Patrick Magennis

Survival following primary surgery for oral cancer

The main aims of this article are to report the overall and disease-specific survival of a consecutive series of patients presenting with oral cancer from 1992 to 2002 and to relate survival to clinical and pathological factors. The article uses population-based age-sex mortality rates in the North-West of England to highlight differences in overall and disease-specific survival. 541 patients with oral squamous cell carcinoma presented to the Regional Maxillofacial Unit from 1992 to 2002. Curative treatment favoured radical primary surgery, 10% (52) received primary radiotherapy. These patients were on average 8 years older with more advanced tumours and overall poorer survival at 5 years, 23% (SE 7%). The remainder of the results refer to 489 patients who had primary curative surgery, 40% (194) of whom received adjuvant radiotherapy. The overall survival (OS) was 56% (SE 2%) and the disease-specific survival (DSS) was 74% (SE 2%). There was a local recurrence rate of 10% (50) and the loco-regional recurrence rate was 21% (103). The second primary rate was 7% (35). Survival figures had improved over the 10-year period from 63% DSS for the first 4 years of the study (1992-1995) compared to 81% for the last 3 years (2000-2002). In stepwise Cox regression the two predictors selected for disease-specific survival were pN status and margins (both p<0.001). Age-sex mortality rates for the North-West indicate that 15.0% of the 489 primary surgery patients might have been expected to die within 5 years if they were typical of the general population and the observed difference between all causes and oral-cancer specific survival was 18.3%. These data emphasise the value of disease-specific survival as an indicator of successful treatment in a cohort that tends to be elderly, from social deprived backgrounds, with life styles and comorbidity that influence overall survival.

Factors that influence the outcome of salvage in free tissue transfer

INTRODUCTION The success of salvage techniques for free tissue transfer is well documented. The aim of this study was to identify factors that influenced the results of salvage operations in a group of patients who required early exploration. METHODS From a database survey of 408 patients who had a total of 427 free tissue transfer reconstructions, 65 (16%) returned to the operating theatre within 7 days. A retrospective analysis of their progress was made from the case records. RESULTS The flap chart was found to be highly accurate for the 65 patients who had returned to the operating theatre, reporting two false positives and one false negative. Forty patients had compromised flaps and 25 had haematomas that required evacuation. The commonest problem with flaps was venous congestion (33/40, 83%), and 29 flaps were successfully salvaged (73%). Most successful salvage attempts were made within 24 hours of the end of the initial operation. The salvage rate was higher for the radial fasciocutaneous flaps (25/30, 83%), than for composite flaps (2/7, 29%). A total of 24/427 flaps failed (6%). CONCLUSIONS We now recommend hourly observations of the flap for 24 hours followed by 4-hourly monitoring for 48 hours. Improved monitoring techniques for composite grafts may result in more being salvaged and a better overall survival.

Patterns of invasion and routes of tumor entry into the mandible by oral squamous cell carcinoma.

An understanding of the patterns, spread, and routes of tumor invasion of the mandible is essential in deciding the appropriate level and extent of mandibular resection in oral squamous cell carcinoma.

Quality of life 5-10 years after primary surgery for oral and oro-pharyngeal cancer

This study reports the quality of life in long-term survivors of oral cancer treated by primary surgery. Two hundred and twenty patients were treated at the Regional Maxillofacial Unit between the years 1987 and 1992, of which 48 were alive and disease free in July 1997. Thirty-eight patients self-completed the following questionnaires: University of Washington Quality of Life Scale (UW-QOL), the European Organisation for Research and Treatment of Cancer (EORTC) core QOQ-C30 (v2) and the EORTC Head and Neck (H&N35). Results for this group were compared with the one year findings of a similar prospective cohort treated in 1995. Long-term survivors tended to report a good or excellent quality of life. Quality of life deficits in the long-term survivors were similar to those at one year. However, a larger longitudinal study is required to test this relationship more rigorously. The similarity of domain scores suggests that quality of life evaluation at one year is a useful marker of long-term outcome.

Factors that influence the method of mandibular resection in the management of oral squamous cell carcinoma.

The method of conservative (rim) resection of the mandible is now well established and provides good control of disease in the primary site. There are few audits of this technique in terms of margins of resection for both rim and segmental resection of the mandible. Consecutive previously untreated patients managed with resection of the mandible as part of their treatment for oral and oropharyngeal squamous cell carcinoma were recruited for the study. The presence and extent of tumour invasion of the mandible was recorded and a retrospective analysis made to establish the incidence of unnecessary segmental resections. The invasion rate was 33% (8/35) for rims and 83% (54/65) in segmental resections of the mandible, which compares favourably with previous studies and indicates a reasonable accuracy of resection. In between 6 and 11 of the 62 cases (10-17%) a rim resection could have achieved a satisfactory resection margin and retained a functioning lower border of the mandible. The accuracy of resection in terms of margins was greater for mandibular resections (94% clear margins) than soft tissues (62% clear margins). The number of compromised margins was significantly greater in the invaded rim resection group (P=0.018). This study indicates that a more conservative mandibular resection was possible in a few cases. This is unlikely to have an adverse effect on the close or involved margin rate, which depends mainly on the accuracy of the soft tissue resection. Angling the horizontal rim resection to take into account tumour entry at the point of contact will help to ensure a clear bone margin if a conservative approach to mandibular resection is an option.

Salvage outcomes of free tissue transfer in Liverpool: trends over 18 years (1992–2009)

Reconstruction of surgical defects in the head and neck using microvascular free tissue transfer is reliable with success rates in excess of 95%. Our previous audit (1992-1998) showed that 16% of patients required an early return to theatre, and the overall free flap salvage rate was 73%. The medical records of 37 patients who had required early return to theatre (within 7 days) after free tissue transfer were analysed to ascertain the indication for reoperation, and whether surgical intervention had been successful, taking into account the timing and cause of compromise. The results of a retrospective re-audit (1999-2004 and 2005-2009) showed that the return to theatre rate had reduced to 4% overall because of a reduction in the number of cases: those that required evacuation of a neck haematoma, and venous compromise of fasciocutaneous or perforator free flaps. Salvage of flaps was most successful when done within the first 24h, and in cases of venous compromise. Three percent of free flaps failed without attempted salvage; most were late failures. Overall survival (1992-2009) for composite free flaps (93%) was lower than for fasciocutaneous or perforator free flaps (96%). Between 2005 and 2009 our overall free flap survival rate was 98%.

Postoperative radiotherapy for patients with oral squamous cell carcinoma with intermediate risk of recurrence: A case match study

The purpose of this study was to determine the effect of postoperative radiotherapy (PORT) on recurrence and survival in patients with oral squamous cell carcinoma (OSCC) of intermediate recurrence risk.

What attracts people to a career in oral and maxillofacial surgery? A questionnaire survey

A key aspect of recruiting and retaining the best trainees is identification of the factors that attracted them to OMFS. Although such factors have been examined for medicine in general, we know of no previous study that has looked at those that are specific to OMFS. We distributed a survey online to roughly 1500 people who had registered an interest in OMFS over the past seven years. Personal data, and those about education and employment, were recorded, together with particular factors that drew them to OMFS. Of the 251 trainees who responded, 177 (71%) were interested in a career in OMFS. Differences among sub-groups related to dual qualification, sex, and relationships. Open comments identified the following attractive factors: variety of work, intellectually interesting work, collegiate atmosphere within OMFS, and making a difference to patients. The personalities of those who continued with OMFS training placed high value on achievement, and were more conscientious. The factors identified suggest that the positioning of OMFS as a complex, challenging, and varied hospital-based surgical specialty is key to attracting trainees, and these will be used in future research so that we can move forward from identifying preferences to assessing the relative value placed on those preferences. The data will be useful in the development of strategies to attract new trainees and retain them in the specialty.

Otalgia Article Rides Again: Teeth are rarely to blame

Impacted teeth—teeth which have failed to fully erupt through the gums—are not in themselves symptomatic.1 They can develop an infection where the crown is partially covered by gum. This is called pericoronitis, and pain from this …