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Distraction Osteogenesis in the Irradiated Mandible for Segmental Mandibular Reconstruction
LETTERS TO THE EDITOR J Oral Maxillofac Surg 67:1573-1575, 2009
RE: REGIONAL RELAPSE FROM RESEEDING OF THE HISTOLOGICALLY NEGATIVE NECK BY LARYNGEAL CANCER RECURRENCE AND SALVAGE CHEMORADIATION To the Editor:—The article titled “Regional relapse from reseeding of the histologically negative neck by laryngeal cancer recurrence and salvage chemoradiation” (J Oral Maxillofac Surg 66:2158-2160) succeeds in the final treatment, which is described as salvage chemoradiation by the authors. I appreciate the authors for their success, but I am confused by some insufficient explanations in the text; therefore, I kindly want to ask some questions of the authors. First, after a histopathologic examination that describes positive surgical margins in the inferior part of the specimen, how can we believe that the second tumor is a second primary, even though the authors describe this situation with Braakhuis?1 The first tumor was a supraglottic tumor and, after surgery, inferior margin positivity was demonstrated. The second tumor was a glottic tumor, and the glottis is an inferior part of supraglottis; therefore, it is difficult to think of it as a second primary instead of a recurrence. Second, in the first operation, the patient underwent selective modified neck dissection. Which levels were resected? Also, does this type of neck dissection include the level I lymphatics? Finally, why did the authors not consider salvage surgery for this patient before salvage chemoradiation and accept her as unresectable? I do not believe the masses at the submandibular region and above the stoma would have been operable. MEHMET EKEN, MD ELIF ESRA EKEN, MD Istanbul, Turkey
Reference 1. Braakhuis BJM, Tabor MP, Leemans CR, et al: Second primary tumors and field cancerization in oral and oropharyngeal cancer: Molecular techniques provide new insights and definitions. Head Neck 24:198, 2002
In addition, most head and neck cancer recurrences are detected within the first 2 to 3 years after initial therapy. We, therefore, agree with our respected colleagues that the second lesion that occurred in our patient could have been another primary malignant neoplasm. However, although we could not be absolutely certain, we considered that there was a greater possibility of recurrent disease when the resection margins are tumor positive (compared with negative surgical margins)—which was the case in our patient. Because “the particular treatment of cervical lymphatics in patients with head and neck squamous cell cancers is based substantially on the orderly and predictable spread . . . depending on the primary tumor site,”1 at our institutions, when the primary neoplasm originates from the larynx, selective neck dissection involves the removal of lymph nodes at levels II, III, and IV of the neck. Level I nodes were not removed in our presented case. We concur with our colleagues that said lesions could have been managed by salvage surgery, especially the peristomal tumor (a Sisson type I lesion2—an early condition that is reportedly saved successfully)3; however, because of the previous operations, we believe that further rescue surgery might have been fraught with greater morbidity. FEDERICO L. AMPIL, MD GHALI E. GHALI, MD, DDS Shreveport, LA
References 1. Ferlito A, Rinaldo A: Neck dissection: Historical and current concepts. Am J Otolaryngol 26:289, 2005 2. Sisson GA, Bytell DE, Becker SP: Mediastinal dissection—1976: Indications and newer techniques. Laryngoscope 87:751, 1977 3. Gluckman JL, Hamaker RC, Schuller DE, et al: Surgical salvage for stomal recurrence: A multi-institutional experience. Laryngoscope 97:1025, 1987
doi:10.1016/j.joms.2009.02.009
DISTRACTION OSTEOGENESIS IN THE IRRADIATED MANDIBLE FOR SEGMENTAL MANDIBULAR RECONSTRUCTION
doi:10.1016/j.joms.2008.12.061
In reply:—We thank Drs Eken and Eken for their comments. A second primary cancer is usually considered present (whenever 2 metachronous tumors are observed) if the histologic type of the second neoplasm is different from the first.
To the Editor:—With the recent advent of distraction osteogenesis (DO) for the treatment of segmental mandibular defects after oncologic resection, a new reconstruction method has been added to the armamentarium of the head and neck surgeon. Although good results have been re-
Letters to the Editor are considered for publication (subject to editing and abridgment), provided they are submitted in 1 of 2 ways. If typewritten, they must be submitted in duplicate, signed by all authors, double-spaced, and should not exceed 40 typewritten lines of manuscript text (excluding references). You may also e-mail your Letters to the Editor to [email protected]. The same length limits apply. Letters should not duplicate similar material being submitted or published elsewhere. Letters responding to a recent Journal article must be received within 6 weeks of the article’s publication. Receipt of letters is not acknowledged and there is no guarantee that your letter will be published. We cannot provide prepublication proofs. Submitting the letter constitutes your permission for its publication in any current or subsequent issue or edition of the Journal, in any form or media, now known or hereafter developed.
1573
1574
LETTER TO THE EDITOR might limit the use of DO in the management of mandibular segmental defects. R. GONZÁLEZ-GARCÍA, MD L. NAVAL-GÍAS, MD, DMD, PHD F. J. RODRÍGUEZ-CAMPO, MD Madrid, Spain
References 1. González-García R, Rubio-Bueno P, Naval-Gías L, et al: Internal distraction osteogenesis in mandibular reconstruction: Clinical experience in 10 cases. Plast Reconstr Surg 121:563, 2008 2. Raghoebar GM, Jansma J, Vissink A, et al: Distraction osteogenesis in the irradiated mandible: A case report. J Craniomaxillofacial Surg 33:246, 2005 3. Gantous A, Phillips JH, Catton P, et al: Distraction osteogenesis in the irradiated mandible. Plast Reconstr Surg 93:164, 1994 4. Herford AS: Use of a plate-guided distraction device for transport distraction osteogenesis of the mandible. J Oral Maxillofac Surg 62:412, 2004 5. Holmes SB, Lloyd T, Coghlan KM, et al: Distraction osteogenesis in the mandible in the previously irradiated patient. J Oral Maxillofac Surg 60:305, 2002
doi:10.1016/j.joms.2005.08.027
FIGURE 1. A, Panoramic radiograph showing placement of distraction device over mandibular segmental defect. B, Three-dimensional computed tomography scan showing complete bone formation after distraction procedure.
ported with this technique,1 the role of postoperative radiotherapy remains controversial. Moreover, the clinical use of DO has been limited owing to the unknown effects of distraction in the irradiated mandible.2 Contradictory findings have been reported concerning DO and radiotherapy. Gantous et al,3 in an experimental study of dogs, failed to show a relationship between radiotherapy and DO. In a recent clinical report by Herford,4 2 patients received postoperative radiotherapy as a part of their treatment, with adequate bone formation. However, Holmes et al5 reported on 2 patients treated with radiotherapy who failed to achieve osteogenesis with distraction. Three patients with mandibular segmental defects after tumor resection were recently treated by our group using DO (Fig 1). All 3 had received postoperative radiotherapy with a dose of 62 to 70 Gy. Two patients developed complete new bone formation, but the third did not. Characteristically, good quality soft tissue was present in all 3 patients, and all had a better facial appearance and reposition of the symphyseal region, although uniform results were not obtained in relation to bone formation. The ability of DO to result in a well-defined soft tissue pocket must not be undervalued, because it may facilitate bone grafting repositioning without the use of a vascularized free flap. This finding seems to be in concordance with that reported by Raghoebar et al.2 In relation to the postoperative radiotherapy dose, it has been hypothesized that a threshold might exist above which DO becomes troublesome, probably a cumulative dose of 50 Gy. Because similar radiotherapy cumulative doses were administered to our 3 patients, we cannot support this hypothesis without a careful analysis of all possible factors contributing to bone formation failure. Consequently, additional controlled studies are necessary to assess whether the need for postoperative radiotherapy
META-ANALYSIS STANDARDS To the Editor:—I was most interested to read the original article by Nussbaum et al1 and the letter from Markiewicz and Arce2 and subsequent author response.3 I note that while published in 2008, the article only considered articles published up to 2004, and no dates of submission to and acceptance by your journal were given. It would be interesting to know these details. There is no mention of the 2006 article by Eckelt et al4 entitled ”Open versus closed treatment of fractures of the mandibular condylar process—A prospective randomized multi-centre study.” This was a study that considered all the outcome measures and addressed the shortcomings suggested by Laskin and Best,3 and it was carried out between 2003 and 2005. It is also magnanimous that Laskin and Best3 admit to being “narrow-minded Americans”; however, it would be interesting to know which “prominent investigators” were contacted during preparation—were these also only based in America? I am sure that if the many prominent European investigators (eg, Professors Eckelt and Rasse) had been approached or the authors had contacted either SORG or AO (the 2 largest European organizations carrying out maxillofacial research), then the authors would have been advised of the existence of the trial of Eckelt et al4 and probably its outcome. It is therefore unfortunate that an article published in your journal in 2008 concludes that “There is a need for better standardization of data collection as well as randomization of the patients treated in future studies to accurately compare the 2 methods”1 when such an article was published elsewhere, 2 years earlier. Perhaps we should all be prepared to consider publications from other regions and in different languages to best serve our patients. In addition, this may highlight the need for streamlining of the refereeing and publication processes and earlier E-publishing. RICHARD A. LOUKOTA, FRCS, FDSRCS Leeds, England
RE: REGIONAL RELAPSE FROM RESEEDING OF THE HISTOLOGICALLY NEGATIVE NECK BY LARYNGEAL CANCER RECURRENCE AND SALVAGE CHEMORADIATION To the Editor:—The article titled “Regional relapse from reseeding of the histologically negative neck by laryngeal cancer recurrence and salvage chemoradiation” (J Oral Maxillofac Surg 66:2158-2160) succeeds in the final treatment, which is described as salvage chemoradiation by the authors. I appreciate the authors for their success, but I am confused by some insufficient explanations in the text; therefore, I kindly want to ask some questions of the authors. First, after a histopathologic examination that describes positive surgical margins in the inferior part of the specimen, how can we believe that the second tumor is a second primary, even though the authors describe this situation with Braakhuis?1 The first tumor was a supraglottic tumor and, after surgery, inferior margin positivity was demonstrated. The second tumor was a glottic tumor, and the glottis is an inferior part of supraglottis; therefore, it is difficult to think of it as a second primary instead of a recurrence. Second, in the first operation, the patient underwent selective modified neck dissection. Which levels were resected? Also, does this type of neck dissection include the level I lymphatics? Finally, why did the authors not consider salvage surgery for this patient before salvage chemoradiation and accept her as unresectable? I do not believe the masses at the submandibular region and above the stoma would have been operable. MEHMET EKEN, MD ELIF ESRA EKEN, MD Istanbul, Turkey
Reference 1. Braakhuis BJM, Tabor MP, Leemans CR, et al: Second primary tumors and field cancerization in oral and oropharyngeal cancer: Molecular techniques provide new insights and definitions. Head Neck 24:198, 2002
In addition, most head and neck cancer recurrences are detected within the first 2 to 3 years after initial therapy. We, therefore, agree with our respected colleagues that the second lesion that occurred in our patient could have been another primary malignant neoplasm. However, although we could not be absolutely certain, we considered that there was a greater possibility of recurrent disease when the resection margins are tumor positive (compared with negative surgical margins)—which was the case in our patient. Because “the particular treatment of cervical lymphatics in patients with head and neck squamous cell cancers is based substantially on the orderly and predictable spread . . . depending on the primary tumor site,”1 at our institutions, when the primary neoplasm originates from the larynx, selective neck dissection involves the removal of lymph nodes at levels II, III, and IV of the neck. Level I nodes were not removed in our presented case. We concur with our colleagues that said lesions could have been managed by salvage surgery, especially the peristomal tumor (a Sisson type I lesion2—an early condition that is reportedly saved successfully)3; however, because of the previous operations, we believe that further rescue surgery might have been fraught with greater morbidity. FEDERICO L. AMPIL, MD GHALI E. GHALI, MD, DDS Shreveport, LA
References 1. Ferlito A, Rinaldo A: Neck dissection: Historical and current concepts. Am J Otolaryngol 26:289, 2005 2. Sisson GA, Bytell DE, Becker SP: Mediastinal dissection—1976: Indications and newer techniques. Laryngoscope 87:751, 1977 3. Gluckman JL, Hamaker RC, Schuller DE, et al: Surgical salvage for stomal recurrence: A multi-institutional experience. Laryngoscope 97:1025, 1987
doi:10.1016/j.joms.2009.02.009
DISTRACTION OSTEOGENESIS IN THE IRRADIATED MANDIBLE FOR SEGMENTAL MANDIBULAR RECONSTRUCTION
doi:10.1016/j.joms.2008.12.061
In reply:—We thank Drs Eken and Eken for their comments. A second primary cancer is usually considered present (whenever 2 metachronous tumors are observed) if the histologic type of the second neoplasm is different from the first.
To the Editor:—With the recent advent of distraction osteogenesis (DO) for the treatment of segmental mandibular defects after oncologic resection, a new reconstruction method has been added to the armamentarium of the head and neck surgeon. Although good results have been re-
Letters to the Editor are considered for publication (subject to editing and abridgment), provided they are submitted in 1 of 2 ways. If typewritten, they must be submitted in duplicate, signed by all authors, double-spaced, and should not exceed 40 typewritten lines of manuscript text (excluding references). You may also e-mail your Letters to the Editor to [email protected]. The same length limits apply. Letters should not duplicate similar material being submitted or published elsewhere. Letters responding to a recent Journal article must be received within 6 weeks of the article’s publication. Receipt of letters is not acknowledged and there is no guarantee that your letter will be published. We cannot provide prepublication proofs. Submitting the letter constitutes your permission for its publication in any current or subsequent issue or edition of the Journal, in any form or media, now known or hereafter developed.
1573
1574
LETTER TO THE EDITOR might limit the use of DO in the management of mandibular segmental defects. R. GONZÁLEZ-GARCÍA, MD L. NAVAL-GÍAS, MD, DMD, PHD F. J. RODRÍGUEZ-CAMPO, MD Madrid, Spain
References 1. González-García R, Rubio-Bueno P, Naval-Gías L, et al: Internal distraction osteogenesis in mandibular reconstruction: Clinical experience in 10 cases. Plast Reconstr Surg 121:563, 2008 2. Raghoebar GM, Jansma J, Vissink A, et al: Distraction osteogenesis in the irradiated mandible: A case report. J Craniomaxillofacial Surg 33:246, 2005 3. Gantous A, Phillips JH, Catton P, et al: Distraction osteogenesis in the irradiated mandible. Plast Reconstr Surg 93:164, 1994 4. Herford AS: Use of a plate-guided distraction device for transport distraction osteogenesis of the mandible. J Oral Maxillofac Surg 62:412, 2004 5. Holmes SB, Lloyd T, Coghlan KM, et al: Distraction osteogenesis in the mandible in the previously irradiated patient. J Oral Maxillofac Surg 60:305, 2002
doi:10.1016/j.joms.2005.08.027
FIGURE 1. A, Panoramic radiograph showing placement of distraction device over mandibular segmental defect. B, Three-dimensional computed tomography scan showing complete bone formation after distraction procedure.
ported with this technique,1 the role of postoperative radiotherapy remains controversial. Moreover, the clinical use of DO has been limited owing to the unknown effects of distraction in the irradiated mandible.2 Contradictory findings have been reported concerning DO and radiotherapy. Gantous et al,3 in an experimental study of dogs, failed to show a relationship between radiotherapy and DO. In a recent clinical report by Herford,4 2 patients received postoperative radiotherapy as a part of their treatment, with adequate bone formation. However, Holmes et al5 reported on 2 patients treated with radiotherapy who failed to achieve osteogenesis with distraction. Three patients with mandibular segmental defects after tumor resection were recently treated by our group using DO (Fig 1). All 3 had received postoperative radiotherapy with a dose of 62 to 70 Gy. Two patients developed complete new bone formation, but the third did not. Characteristically, good quality soft tissue was present in all 3 patients, and all had a better facial appearance and reposition of the symphyseal region, although uniform results were not obtained in relation to bone formation. The ability of DO to result in a well-defined soft tissue pocket must not be undervalued, because it may facilitate bone grafting repositioning without the use of a vascularized free flap. This finding seems to be in concordance with that reported by Raghoebar et al.2 In relation to the postoperative radiotherapy dose, it has been hypothesized that a threshold might exist above which DO becomes troublesome, probably a cumulative dose of 50 Gy. Because similar radiotherapy cumulative doses were administered to our 3 patients, we cannot support this hypothesis without a careful analysis of all possible factors contributing to bone formation failure. Consequently, additional controlled studies are necessary to assess whether the need for postoperative radiotherapy
META-ANALYSIS STANDARDS To the Editor:—I was most interested to read the original article by Nussbaum et al1 and the letter from Markiewicz and Arce2 and subsequent author response.3 I note that while published in 2008, the article only considered articles published up to 2004, and no dates of submission to and acceptance by your journal were given. It would be interesting to know these details. There is no mention of the 2006 article by Eckelt et al4 entitled ”Open versus closed treatment of fractures of the mandibular condylar process—A prospective randomized multi-centre study.” This was a study that considered all the outcome measures and addressed the shortcomings suggested by Laskin and Best,3 and it was carried out between 2003 and 2005. It is also magnanimous that Laskin and Best3 admit to being “narrow-minded Americans”; however, it would be interesting to know which “prominent investigators” were contacted during preparation—were these also only based in America? I am sure that if the many prominent European investigators (eg, Professors Eckelt and Rasse) had been approached or the authors had contacted either SORG or AO (the 2 largest European organizations carrying out maxillofacial research), then the authors would have been advised of the existence of the trial of Eckelt et al4 and probably its outcome. It is therefore unfortunate that an article published in your journal in 2008 concludes that “There is a need for better standardization of data collection as well as randomization of the patients treated in future studies to accurately compare the 2 methods”1 when such an article was published elsewhere, 2 years earlier. Perhaps we should all be prepared to consider publications from other regions and in different languages to best serve our patients. In addition, this may highlight the need for streamlining of the refereeing and publication processes and earlier E-publishing. RICHARD A. LOUKOTA, FRCS, FDSRCS Leeds, England