Tim A. Iseli

Functional outcomes of fibula and osteocutaneous forearm free flap reconstruction for segmental mandibular defects.

To demonstrate that the osteocutaneous radial forearm free flap provides equivalent functional outcomes and improved morbidity compared to the fibular free flap in mandibular reconstruction.

Outcomes of Salvage Surgery With Free Flap Reconstruction for Recurrent Oral and Oropharyngeal Cancer

To evaluate outcomes of salvage surgery with free flap reconstruction for recurrent squamous cell carcinoma of the oropharynx and oral cavity with increased use of chemoradiotherapy.

Outcomes of static and dynamic facial nerve repair in head and neck cancer.

Determine outcomes associated with nerve grafting versus static repair following facial nerve resection.

Are wider surgical margins needed for early oral tongue cancer

BACKGROUND Traditionally, a 1-cm surgical resection margin is used for early oral tongue tumours. METHODS All tumour stage one (n = 65) and stage two (n = 13) oral tongue cancers treated between January 1999 and January 2009 were followed for a median of 38 months (minimum 12 months). The sites of close and involved margins were histologically reviewed. RESULTS Involved and close margins occurred in 14 and 55 per cent of cases, respectively. The number of involved vs clear or close margins was equivalent in tumour stage one (90 vs 82 per cent), node-negative (100 vs 84 per cent) and perineural or lymphovascular invasion (20 vs 21 per cent) cases. Close or involved margins were similarly likely to be posterior (59 per cent) as anterior (41 per cent, p = 0.22), lateral (57 per cent) as medial (43 per cent, p = 0.34), and mucosal (59 per cent) as deep (41 per cent, p = 0.22). Local recurrence occurred in 28 per cent of cases at a median of 12 months, and was more likely in cases with involved (50 per cent) than clear or close margins (25 per cent, p = 0.10). Disease-free survival was worse in involved margins cases (p = 0.002). CONCLUSION Involved margins are common in early tongue tumours, and are associated with increased local recurrence and worse survival. Close or involved margins occur in all directions and all tumour types. A wider margin may be justified.

Preoperative evaluation of oral tongue squamous cell carcinoma with intraoral ultrasound and magnetic resonance imaging-comparison with histopathological tumour thickness and accuracy in guiding patient management.

The aim of this study was to investigate the correlation between tumour thickness (TT) on intraoral ultrasound (US) and magnetic resonance imaging (MRI) with the histologically determined TT of tongue cancers. Secondary objectives included evaluation of potential confounders that affect this association and the predictive value for simultaneous neck dissection. Eighty-eight consecutive patients referred to the study institution between January 2007 and August 2012 with the presumptive diagnosis of invasive squamous cell carcinoma (SCC) of the tongue were analyzed. Seventy-nine patients had preoperative US and 81 had MRI. Correlation between image-determined TT and histological TT was assessed by Bland-Altman plot and Pearsons correlation coefficient. Potential confounders were assessed by subgroup analysis. Preoperative TT as determined by US demonstrated high correlation and MRI moderate correlation with histological TT. With subgroup analysis, negative associations were biopsy prior to imaging and resection diagnosis other than invasive SCC. Our experience suggests that US could be considered the initial modality of choice for preoperative assessment of TT.

Non-smoking non-drinking elderly females: a clinically distinct subgroup of oral squamous cell carcinoma patients

There is growing interest in non-smoking non-drinking (NSND) patients presenting with oral squamous cell carcinoma (OSCC). There are, however, few published reports of OSCC in the elderly. We describe a subgroup of elderly NSND patients presenting with OSCC. Patients with SCC of the oral cavity were retrospectively assessed from the Head and Neck Oncology Tumour Stream database of the Royal Melbourne Hospital. Epidemiological and clinical data for 169 consecutive patients were reviewed and analysed. NSND patients were more likely to be females with a higher median age at presentation. They were more likely to have maxillary alveolus tumours and oral tongue tumours, with retromolar or mandibular tumours less likely. Second primary tumours for this subgroup were confined to the oral cavity. NSND elderly females experienced a worse disease-specific mortality. We have identified a distinct subgroup of elderly female patients presenting with OSCC not associated with the traditional risk factors of tobacco and alcohol, who have a worse prognosis. Altered management algorithms may prove beneficial for these patients, and further investigation and genetic analysis are required to delineate the aetiology of these carcinomas.

Functional outcomes following secondary free flap reconstruction of the head and neck

To evaluate head and neck patients undergoing secondary (delayed) free flap reconstructions.

Squamous cell carcinoma arising in the skin of a deltopectoral flap 27 years after pharyngeal reconstruction

Development of a second primary squamous cell carcinoma in the skin of a flap used for pharyngeal reconstruction is rare.

Postoperative Reirradiation for Mucosal Head and Neck Squamous Cell Carcinomas

OBJECTIVES To compare toxic effects and functional outcomes of reirradiation with and without salvage surgery for nonnasopharyngeal mucosal head and neck squamous cell carcinoma. DESIGN Retrospective review. SETTING Academic tertiary referral hospital. PATIENTS Between December 1992 and March 2007, a total of 87 patients underwent reirradiation (64 for cure and 23 for palliation). INTERVENTION Patients underwent reirradiation with (n = 38) or without salvage surgery (n = 49). After January 2000 there was increased use of concurrent platinum-based chemotherapy (80% vs 5%) and intensity-modulated radiation therapy (82% vs 0%). MAIN OUTCOME MEASURES Early and late toxic effects of treatment by Radiation Therapy Oncology Group criteria, tracheostomy retention, gastrostomy tube dependence, and survival. RESULTS The median follow-up among patients alive at last contact was 5.0 years. Compared with reirradiation without surgery, postoperative reirradiation was associated with increased early grade 3 to grade 5 toxic effects (50% [19 of 38] vs 29% [14 of 49], P = .04) and with longer median survival (17.3 vs 8.9 months, P < .001). Free-flap reconstruction decreased early toxic effects in the surgical cohort by 16% (from 60% [9 of 15] to 43% [10 of 23], P = .32). Gastrostomy tube dependence (P = .05) and tracheostomy retention (P = .04) have increased since 2000. The median survival for curative patients was 12.5 months. The estimated 2-year survival was 25%, and the estimated 5-year survival was 8%. CONCLUSIONS Reirradiation represents the only chance for cure in patients with unresectable disease. After surgery, reirradiation is performed in patients at high risk of locoregional recurrence and may increase acute toxic effects. However, free-flap reconstruction may reduce toxic effects. Functional outcomes have declined since 2000 likely because of the addition of concurrent platinum-based chemotherapy. Future research may define the subpopulation of postoperative patients for whom survival benefits most outweigh reirradiation toxic effects.

Prophylactic Neck Dissection in Early Oral Tongue Squamous Cell Carcinoma 2.1 to 4.0 mm Depth

Objective. Regional recurrence is common following surgery for T1/T2 oral tongue squamous cell carcinoma (SCC). Tumor depth >4.0 mm is commonly assigned as an indication for prophylactic neck dissection to improve regional control. Prophylactic neck dissection may detect extracapsular extension, a poor prognostic sign where adjuvant chemotherapy is indicated. The hypothesis in this study is that regional recurrence is a significant problem in 2.1- to 4.0-mm-depth tumors, and detection of extracapsular extension may be important in this group. Study Design. Retrospective chart review. Setting. Australian tertiary referral center. Subjects and Methods. Review of all patients with T1/T2 oral tongue SCC treated surgically between January 1991 and January 2009 (n = 81). Results. Twenty-nine prophylactic and 5 therapeutic neck dissections followed for a median 34 months (range, 4-132 months). Tumor depths were 0 to 2.0 mm (n = 15), 2.1 to 4.0 mm (n = 18), 4.1 to 7.0 mm (n = 26), and >7.0 mm (n = 22). Tumors 2.1 to 4.0 mm depth had similar rates of occult nodes as 4.1 to 7.0 mm depth (25% vs 20%). Regional recurrence occurred in 31% overall, 44% in tumors 2.1 to 4.0 mm, and 27% in tumors 4.1 to 7.0 mm depth. Prophylactic neck dissection reduced regional recurrence (17% vs 43%, P = .02). Patients with pathologically negative necks had lower rates of regional recurrence than those with occult nodes (9% vs 50%, P < .01). Extracapsular extension increased regional recurrence (43% vs 7%, P = .02), including 25% of dissected necks with tumor depth 2.1 to 4.0 mm. Conclusions. Regional recurrence is a significant problem in 2.1- to 4.0-mm-depth T1/T2 tongue tumors. Prophylactic neck dissection may improve regional control in patients with adequate primary resection margins and determine need for adjuvant therapies in 2.1- to 4.0-mm-depth tumors.