Multi-omics analysis of overexpressed tumor-associated proteins: gene expression, immunopeptide presentation, and antibody response in oropharyngeal squamous cell carcinoma, with a focus on cancer-testis antigens

Introduction

The human leukocyte antigen complex (HLA) is essential for inducing specific immune responses to cancer by presenting tumor-associated peptides (TAP) to T cells. Overexpressed tumor associated antigens, mainly cancer-testis antigens (CTA), are outlined as essential targets for immunotherapy in oropharyngeal squamous cell carcinoma (OPSCC). This study assessed the degree to which presentation, gene expression, and antibody response (AR) of TAP, mainly CTA, are correlated in OPSCC patients to evaluate their potential as immunotherapy targets.

Materials and methods

Snap-frozen tumor (NLigand/RNA=40), healthy mucosa (NRNA=6), and healthy tonsils (NLigand=5) samples were obtained. RNA-Seq was performed using Illumina HiSeq 2500/NovaSeq 6000 and whole exome sequencing (WES) utilizing NextSeq500. HLA ligands were isolated from tumor tissue using immunoaffinity purification, UHPLC, and analyzed by tandem MS. Antibodies were measured in serum (NAb=27) utilizing the KREX™ CT262 protein array. Data analysis focused on 312 proteins (KREX™ CT262 panel + overexpressed self-proteins).

Results

183 and 94 of HLA class I and II TAP were identified by comparative profiling with healthy tonsils. Genes from 26 TAP were overexpressed in tumors compared to healthy mucosa (LFC>1; FDR<0.05). Low concordance (r=0.25; p<0.0001) was found between upregulated mRNA and class I TAP. The specific mode of correlation of TAP was found to be dependent on clinical parameters. A lack of correlation was observed both between mRNA and class II TAP, as well as between class II tumor-unique TAP (TAP-U) presentation and antibody response (AR) levels.

Discussion

This study demonstrates that focusing exclusively on gene transcript levels fails to capture the full extent of TAP presentation in OPSCC. Furthermore, our findings reveal that although CTA are presented at relatively low levels, a few CTA TAP-U show potential as targets for immunotherapy.

Profunda Artery Perforator Flap Tongue Reconstruction: An Effective and Safe Alternative to the Anterolateral Thigh Flap

BACKGROUND

The anterolateral thigh (ALT) perforator flap is a workhorse flap for tongue reconstruction. The authors present an alternative option using the profunda artery perforator (PAP) flap for glossectomy reconstruction compared with the ALT flap.

METHODS

A retrospective review was conducted of 65 patients who underwent subtotal or total glossectomy reconstruction between 2016 and 2020 (46 ALT versus 19 PAP flaps). Flap volume was assessed using computed tomography scans at two different time points. Quality of life and functional outcomes were measured using the MD Anderson Symptom Inventory for Head and Neck Cancer.

RESULTS

Patients receiving a PAP flap had significantly lower body mass index compared with those receiving an ALT flap (22.7 ± 5.0 versus 25.8 ± 5.1; P = 0.014). Donor-site and recipient-site complications were similar, as was the mean flap volume 7 months after surgery (30.9% for ALT versus 28.1% for PAP; P = 0.93). Radiation and chemotherapy did not appear to have a significant effect on flap volume change over time. The most frequently reported high-severity items in MD Anderson Symptom Inventory for Head and Neck Cancer were swallowing/chewing and voice/speech for both cohorts. Patients who had reconstruction with a PAP flap had significantly better swallowing function ( P = 0.034).

CONCLUSIONS

Both the PAP and ALT flaps appear to be safe and effective choices for subtotal and total tongue reconstruction. The PAP flap can serve as an alternative donor site, especially in patients with low body mass index and thin lateral-thigh thickness undergoing reconstruction of extensive glossectomy defects.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Outcomes of Head and Neck Microvascular Free Tissue Transfer for Advanced Cutaneous Squamous Cell Carcinoma: A Comparison of Solid Organ Transplant Recipients to Nontransplant Patients

BACKGROUND

Patients with solid organ transplant (SOT) are at increased risk of developing aggressive cutaneous malignancies due to their immunosuppression, particularly cutaneous squamous cell carcinoma (cSCC).

PURPOSE

There is limited data regarding SOT patients with locally advanced cSCC requiring radical surgery and microvascular free tissue transfer (MVFTT). Our objectives were to characterize outcomes in SOT patients and compare them with a non-SOT cohort.

STUDY DESIGN

This is a retrospective cohort study of patients undergoing MVFTT for advanced cSCC of the head and neck between January 2016 and May 2020 at a tertiary referral center. Patients who underwent MVFTT as part of curative intent surgery for advanced cSCC during the study were considered for inclusion. Exclusion criteria included distant metastasis, palliative intent treatment, age less than 18 years, and lip primaries.

PREDICTOR

The predictor variable was SOT status. A cohort of non-SOT patients was matched to the SOT cohort based on age, smoking status, tumor stage, and defect size.

MAIN OUTCOME VARIABLES

The primary reconstructive outcome was the major surgical complications and secondary outcome measures included major medical complications and minor surgical complications. The primary oncologic outcome was overall survival and the secondary outcome was disease-specific survival. The primary predictor was transplant status.

COVARIATES

Covariates included patient comorbidities, prior treatment, tumor stage, type of reconstruction, pathologic findings, and adjuvant therapy.

ANALYSIS

Continuous and categorical variables were compared using Student's T test and Fisher's exact test. Survival was calculated using the Kaplan-Meier method and differences in survival between groups were calculated using the log-rank test. Statistical significance was set a priori at P ≤ .05.

RESULTS

Fourteen SOT and 14 matched non-SOT patients met inclusion criteria. There was not a statistically significant difference in the rate of major surgical complications (7 vs 7%, P = .74) between the SOT and non-SOT cohorts. Rates of minor (21 vs 43%, P = .26) wound complications and medical complications (0 vs 14%, P = .24) were also similar between the SOT and non-SOT cohorts. Locoregional recurrences and distant metastasis were more common for SOT patients, though this was not statistically significant. Overall survival was significantly worse for SOT patients (21.7 vs 31.0 months, P = .04), though there was not a significant difference in disease-free survival (9.8 vs 31.0 months, P = .17).

CONCLUSIONS AND RELEVANCE

MVFTT in the management of SOT patients with locally advanced head and neck cSCC demonstrates similar complication rates with non-SOT patients. While survival and oncologic outcomes are worse in the SOT cohort, aggressive surgical intervention with MVFTT can be performed with comparable complication rates to patients without a history of SOT.

Analysis of T1-T2 stage oropharyngeal squamous cell carcinoma treated with transoral robotic surgery

Objective

Transoral robotic surgery (TORS) has become an effective treatment for early-stage oropharyngeal squamous cell carcinomas (OPSCCs). We aimed to analyze the clinical safety and efficacy of TORS for human papilloma virus (HPV)-positive and HPV-negative OPSCC in China.

Methods

Patients with OPSCC of pT1-T2 stage who underwent TORS from March 2017 to December 2021 were analyzed.

Results

A total of 83 patients (HPV-positive, n = 25; HPV-negative, n = 58) were included. The median age of the patients was 57.0 years and 71 were men. The majority of primary tumor sites were palatine tonsils (52, 62.7%) and base of tongues (20, 24.1%). Three patients have a positive margin. A total of 12 (14.5%) patients received tracheotomies, the average duration of tracheostomy tube use was 9.4 days, and nasogastric tube was 14.5 days. No patient had a long-term tracheotomy. The 3-year overall survival (OS), disease-free survival (DFS), and recurrence-free survival (RFS) for all 83 patients were 89.5%, 80.1%, and 83.3%, respectively. The OS at 3 years between the HPV-positive group and HPV-negative group were 100% versus 84.3% (P = .07), while the DFS and RFS between two groups also showed no significant difference. Among multivariate cox regression analysis of all potential risk factors, smoking was the significant risk factors for disease recurrence (P < .05).

Conclusion

Transoral robotic surgery achieved encouraging oncologic outcomes and safety in T1-T2 stage OPSCC treatment, regardless of HPV status.

Level of Evidence

4.

Prognostic factors in oropharyngeal squamous cell carcinoma in the state of São Paulo, Brazil: 10-year follow-up

OBJECTIVE

To descriptively analyze the epidemiological data, clinical stage, and outcomes of oropharyngeal squamous cell carcinoma in the state of São Paulo, Brazil, and to estimate the influence of clinical stage and treatment type on overall and disease-free survival.

METHODS

We retrospectively analyzed epidemiological data from the São Paulo Cancer Center Foundation database relative to patients with oropharyngeal squamous cell carcinoma diagnosed between 2004 and 2014 in the state of São Paulo. Univariate and multivariate Cox regression analyses were performed to assess factors associated with the outcomes. A forward stepwise selection procedure was used. Survival curves were estimated by the Kaplan-Meier method and compared by the Gehan-Breslow-Wilcoxon test.

RESULTS

A total of 8075 individuals with oropharyngeal squamous cell carcinoma were identified. Of these, 86.3% were diagnosed at an advanced stage and 13.7% at an early stage. Only 27.2% of patients were treated surgically, whereas 57.5% were treated medically. Patients undergoing surgery had longer overall survival than those receiving medical treatment in both early- and advanced-stage oropharyngeal squamous cell carcinoma. However, there was no significant difference in disease-free survival between surgical and medical treatment.

CONCLUSION

No significant difference in disease-free survival between medical and surgical treatment suggests similar complete remission rates with both approaches. Patients receiving medical treatment had shorter overall survival, which may be due to complications from chemotherapy and radiotherapy. However, we cannot confirm this relationship based on the data provided by the São Paulo Cancer Center Foundation. Prospective studies are warranted to assess whether the lower overall survival rate in patients receiving medical treatment is secondary to complications from chemotherapy and radiotherapy.

LEVEL OF EVIDENCE

2C.

De-Escalation Strategies for Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma—Where Are We Now?

The prevalence of oropharyngeal squamous cell carcinoma has been increasing in North America due to human papillomavirus-associated disease. It is molecularly distinct and differs from other head and neck cancers due to the young population and high survival rate. The treatment regimens currently in place cause significant long-term toxicities. Studies have transitioned from mortality-based outcomes to patient-reported outcomes assessing quality of life. There are many completed and ongoing trials investigating alternative therapy regimens or de-escalation strategies to minimize the negative secondary effects while maintaining overall survival and disease-free survival. The goal of this review is to discuss the most recent advancements within the field while summarizing and reviewing the available evidence.

Reconstruction of medium-size defects of the oral cavity: radial forearm free flap vs facial artery musculo-mucosal flap

Background

The radial forearm free flap (RFFF) is the most commonly used flap for defects of the oral cavity. The facial artery musculomucosal (FAMM) is a safe and effective method to reconstruct medium sized defects of the oral cavity. No comparison exists between the FAMM flap and RFFF.

Methods

1) Retrospective chart review from 2007 to 2016. 2) Cost difference analysis.

Results

Thirteen FAMM flap cases and 18 RFFF met inclusion criteria. The FAMM flap showed a tendency to lower rates of return to the operating room (p = 0.065) as well as lower rates of complications not requiring return to the OR with 1 complication in 1 patient as opposed to 10 patients with 15 complications (p = 0.008). Also, FAMM flap had shorter operative times compared to the RFFF group (7.2HR and 8.9 HR respectively, p = 0.002). The average operative room related costs for a FAMM flap were 6510 CAD vs 10,703 CAD for RFFF (p < 0.0005). Speech and swallowing outcomes were similar (p > 0.05).

Conclusion

The FAMM flap can be used for reconstruction of medium-size defects of the oral cavity with functional outcomes similar to the RFFF while decreasing the associated costs and morbidity.

Graphical Abstract

Patient Selection for Transoral Robotic Surgery (TORS) in Oropharyngeal Squamous Cell Carcinoma: What the Surgeon Wants to Know

ABSTRACT

Transoral robotic surgery (TORS) is an excellent treatment strategy for well-selected patients with oropharyngeal squamous cell carcinoma. Potential benefits of TORS are greatest among patients for whom surgical resection will reduce or eliminate the need for adjuvant therapy. Proper patient selection largely depends on imaging, which is used to determine tumor resectability, to inform expected morbidity and functional outcome, to assess the potential need for adjuvant therapy, to evaluate for vascular or other anatomic contraindications, and to gauge adequacy of transoral access to the tumor. This article provides the radiologist with a practical and accessible approach to interpreting preoperative imaging among patients with oropharyngeal cancer, emphasizing what the surgeon wants to know to inform the determination of whether the patient is a TORS candidate and why this information is important. By accurately reporting this information, the radiologist facilitates the multidisciplinary care team's selection of a treatment regimen optimized for the circumstances of the individual patient.

Examining the relationship of immunotherapy and wound complications following flap reconstruction in patients with head and neck cancer

BACKGROUND

Immunotherapy agents are used to treat advanced head and neck lesions. We aim to elucidate relationship between immunotherapy and surgical wound complications.

METHODS

Retrospective multi-institutional case series evaluating patients undergoing ablative and flap reconstructive surgery and immunotherapy treatment.

MAIN OUTCOME

wound complications.

RESULTS

Eight-two (62%) patients received preoperative therapy, 89 (67%) postoperative, and 33 (25%) in both settings. Forty-one (31%) patients had recipient site complications, 12 (9%) had donor site. Nineteen (14%) had major recipient site complications, 22 (17%) had minor. There was no statistically significant difference in complications based on patient or tumor-specific variables. Preoperative therapy alone demonstrated increased major complications (odds ratio [OR] 3.7, p = 0.04), and trend to more donor site complications (OR 7.4, p = 0.06), however treatment in both preoperative and postoperative therapy was not.

CONCLUSIONS

Preoperative immunotherapy may be associated with increased wound complications. Controlled studies are necessary to delineate this association and potential risks of therapy.

Modified Clavien-Dindo Classification and Outcome Prediction in Free Flap Reconstruction among Patients with Head and Neck Cancer

Because of limitations caused by unique complications of free flap reconstruction, the Clavien–Dindo classification was modified to include grade “IIIc” for “partial or total free flap failure.” From 2013 to 2018, 116 patients who had undergone free flap reconstruction for head and neck cancer with grade III or higher postoperative complications were grouped using the “Modified” Clavien–Dindo classification. Alcoholism displayed significant predictive effects between grade IIIb and IIIc (72.7% vs. 50%, p = 0.028). Significant differences were observed between grade IIIb and IIIc in the duration of hospital stay (23.1 ± 10.1 vs. 28.6 ± 11.9 days, p = 0.015), duration of intensive care unit stay (6.0 ± 3.4 vs. 8.7 ± 4.3 days, p = 0.001), reoperation times during the current hospitalization (1.4 ± 0.8 vs. 2.0 ± 1.0 times, p < 0.001), and wound infection rate (29.9% vs. 62.5%, p = 0.002). The severity levels were significantly positively correlated with reoperation times during the current hospitalization (p < 0.001), ICU stay (p = 0.001), and hospital stay (p < 0.001). The modified Clavien–Dindo classification with grade IIIc describes the perioperative complications of head and neck free flap reconstruction to predict clinical outcomes based on severity.

Factors Affecting Postoperative Complications After Reconstructive Surgery in Oral Carcinoma Patients: A Prospective Study of 100 Patients

Postoperative complications may result in significant functional morbidity, poor cosmetic results, prolonged hospitalization, preclusion of optimal treatment for the cancer, or even be pose threat to life. We prospectively assessed postoperative complications in 100 patients who underwent surgical resection with free or pedicled flap reconstruction as a primary modality of treatment in patients with carcinoma of the oral cavity. One hundred consecutive patients who underwent reconstructive surgery for oral cancer were prospectively analyzed for age, gender, comorbidities, tumor stage, nodal stage, primary sub-site of tumour, reconstructive procedure (free or pedicled), duration of surgery, blood transfusions during surgery, preoperative weight and body mass index, patient generated subjective global assessment status and tracheostomy to determine their effect on postoperative complications as determined on the CD scale. The sample comprised 100 patients with a mean age of 52.12 years (range 24-80 years) and 74% men (M:F ratio 3:1). A total of 40 patients developed surgical complications (including two deaths) while medical complications were seen in 10 patients (including one death). Tracheostomy (52 vs. 7%, p = 0.002) and age (54 vs. 49 years, p = 0.031) were associated with higher complication rate. Higher age and tracheostomy is associated with higher complications in postoperative period.

Transoral robotic surgery for oropharyngeal cancer: patient selection and special considerations

The increasing incidence of oropharyngeal squamous cell carcinoma (OPSCC) emphasizes the importance of optimizing treatment for the disease. Historical protocol has utilized definitive radiation and invasive open procedures; these techniques expose the patient to significant risks and morbidity. Transoral robotic surgery (TORS) has emerged as a therapeutic modality with promise. Here, the literature regarding proper patient selection and other considerations for this procedure was reviewed. Multiple patient and tumor-related factors were found to be relevant for successful use of this treatment strategy. Outcomes regarding early and advanced-stage OPSCC were analyzed. Finally, the literature regarding use of TORS in three distinct patient populations, individuals with primary OPSCC, carcinoma of unknown primary and those with recurrent OPSCC, was examined.

Primary surgical management with radial forearm free flap reconstruction in T4 oropharyngeal cancer: Complications and functional outcomes

PURPOSE

Functional outcomes and complication rates after open surgery for advanced-stage oropharyngeal cancers are rarely reported. These measures are critical for choice of treatment modality and patient counseling. We describe the long term functional outcomes and associated complications of primary surgical management of T4 oropharyngeal cancers reconstructed with radial forearm free flaps.

MATERIALS AND METHODS

A retrospective review was performed of 40 patients with T4 oropharyngeal cancers treated between 2005 and 2015 at a tertiary care center.

RESULTS

Forty patients with T4 oropharyngeal cancers underwent open surgical resection and radial forearm free flap reconstruction at the time of surgery. Mandibulotomy was required in 33 (82.5%) cases. Thirty-five (87.5%) patients received adjuvant radiation or combined chemotherapy and radiation. Tracheostomy was performed in all patients, but every patient was eventually decannulated. Twenty (57.1%) patients required gastrostomy tube placement at some point during treatment; however, 91.4% were on a completely oral diet with a mean FOSS score of 1.6 by 1year after completion of treatment. The addition of adjuvant treatment was the only factor significantly associated with poorer FOSS scores. The overall rates of short and long-term complications were 60.0% and 57.1% respectively. The most common short and long-term complications were infection (30.0%) and velopharyngeal insufficiency (25.7%) respectively.

CONCLUSIONS

Traditional open surgical approaches to large tumors of the oropharynx carry higher complication rates than more recent advanced transoral approaches. However, they can still be utilized with excellent long-term functional results in certain cases of advance oropharyngeal cancers not amenable to transoral approaches. With careful reconstruction of oropharyngeal defects, over 90% of patients can achieve a completely oral diet.

Clinical outcome and health-related quality-of-life following microsurgical reconstruction in patients with oral and oropharyngeal cancer

CONCLUSION

Radial forearm free flap (RFFF) and fibula free flap (FFF) provide high safety and reliability with low incidence of free flap failure and an acceptable level of complications and health-related quality-of-life (HRQoL).

OBJECTIVES

To determine the clinical outcomes and long-term HRQoL in patients with oral or oropharyngeal cancer following free flap reconstruction.

METHODS

A retrospective review of medical records and self-administered HRQoL questionnaires, EORTC QLQ-C30, and -H&N35. All patients who underwent surgery for oral or oropharyngeal cancer followed by primary reconstruction by RFFF or FFF at Rigshospitalet between September 2001 and November 2011 were included.

RESULTS

The study comprised 19 patients still alive out of 61 patients. The free flap success rate was 94.7%. Early post-operative complications occurred in 11 patients (57.9%); however, only three cases (15.8%) required re-surgery. Nine patients (47.4%) developed late complications, including mandibular osteoradionecrosis in six cases (31.6%). Most patients obtained acceptable values of global quality-of-life and relatively high scores on the functional scales.

Multivariate analysis as an advantageous approach for prediction of the adverse outcome in head and neck microvascular reconstructive surgery

BACKGROUND

The use of a free flap has become a mainstay of reconstruction following the ablative surgery in head and neck. The success rates are about 90%, however, several factors have been described to have an adverse effect on free flap survival.

METHODS

We have performed a retrospective analysis of the treatment outcome of 93 microvascular flaps and evaluated the factors influencing the risk of flap loss including patients' age, body mass index, smoking, general medical history and previous oncological treatment.

RESULTS

Out of 93 flaps the total necrosis have been observed in 15 flaps with gradual improvement in the consecutive years. In individual analysis the patients age, BMI, and comorbidities did not reveal any significant relation. The history of any previous oncological treatment represented a significant adverse factor of success rate (p=0.035), and was even more significant when patients experienced all treatment modalities prior to the reconstructive procedure (p=0.009). Multivariate logistic regression model indicated that only surgery (p=0.0008), chemotherapy (p=0.02), cardiovascular diseases (p=0.05) and patient's age (p=0.02) represented significant factors impairing the success rate.

CONCLUSION

Incorporating multivariate analysis represents important statistical approach for better prediction of free flaps survival in head and neck reconstructive surgery. Incorporation of additional collective information could provide more precise approach in the risk of the flap loss assessment.

Comprehensive analysis of functional outcomes and survival after microvascular reconstruction of glossectomy defects

BACKGROUND

Few studies on tongue reconstruction provide a comprehensive, multidisciplinary analysis examining defect size, flap selection, function, and long-term survival. This report presents the largest study in the literature evaluating free flap reconstruction after glossectomy.

METHODS

A retrospective review of patients undergoing free flap glossectomy reconstruction from 2000 to 2012 was performed.

RESULTS

In this review, 268 patients were identified. Resections involving the tongue only included 59 partial glossectomies, 86 hemiglossectomies, 28 subtotal glossectomies, and 24 total glossectomies. Glossectomies performed with mandibulectomies were analyzed independently for speech and swallowing function (32 partial glossectomies, 18 hemiglossectomies, 8 subtotal glossectomies, and 13 total glossectomies with mandibulectomy). A total of 299 free flaps were performed, with 30 patients receiving two free flaps. Multivariate analysis demonstrating smoking (p = 0.018), composite resections (p < 0.001), and larger resections (total and subtotal glossectomies; p < 0.001) were associated with significantly worse speech results. Advanced age (p = 0.002), radiation (p = 0.003), and larger or composite resections had significantly worse swallowing function (p < 0.001). Patients with a persistent tracheostomy had significantly worse speech and swallowing function (p < 0.001), whereas innervated flaps were associated with superior speech (p = 0.049) and better swallowing function (p = 0.004). The surgical complication rate was 23.5 %, with only one total flap loss. Tumor stage (p = 0.003), positive margins (p < 0.001), lymphovascular invasion (p = 0.023), and chemotherapy (p < 0.001) were associated with significantly worse overall survival. The median overall survival time was 50.5 months (range 39-79 months).

CONCLUSIONS

Although comorbidities and the extent of resection impair both speech and swallowing, reconstruction, particularly with innervated free flaps, still affords the majority of patients' reasonable function.

Reconstructive Surgery for Head and Neck Cancer Patients

The field of head and neck surgery has gone through numerous changes in the past two decades. Microvascular free flap reconstructions largely replaced other techniques. More importantly, there has been a paradigm shift toward seeking not only to achieve reliable wound closure to protect vital structures, but also to reestablish normal function and appearance. The present paper will present an algorithmic approach to head and neck reconstruction of various subsites, using an evidence-based approach wherever possible.

A comprehensive algorithm for oncologic maxillary reconstruction

BACKGROUND

Management of maxillary defects is among the most challenging and controversial areas of head and neck reconstruction. The authors develop a treatment algorithm based on outcomes following free flap reconstruction of various maxillary defects.

METHODS

A review of 246 maxillary free flap reconstructions was performed.

RESULTS

The authors' analysis demonstrated that the palatoalveolar resection predicted use of soft-tissue (n = 200) versus osteocutaneous (n = 46) free flaps, depending on the location and extent of the defect. Whether the orbital floor or the entire orbital contents were resected also had implications for flap choice and whether bone grafts or alloplasts were needed. The perioperative complication rate was 37.8 percent, including a 3.3 percent incidence of flap loss. The long-term complication rate was 12.1 percent, including a 7.5 percent fistula rate. Complications related to orbital floor reconstruction were not dependent on the material used (p = 0.18). Greater than 80 percent speech intelligibility was achieved by 95.1 percent of patients, and 90.6 percent tolerated an unrestricted or soft diet.

CONCLUSIONS

To restore both midfacial form and function, the palatoalveolar defect and the status of the orbital floor and orbital contents must be addressed. Defects that involve the anterior maxilla should be addressed with osteocutaneous free flaps if possible, and posterior defects can often be reconstructed with soft-tissue free flaps. The orbital floor requires rigid reconstruction, with either bone grafts or alloplasts, unless the orbital contents have also been exenterated, in which case a soft-tissue free flap should be used to close the orbital cavity.