Joshua E. Lubek

Gingival carcinoma: retrospective analysis of 72 patients and indications for elective neck dissection.

Gingival squamous cell carcinoma (SCC) is relatively uncommon, and little is known about its metastatic pattern. We retrospectively reviewed 864 consecutive patients with oral SCC who were seen at the University of Maryland Department of Oral and Maxillofacial Surgery (1991-2005), and identified 111 cases of gingival SCC. Inclusion criteria were fulfilled in 72 patients (mean duration of follow up 49 (1-153) months). Mean (range) age was 72 (45-93) years; 41 patients were women and 31 men. Distribution was almost equal: mandible 35 and maxilla 37. Forty (56%) were in the early stages (pI/II) and 32 (44%) in the later stages (pIII/IV). Twenty-nine patients had primary neck dissections, of whom 7/21 had clear, and 6/8 invaded, cervical nodes. The total number of occult nodal metastases was 9/29 (31%) in the mandible and 14/35 in the maxilla (one patient with initially clear nodes had both invaded nodes at neck dissection and a recurrence in the neck). The number of early compared with late stage occult metastases was 4 of 20 patients (20% T1/T2) and 5 of 9 patients (55% T3/T4) in the mandible and 2 of 22 patients (9% T1/T2) and 2 of 13 patients (15% T3/T4) in the maxilla. Two of 9 patients developed occult nodes within T2 maxillary gingival SCC. Bony invasion was identified in 17 patients (24%) occurring in 8 of 19 patients (42%) with invaded nodes compared with 9 of 53 patients (17%) with clear nodes. Overall survival at 2 and 5 years was 53 of 72 patients (74%) and 27 of 72 patients (38%) respectively. Elective neck dissection is indicated for all stages of mandibular gingival tumours and T3/T4 carcinomas of the maxillary gingiva. T2 maxillary SCC should be considered for elective neck dissection. Overall disease-free survival was worse among those with cervical metastases (p=0.004) and those who had had marginal resections (p=0.04).

Oral maxillary squamous carcinoma: An indication for neck dissection in the clinically negative neck

This multicenter study was undertaken to characterize the metastatic behavior of oral maxillary squamous carcinoma and to determine the role of selective neck dissection.

Venous Anastomoses Using Microvascular Coupler in Free Flap Head and Neck Reconstruction

PURPOSE This study is a retrospective review of the experience using the venous coupler for head and neck reconstruction over a 3-year period at the University of Maryland Medical Center, Department of Oral and Maxillofacial Surgery. MATERIALS AND METHODS One hundred seventy-eight consecutive cases of microvascular free flaps between May 2007 and September 2010 were retrospectively reviewed. Data were collected by demographic information, flap type, recipient vessels, method of anastomosis, coupler size, coupler orientation, complications associated with coupler, and reconstruction results. Fisher exact test was used for statistical analysis. RESULTS There were 294 anastomotic coupler devices used in 173 flaps, with hand-sewn venous anastomoses performed in 5 patients. The overall flap success rate was 94.9% (169/178). Success rate among cases in which the coupler was used was 95.4% (8/173). Total coupler venous thrombosis rate was 4.0% (7/173), with a statistically significant difference (P < .05) in reference to the number of venous anastomoses performed: 58 cases had a single vein anastomosed, 5 cases developed thrombosis; while the 115 flaps with 2 venous anastomoses, only 2 cases had thrombosis. CONCLUSIONS The microvascular coupler is reliable for venous anastomosis in free flap head and neck reconstruction; dual-vein anastomoses appear to have better results than single-vein anastomoses. Flow coupler has a promising utility in monitoring buried flaps and flaps that are difficult to observe. The microvascular coupler deserves to be more commonly used in free flap head and neck reconstruction.

A Retrospective Analysis of Squamous Carcinoma of the Buccal Mucosa: An Aggressive Subsite Within the Oral Cavity

PURPOSE Squamous carcinoma of the buccal mucosa is relatively uncommon in the North American population. It is considered an aggressive cancer, with difficulty in obtaining negative surgical margins and poor locoregional control. This single-institution retrospective analysis attempted to identify prognostic variables, treatment outcomes, and survival patterns of patients with buccal carcinoma. MATERIALS AND METHODS A retrospective chart review of all patients with buccal carcinoma treated in the Department of Oral and Maxillofacial Surgery, University of Maryland from 1992 through 2008 was conducted. Thirty newly diagnosed and previously untreated patients were reviewed and their outcomes data were analyzed. RESULTS Thirteen female and 17 male patients were identified (mean age, 64 yr). Eighteen patients had early-stage disease (stages I to II). Fifteen patients (50%) developed recurrence, with 13 patients developing local recurrence despite 80% of patients achieving negative surgical margins. The overall nodal metastasis rate was 43%, with an occult nodal rate of 32%. Overall 2- and 5-year survival rates were 69% and 53%, respectively. Thirty-nine percent of patients not receiving adjuvant therapy developed recurrence. Early recurrence tended to occur more commonly and was a poor prognostic indicator of successful salvage. CONCLUSIONS Buccal carcinoma is an aggressive disease, with high rates of locoregional disease recurrence independent of surgical margin status. Elective neck dissection and adjuvant therapy should be considered for early-stage disease. Successful salvage is rare in cases of early recurrence.

An Update on Squamous Carcinoma of the Oral Cavity, Oropharynx, and Maxillary Sinus

There are more than 45,000 new cancer cases involving the head and neck diagnosed each year within the United States. Squamous cell carcinoma accounts for the majority of cases, often occurring within the oral cavity and oropharynx. This article reviews current literature and various controversial topics involving the diagnosis and treatment strategies for patients with oral cavity/oropharyngeal cancers. Although not considered cancer within the oral cavity, maxillary sinus squamous cell carcinoma is discussed.

The role of neck dissection and postoperative adjuvant radiotherapy in cN0 patients with PNI-positive squamous cell carcinoma of the oral cavity.

INTRODUCTION Loco-regional recurrence is one of the main causes of treatment failure in patients with oral squamous cell carcinoma (OSCC). Perineural invasion (PNI) is widely accepted as an oncologic feature strongly associated with aggressive behavior, disease recurrence and poorer prognosis. This study investigated the role of PNI in OSCC patients, regarding the controversial issues of its impact on loco-regional recurrence, neck management and postoperative adjuvant treatment decisions. MATERIALS AND METHODS A total of 367 patients with OSCC were analyzed at a tertiary care cancer center with the purpose of investigating the prognostic significance of PNI regarding neck involvement, local recurrence, regional recurrence and disease-specific survival. Two subgroups of 39 patients each, one with PNI-positive and one with PNI-negative tumors, but otherwise similar histopathological features, were retrospectively analyzed. All patients had negative resection margins, no lympho-vascular invasion and pN0-1 disease without ECS. The mean follow up period was 42.7 months. RESULTS Univariate and multivariate analyses showed that the perineural invasion was an independent prognostic factor for lymph node metastasis and regional recurrence, but not for local recurrence. Elective neck dissection was strongly associated with a lower risk of regional recurrence, as well as with a better disease-specific survival, in PNI-positive cN0 patients. Postoperative radiation therapy appears not to reduce the incidence of recurrence. CONCLUSION Perineural invasion should be considered as an independent predictor for cervical lymph node involvement. Elective neck dissection could therefore be an indicator in improving neck control and subsequently disease-specific survival in cN0 patients with PNI-positive SCC.

Low Prealbumin Level Is a Risk Factor for Microvascular Free Flap Failure

PURPOSE The purposes of this study were 1) to estimate and compare the 1-month survival rates of patients with acute malnutrition (low prealbumin level) and patients who are not malnourished (normal prealbumin level) and 2) to identify risk factors associated with microvascular free flap failure. MATERIALS AND METHODS To address the research purposes, we designed a retrospective cohort study and enrolled a sample composed of patients who underwent head and neck microvascular reconstruction and had prealbumin levels measured in the perioperative period. The primary predictor variable was nutritional status (low vs normal prealbumin level). The primary outcome variable was flap survival. One-month survival rates were estimated by use of Kaplan-Meier survival analyses. Risk factors for free flap failure were identified by use of multivariate marginal Cox proportional hazards modeling. RESULTS The sample was composed of 162 patients who underwent microvascular free tissue transfer during the study enrollment period. The 1-month survival estimates for patients who were and were not malnourished were 76.5% (95% confidence interval [CI], 48.8% to 90.5%) and 95.2% (95% CI, 90.1% to 97.7%), respectively (P = .002). In the adjusted Cox hazards proportions model, acute malnutrition was associated with a 4-fold increased risk of failure (P = .04) in comparison with those patients with a normal nutritional status. CONCLUSIONS Acute malnutrition in patients undergoing microvascular free flap reconstruction in the head and neck region was associated with an increased risk for free flap failure.

Analysis of an implantable venous anastomotic flow coupler: experience in head and neck free flap reconstruction.

Monitoring microvascular free flaps can present a difficult challenge. This is especially true in cases of buried or intra-oral free flaps. The authors conducted a retrospective review of 19 consecutive free flaps for head and neck reconstruction using a novel monitoring device, which combines a venous anastomotic coupler and an implantable microdoppler (Synovis Micro Companies Alliance Inc., Birmingham, AL, USA). 20 venous anastomoses were performed and monitored with the venous flow coupler device. Monitoring ranged from intra-operatively to postoperative day 7 (mean 4.2 days). Accurate flow signal interpretation was correct in 18 of 20 anastomoses (90%) but only 14 of the 20 coupled anastomoses (70%) were monitored for the complete period of time as desired by the surgeons. All 19 flaps survived. The venous anastomotic flow coupler appears to be a reliable adjunct to free flap monitoring and may help to improve it, with early detection of flap compromise and salvage.

Treatment of cT1N0M0 tongue cancer: outcome and prognostic parameters.

PURPOSE The objective of the present study was to summarize the treatment and outcomes of cT1N0M0 tongue cancer for which the management is less defined. MATERIALS AND METHODS A total of 65 consecutive cases of cT1 tongue cancer were retrospectively reviewed. The Fisher exact, χ(2), and Wilcoxon tests were used to statistically analyze the data. RESULTS The tumor depth had a significant relation to the presence of neck metastasis (P < .05). A 3-mm cutoff point provided better predictive value, with a sensitivity of 92.9% and specificity of 43.1%. The biopsy depth combined with palpation was accurate in determining the tumor depth preoperatively in 87.7%. On multivariate analysis, only the tumor site (ventral tongue) and the presence of erythroleukoplakia had any significant relation to disease-free survival (P = .010). CONCLUSIONS Elective neck dissection should be considered for patients with cT1N0 oral tongue squamous carcinoma with a biopsy depth of 3 mm or greater. The biopsy depth, combined with the clinical examination findings, is a useful method to help determine the tumor depth preoperatively.

Head and neck cancer surgery in an elderly patient population: a retrospective review

Should advanced age be a contraindication to the surgical management of head and neck cancer patients? A retrospective chart review was performed of patients aged ≥80 years treated surgically for a head and neck malignancy during the period 1996-2011 in a tertiary care cancer centre. The average follow-up was 32 months. Fifty-three patients were identified (mean age 85 years). Cardiovascular disease was the most prevalent co-morbidity (43%). Forty-five patients (85%) had oral cavity/oropharynx squamous cell carcinoma. Surgeries performed included 40 neck dissections and 12 microvascular free flaps. The average length of hospital stay (LOS) was 6.4 days. An increased LOS was significant in patients requiring free flap reconstruction (P<0.01). There were no perioperative deaths or free flap failures. The most common postoperative complications were cardiovascular (n=8), infection (n=10), and delirium (n=6). Thirty-four patients were discharged directly home. Free flap reconstruction did not adversely affect discharge disposition (P>0.05). More than 75% of patients did not report any major limitations to their activities of daily living. Major head and neck surgical procedures can be tolerated by patients of advanced age using careful patient selection. Age alone should not be a primary factor in the management of head and neck cancer patients.