Mandibulotomy access to tumour sites: fewer complications for postoperative compared with preoperative radiotherapy

Predictors of survival in advanced oral cancers after salvage surgery with free tissue flap reconstruction

OBJECTIVE

To identify prognostic factors for patients with advanced persistent, recurrent, or 2nd primary oral cavity squamous cell carcinoma (OCSCC) potentially unsuitable for salvage surgery with free tissue flap (FTF) reconstruction.

MATERIALS AND METHODS

A population-based cohort of 83 consecutive patients with advanced OCSCC who underwent salvage surgery with FTF reconstruction at a tertiary referral centre between 1990 and 2017. Retrospective uni- and multivariable analyses were performed to identify factors affecting all-cause mortality (ACM), i.e., overall survival (OS), as well as disease-specific mortality (DSM), i.e., disease-specific survival (DSS) after salvage surgery.

RESULTS

Median disease-free interval until recurrence was 15 months with recurrent stage I/II in 31% and III/IV in 69%. Median age at salvage surgery was 67 years (range 31-87) and the median follow-up (alive patients) 126 months. At 2, 5, and 10 years after salvage surgery, respectively, DSS rates were 61%, 44%, and 37% and OS rates 52%, 30%, and 22%. Median DSS was 26 and OS 43 months. Multivariable analysis identified recurrent clinical regional (cN-plus) disease [HR 3.57; p < .001] and elevated gamma-glutamyl transferase (GGT) [HR 3.30; p = .003] as independent pre-salvage predictors for poor OS after salvage, whereas initial cN-plus [HR 2.07; p = .039] and recurrent cN-plus disease [HR 5.14; p < .001] predicted poor DSS. Among post-salvage factors, extranodal extension according to histopathology [HR ACM 6.11; HR DSM 9.99; p < .001] as well as positive [HR ACM 4.98; DSM 7.51; p < 0.001] and narrow surgical margins [HR ACM 2.12; DSM HR 2.80; p < 0.01] emerged as independent factors for poor survival.

CONCLUSION

While salvage surgery with FTF reconstruction is the primary curative option for patients with advanced recurrent OCSCC, the present findings may help guide discussions with patients who have advanced recurrent regional disease and high GGT preoperatively, especially if there is a small chance of reaching surgical radicality.

Osteoradionecrosis After Mandibulotomy and Marginal Mandibulectomy in Patients With Oral Cancer

Objectives Osteoradionecrosis is one of the most severe complications in patients with head and neck cancer, which is characterized by persistent exposed and devitalized bone without proper healing after radiation. The extent to which mandibulotomy and marginal mandibulectomy influence the occurrence of osteoradionecrosis remains unclear. This study evaluated the incidence and risk factors for developing osteoradionecrosis of the mandible after oral cancer treatments. Methods A retrospective study was performed to analyze medical records of patients who underwent surgery and postoperative radiotherapy for oral cancers from 2009 to 2019 at a tertiary care hospital. Patient characteristics, incidence, and risk factors for developing osteoradionecrosis were reviewed. Comparisons between continuous and categorical data were performed using t-test and Chi-squared test. Cox regression analysis was used to assess the association between factors and the development of osteoradionecrosis. Results Among the 61 patients included in the study, osteoradionecrosis of the mandible occurred in 9 of 32 (28.1%) patients who underwent mandibular surgery during oral cancer resection (marginal mandibulectomy and/or mandibulotomy) and 2 of 29 (6.9%) patients without mandibular surgery. The development of osteoradionecrosis was significantly associated with performing mandibular surgery (hazard ratio 4.64, 95% confidence interval: 1.002, 21.5) and HIV infection (hazard ratio 8.53, 95% confidence interval: 2.2, 33.3). In the subgroup analysis of mandibular surgery, the development of osteoradionecrosis significantly increased in patients undergoing mandibulotomy (hazard ratio 6.62, 95% confidence interval: 1.3, 34.8) but not in patients undergoing marginal mandibulectomy (hazard ratio 3.56, 95% confidence interval: 0.6, 22.0). The analysis also showed that concurrent chemoradiation, radiation doses ≥ 60 Gy, and smoking were potential risk factors for the development of osteoradionecrosis, but none of these factors were statistically significant. Conclusion Our findings suggest that mandibular surgery is a significant risk factor for the development of osteoradionecrosis in patients with oral cancer. Further studies including larger population sizes are required to verify these findings.

Morbidity related to the lip-split mandibulotomy approach: a systematic and narrative review

The lip-split mandibulotomy (LSMA) is an access procedure that has been used in head and neck (H&N) surgery as an aid to surgical resection of inaccessible tumours of the postertior oral cavity and oropharynx. Anecdotal evidence suggests that it has significant morbidity. Voices of concern within the H&N surgical community suggest that it has been abandoned in favour of technological advances such as robotic surgery. We report here the first (to our knowledge) registered systematic review of its kind, documenting the safety and efficiency of LSMA in H&N surgery. We performed a PRISMA-guided systematic review (PROSPERO-registered) and identified reports using a search algorithm in MEDLINE/EMBASE. LSMA-related surgical complications were recorded using the Clavien-Dindo classification. Secondary outcomes included swallowing dysfunction, facial cosmesis, and patient satisfaction recorded in health-related quality of life questionnaires (HRQoL). From 125 studies identified, 54 met the inclusion criteria (3872 patients). The LSMA mortality rate was 0%; we did not identify a single case of perioperative death. The median rate of osteoradionecrosis was 5.4%, whereas fistula formation was 5.7%. Malunion was noted in 4.9%. Other complications (surgical site infection, plate exposure) were around 5%. There was significant between-study variation with regards to swallowing assessment tools, but overall there was no significant difference in outcomes. This was also the case for the HRQoL questionairres. LSMA is a safe procedure with an acceptable rate of complications, and should definitely remain in the armamentarium of H&N surgery.

[Critical aspects of the transmandibular approach to the oral cavity and oropharynx]

BACKGROUND

In the context of tumor surgery, the median mandibulotomy as an access route to the oral cavity and oropharynx provides an excellent overview of the surgical site. However, it is not regarded entirely unproblematic with regard to early and later complications that may arise.

OBJECTIVE

The results and complications of the median mandibulotomy will be presented based on data collected from our own patient collective.

MATERIALS AND METHODS

A total of 21 patients who had undergone a median mandibulotomy as part of tumor surgery at the Department of Otorhinolaryngology of the SRH Zentralklinikum Suhl were examined over a period from 01 January 2010 to 31 December 2020. The patient files were retrospectively evaluated.

RESULTS

A stair-step median mandibulotomy was performed in all 21 patients. Reconstruction was performed using a 2.8 mm thick angled mandibular plate and bicortical locking screws. The mean follow-up period was 29.8 months. In all, 7 patients (33%) had a recurrence at the time of surgery; 5 patients (24%) had already undergone pre-radiation. Furthermore, 18 patients (85.7%) received adjuvant radiotherapy. We found plate loosening or extrusion in 0 of 21 cases. A salivary fistula (4.7%) was observed in 1 patient. Trismus was found in 4 (19%) cases during follow-up. Osteoradionecrosis was found in 2 (9.5%) of 21 cases. Cosmetic deficits were not observed.

CONCLUSION

Our results show that the stair-step median mandibulotomy in combination with a 2.8 mm thick reconstruction plate and bicortical locking screws leads to a stable and safe reconstruction even with pre-irradiated situations. Plate loosening or extrusion did not occur.