasises the lack of data for the combination of preoperative techniques to enhance safe oncological resection of the mandible. Based on the evidence gathered in this review an algorithm of assessment of possible mandibular invasion is proposed. With new technologies available and 3-dimensional models to help plan the mandibular resection and reconstruction, the potential of combining preoperative investigations should be fully realised through prospective research.

Comparison of postoperative complications in early versus delayed tracheostomy decannulation in patients undergoing oral cancer surgery with microvascular reconstruction.

The purpose of this study was to determine the relationship of early and delayed tracheostomy decannulation protocols on the length of stay, time to oral feeding and incidence of postoperative complications in patients undergoing microvascular reconstruction for oral cancer. A review of all patients who underwent surgical management of oral squamous cell carcinoma (OSCC) over the study period from 01/07/2017 to 31/06/2021 was performed. Patients who underwent elective tracheostomy as part of their microvascular reconstruction were included. Two cohorts were identified based on distinct postoperative tracheostomy decannulation protocols; early (Within 7 days) and delayed (≥7 days). Time to oral feeding, length of stay and complication rates was determined for both groups for statistical analysis. A total of 103 patients with OSCC were included in the study. The overall complication rate was 35.9% and were more likely in node positive patients (53.7% vs 23.2%; p = 0.003) and in cases where the geniohyoid muscle complex was disrupted during tumour resection (66.7% vs 31.9%; p = 0.026). Early decannulation was significantly associated with shorter length of hospital stay (10 days vs 15 days) and earlier removal of nasogastric feeding tubes (7 vs 10 days). There was no difference in the overall complication rate between the two groups (33.3% vs 37.5%; p = 0.833). Early decannulation in appropriately selected patients is recommended as it significantly reduces the length of hospital stay and aids in early resumption of oral intake. Furthermore, this approach is not associated with increased rates of complications.

Objective speech outcomes after surgical treatment for oral cancer: An acoustic analysis of a spontaneous speech corpus containing 32.850 tokens.

INTRODUCTION: Surgical treatment for oral cancer leads to lasting changes of the vocal tract and individuals treated for oral cancer (ITOC) often experience speech problems. The purpose of this study was to analyse the acoustic properties of the spontaneous speech of individuals who were surgically treated for oral cancer. It was investigated (1) how key spectral measures of articulation change post-treatment; (2) whether changes are more related to target manner or place of articulation; and (3) how spectral measures develop at various time points following treatment. METHOD: A corpus consisting of 32.850 tokens was constructed by manually segmenting the speech of five (four female - one male) American English speaking ITOC. General acoustic characteristics (duration and spectral tilt), plosives (burst frequency), fricatives (centre of gravity and spectral skewness), and vowels (F1 and F2) were analysed using linear mixed effects regression and compared to control speech. Moreover, a within speaker analysis was performed for speakers with multiple recordings. RESULTS: Manner of articulation is more predictive of post-treatment changes than place of articulation. Compared to controls, ITOC produced the fricatives /f, v, θ, ð, s, z, ʃ, ʒ/ with a lower centre of gravity while no differences were found for plosives and vowels. Longitudinal analyses show high within-speaker variation, but general improvements one-year post-treatment. CONCLUSIONS: Surgical oral cancer treatment changes the spectral properties of speech. Fricatives with varying manner of articulations were distorted, suggesting that manner of articulation is more predictive than place of articulation in identifying general problem areas for ITOC.