Combined SPECT/CT improves detection of initial bone invasion and determination of resection margins in squamous cell carcinoma of the head and neck compared to conventional imaging modalities.

PURPOSE: Knowledge of the presence and extent of bone infiltration is crucial for planning the resection of potential bone-infiltrating squamous cell carcinomas of the head and neck (HNSCC). Routinely, plain-film radiography, multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) are used for preoperative staging, but they show relatively high rates of false-positive and false-negative findings. Scintigraphy with (99m)Tc-bisphosphonate has the ability to show increased metabolic bone activity. If combined with anatomical imaging (e.g. (SPECT)/CT), it facilitates the precise localization of malignant bone lesions. The aim of this study was to analyse the indications and advantages of SPECT/CT compared with standard imaging modalities and histology with regard to specificity and sensitivity METHODS: A longitudinally evaluated group of 30 patients with biopsy-proven HNSCC adjacent to the mandible underwent (99m)Tc-bisphosphonate SPECT/CT, MRI, MSCT and conventional radiography before partial or rim resection of the mandible was performed. Bone infiltration was first evaluated with plain films, MSCT and MRI. In a second reading, SPECT/CT data were taken into account. The results (region and certainty of bone invasion) were evaluated among the different imaging modalities and finally compared with histological specimens from surgical resection as the standard of reference. For a better evaluation of the hybrid property of SPECT/CT, a retrospectively evaluated group of 20 additional patients with tumour locations similar to those of the longitudinally examined SPECT/CT group underwent SPECT, MSCT and MRI. To assess the influence of dental foci on the specificity of the imaging modalities, all patients were separated into two subgroups depending on the presence or absence of teeth in the area of potential tumour-bone contact. RESULTS: Histologically proven bone infiltration was found in 17 patients (57 %) when analysed by conventional imaging modalities. SPECT/CT data revealed bone infiltration in two additional patients (7 %), who both showed discrete cortical bone erosion not visible by MSCT or MRI. There were no false-positive or false-negative findings on SPECT/CT. The quality criteria for detecting bone involvement in HNSCC by SPECT/CT were as follows: sensitivity 100 % (lower 95 % confidence interval limit 80 %), specificity 100 % (75 %), positive predictive value 100 % (80 %) and negative predictive value 100 % (75 %). Corresponding data for MRI were 95 % (76 %), 94 % (73 %), 95 % (76 %) and 94 % (73 %), and for MSCT were 89 % (71 %), 100 % (85 %), 100 % (86 %) and 88 % (69 %). In the retrospective evaluation SPECT showed results similar to SPECT/CT. CONCLUSION: Hybrid SPECT/CT has a high specificity as it can provide additional information about the existence and local extent of malignant bone infiltration of the mandible. Although the sensitivity of conventional SPECT is similar to that of SPECT/CT, the latter provides a much better delineation of the local tumour-bone contact area. Based on this information, surgical intervention of the rim versus partial resection can be planned and performed more precisely. Patient outcome can be improved by avoiding undertreatment and unnecessary or overextended bone resections.

Consistent Value of Two-Stage Pedicle Flaps in the Age of Microsurgical Maxillofacial Reconstruction.

Introduction: Up to the second half of the twentieth century, pedicled flaps marked the gold standard in reconstructive surgery. Followed by the introduction of microsurgical techniques, these flaps were increasingly abandoned. We conducted a retrospective study to determine the value of two-stage pedicle flaps in modern maxillofacial reconstruction. Material & Methods: A chart review from October 2017 to November 2020 was performed to identify patients who were treated by a two-stage pedicle flap in our Department of Oral and Maxillofacial Surgery. Results: A total of 31 patients, 17 female and 14 males received 36 two-stage pedicle flaps. All patients were in noticeably impaired health condition with a majority of ASA-score 3. The defect location mainly contained extraoral resections (58.3%). A variety of flaps were harvested consisting of buccal flaps, Abbe flaps, forehead flaps, deltopectoral flaps, nasolabial flaps, and a tubed flap. Discussion: The study outlines two indications for the use of two-stage pedicle flaps. Firstly, as a back-up strategy in heavily pre-treated wound beds and secondly in an almost contrarily indication as a first-choice reconstructive option of the facial skin in esthetic demanding cases. Conclusion: The timesaving and straight forward surgical approach as well as their low postsurgical complications and strong long-time success rates secure the two-stage pedicle flap a justified niche role in times of microsurgical maxillofacial reconstruction. Supplementary Information: The online version contains supplementary material available at 10.1007/s12663-021-01635-9.

Three-dimensional evaluation of condylar position after mandibular reconstruction with a fibula free flap-comparison of different surgical techniques.

Three-dimensional positional changes of the temporomandibular joint after mandible reconstruction using microvascular fibula flaps were investigated in 58 patients. The results of preoperative virtually planned surgery, intraoperative resection- and cutting-guided surgery, and non-guided surgery were compared. Pre- and postoperative computed tomography data of each patient were processed and superimposed digitally. The condyle deviations and rotations along the axes and planes of the skull, as well as Euclidean distances, were determined. Reliability analyses, descriptive statistics, and non-parametric tests were performed with the alpha level set at P = 0.05. Reliability proved to be excellent for all variables. The median Euclidean distance was 2.07 mm for the left condyle and 2.11 mm for the right condyle. Deviations of ≥ 10 mm occurred in nine (16%) cases. The maximum deviation occurred in the horizontal plane and the least deviation in the sagittal plane. Median rotation was ≤ 1.4° around all axes. The condylar displacements did not differ significantly between the different surgical techniques investigated. The three-dimensional measurement method applied is highly reliable for evaluating the three-dimensional condylar position after mandibular reconstruction.

Performance of different osteosynthesis materials in microvascular fibula free flap reconstruction.

Fibular free flap (FFF) is the main reconstructive choice for large mandibular defects. Recent improvements have been made regarding planning and surgical procedure, but choice of osteosynthesis material (OSM) for segment-fixation remains controversial. A retrospective cohort study obtained clinical and radiological data from FFF-patients. Data were screened for OSM, surgical procedure and complications as OSM fractures, loosening, exposure, or insufficient osseous consolidation. Eighty patients with FFF were included. Planning was CAD/CAM (n=29), Recon Guide (n=26) or without planning (n=25). OSM was 2.0mm-miniplates in standard (n=26), preformed (n=6), CAD/CAM (n=14) or ReconGuide (n=23) variation and 2.3mm-reconstruction-plates in standard (n=5) or CAD/CAM (n=6) variation. Complications were observed in 21 cases, fractures occurred 10 times overall, but with low rates for preformed (n=1), ReconGuide (n=3) and none for CAD/CAM. Analysis detected significant correlations between used OSM and plate exposure (p = 0.000), but none regarding fracture (p = 0.275), loosening (p = 0.714) or insufficient osseous consolidation (p = 0.208). No correlations were observed between complications and OSM (p = 0.609) or diagnosis (p = 0.716). Fixation of FFF segments for reconstruction is possible with various OSM providing good clinical outcome. No significant differences were detected regarding prevention of complications by any osteosynthesis material (miniplate vs. macroplate). Although no differences were detected, miniplate usage is advocated whenever clinically reasonable, due to easier reintervention possibilities and reduced implanted foreign material. Nevertheless, decision for ideal OSM must remain patient-specific and cannot be generalised.

Expression of antimicrobial peptides in cutaneous infections after skin surgery.

BACKGROUND: Increasing numbers of antibiotics have lost efficiency because of bacterial resistance. The consequences can be severe when surgical wounds become infected during postoperative care. Natural peptide antibiotics, the so-called host defence peptides (HDPs), have been investigated since the 1990s in a search for alternative treatment strategies. HDPs build up a protection shield against pathological microorganisms, especially in human epithelium. The use of HDPs is currently being discussed as a new antimicrobial therapeutic strategy. Accordingly, a profound knowledge of the quantitative relationships of the effectors is essential. OBJECTIVES: To evaluate differences in HDP expression between postoperatively inflamed and healthy epithelium. METHODS: Expression profiles of the genes encoding HDP human beta-defensin (hBD)-1 (DEFB1, previously known as HBD-1), hBD-2 (DEFB4A, previously known as HBD-2), hBD-3 (DEFB103A, previously known as HBD-3) and psoriasin (S100A7) were assessed in samples of surgical wound healing disorders (n = 27) and healthy epithelium (n = 16) by using real-time polymerase chain reaction. Immunohistochemical staining was performed in the same samples. RESULTS: A significant overexpression of DEFB4A (P < 0.001), DEFB103A (P = 0.001) and S100A7 (P < 0.001) was found in cutaneous surgical site infections. Immunohistochemistry revealed intensely elevated protein levels of psoriasin in infected wounds, and differences in distribution with respect to the epithelial layers. CONCLUSIONS: The study demonstrates upregulated mRNA expression and protein levels of HDPs in postoperatively inflamed epithelium. The results may be a starting point for novel pharmacological treatments.

Management of facial necrotizing fasciitis.

Necrotizing fasciitis is a progressive, life-threatening, bacterial infection of the skin, the subcutaneous tissue and the underlying fascia, in most cases caused by ss-hemolytic group A streptococcus. Only early diagnosis and aggressive therapy including broad spectrum antibiotics and surgical intervention can avoid systemic toxicity with a high mortality rate. This uncommon disease generally occurs in the lower extremities and trunk, and only rarely affects the head and neck region. When located in the face necrotizing fasciitis is associated with severe cosmetic and functional restrictions due to the invasive infection and often to the necessary surgical treatment. Generally surgical intervention cannot be performed in the face as aggressively as in the extremities and trunk, since a lot of vital structures are found in a relatively small area. In the following article, we present the successful diagnostic and therapeutic management of an isolated facial necrotizing fasciitis as a consequence of a nasal bone fracture with a minor dermal cut.

Life-threatening complications associated with acute monocytic leukaemia after dental treatment.

It is highly recommended to conduct a prophylactic check for any dental problems on patients who suffer from leukaemia before chemotherapy begins. Bacteraemia caused by oral microflora may be very dangerous for patients with haematological malignancies. However, it should be noted that the prophylactic process itself might bring about life-threatening complications if there is only a short interval between dental treatment and the beginning of chemotherapy, or if the dental treatment is too aggressive. We present a case where this prophylactic procedure produced life-threatening complications for a patient with acute myeloid leukaemia.

Survival benefit for patients treated in a certified head and neck tumor center.

OBJECTIVE: Increasing effort has been put in the implementation and certification of head and neck tumor centers in order to establish standardized, quality assured health care for head and neck tumor patients. This study evaluated survival rates after treatment in a certified head and neck tumor center (CHNTC) vs. a non-certified head and neck tumor center (non-CHNTC) in Middle Franconia, Germany. PATIENTS AND METHODS: Age, sex, possible obituary, and typical relevant prognostic variables were analyzed. Diagnosis was recorded according to ICD10. Clinical and pathological TNM staging, tumor grading, localization, R-stage, and morphology were assessed (ICD-0). Patients diagnosed with oral cancer (N=1047) were divided into groups based on where they received their primary treatment; CHNTCs or non-CHNTCs. RESULTS: Patients treated at CHNTCs had significantly higher survival rates vs. those treated at non-CHNTC (p=0.023) in univariate analysis. In a Cox regression model, survival rates for patients with pN0 and pN+ stage were similar at both types of centers. Men with pN0 had significantly lower survival rates (HR=0.497, p<0.001). Age had a statistically significant influence on survival rates independently from pN stage (HR=1.031 per year, p<0.001 in both groups). CONCLUSIONS: Patients treated at CHNTC had better survival rates than those treated at non-CHNTC.

Clinical outcome and patient satisfaction after mandibular reconstruction with free fibula flaps.

This study evaluated the difference between female and male patients' perception of functional and aesthetic outcomes after mandibular reconstruction with free fibular flaps, the transplant of choice for defects exceeding the length of half a mandible or the simultaneous covering of a soft-tissue defect. Based on clinical records, 54 patients with a mean postoperative follow up of 63 months were reviewed retrospectively. In addition, each patient completed a 12-item scaled questionnaire to assess perception of pain, speech, mastication and deglutition on recipient site, as well as pain, oedema, gait disturbances, difficulties in going upstairs and spraining on donor site. Functional scores on mastication were low for both sexes. The male group showed a higher rating of permanent or frequent difficulties in deglutition and speech. Aesthetic outcome for the recipient region was judged as poor by 62% of the female and 34% of the male patients. Donor site morbidity was described as mild by both sexes with excellent cosmetic results. The perception of facial changes appears to be impacted by gender. Female patients view the aesthetic results of mandibular reconstruction more negatively than do men, but express greater satisfaction with functional outcome. Objective clinician-rated measurements of the donor and recipient region do not always correlate with patient perception of outcome.

Intraoperative cell isolation for a cytological assessment of bone resection margins in patients with head and neck cancer.

The intraoperative cytological assessment of bony resection margins (ICAB) is a feasible diagnostic approach to support frozen section for assessment of invasion of margins of soft and hard tissue. However, complex resection margins could challenge both diagnostic approaches. Our objective here was to identify the limitations of intraoperative diagnostic methods for assessing margins. We present an advanced cytological approach to assess complex margins that may solve the problem. Data from 119 patients in whom frozen section was supported by ICAB, were reviewed and the reasons for false results analysed. In 35 patients with squamous cell carcinoma infiltrating bone, specimens (n=100) from the resection margin went through an intraoperative cell isolation process for the cytological assessment of bony margins (ICAB). The results were compared with the histological results of the corresponding margins of bone as a reference. Limitations to the assessment of operative bony margins intraoperatively included an infiltrative histological pattern of growth of the carcinoma, with carcinoma cells disseminated within the cancellous bone, complex and uneven resection margins with soft and bony tissue, inflammation, and signs of previous radiotherapy. Intraoperative cell isolation plus (ICICAB) allowed the microscopic assessment of up to 1cm3 of bony tissue to detect disseminated carcinoma cells within the cancellous bone with a sensitivity of 92.3% (95% CI 74.9% to 99.1%), and a specificity of 100% (95% CI 95.1% to 100%), and positive and negative predictive values of 100% (95% CI 85.8% to 100%) and 97.4% (95%CI 90.8% to 99.7%), respectively. Intraoperative cell isolation is a feasible new technique to support ICAB and frozen section in the assessment of bony and soft tissue margins.

Perioperative serum levels of procalcitonin, C-reactive protein, and leukocytes in head and neck free flaps.

Microvascular free flaps are considered to be the gold standard in reconstructive head and neck surgery. However, reduced postoperative transplant perfusion is one of the serious postoperative complications and calls for close and reliable monitoring. Procalcitonin, C-reactive protein, and leukocytes are closely associated with local and systemic inflammatory reactions and might have prognostic capacity concerning tissue necrosis. This study aimed to evaluate perioperative serum levels of these three biomarkers to assess their potential in postoperative flap monitoring. A total of 100 patients with microvascular head and neck reconstructions were included in the study. Perioperative serum levels of parameters were measured and the clinical data were analyzed and correlated. A total of 13% of all flaps developed reduced postoperative perfusion. Analysis of the parameters revealed statistically significant differences in the overall patient collective over time, irrespective of clinically reduced flap perfusion. Co-factors such as sex and history of tobacco and alcohol abuse showed significant differences. The efficacy of the parameters in free flap monitoring has not been verified, although the role of procalcitonin in postoperative monitoring, with special regard to the early detection of infections, is underlined by the present study results.

The early use of a perforator flap of the lateral lower limb in maxillofacial reconstructive surgery.

The development of perforator-based flaps led to new donor sites and enlarged the spectrum of recipient vessels using arteries and veins of very small calibres. Although these flaps, which are directly anastomosed at their terminal cutaneous branches, are becoming more and more important for reconstructions in other regions of the body, perforator-based flaps have not played an important role in maxillofacial surgery until now. This study reports the experience with 24 consecutive perforator flaps from the lateral lower limb for intra- and extraoral defect coverage. Septo- or myoseptocutaneous perforators from the peroneal artery served as the flap pedicle having a length of 4-7 cm and diameters of 1-2 mm. Indications were reconstructions of the floor of the mouth (10), soft palate (3), tongue (6), closure of perforating cheek defects (2) and reconstruction of the facial skin (3). Anastomoses were performed to the lingual, facial, temporal or thyroid superior artery. Except for 2 cases, all perforator-based flaps were healed well and the morbidity of the donor site was nearly negligible. According to the early experience in this study, perforator-based flaps from the lateral lower limb may have an indication if recipient vessels available are close to the defect and if very low donor site morbidity is important to the patient.

Reversible ischaemia after raising a radial forearm flap with ulceration of three fingers in a cigarette smoker.

The radial forearm flap is a standard method for the reconstruction of intraoral defects of soft tissues. We report the case of a middle-aged man who developed ischaemia in three fingers after a fasciocutaneous radial flap had been raised. The preoperative Allen test to diagnose occlusion of radial or ulnar artery was satisfactory. Soon after the operation the patient resumed smoking and four weeks later he developed ulcers on the thumb, index, and middle fingers. Only after he had stopped smoking and been given acetylsalicylic acid and heparin did blood flow and capillary hemoglobin oxygenation increase. As a result, his radial fingers recovered completely.

Accuracy of mandibular reconstruction by three-dimensional guided vascularised fibular free flap after segmental mandibulectomy.

Mandibular reconstruction with a fibular free flap has become standard in specialised centres for head and neck reconstruction, particularly for defects with more than one osteotomy that are challenging even for experienced surgeons. Virtual surgical planning is a potential tool to facilitate harvesting of the fibula and the osteostomy. The purpose of this study was to compare the two methods of mandibular reconstruction - conventionally planned (conventional group) and "virtually" planned (virtual group) - with regard to accuracy, bony consolidation, complications, and operating time. Fifty patients who required mandibular reconstruction after segmental mandibulectomy were evaluated retrospectively, 24 virtually planned and 26 conventionally planned. The overall survival of flaps was 92% (46/50). The bony consolidation rate in the virtual group was significantly better than that in the conventional group (p=0.002). The difference between the angle of the mandible before and after was highly significant with a median of 11.5° (range 2°-75°) in the conventional group and 4.5° (range 0-18°) in the virtual group (p=0.0001). Operations were mean (SD) of 34 (21.2) minutes shorter in virtually-planned cases (p=0.12). The overall morbidity did not differ significantly between the groups. The use of virtual surgical planning in mandibular reconstruction by fibular free flap is beneficial for optimising accuracy, consolidation of bony segments, and operating time, while increasing the predictability of results for the surgeon. However, additional costs have to be carefully weighed against the benefits.

Radiotherapy for oral cancer decreases the cutaneous expression of host defence peptides.

INTRODUCTION: Bacterial resistance against antibiotics has become an increasing challenge in the treatment of cutaneous infections. Consequences can be severe, especially in infected wounds following previous local radiotherapy. Certain endogenous peptide antibiotics, the host defence peptides (HDPs), exhibit broad-spectrum antimicrobial activity and promote wound healing. Their use as supplements to conventional antibiotics is a current topic of discussion; however, knowledge of their quantities in healthy and compromised tissue is a prerequisite for such discussion. To date, no data concerning HDP quantities in irradiated skin are available. METHODS: Expression profiles of the genes encoding HDPs, namely human beta-defensin-1 (DEFB1, hBD-1), beta-defensin-2 (DEFB4A, hBD-2), beta-defensin-3 (DEFB103, hBD-3) and S100A7, were assessed in samples of non-irradiated and irradiated neck. RESULTS: A reduction in the expression of all of the examined genes was observed in irradiated skin when compared with non-irradiated skin (statistically significant in the case of S100A7, P = 0.013). Immunohistochemistry revealed differences in HDP distribution with respect to the epithelial layers. CONCLUSION: The study demonstrates a significant reduction in HDP gene expression in neck skin as a result of radiotherapy. These findings might represent a starting point for novel treatments of cutaneous infections in irradiated patients, such as topical supplementation of synthetic HDP.

Which kind of frontal mandibulotomy is the smartest? A biomechanical study.

PURPOSE: Retrospective clinical evaluation and biomechanical tests were performed to compare the primary stability and the rate of pseudarthrosis formation after irradiation for two types of mandibular split osteotomies: the stairstep osteotomy (SSO) and the straight-line osteotomy (SLO). METHODS: The postoperative occurrence of pseudarthrosis was retrospectively analysed in 46 non-consecutive clinical cases of SSO and SLO between 2003 and 2013. Biomechanical tests were performed on 12 standardised synthetic mandibles (Synbone) to compare the SSO and SLO approaches. Two 2.0 mm monocortical miniplates (Medartis) were used for osteosynthesis. The artificial mandible specimens were loaded to 300 N on the Mandibulator test bench while interfragmentary motion was measured using the PONTOS optical measurement device. RESULTS: The retrospective clinical analysis showed a rate of pseudarthrosis of 19% in the SLO group versus only 5% in the SSO group (p = 0.17). In the biomechanical investigation, the average interfragmentary movement was 14.3 ± 7.70 for the SLO group and 4.57 ± 2.33 for the SSO group under a maximum load of 300 N, resulting in a statistically significant difference between the two approaches (p = 0.014). CONCLUSION: To minimise the rate of postoperative pseudarthrosis formation, SSO is superior to SLO for mandibular split procedures, because SSO provides greater resistance to vertical loads and allows less interfragmentary movement. LEVEL OF EVIDENCE: 2C (Outcomes research).

Loco-regional recurrence after surgical treatment of oral squamous cell carcinoma: Proposals for follow-up imaging based on literature, national guidelines and institutional experience.

The recurrence rate following the treatment of oral squamous cell carcinoma (OSCC) by primary surgery is about 10%-26%. The earliest possible diagnosis of residual tumour, recurrence of local tumour disease, and subsequent metastasis is essential for an improvement of the overall survival and of the survival period for affected patients. No international consensus exists for a post-therapeutic surveillance schedule for OSCCs. Based on a review of the literature, existing guidelines, and our institutional experience, we have established an algorithm for the follow-up of these patients regarding the timing and techniques of postoperative imaging. We recommend a follow-up interval of 6 weeks during the first half-year after discharge from hospital by single clinical and alternating clinical check-ups combined with computed tomography (CT) or magnetic resonance imaging (MRI), followed by an interval of 3 months in the second half-year, with clinical and radiological check-ups. In year 2, we recommend a follow-up interval of 3 months with single clinical and alternating clinical check-ups combined with CT or MRI. In year 3, we recommend screening every 6 months, both clinically and via imaging, because of the decreased risk of recurrence. From year 5 onwards, our recommendation is a clinical and imaging-based examination every 6-12 months, depending on patient risk factors and disease progression. Four standard imaging techniques, namely positron emission tomography (PET), CT, MRI, and ultrasound (US), are discussed concerning their range of application, sensitivity, and specificity. Furthermore, the technical aspects of our institutional protocols are described in detail. In highly frequented head and neck cancer centres, PET and US are of secondary importance, since CT and MRI are nowadays highly efficient tools in primary diagnostic and post-therapeutic surveillance.