Functional outcomes and survival of patients with oral and oropharyngeal cancer after total glossectomy

Functional outcomes and complications of total glossectomy with laryngeal preservation and flap reconstruction: A systematic review and meta-analysis

OBJECTIVE

To analyze the functional outcomes and complications of total glossectomy with laryngeal preservation and reconstruction with free or pedicled flaps.

METHODS

A search was conducted using Pubmed/MEDLINE, Cochrane Library, Scopus, and Google Scholar databases. A single arm meta-analysis was performed for feeding tube dependence (FTD), tracheostomy dependence (TD), and speech intelligibility (SI) rates. Peri-operative sequels and complications were evaluated as secondary outcomes.

RESULTS

A total number of 642 patients (median age: 54.2 years; 95% CI 52.1-58) were included. Functional assessment was performed after a median of 12 months (n = 623/642; 95% CI 10.6-12). Overall, the cumulative FTD rate was 22.9% (n = 188/627; 95% CI 10.2-38.7), the TD rate was 7.3% (n = 95/549; 95% CI 1.9-15.8), and the SI was 91.1% (n = 314/409; 95% CI 80.7%-97.8). The cumulative complication rate was 33.1% (n = 592/642). Eighteen patients (n = 18/592; 3.0%) experienced a major fistula, while aspiration pneumonia occurred in 17 cases (n = 17/592; 2.8%).

CONCLUSIONS

Total glossectomy with laryngeal preservation and pedicled/free flaps reconstruction may guarantee good functional results and an acceptable quality of life. Further prospective studies are advised to define clinical guidelines about proper patients' and flaps' selection.

Optimization of total tongue functional reconstruction with the sushi roll technique and its application in pectoralis major myocutaneous flaps

A protuberant shape and sufficient volume are the most important parameters for total tongue reconstruction. The conventional pectoralis major myocutaneous (PMMC) flap undergoes collapse due to atrophy of the denervated muscle. In a new technique, this flap was rolled up like sushi to reshape the neotongue. This study explored the feasibility and effect of the 'sushi roll' technique for precise total functional reconstruction of the tongue using a PMMC flap. Thirty patients scheduled for total glossectomy and PMMC flap reconstruction were recruited. The sushi roll technique was performed in 15 patients and the conventional repair in 15 patients. Outcomes were compared between the two groups. The flap survived in all 30 patients. The sushi roll group showed superior results to the conventional group in terms of time to oral alimentation (P = 0.012) and decannulation (P = 0.041), as well as swallowing function (P = 0.032), speech intelligibility (P < 0.001), shape (P < 0.001), and quality of life score (P < 0.001) at 12 months. The innovative sushi roll technique uses a folding method that utilizes the length rather than the thickness and width of the flap to maintain the volume and protuberance of the neotongue, which results in acceptable function and improved quality of life.

Functional Outcomes After Surgical Resection of Tongue Cancer; A Comparative Study Between Primary Closure, Secondary Intention Healing and Flap Reconstruction

The purpose of the study was to assess and compare the quality of speech and swallowing between three reconstruction options (primary closure-group A, secondary intention healing-group B and flap reconstruction-group C), in small to moderate sized onco-surgical defects of oral tongue. 47 patients fulfilled the eligibility criteria during the study period, of which, 15 belonged to group A, 16 belonged to group B, 16 were in group C. Speech and swallowing assessment was done using Speech Intelligibility Assessment score and MD Anderson Dysphagia Inventory, respectively. The above tests were administered pre-operatively, 1 month and 6 months post-operativey in all the study participants. The average scores of speech intelligibility at 1 month were 66.13% (±19.96), 70.04% (±12.28) and 37.31% (±11.29) for groups A, B and C respectively. Similarly, average long term scores for speech intelligibility in these three groups were 72.7% (±17.72), 83.3% (±12.78) and 52.8% (±11.74) respectively. With regards to swallowing the composite scores at 1 month were 73.67 (±13.69), 68.31 (±16.06) and 41.81 (±5.44), and at 6 months were 83.2 (±10.24), 79.31 (±12.29) and 57.88 (±7.37), respectively for groups A, B and C. All the differences were statistically significant (p < 0.05). Healing by secondary intention offered the best functional outcome in terms of speech intelligibility, and primary closure offered best swallowing outcomes in operated cases of oral tongue. This trial has been registered with the Clinical Trials Registry-India in December 2018 (CTRI Reg. No: CTRI/2018/12/016803).

An alternative surgical technique for advanced tongue/tongue base cancer without free flap reconstruction

BACKGROUND/PURPOSE

Locally advanced tongue or tongue base cancer is recommended to be treated by radical resection that is usually detrimental to physiological functions. This study reports the efficacy and treatment outcome of the patients who had received total glossectomy and laryngeal suspension without lip-split mandibulotomy and free flap reconstruction to preserve laryngopharyngeal function.

METHODS

From 2010 to 2018, 37 consecutive patients who had received the surgery were retrospectively recruited.

RESULTS

The overall five-year survival is 72%. The postoperative dependent rate of feeding tube and tracheostomy largely decreases within 1-year follow-up. Treated by this surgical method, these patients are free from facial disfiguration, donor site morbidity, and destructive mastication and occlusion. It is also feasible to perform this surgical technique in the recurrent cases previously treated by chemoradiation.

CONCLUSION

Total glossectomy with laryngeal suspension can be successfully applied to locally advanced tongue or tongue base cancer, and benefits the patients with improved survival and preserved physiological function. Especially surgeons for free flap reconstruction are understaffed at some regional or district hospitals.

Adding Concomitant Chemotherapy to Postoperative Radiotherapy in Oral Cavity Carcinoma with Minor Risk Factors: Systematic Review of the Literature and Meta-Analysis

When presenting with major pathological risk factors, adjuvant radio-chemotherapy for oral cavity cancers (OCC) is recommended, but the addition of chemotherapy to radiotherapy (POCRT) when only minor pathological risk factors are present is controversial. A systematic review following the PICO-PRISMA methodology (PROSPERO registration ID: CRD42021267498) was conducted using the PubMed, Embase, and Cochrane libraries. Studies assessing outcomes of POCRT in patients with solely minor risk factors (perineural invasion or lymph vascular invasion; pN1 single; DOI ≥ 5 mm; close margin < 2−5 mm; node-positive level IV or V; pT3 or pT4; multiple lymph nodes without ENE) were evaluated. A meta-analysis technique with a single-arm study was performed. Radiotherapy was combined with chemotherapy in all studies. One study only included patients treated with POCRT. In the other 12 studies, patients were treated with only PORT (12,883 patients) and with POCRT (10,663 patients). Among the patients treated with POCRT, the pooled 3 year OS rate was 72.9% (95%CI: 65.5−79.2%); the pooled 3 year DFS was 70.9% (95%CI: 48.8−86.2%); and the pooled LRFS was 69.8% (95%CI: 46.1−86.1%). Results are in favor of POCRT in terms of OS but not significant for DFS and LRFS, probably due to the heterogeneity of the included studies and a combination of different prognostic factors.

Outcomes After Oral Cavity and Oropharyngeal Salvage Surgery

OBJECTIVES

Investigate outcomes following oral cavity and oropharyngeal salvage surgery.

METHODS

Adult patients who underwent salvage surgery for recurrent squamous cell carcinoma of the oral cavity and oropharynx from 1996 to 2018 were analyzed using multivariable Cox proportional hazards regression. Disease-free survival (DFS), overall survival (OS), associated factors, and basic quality measures were analyzed.

RESULTS

One hundred and eight patients (72% oral cavity, 28% oropharynx) were followed for a median of 17.9 months. Median DFS and OS were 9.9 and 21 months, respectively. Surgery with adjuvant chemoradiotherapy compared to surgery alone (hazard ratio [HR] = 0.15, 95% confidence interval [CI]: 0.03-0.78) and negative margins (HR = 0.36, 95% CI: 0.14-0.90) were associated with better DFS, while lymphovascular space invasion (LVSI) (HR = 2.66, 95% CI: 1.14-6.19) and higher stage (III vs. I-II, HR = 3.94, 95% CI: 1.22-12.71) were associated with worse DFS. Higher stage was associated with worse OS (HR = 3.79, 95% CI: 1.09-13.19). Patients were hospitalized for a median of 8 days with 24% readmitted within 30 days. A total of 72% and 38% of patients, respectively, underwent placement of a feeding tube or tracheostomy.

CONCLUSIONS

After oral cavity and oropharyngeal salvage surgery, adjuvant chemoradiotherapy, negative margins, negative LVSI, and lower stage were associated with a lower risk of recurrence. Only lower-stage disease was associated with improved survival. The majority of patients had feeding tubes, half underwent free tissue transfer, a third required tracheostomy, and a quarter was readmitted.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Orocutaneous Fistula After Oral Cavity Resection and Reconstruction: Systematic Review and Meta-Analysis

OBJECTIVE

Orocutaneous fistula (OCF) after reconstruction for oral cavity resection can lead to prolonged hospitalization and adjuvant treatment delay. Few studies have examined factors leading to OCF after oral cavity resection. Primary objective: evaluate overall incidence and factors associated with OCF after oral cavity reconstruction.

DATA SOURCES

Scopus 1960-database was searched for terms: "orocutaneous fistula," "oro cutaneous fistula," "oral cutaneous fistula," "orocervical fistula," "oral cavity salivary fistula."

REVIEW METHODS

English language studies with >5 patients undergoing reconstruction after oral cavity cancer resection were included. About 1057 records initially screened; 214 full texts assessed; 78 full-texts included. PRISMA guidelines were followed, and MINORS criteria used to assess risk of bias. Data were pooled using random-effects model. Primary outcome was OCF incidence. Meta-analysis to determine the effect of preoperative radiation on OCF conducted on 12 eligible studies. Pre-collection hypothesis was that prior radiation therapy is associated with increased OCF incidence. Post-collection analyses: free versus pedicled flaps; mandible-sparing versus segmental mandibulectomy.

RESULTS

Seventy-eight studies were included in meta-analysis of overall OCF incidence. Pooled effect size showed overall incidence of OCF to be 7.71% (95% CI, 6.28%-9.13%) among 5400 patients. Meta-analysis of preoperative radiation therapy on OCF showed a pooled odds ratio of 1.68 (95% CI, 0.93-3.06). OCF incidence was similar between patients undergoing free versus pedicled reconstruction, or segmental mandibulectomy versus mandible-sparing resection.

CONCLUSION

Orocutaneous fistula after oral cavity resection has significant incidence and clinical impact. Risk of OCF persists despite advances in reconstructive options; there is a trend toward higher risk after prior radiation.

Do medial sural artery perforator flaps have better clinical outcomes compared to the rectus abdominis perforator (DIEAP) flap in reconstruction of glossectomy defects? A Prisma guided meta-analysis

BACKGROUND

There is an increasing evidence for the use of thin flaps based on vascular perforators for reconstructive surgeries. The medial sural and deep inferior epigastric artery flaps offer versatility for the reconstruction of major defects of the head and neck.

OBJECTIVES

"Whether medial sural artery perforator (MSAP) flap or rectus abdominis perforator flap is better for the reconstruction of glossectomy defects in terms of functional outcome?"

DATA SOURCES

PubMed, Cochrane Library, clinicaltrials.gov and hand searches.

PARTICIPANTS AND INTERVENTIONS

Patients who underwent tongue reconstruction with either MSAP flap or deep inferior epigastric artery perforator (DIEAP) flap.

STUDY APPRAISAL AND SYNTHESIS METHODS

Based on defined study criteria 6 studies were selected according to Prisma Guidelines. The overall estimated effect was categorized as significant where P < 0.05.

RESULTS

There was no significant difference between both flaps in terms of receptor site complications (P = 0.223). Overall odds ratio (OR) for complications was 1.35 (95% confidence interval [CI]: 0.412-0.736) and the test for overall effect t value was 2.836, P < 0.05. Overall OR was 6.01 (95% CI 0.5-7.45) and the test for overall effect t value was 1.41, P < 0.05 indicating there was a statistical difference in the intelligibility of speech.

LIMITATIONS

Anatomical variations, under-reporting of studies and lack of universal tool for speech intelligibility.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Both the flaps are comparable in terms of functional outcome. Medium-sized defects can be reconstructed with MSAP and composite larger defects would benefit from DIEAP. In females, anterolateral thigh flap still remains the choice for composite reconstructions.

Oncological outcomes in patients undergoing major glossectomy for advanced carcinoma of the oral tongue

INTRODUCTION

Major glossectomy is the treatment of choice in locally advanced tongue cancer. It remains the only option in the presence of recurrent or residual disease. The long-term outcomes for patients undergoing major glossectomy have traditionally been poor, with significant morbidity and poor oncological outcomes. The aim of this study was to report on oncological outcomes in patients undergoing major glossectomy.

METHODS

All patients undergoing major glossectomy between 2014 and 2018 were included in the study. The data of 85 patients with advanced carcinoma of the oral tongue were evaluated. All were under the care of a single surgical and reconstructive team at two hospitals in Mumbai.

RESULTS

The median patient age was 45 years. At the most recent follow-up, 55 patients (65%) were alive, 47 of whom were disease free. Twenty-nine patients (34%) had locoregional recurrence and twenty-five (29%) had distant metastasis. At a median follow-up of 19 months, rates for 2-year locoregional control, disease free survival (DFS) and overall survival (OS) were 69%, 61% and 62% respectively. Perinodal extension demonstrated a trend towards poor DFS (p=0.060), as did perineural invasion (p=0.055). Node positivity was a significant factor for poor OS, DFS and locoregional control. Multiple node involvement was significantly associated with poor OS on multivariate analysis (p=0.002).

CONCLUSIONS

Node positivity and multiple node involvement were associated with poor outcomes. Major glossectomy may be offered as a curative option for selected patients with advanced carcinoma of the oral tongue with node negative or limited neck nodal disease (N1).