End results of 114 extended "commando" operations for retromolar trigone carcinoma

Compartmental surgery for T4b oral squamous cell carcinoma involving the masticatory space

PURPOSE OF REVIEW

This review aims to describe the oncological outcomes of T4b oral squamous cell carcinomas (OSCC) with masticatory space involvement as well as the surgical approaches that are able to achieve compartmental 'en bloc' resection of these lesions.

RECENT FINDINGS

The masticatory space is subdivided into infra-notch and supra-notch spaces according to the axial plane passing through the mandibular notch between the coronoid process and the condyle neck. Compartmental resection for T4b OSCC with masticatory space invasion can be successfully achieved via purely external approaches or combining external and transnasal endoscopic routes. Infra-notch T4b OSCC showed survival outcomes comparable to T4a OSCC, thus prompting treatment with curative intent.

SUMMARY

Compartmental resection of the masticatory space is technically feasible with comprehensive control of tumour margins. Use of a transnasal endoscopic anterior route within a multiportal approach may provide better control of margins at the level of the pterygo-maxillary fissure. Equivalent survival outcomes between T4a and infra-notch T4b OSCC are reported. Thus, a downstaging of the latter to T4a is advisable and compartmental surgery of such advanced lesions could be considered as a first-line treatment option in selected patients.

Oral Cavity Cancer Surgical and Nodal Management: A Review From the American Head and Neck Society

Importance

Lymph node metastases from oral cavity cancers are seen frequently, and there is still inconsistency, and occasional controversies, regarding the surgical management of the neck in patients with oral cancer. This review is intended to offer a surgically focused discussion of the current recommendations regarding management of the neck, focusing on the indications and extent of dissection required in patients with oral cavity squamous cell carcinoma while balancing surgical risk and oncologic outcome.

Observations

The surgical management of the neck for oral cavity cancer has been robustly studied, as evidenced by substantial existing literature surrounding the topic. Prior published investigations have provided a sound foundation on which data-driven treatment algorithms can generally be recommended.

Conclusions

Existing literature suggests that patients with oral cavity cancer should be fully staged preoperatively, and most patients should receive a neck dissection even when clinically N0. Quality standards supported by the literature include separation of each level during specimen handling and lymph node yield of 18 or more nodes. Sentinel lymph node biopsy can be considered in select tumors and within a well-trained multidisciplinary team.

Clinico pathological characteristics and survival outcome in oral cavity cancer with masticator space involvement (T4b) - A single institutional experience

INTRODUCTION

Oral cavity cancer with the masticator space involvement is considered as very advanced localised diseas e and staged as T4b in AJCC 8th edition. NCCN guidelines consider this as inoperable. This study intends to compare the different treatment modalities in T4b oral cavity cancer and their impact on survival.

PATIENTS AND METHODS

This is a retrospective study of 150 patients with T4b oral cavity ca, from 2013to 2015 and follow up data till 31 st July 2019 were collected. All patients had biopsy proven SCC and CT evidence of masticator space involvement.

RESULTS

Total of 150 patients were included. 102 patients had received curative treatment and 48 patients had received palliative treatment. In the curative group 84% were treated with surgery and adjuvant treatment and remaining had received RT with or without chemotherapy. 90% patients in the surgically treated group had attained margin negative resection. 4 year OS in the curatively treated group was 58.9% and in the palliative group was 12%. The surgically treated patients in the curative arm had a significant survival advantage over the patients who had received only RT with or without chemotherapy, (63.5% v/s 34%, p = 0.001).

CONCLUSION

Curatively treated oral cavity cancer with masticator space involvement has survival outcome comparable to the published survival data of those without masticator space involvement. Radical intent treatment, preferably surgery should be offered to all patients with masticator space involvement, if negative margin is anticipated from preoperative imaging.

Surgical treatment and prognosis of posteriorly invading oral cancer: Potential clinical significance of pterygomandibular raphe

Background/purpose

The prognosis of oral squamous cell carcinoma (OSCC) with posterior invasion is poor. We examined whether the pterygomandibular raphe (PMR) is useful for the diagnosis of invasion and determination of surgical methods.

Materials and methods

Of 390 patients with OSCC treated surgically at our hospital between June 2009 and June 2020, 80 patients with posterior invasion were included in the study. Preoperative magnetic resonance imaging was used to classify the lesions into three types: non-contact with PMR (non-contact type), contact with PMR (contact type), and invasion beyond PMR (invasion type). We compared the local control, recurrence, and survival rates of each of the three types.

Results

The invasion type showed a significantly higher recurrence rate than the non-contact type (P < 0.001) and contact type (P = 0.018). Overall survival rate comparisons showed that the invasion type had significantly worse prognosis than the non-contact (P = 0.004) and contact types (P = 0.041).

Conclusion

OSCCs with posterior invasion beyond the PMR showed a poor treatment outcome and, therefore, should be treated with caution. The initial surgery is especially important and must ensure local control. This study indicates that the PMR is an important criterion for surgical method determination and that invasion beyond the PMR is a predictor of local recurrence and poor prognosis.

A systematic review of therapeutic outcomes following treatment of squamous cell carcinoma of the retromolar trigone

Squamous cell carcinoma (SCC) of the retromolar trigone (RMT) is a rare but potentially fatal disease that carries a poor prognosis due to its unique anatomic position. RMT SCCs tend to spread to vital nearby structures, including the tonsillar pillar, masticatory muscles, and underlying mandibular bone, even in their early stages, and aggressive treatment is often warranted. This systematic review appraises and qualitatively analyzes all available literature regarding the survival outcomes and prognosis of RMT SCC. Four databases were searched to identify all eligible articles published since January 1980. Of the 1,248 studies, a total of 15 studies representing 4,838 cases met the inclusion criteria. The evaluated patients had a high rate of advanced tumor stage (T3 or T4: 61.4%), lymph node metastasis (38.8%), and mandibular bone invasion (24%) at the time of diagnosis. Aggressive surgical treatments such as lip-splitting (92%), segmental mandibulectomy (61.1%), radical neck dissection (44.1%), and reconstruction using free flaps (49.5%) was undertaken for 92% of the pooled patient population. The mean rates for local, regional, and systemic recurrence were 23.40%, 8.40%, and 8.50%, respectively. The mean 5-year overall survival rate was 38.90%. Osteonecrosis was noted in 11.6% of the 328 patients who received radiotherapy. In conclusion, RMT SCC is generally associated with high recurrence, low survival, and high postoperative complication rates. Early diagnosis and aggressive treatment are thus warranted. However, significant methodological problems hamper current knowledge. Future studies of this topic that use randomized or cohort designs are thus needed.

Machine Learning Predicts Lymph Node Metastasis in Early-Stage Oral Tongue Squamous Cell Carcinoma

PURPOSE

Early-stage oral tongue squamous cell cancer (OTSCC) has a rate of metastasis to the cervical lymph nodes of 20 to 50%. This study aimed to build and validate 4 machine learning (ML) models to predict the occurrence of lymph node metastasis before and after surgery for early-stage (cT1N0 to cT2N0) OTSCC.

MATERIALS AND METHODS

We designed a retrospective cross-sectional study and reviewed the clinical and pathologic records of patients with early-stage OTSCC. The sample was composed of 2 groups with different node status (positive or negative) and was randomly split into training (70%) and testing (30%) sets. Four common ML algorithms-logistic regression, random forest, support vector machine, and naive Bayes-were used to predict pathologic nodal metastasis of early-stage OTSCC. The area under the receiver operating characteristic curve (AUC), sensitivity, and specificity were used to assess the performance of these models and conventional methods including depth of invasion (DOI), neutrophil-to-lymphocyte ratio (NLR), and tumor budding.

RESULTS

A total of 145 patients (56 with positive and 89 with negative lymph nodes) were included in this study. The performance of ML models was significantly superior to that of conventional prediction methods. The random forest model performed best (AUC, 0.786; sensitivity, 85%; specificity, 75%) and exceeded the performance of NLR (AUC, 0.539; sensitivity, 53.6%; specificity, 53.9%; P = .003). When DOI, worst pattern of invasion, lymphocytic host response, and tumor budding were added to model analysis according to patients' postoperative pathologic records, the support vector machine model performed best (AUC, 0.956; sensitivity, 100%; specificity, 87.5%) and was superior to univariate assessment of tumor budding (AUC, 0.830; sensitivity, 80.9%; specificity, 87.5%, P = .002), DOI (AUC, 0.613; sensitivity, 91.1%; specificity, 31.5%; P < .001), and NLR.

CONCLUSIONS

ML shows a better performance in predicting lymph node metastasis of early-stage OTSCC than conventional prediction methods of DOI, NLR, or tumor budding.

Squamous cell carcinoma of the retromolar trigone: Treatment outcomes

OBJECTIVE

Squamous cell carcinoma (SCC) of the retromolar trigone is uncommon, accounting for 1.4% of all oral cancer cases in Japan. Few studies have examined the optimal treatment for this cancer. The aim of this study was to evaluate the outcome of treatment for primary SCC of the retromolar area.

METHODS

We retrospectively analyzed the outcome and prognosis of 45 patients (38 men, 7 women) with SCC of the retromolar trigone who underwent treatment in our department between July 1992 and March 2011.

RESULTS

Mean age was 62.4 years. Clinical stages were: stage I (n=4, 8.9%); stage II (n=10, 22.2%); stage III (n=5, 11.1%); and stage IVa (n=26, 57.8%). Surgical resection was performed in all patients and 6 patients also received postoperative radiotherapy. Reconstructive surgery using free flaps was performed in 38 patients; postoperative complications occurred in 5 of these patients. The 3-year local control rate was 80%, and the 3-year over all survival rates for stage I, II, III, and IV disease were 100%, 80%, 40%, and 49.2%, respectively. Cause of death was the original disease in 23 cases and other diseases in 2 cases. The most common cause of death from the original disease was cervical lymph node metastasis.

CONCLUSION

The presence of cervical lymph node metastasis was a negative prognostic factor. Marginal mandibulectomy may be selected for patients without distinct bone-marrow infiltration.

Treatment Outcomes of Rare Retromolar Trigone Squamous Cell Carcinoma Using Combined Modalities

Background

Retromolar trigone squamous cell carcinoma is relatively uncommon and due to its complex anatomy has always remained a challenge in terms of loco-regional control and survival. Surgery, radiotherapy, and chemotherapy as combined modalities have been used but high recurrence rates result in poor outcome.

Methods

We have retrospectively evaluated records of 62 patients treated in Head and Neck Oncology unit of Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH and RC), Lahore, Pakistan from 2004 to 2014 who were included based on the criteria of histopathological proven squamous cell carcinoma of retromolar trigone (RMT) treated with radical intent. Diagnostic workup for all patients involved clinical examination, imaging modalities usually magnetic resonance imaging (MRI), computerized tomography (CT), Orthopantomogram (OPG), and chest x-ray (CXR) to evaluate regional and distant metastasis, respectively. Kaplan-Meier survival curves were used to depict survival.

Results

The study was comprised of 36 male and 26 female patients. Treatment modalities used are surgery only (n = 1), radiotherapy alone (n = 13), radiotherapy followed by surgery (n = 10), chemoradiotherapy (n = 16), induction chemotherapy followed by concurrent chemoradiotherapy (n = 19), induction chemotherapy followed by surgery, and radiotherapy (n = 2). Surgical interventions include wide local excisions (n = 6), marginal mandibulectomy (n = 4), and segmental mandibulectomy (n = 4). Surgical margins were clear in 54%, close in 38%, and involved in 8% of patients. AJCC 7th edition showed cT1 8%, cT2 22%, cT3 14%, and cT4 56% while pT1 2%, pT2 3%, and pT4 8%. During follow-up, 18% patients have come up with local recurrence, 22% showed persistent disease while 9% have presented with distant metastasis. The five-year and overall survivals are 38% and 22%, respectively.

Conclusion

Retromolar trigone involvement poses many vital structures at risk of involvement. Late presentation results in involvement of masticator space compromising both mouth opening and surgical outcomes. Surgery and radiotherapy have shown comparable results in disease control. Bone invasion has shown poor outcome in terms of loco-regional control and overall survival.

Intensity-modulated radiotherapy for head and neck surgeons

The development of intensity-modulated radiotherapy (IMRT) has played a major role in improving outcomes and decreasing morbidity in patients with head and neck cancer. This review addresses this vital modality with a focus on the important role of the head and neck surgeon. The technique as well as its benefits and points of caution are outlined, the definitions of tumor and treatment volumes are discussed, and the dose and fractionation are detailed. Following this are several sections dedicated to the role of the head and neck surgeon in the planning of both definitive and postoperative radiotherapy to the primary site and neck. There is a focus throughout on anatomic and surgical considerations; commonly encountered situations are illustrated. With a deeper understanding of this technique and their own pivotal contribution to target delineation, head and neck surgeons will be poised to expand their role and improve cancer care for their patients. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2368-E2373, 2016.

Retromolar trigone squamous cell carcinoma treated with radiotherapy alone or combined with surgery: a 10-year update

PURPOSE/OBJECTIVES

Treatment outcomes were analyzed for patients who received radiotherapy for squamous cell carcinoma of the retromolar trigone at a single institution.

MATERIALS/METHODS

We reviewed the medical records of 110 patients treated with radiotherapy alone (n=36) or radiotherapy combined with surgical resection of the primary tumor (n=74) between June 1966 and October 2013. The median follow-up was 4.5years for all patients and 11.8years for living patients (range, 1.3-23.5years).

RESULTS

The 5-year local-regional control rates after definitive radiotherapy versus surgery and radiotherapy for stages I-III were 52% and 89% and for stage IV they were 46% and 58%, respectively. The 5-year cause-specific survival rates after definitive radiotherapy compared with surgery and radiotherapy for stages I-III were 57% and 82% and for stage IV they were 45% and 43%, respectively. Multivariate analyses revealed that the likelihood of cure was better with surgery and radiotherapy compared with radiotherapy alone (p=0.041).

CONCLUSION

Patients treated with surgery and radiotherapy had a better chance of cure than those treated with radiotherapy alone. Complications of treatment were common in both groups but more common in patients who underwent surgery.

A comparative study of fused FDG PET/MRI, PET/CT, MRI, and CT imaging for assessing surrounding tissue invasion of advanced buccal squamous cell carcinoma

PURPOSE

This study aimed to evaluate the diagnostic value of fused fluorodeoxyglucose positron emission tomography and magnetic resonance imaging (PET/MRI) compared with PET/computed tomography (CT), MRI, and CT in assessing surrounding tissue invasion of advanced buccal squamous cell carcinoma (BSCC).

MATERIALS AND METHODS

PET/CT and MRI were performed in 17 consecutive patients with suspected masticator space invasion of BSCC from CT images. Attenuation-corrected PET and head and neck MRI datasets were registered. For pathologic correlation, 4 regions of interest were examined, including the maxilla, mandible, pterygoid, and masseter muscle. The tumor maximal diameter, measured by different imaging modalities, was correlated with pathology results.

RESULTS

All PET/MRI fusions were verified as well matched using specific anatomic criteria. For pathology results, 1 patient had inflammation only, 1 had spindle cell cancer, and 15 had squamous cell cancer. Of 64 regions of interest, 20 (31.3%) harbored tumor invasion. The likelihood ratio was highest in fused PET/MRI (42.56) compared with PET/CT (25.02), MRI (22.94), and CT (8.6; all P < 0.05). The sensitivity and specificity of fused PET/MRI were also highest among the 4 modalities (90.0%/90.9%, 80.0%/84.1%, 80.0%/79.5%, and 55.0%/81.8%, respectively). The level of confidence was higher in fused PET/MRI or MRI than in PET/CT or CT (85.9%, 85.9%, 70.3%, 73.4%, respectively). The maximal lesion size was 3.0 to 6.0 cm in the pathology specimen. Regression analysis showed better agreement between fused PET/MRI and pathology results.

CONCLUSIONS

Fused PET/MRI is more reliable for focal invasion assessment and tumor size delineation in advanced BSCC compared with PET/CT, MRI, and CT. PET/CT has the lowest confidence level, which may limit its use in the clinical setting.

Population-based study of treatment outcomes in squamous cell carcinoma of the retromolar trigone

BACKGROUND

Carcinoma of the retromolar trigone is relatively uncommon. High rates of local recurrence account for a relatively poor prognosis.

STUDY DESIGN

A population-based historical cohort of 76 cases with biopsy-proven squamous cell carcinoma of the retromolar trigone were studied as a case series. Kaplan-Meier survival curves and log rank test were used for statistical analysis.

RESULTS

The mean age was 67.2 years. Fifty-six patients were male, 45% had T1 or T2 tumors, and 61% were staged as N0. Treatment included radiotherapy in 35%, surgery alone in 26%, surgery and radiotherapy in 23%, and 16% received palliative treatment. The absolute and disease-specific survivals at 5 years were 51.4% and 67.7%, respectively. In patients treated with surgery, the resection margin status predicted the overall 5-year survival (P = .027), with 75% of patients with negative margins surviving 5 years versus a survival of 0% of patients with involved margins.

CONCLUSIONS

Squamous cell carcinoma of the retromolar trigone has a poor survival rate for early-stage disease. Adequate surgical margins can improve survival.

T4b oral cavity cancer below the mandibular notch is resectable with a favorable outcome

According to the AJCC 2002 staging system, squamous cell carcinoma of the oral cavity (OSCC) with T4b is unresectable. Herein, we report on our surgical outcome for T4b OSCC. All patients were enrolled before 2002. From January 1996 to December 2000, 45 consecutive untreated T4b OSCC patients were included. According to the trans-axial plane of the mandibular notch on CT/MRI, seven were supra-notch T4b and 38 were infra-notch T4b tumors. Significantly higher 5-year loco-regional control and survivals were observed in patients with infra-notch T4b than with supra-notch T4b. In the infra-notch group, pN0-1 patients had a significantly higher 5-year loco-regional control and survivals than pN2 patients. Nerve invasion was the sole significant adverse factor for loco-regional control and survivals in the infra-notch T4b group with pN0-1. Our retrospective study demonstrated that OSCC patients of infra-notch T4b with pN0-1 and no nerve invasion might have a favorable surgical outcome.

Postoperative Medical Complications???-Not Microsurgical Complications???-Negatively Influence the Morbidity, Mortality, and True Costs after Microsurgical Reconstruction for Head and Neck Cancer

BACKGROUND

Immediate reconstruction of composite head and neck defects using free tissue transfer is an accepted treatment standard. There remains, however, ongoing debate on whether the costs associated with this reconstructive approach merit its selection, especially considering poor patient prognoses and the high cost of care.

METHODS

A retrospective review of the last 100 consecutive patients undergoing microsurgical reconstruction for head and neck cancer by the two senior surgeons was performed to determine whether microsurgical complications or postoperative medical complications had the more profound influence on morbidity and mortality outcomes and the true costs of these reconstructions.

RESULTS

Two patients required re-exploration of the microsurgical anastomoses, for a re-exploration rate of 2 percent, and one flap failed, for a flap success rate of 99 percent. The major surgical complication rate requiring a second operative procedure was 6 percent. Sixteen percent had minor surgical complications related to the donor site. Major medical complications, defined as a significant risk to the patient's life, occurred in 5 percent of the patients, but there was a 37 percent incidence of "minor" medical complications primarily caused by pulmonary problems and alcohol withdrawal. Postsurgical complications almost doubled the average hospital stay from 13.5 days for those patients without complications to 24 days for patients with complications. Thirty-six percent of the true cost of microsurgical reconstruction of head and neck cancer was due to the intensive care unit and hospital room costs, and 24 percent was due to operating room costs. Postsurgical complications resulted in a 70.7 percent increase in true costs, reflecting a prolonged stay in the intensive care unit and not an increase in operating room costs or regular hospital room costs.

CONCLUSION

Postoperative medical complications in these elderly, debilitated patients related to pulmonary problems and alcohol withdrawal were statistically far more important in negatively affecting the outcomes and true costs of microsurgical reconstruction.

A mandibulectomia marginal no tratamento dos tumores de loja amigdalina e região retromolar

A ressecção do ramo ascendente da mandíbula ocasiona um déficit funcional e estético considerável. OBJETIVO: Comparar a mandibulectomia marginal e segmentar de tumores avançados de loja amigdalina e região retromolar sem envolvimento ósseo mandibular detectado no período pré-operatório, em relação à sobrevida e recidiva loco-regional. Forma de Estudo: Estudo de coorte contemporânea com corte transversal. MATERIAL E MÉTODO: Compararam-se 20 pacientes tratados com mandibulectomia marginal e 22 tratados com mandibulectomia segmentar de outubro de 1994 a dezembro de 2001 em serviço de referência em Cirurgia de Cabeça e Pescoço. RESULTADOS: Dos 20 pacientes tratados com mandibulectomia marginal, 35% morreram com doença, 15% por recidiva local, 15% por recidiva regional e 5% por recidiva loco-regional. Dos 22 pacientes tratados com mandibulectomia segmentar 45,4% morreram pela doença, sendo 31,8% por recidiva local e 13,6% por recidiva à distância. Na análise pelo método de Kaplan-Meier o grupo tratado com mandibulectomia marginal apresentou uma taxa de 55%, e o grupo tratado com ressecção segmentar 45% com p= 0,8329. CONCLUSÕES: A análise dos dois grupos evidenciou que a conservação do ramo ascendente da mandíbula, mesmo em lesões avançadas, sem envolvimento mandibular, não aumenta o índice de recidiva.

Marginal mandibulectomy in the surgical treatment of tonsil and retromolar trigone tumours

Resection of the ascending ramus of the mandible can result in considerable functional and esthetic damage.

AIM

To compare the survival rate and local and regional recurrence in marginal and segmental mandibulectomy for advanced tonsil and retromolar trigone tumours with no mandibular invasion. PLACE AND PERIOD: Reference Head & Neck Service, between October 1994 and December 2001.

MATERIAL AND METHOD

20 stage IV patients undergoing marginal mandibulectomy and 22 undergoing segmental mandibulectomy were compared.

CASE STUDY

a contemporary cross-sectional cohort study.

RESULTS

Of 20 patients undergoing marginal mandibulectomy, 35% died of the disease, 15% due to local recurrence, 15% due to regional recurrence and 5% due to local and regional recurrence. Of 22 patients undergoing segmentary mandibulectomy, 36,4% died of the disease, 31,8% due to local recurrence and 13,6% due to distant recurrence. The Kaplan-Meier analysis showed a 55% survival rate for the marginal mandibulectomy group, and a 45% survival rate for the segmental group (p= 0.8329).

CONCLUSIONS

Analysis of the two groups showed that conservation of the ascending ramus of the mandible, even in advanced lesions with no mandibular involvement, does not increase the recurrence rate.

The effect of surgical resection in the region of the retromolar trigone

Tumours in the mucosa of the retromolar trigone (RMT) are rare, but develop insidiously and spread rapidly into surrounding structures. Resection may require radical dissection beginning usually on the medial side of the mandible. Such surgery can put important structures at risk. The normal anatomy of the RMT and its relations has been studied together with simulated surgical incisions and resections. Tissue removed was processed by histological techniques in order to demonstrate structures excised or damaged by the operation. The simulated incision showed that the lingual nerve, submandibular duct and palatoglossus were at particular risk. This could affect sensation, speech, swallowing and movements of the tongue. The findings pose immediate concerns for surgeons operating in this area. Although cancer surgery often involves sacrificing tissue, care should be taken to preserve structures vital to the patient's oral function without compromising oncological principles.

Surgical outcome of T4a and resected T4b oral cavity cancer

BACKGROUND

The American Joint Committee on Cancer (AJCC) 2002 staging system (AJCC 2002) suggested that squamous cell carcinoma of the oral cavity (OSCC) with T4b is unresectable. The current retrospective results show that selected T4b patients were resectable with favorable outcomes.

METHODS

From January 1996 to December 2000, 103 consecutive untreated T4 OSCC patients (reclassified by AJCC 2002) without carotid artery encasement and skull base extension were eligible for radical treatment. All received head-and-neck magnetic resonance imaging (MRI) and/or computed tomography (CT) scans before operation. The surgical principles were safety margins of > or =1 cm for primary tumors, modified/radical neck dissections for clinical lymph node-positive disease, and supraomohyoid neck dissection for lymph node-negative disease. In all, 95.1% of patients (98 of 103 patients) underwent free-flap reconstructions. Adjuvant radiotherapy or concomitant chemoradiotherapy was administered to those with pathological T4 (AJCC 1997), cervical lymph node metastasis, or close margins (< or =4 mm). Survivals were calculated according to the method of Kaplan and Meier.

RESULTS

In all, 58 patients were classified as having T4a disease and 45 were classified as having T4b disease. No statistical difference was observed in the 5-year local control, neck control, disease-free survival, and overall survival rates between the T4a and T4b groups. In multivariate analyses, pathologic lymph node status (pN0-1 vs. pN2) was found to be the sole independent predictor for T4b for local control (P = .012), disease-free survival (P = .005), and overall survival (P = .008).

CONCLUSIONS

Selected T4b OSCC patients were found to be resectable with outcomes that were comparable to those of T4a OSCC patients and may benefit from radical surgery, free-flap reconstruction, and adjuvant therapy. A pathologic lymph node status of > or =2 was found to be the sole independent predictor for T4b disease in local control and survival.

Treatment of Squamous Cell Carcinoma of the Retromolar Trigone

OBJECTIVES

Retromolar trigone (RMT) squamous cell carcinoma is uncommon but notorious for poor prognosis. We reviewed our experience in the management of RMT cancer to determine survival rates and to identify prognostic factors.

METHODS

Fifty patients with RMT squamous cell carcinoma were treated with surgery and/or radiation or chemoradiation therapy between July 1993 and June 2004 at Chang Gung Memorial Hospital, Taiwan. Patients were followed up for 3 to 106 months (mean, 36 months). There were 6 stage I, 13 stage II, 4 stage II, and 27 stage N patients.

RESULTS

The 5-year actuarial survival rate for stage I to N and all stages were 100%, 74.1%, 75%, 43.6%, and 60.6%, respectively. Seventeen (34%) patients had maxilla bone (11 [22%]) or mandible bone (9 [18%]) invasion. Eleven (22%) patients had masticator space involvement. Cervical metastasis rate was 26%. Multivariate analysis revealed that masticator space involvement, neck recurrence, and cervical metastasis were poor prognosticators of survival by order. The maxilla bone was more apt to be involved by RMT cancer than the mandible. Patients with masticator space involvement had a 5-year actuarial survival rate of 22.5% and the mean survival time was only 37.8 months.

CONCLUSIONS

RMT squamous cell carcinomas are aggressive tumors. The maxilla is more apt to be involved than the mandible. Deep infiltration of the masticator space and invasion of the maxilla and mandible worsen the prognosis.

Prognostic factors in salvage surgery for recurrent oral and oropharyngeal cancer

BACKGROUND

Therapeutic decisions in recurrent oral and oropharyngeal squamous carcinoma (SCC) remain controversial.

METHODS

Two hundred forty-six consecutive patients who underwent salvage surgery for recurrent squamous cell carcinoma (SCC) of the oral cavity and oropharynx were studied. The tumor sites were lip, 33 cases; oral cavity, 143; oropharynx, 70. The previous treatment was surgery in 73 patients, radiotherapy in 96, combined surgery and radiotherapy in 76, and chemotherapy in one. The clinical stage of recurrence was I/II in 51 cases and III/IV in 195 cases. The disease-free interval (DFI) was less than 1 year in 156 cases and greater than 1 year in 90 cases.

RESULTS

The rate of recurrence was 54.9%, and the overall 5-year actuarial survival rate was 32.3%. The significant prognostic factors in multivariate analysis were restage (p = .049) and DFI (p = .045).

CONCLUSION

Patients with recurrent oral and oropharyngeal SCC at initial clinical stages (rCS I and II) and with a DFI greater than 1 year had a favorable prognosis.

Superiorly based and island masseter muscle flaps for repairing oropharyngeal defects

INTRODUCTION

Tumours of the posterior part of the mouth and/or the oropharynx are often diagnosed at advanced stages. Reconstruction in this region has advanced considerably during the last three decades. Although microsurgery has offered major progress and has obviously improved the patients' outcome, the use of local and regional flaps generally remains an ideal solution for reconstruction.

MATERIAL AND METHODS

Between January 1994 and December 2001, the defects resulting from resection in 22 out of 38 patients with retromolar and/or anterior faucial pillar squamous cell carcinomas treated at this institution, were repaired by one of two types of masseter muscle flaps. The first type is the superiorly based or cross-over masseter muscle flap, and the second type the island muscle flap (being a modification of the first type).

RESULTS

The superiorly based masseter muscle flap was used in 12 patients and the island masseter muscle flap in 10. Both techniques offer a quick and reliable method for repairing oropharyngeal defects in oncologically "safe" cases. Neither require elaborate technique or aftercare.

CONCLUSION

The island masseter muscle flap has an advantage over the superiorly based masseteric flap, as it is more flexible, pliable for larger defects, and causes no postoperative trismus.

Retromolar trigone squamous cell carcinoma treated with radiotherapy alone or combined with surgery

BACKGROUND

Treatment outcomes were analyzed for retromolar trigone squamous cell carcinoma.

METHODS

Between June 1966 and August 2003, 99 patients were treated with radiotherapy alone (35 patients) or radiotherapy combined with surgery (64 patients). Followup ranged from 0.2 to 23.8 years (median, 3.3 yrs). All living patients had followup for at least 1 year.

RESULTS

The 5-year local-regional control rates after definitive radiotherapy versus surgery and radiotherapy were as follows: Stages I-III, 51% and 87%; Stage IV, 42% and 62%; and overall, 48% and 71%, respectively. The 5-year cause-specific survival rates after definitive radiotherapy compared with surgery and radiotherapy were as follows: Stages I-III, 56% and 83%; Stage IV, 50% and 61%; and overall, 52% and 69%, respectively. Multivariate analyses revealed that the likelihood of cure was better with surgery and radiotherapy compared with definitive radiotherapy.

CONCLUSIONS

The likelihood of cure after treatment for retromolar trigone squamous cell carcinoma was influenced by the extent of disease and treatment. Patients treated with surgery and radiotherapy had a better outcome than those treated with radiotherapy alone.

Predictive factors of occult metastasis and prognosis of clinical stages I and II squamous cell carcinoma of the tongue and floor of the mouth

The incidence of occult neck metastasis in early stage tumours of the tongue and floor of the mouth varies from 20% to 30%, and the survival rates in 5 years from 73% to 97%. This study analyzes the rates of occult metastasis and prognostic factors for clinical stages I and II squamous cell carcinoma of the tongue and floor of the mouth. The records of patients with squamous cell carcinoma of the tongue and floor of the mouth, without prior treatment and treated by surgery between 1965 and 1998 were reviewed. All cases were re-staged and the surgical specimens were reviewed. This study included 193 patients, 145 men (75.1%), with ages ranging from 29 to 89 years old (mean, 60 years). The tumour site was the tongue in 132 cases (68.4%), the floor of the mouth in 45 (23.3%) and both in 16 (8.3%). With regard to stage, 85 cases were at clinical stage I (44.0%) and 108, clinical stage II (56.0%). One hundred and seventeen patients (60.6%) were submitted to a neck dissection and 27 (23.1%) had metastasic lymph nodes (pN+). The only factor associated with the presence of occult metastasis for all patients was the presence of muscular infiltration (p = 0.020); for tongue tumours the presence of vascular embolization (p = 0.043) and the presence of desmoplastic reaction (p = 0.050); for floor of the mouth tumours and T2 tumors, the histological grade (p = 0.025 and p = 0.035, respectively). Disease-free survival in 5 years was 66.4% and overall survival in 5 years 68.5%. The only factor associated with disease-free survival was the presence of muscular infiltration (p = 0.019) and with overall survival were gender (p = 0.002) and clinical stage (p = 0.031). Tumours of the tongue and floor of the mouth in the initial stages, which had muscular infiltration showed a higher probability of occult metastasis and lower disease-free survival; T2 tumours showed a worse survival as did patients of the male gender.

Management of cancer of the retromolar trigone

Treatment of cancer of the retromolar trigone (RMT) is controversial. While early lesions may be managed with single-modality, more advanced lesions may invade the mandible, pterygoid musculature, and the adjacent mucosa of the tonsillar pillar and soft palate, therefore making therapeutic decisions more complicated. Treatment options traditionally include surgical resection, external beam irradiation, and combined modality therapy. The choice of therapy is dependent on the extent of the tumor, nodal metastasis, and the medical status of the patient and comorbid conditions. The following review outlines the current issues relevant to the diagnosis and therapy of patients with RMT malignancy.

Cancer of retromolar trigone: long-term radiation therapy outcome

BACKGROUND

Cancer of the retromolar trigone is an uncommon head and neck cancer. In this retrospective study, we identified the prognostic factors and evaluated the therapeutic outcomes of patients treated with preoperative radiation therapy (RT), postoperative RT, and RT alone.

METHODS

Between 1971 and 1994, 65 patients with histologically proven epidermoid carcinoma of the retromolar trigone were treated at the Mallinckrodt Institute of Radiology; 10 patients received preoperative RT (30-55.2 Gy), 39 received postoperative RT (46-66.6 Gy), and 15 were treated with RT alone (63-74 Gy). Surgery included 44 composite resections and 7 wide excisions. The minimum follow-up was 5 years.

RESULTS

The 5-year disease-free survival rates were 90% with preoperative RT, 63% with postoperative RT, and 31% with RT alone. The 5-year disease-free survival rates were 76% for patients with T1 disease, 50% for T2, 72% for T3, and 54% for T4. The 5-year disease-free survival rates were 69% for patients with NO disease, 56% for N1, and 26% for N2. The locoregional recurrence rates were 10% (1 of 10) for preoperative RT, 23% (9 of 39) for postoperative RT, and 44% (7 of 16) for RT alone. On multivariate analysis, the significant factors for disease-free survival were treatment modality (p =.002) and N stage (p =.012); for locoregional control it was treatment modality (p =.046); and for distant metastasis it was N stage (p =.002). The incidence of bone necrosis, soft tissue necrosis, and severe trismus was 12% with postoperative RT, 11% with RT alone, and none with preoperative RT.

CONCLUSIONS

Combination surgery with postoperative or preoperative RT offers better locoregional control and disease-free survival than RT alone for epidermoid carcinoma of the retromolar trigone. Lymph node status significantly influences the disease-free survival and distant metastasis rates.

Use of computed tomography in the assessment of mandibular invasion in carcinoma of the retromolar trigone

Carcinomas originating in the retromolar trigone (RMT) are uncommon and characterized by early spread. Determination of mandibular invasion is significant for planning therapy and determining prognosis. For oral cavity cancers in general, CT is reasonably accurate in assessing bone invasion. However, there is a paucity of information specifically addressing the value of CT in the RMT. In this study, the records of patients with biopsy-proven RMT carcinomas treated between 1984 and 1998 were reviewed with attention to preoperative CT scans and histopathologic findings during surgery. Half of the patients who were treated with primary resection had mandibular invasion. Bone invasion was not identified radiographically in 27% of patients with preoperative CT scans. The sensitivity of CT for bone involvement in RMT cancers was 50%, with a negative predictive value of 61.1%. The positive predictive value was 91.1%. These findings suggest that CT is a useful, but potentially inaccurate, predictor of bone invasion in the RMT.

Prognostic significance of the distribution of neck node metastasis from oral carcinoma

BACKGROUND

Carcinoma of the oral cavity presents a high risk for neck metastasis, which reduces the probability of regional control and survival.

OBJECTIVES

The main objective of this study is to analyze prognostic implications of the distribution of neck metastasis in 513 patients with squamous cell carcinoma of the oral cavity.

PATIENTS AND METHODS

All patients underwent surgery from 1970-1992. Tumor stages were I, 63; II, 120; III, 173; and IV, 157. Neck dissections were performed in 448 patients (115 bilateral).

RESULTS

By use of multivariate regression techniques the level of lymph node involvement was the most important prognostic factor (relative risks from 1.8 to 2.5). The following variables were also associated with prognosis: mobility of lymph nodes, sex, T stage, age, and tumor thickness.

CONCLUSIONS

The level of ipsilateral lymph node involvement was the most significant prognostic factor patients with in oral cancer who underwent surgical treatment. A significant decrease in survival also was seen with regard to the involvement of multiple contralateral lymph nodes. Our results support the indication of elective neck dissections in high-risk patients because among the cases that had metastases at follow-up, 50% were not candidates for salvage treatment.

Use of computed tomography in the assessment of mandibular invasion in carcinoma of the retromolar trigone

Carcinomas originating in the retromolar trigone (RMT) are uncommon and characterized by early spread. Determination of mandibular invasion is significant for planning therapy and determining prognosis. For oral cavity cancers in general, CT is reasonably accurate in assessing bone invasion. However, there is a paucity of information specifically addressing the value of CT in the RMT. In this study, the records of patients with biopsy-proven RMT carcinomas treated between 1984 and 1998 were reviewed with attention to preoperative CT scans and histopathologic findings during surgery. Half of the patients who were treated with primary resection had mandibular invasion. Bone invasion was not identified radiographically in 27% of patients with preoperative CT scans. The sensitivity of CT for bone involvement in RMT cancers was 50%, with a negative predictive value of 61.1%. The positive predictive value was 91.1%. These findings suggest that CT is a useful, but potentially inaccurate, predictor of bone invasion in the RMT.

Factors influencing contralateral lymph node metastasis from oral carcinoma

BACKGROUND

An ipsilateral neck dissection is mandatory during initial treatment stages II-IV oral carcinomas. However, no consensus exists whether or not to perform an elective contralateral neck dissection.

METHODS

Five hundred thirteen consecutive cases of squamous cell carcinoma (269 tongue, 135 floor of the mouth, 44 inferior gingiva, 65 retromolar trigone) were reviewed. Tumor stages were: 69 T1, 227 T2, 217 T3-T4, 263 N0, 250 N1-N3. A total of 563 neck dissections were performed in 448 patients. Univariate and multivariate analysis of risk factors were performed using logistic regression.

RESULTS

Two hundred twenty-three patients (49.8%) had positive nodes in the specimen (182 ipsilateral, 36 bilateral, 5 contralateral). Contralateral neck recurrences occurred in 38 cases (33 not submitted to a contralateral neck dissection initially). Multivariate logistic regression analysis demonstrated that clinical stage (p = .0001), tumor crossing midline (p = .0011), and floor of the mouth involvement (p = .0236) were the most important predictors of contralateral metastasis.

CONCLUSION

The contralateral side of the neck is a common and potentially preventable site of recurrence in tumors of the oral cavity. The multivariate model obtained discriminates patients with low and high risk (more than 20%) of contralateral metastasis. The application of this mathematical model can be useful for the indication of contralateral neck dissections, because not all tumors crossing midline are associated to a high risk (stages I and II tumors not involving the floor of the mouth) and not all tumors not crossing midline are at low risk (stages III and IV tumors involving the floor of the mouth).

Results of a prospective trial on elective modified radical classical versus supraomohyoid neck dissection in the management of oral squamous carcinoma. Brazilian Head and Neck Cancer Study Group

BACKGROUND

Elective treatment of the neck in oral squamous cell carcinoma has changed over the last 20 years. The main object of this report is to present the results of a multi-institutional prospective study designed to compare standard treatment with modified radical classical neck dissection (MRND) to supraomohyoid neck dissection (SOH) in the management of the clinically negative neck in oral cancer patients.

PATIENTS AND METHODS

A total of 148 patients were included in the trial. All patients had previously untreated T2 to T4 N0 squamous cell carcinoma of the oral tongue (62 cases), floor of the mouth (49 cases), inferior gingiva (12 cases), or retromolar trigone (25 cases). Tumor stages were T2, 91; T3, 27; and T4, 30. There were no significant imbalances between groups.

RESULTS

The false-negative rate was 28%, and most positive nodes were sited at level II and III. Complications were seen in 41% of MRND patients and in 25% of SOH patients (P = 0.043). Median total duration of hospitalization was 9 days in MRND patients and 7 days in the SOH group. To date, 19 and 16 patients presented with local and neck recurrences, respectively. The 60-month actuarial survival rates were 63% in the MRND group and 67% in the SOH group (P = 0.7150).

CONCLUSIONS

This study demonstrates that the recurrence and survival rates were similar in both groups. SOH neck dissection can be recommended as standard elective treatment for patients with T2-T4 oral squamous cell carcinomas.