Derrick I. Wallace

Mucoepidermoid carcinoma: A clinicopathologic study of 80 patients with special reference to histological grading

We sought to review our experience with salivary mucoepidermoid carcinoma (MEC) over two decades to confirm the validity and reproducibility of histologic grading and to investigate MIB-1 index as a prognosticator. Diagnosis was confirmed on 80 cases, and chart review or patient contact was achieved for 48 patients, with follow-up from 5 to 240 months (median 36 months). Immunohistochemistry with citrate antigen retrieval for MIB-1 was performed on a subset of cases. Kaplan-Meier survival curves were generated for each stage, site, and grade according to our proposed grading system. To address the issue of grading reproducibility, 20 slides were circulated among five observers, without prior discussion; slides were categorized as low-, intermediate-, or high-grade according to ones “own” criteria, and then according to the AFIP criteria proposed by Goode et al. 10 Weighted kappa (&kgr;) estimates were obtained to describe the extent of agreement between pairs of rating. The Wilcoxon signed rank test or the Friedman test as appropriate tested variation across ratings. There was no gender predominance and a wide age range (15–86 years, median 49 years). The two most common sites were parotid and palate. All grade 1 MECs presented as Stage I tumors, and no failures were seen for this category. The local disease failure rates at 75 months for grades 2 and 3 MEC were 30% and 70%, respectively. Tumor grade, stage, and negative margin status all correlated with disease-free survival (DFS) (p = 0.0091, 0.0002, and 0.048, respectively). The MIB index was not found to be predictive of grade. Regarding the reproducibility of grading, the interobserver variation for pathologists using their “own” grading, as expressed by the &kgr; value, ranged from good agreement (&kgr; = 0.79) to poor (&kgr; = 0.27) (average &kgr; = 0.49). A somewhat better interobserver reproducibility was achieved when the pathologists utilized the standardized AFIP criteria (average &kgr; = 0.61, range 0.38–0.77). This greater agreement was also reflected in the Friedman test (statistical testing of intraobserver equality), which indicated significant differences in using ones own grading systems (p = 0.0001) but not in applying the AFIP “standardized” grading (p = 0.33). When ones own grading was compared with the AFIP grading, there were 100 pairs of grading “events,” with 46 disagreements/100 pairs. For 98% of disagreements, the AFIP grading “downgraded” tumors. This led us to reanalyze a subset of 31 patients for DFS versus grade, for our grading schema compared with the AFIP grading. Although statistical significance was not achieved for this subset, the log rank value revealed a trend for our grading (p = 0.0993) compared with the Goode schema (p = 0.2493). This clinicopathologic analysis confirms the predictive value of tumor staging and three-tiered histologic grading. Our grading exercise confirms that there is significant grading disparity for MEC, even among experienced ENT/oral pathologists. The improved reproducibility obtained when the weighted AFIP criteria were used speaks to the need for an accepted and easily reproducible system. However, these proposed criteria have a tendency to downgrade MEC. Therefore, the addition of other criteria (such as vascular invasion, pattern of tumor infiltration [i.e., small islands and individual cells vs cohesive islands]) is necessary. We propose a modified grading schema, which enhances predictability and provides much needed reproducibility.

RECONSTRUCTION OF THE HARD PALATE USING THE RADIAL FOREARM FREE FLAP: INDICATIONS AND OUTCOMES

Although prosthetic obturation is the “gold standard” for restoration of hard‐palate defects, obturators can be problematic. We present 10 cases of palatal reconstruction with the radial forearm free flap and compare patient satisfaction with defect‐matched patients rehabilitated with prosthetic obturation.

Radiation-Induced Malignancy of the Head and Neck:

OBJECTIVE: Our goal was to evaluate our experience with radiation-induced malignancy (RIM), compare that experience to the literature, and review treatment modalities. STUDY DESIGN AND SETTING: The setting is the University of Kansas Medical Center. A retrospective review was performed to identify patients with RIM. Patients were included if they met the criteria for RIM as delineated in the literature. RESULTS: Thirteen patients met the criteria for RIM. The mean latency period was 22 years. Sarcomas were the most common type of RIM and the paranasal sinuses were the most common location. Surgical resection was our treatment of choice. CONCLUSIONS: Our patient series differs from previous reports in that sarcomas were the predominating RIM and the paranasal sinuses were the most common location. We noted a shorter latency period than has been previously published. Surgical excision is the treatment of choice. EBM rating: C.

The role of the osteocutaneous radial forearm free flap in the treatment of mandibular osteoradionecrosis.

OBJECTIVE: To evaluate the role of the osteocutaneous radial forearm free flap (OCRFFF) in the treatment of mandibular osteoradionecrosis (ORN). STUDY DESIGN AND SETTING: Retrospective case review of patients who underwent OCRFFF oromandibular reconstruction after resection of nonviable tissue at an academic tertiary care center because of ORN. Patients with reconstructions other than OCRFFF were excluded from this study. RESULTS: Nine patients underwent a composite oromandibular resection for ORN with a reconstruction using an OCRFFF between April 1998 and February 2003. All patients had failed previous less aggressive surgical and medical management of the ORN. Mean follow-up was 36 months (range, 14-67 months). There were no flap failures or significant immediate postoperative or long-term complications observed. All patients had successful restoration of mandibular integrity and continuity, with 100% success rate of stabilization of ORN. All patients were able to tolerate PO diet, with only one third having to supplement their diet with gastrostomy feedings, compared with 89% gastrostomy dependence preoperatively. CONCLUSIONS: Primary or adjuvant radiotherapy for head and neck malignancies can result in ORN of the mandible. This difficult problem often requires surgical intervention. In our experience, the OCRFFF can be successfully used for oromandibular reconstruction, even in the setting of the heavily radiated tissue with excellent postoperative outcomes. SIGNIFICANCE: This is the first study that demonstrates the efficacy of the OCRFFF as a treatment of mandibular ORN.

Use of the 2.0-mm Locking Reconstruction Plate in Primary Oromandibular Reconstruction after Composite Resection

OBJECTIVE: To review our experience with 2.0-mm locking reconstruction plate (LRP) system for patients requiring oromandibular reconstruction. STUDY DESIGN: Retrospective case review of 43 consecutive patients who underwent mandibular composite resection with immediate reconstruction. SETTING: Tertiary care center. RESULTS: Forty-three patients underwent oromandibular reconstruction with the 2.0-mm mandibular LRP system and free flaps containing vascularized bone. Mean follow-up was 11 months. There were no intraoperative difficulties utilizing this system. Two (5%) patients had partial fasciocutaneous flap loss resulting in plate exposure. There were no instances of plate fracture or complications requiring plate removal to date. CONCLUSION: 2.0-mm LRP mandibular system is reliable even in the setting of previous or adjuvant radiation therapy. Its technical ease of application, contouring malleability, and very low profile have proven to be advantageous in oromandibular reconstruction. SIGNIFICANCE: No previous descriptions of use of the 2.0-mm LRP in combination with osteocutaneous free flaps for mandibular reconstruction are found in the literature. EBM rating: C.

Histoplasmosis presenting as upper airway obstruction.

Once considered a rare disease, histoplasmosis is now one of the most common endemic mycotic diseases in the United States, especially in the Ohio and Mississippi River Valleys and the Central United States. Clinical manifestations of histoplasmosis infection are usually seen in immunocompromised hosts. Disease severity may range from fulminate multi-organ disease to single mucosal ulcers. Head and neck manifestations of disseminated histoplasmosis are not uncommon and include oropharyngeal nodules and ulceration. In this case report we discuss an unusual presentation of a laryngeal histoplasmosis lesion masquerading as an ulcerative supraglottic mass and subacute life-threatening upperairway obstruction. Although the otolaryngeal manifestations of histoplasmosis are well described, there were no case reports of subacute airway obstruction identified in our literature review.

The osteocutaneous radial forearm free flap for mandibular osteoradionecrosis

Abstract Objectives: Primary or adjuvant radiotherapy for head and neck malignancies can result in osteoradionecrosis (ORN) of the mandible. This difficult problem often requires surgical intervention. The purpose of this study is to evaluate the role of the osteocutaneous radial forearm free flap (OCRFFF) in the treatment of mandibular ORN. Methods: This study is a retrospective case review of patients who underwent OCRFFF oromandibular reconstruction after resection of nonviable bone due to ORN. Patients with reconstructions other than OCRFFF were excluded from this study. Demographic, previous treatment, intraoperative and postoperative course data were collected. Results: Nine patients underwent a composite oromandibular resection for ORN and had a reconstruction with OCRFFF between April 1998 and February 2003. All patients had failed previous less aggressive surgical and medical management of the ORN. Five of the 9 patients had also previously undergone hyperbaric oxygen therapy. Mean follow-up was 34 months (range, 9–67 months). There were no flap failures or significant immediate postoperative or long-term complications observed. All patients had successful restoration of mandibular integrity and continuity with 100% success rate of clinical stabilization of the ORN process. All patients were able to tolerate PO diet, with only one third having to supplement their diet with gastrostomy feedings, which was a considerable improvement from the preoperative state. Conclusions: In our experience, the OCRFFF can be successfully used for a single-stage oromandibular reconstruction procedure even in the setting of the heavily radiated tissues with excellent postoperative outcomes.

Use of 2.0-mm locking reconstruction plate system in oromandibular reconstruction

Objectives: Reconstruction plates have been used for many years in mandibular reconstruction. The purpose of this study was to review our experience with the 2.0-mm locking reconstruction plate (LRP) system for patients requiring oromandibular reconstruction. Methods: We conducted a retrospective study of 40 patients who have undergone oromandibular reconstruction using the 2.0 mandibular LRP system. The records were reviewed for demographic information, treatment history, size of the defect, radiation exposure, postoperative complications, and cosmesis. Results: 40 patients underwent oromandibular reconstruction with the 2.0 mandibular LRP system. All but 1 patient had reconstruction using vascularized bone containing free flaps. Patient follow-up ranged up to 23 months with the majority being over 1 year. There were no intraoperative difficulties utilizing the plating system. One patient developed minor external plate exposure due to skin flap loss requiring further surgical intervention. However, there have been no instances of plate fracture or complications requiring plate removal to date. Conclusions: There has been significant progress in the design and materials of mandibular reconstruction plating systems. One of the newest advances in this field is the 2.0-mm locking reconstruction mandibular plate system. This system is reliable even in the setting of previous or adjuvant radiation therapy. Its technical ease of application, contouring malleability, and very low profile have proven to be advantageous in oromandibular reconstruction.