Systematic review of minimally-invasive reconstructive options for oral cavity defects

The oral cavity is a primary site for malignant neoplasms of the head and neck region. Surgery, with or without adjuvant therapy, offers the highest probability of cure by focusing on radical tumour removal and organ function restoration. Reconstructive options are represented by local and free flaps, while small defects can be managed without reconstruction. For medium-sized defects without bone involvement, local flaps can be a good alternative to free flaps in selected patients. The purposes of this article are to analyse the main minimally-invasive reconstructive techniques in oral cancer surgery through a systematic review of the literature and develop a reconstructive algorithm based on the site and size of the defect. We defined minimally-invasive reconstruction as any reconstructive option not involving flap dissection from the neck or other distant areas from the oral cavity. Options considered include: local myo-mucosal or mucosal flaps (based on the facial or buccal arteries, and palatal flap), Bichat’s fat pad flap, and nasolabial flap. Use of biological or synthetic materials is also described. In selected patients with small to moderate-sized defects, the possibility of reconstruction with local flaps can be a viable option.

Compartmental tongue surgery for intermediate-advanced squamous cell carcinoma: A multicentric study

BACKGROUND

A multicentric study was conducted on technical reproducibility of compartmental tongue surgery (CTS) in advanced tongue cancers (OTSCC) and comparison to standard wide margin surgery (SWMS).

METHODS

We studied 551 patients with OTSCC treated by CTS and 50 by SWMS. Oncological outcomes were analyzed. A propensity score was performed to compare survival endpoints for the two cohorts.

RESULTS

In the CTS group, survival and prognosis were significantly associated with positive lymph-nodes, extranodal extension, depth of invasion and involvement of the soft tissue connecting the tongue primary tumor to neck lymph nodes (T-N tract), independently from the center performing the surgery. SWMS versus CTS showed a HR Cause-Specific Survival (CSS) of 3.24 (95% CI: 1.71-6.11; p < 0.001); HR Loco-Regional Recurrence Free Survival (LRRFS) of 2.54 (95% CI: 1.47-4.40; p < 0.001); HR Overall Survival (OS) of 0.11 (95% CI: 0.01-0.77; p = 0.03).

CONCLUSION

Performing the CTS could provide better CSS and LRRFS than SWMS regardless of the center performing the surgery, in advanced OTSSC.

Beyond the boundaries of compartmental hemiglossectomy: a proposal for an anatomically based classification of surgical approaches to advanced oral tongue squamous cell carcinoma

INTRODUCTION

In the last decade, compartmental surgery (CTS) has been the surgical approach of choice for advanced tumors of the tongue and oral floor.

METHODS

Advanced tumors (cT3-T4) oral tongue squamous cell carcinoma (OTSCC) may extend beyond the lingual septum and involve the contralateral hemitongue, developing along the intrinsic transverse muscle. The disease may then involve the genioglossus muscle and, more laterally, the hyoglossus muscle.

RESULTS

The surgical approach to the contralateral tongue must be guided by anatomic and anatomopathological principles to achieve a safe oncological resection based on the principles of CTS.

CONCLUSION

We propose a schematic classification of glossectomies that extend to the contralateral hemitongue based on the anatomy and pathways of tumor spread.

Endoscopic-assisted multi-portal compartmental resection of the masticatory space in oral cancer: Anatomical study and preliminary clinical experience

OBJECTIVES

To present an anatomical cadaver dissection study and our preliminary surgical experience with endoscopic-assisted multi-portal compartmental resection of the masticatory space (MS) in locally advanced oral squamous cell carcinoma (OSCC) of the retromolar area.

MATERIALS AND METHODS

Two fresh-frozen cadaver heads were dissected in the Laboratory of Anatomy to define the surgical steps of an endoscopic-assisted multi-portal compartmental approach to the MS. After this preclinical anatomical study, patients affected by locally advanced OSCC originating from the retromolar area with extension to the MS were prospectively enrolled and operated at two Italian referral centers for head and neck cancer between October 2019 and May 2020.

RESULTS

Surgical technique of endoscopic-assisted multi-portal compartmental resection of the MS was preclinically defined step by step in 3 phases: transnasal, transoral/trancervical, and multi-portal. Compartmental resection of the MS was successfully completed in all specimens (4 MSs dissected). The surgical technique was subsequently applied in 3 patients affected by primary OSCC of the retromolar area, providing satisfactory results in terms of negative resection margins and local control.

CONCLUSIONS

Multi-portal compartmental resection of the MS combining the transnasal and transoral/transcervical corridors is technically feasible. Such an approach to the MS in locally advanced OSCC provides different angles of incidence to the target and full control of tumor margins.

Anatomically-based transoral surgical approach to early-stage oral tongue squamous cell carcinoma

The mainstream of treatment of early-stage oral tongue squamous cell carcinoma (OTSCC) is represented by transoral resection with "adequate" free margins. Despite that, a precise and shared definition of "adequate margin" is lacking, and so is a standardized transoral surgical technique.The tongue is a symmetrically paired organ, consisting of intertwining intrinsic and extrinsic muscles, which can be distinguished during dissection. Routes of tumoral spread in oral tongue cancer are well-known and should be taken into account during resection. We propose herein a standardized and replicable surgical technique to resect early-stage OTSCC, based on rational anatomical considerations.