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Marginal mandibulectomy for lateral sulcus tumours
EJSO (2004) 30, 804–806
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Marginal mandibulectomy for lateral sulcus tumours K.A. Pathak*, R. Agarwal, M.S. Deshpande Head and Neck Service, Department of Surgical Oncology, Tata Memorial Hospital, Dr. E. Borges Road, Mumbai 400 012, India Accepted for publication 11 May 2004 Available online 3 July 2004
KEYWORDS Gingival neoplasms; Mandibular neoplasms; Surgery-oral; Recurrence; Marginal mandibulectomy
Summary Objective. To report a retrospective series of marginal mandibulectomy for cancers of oral cavity, with special reference to squamous cancers of gingival buccal complex. Methods. Retrospective record review of 107 patients who underwent marginal mandibulectomy between 1994 and 2001. Results. Eighty-three marginal mandibulectomies were done for gingivo-buccal complex cancers. Local failure rate was 16%. The 2-year and 5-year disease free survival rates were 69 and 60%, respectively. The local recurrence free survival at the end of 2 and 5 years were 79 and 70%, respectively. Conclusion. In carefully selected patients, marginal mandibulectomy is an oncologically safe procedure to achieve good local control. Q 2004 Elsevier Ltd. All rights reserved.
Introduction Gingivobuccal complex cancers include cancers of the buccal mucosa, alveolus, gingivobuccal sulcus and retro molar trigone. Choosing the appropriate surgical procedure for management of mandible in patients with oral cancer continues to be a challenge for head and neck surgeons. If conservative mandibular resection can achieve cure rates that are comparable to those with segmental mandibulectomy, the less aggressive option is always preferable.1 Marginal mandibulectomy is a mandible preserving procedure for resection of the cancer of the oral cavity involving the mandible superficially or coming close to it. An understanding of the pattern of spread and routes of tumour *Corresponding author. Tel: þ91-22-2417-7177; fax: þ 91-222414-6937. E-mail address: [email protected]
invasion of the mandible is essential in deciding the appropriate level and extent of mandibular resection in oral squamous cell carcinoma.2 The role of marginal mandibulectomy has been extensively studied in cancers of the floor of mouth, which is more common in the western countries. There are few large studies addressing its application in cancers of gingivo-buccal complex.
Patients and methods We report a retrospective survey of 107 patients who underwent marginal mandibulectomy at our hospital from 1994 to 2001. We analysed the data of 92 patients who had squamous cell carcinoma of oral cavity and had follow up of at least 18 months. Fifteen patients with benign or non-squamous cancers of oral cavity (verrucous hyperplasia,
0748-7983/$ - see front matter Q 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2004.05.010
Marginal mandibulectomy for lateral sulcus tumours
myxoma, spindle cell tumour, malignant melanoma) were excluded. The disease free survival curves were calculated using the Kaplan – Meier method and log rank test was used to study the impact of various prognostic factors.
Results Decision of marginal mandibulectomy was based on detailed clinical examination and a panorex X-ray of the mandible. Sixty-two patients had primary tumour in lower gingivo-buccal complex, 14 in lower alveolus, 12 in floor mouth/tongue and four in retromolar trigone. Five patients had T1 tumour, 45 patients had T2, 22 patients had T3 and 18 patients had T4 disease (due to involvement of skin lesion). Primary tumor was not assessable in two patients who had received prior chemotherapy. Thirty-four patients had well differentiated, 49 had moderately differentiated and nine had poorly differentiated squamous carcinoma. On histopathological examination bone involvement was seen in eight patients. Three patients had received preoperative radiotherapy before presenting to this institute. Post-operative radiotherapy was given in 35 patients. Out of them 23 patients had deep muscle involvement, 29 had high-grade tumors and eight had peri nodal spread of disease. In course of follow up 22 patients developed recurrent disease and six had second primary tumour. Local recurrences were most common (12) followed by regional (7) or locoregional (3) recurrences. Out of the 22 recurrences, 15 were considered for salvage, four by radiotherapy alone, eight by surgery alone and three by combination of surgery and radiotherapy. Only six out of the 15 patients had post salvage disease free survival of over 6 months. Overall local control rate inclusive of salvaged recurrences was 90% at the end of 5 years. Positive surgical margins, grade of tumour and the bone involvement did not significantly correlate with local recurrence, probably because of postoperative radiotherapy in these patients. The 2-year and 5-year disease free survival was 69 and 60%, respectively. The local recurrence free survival at the end of 2 and 5 years were 79 and 70%, respectively.
Discussion The management of early oral cancers has gradually changed after Marchetta (1971)3 showed that the mandible is eroded by direct extension of the
805
tumour rather than by the involvement of the periosteal lymphatics. Mandibular arch preserving procedures are used to prevent the cosmetic and the functional problems arising from the segmental mandibular resection. The choice of surgery for the tumours coming close to the mandible would be either a segmental or a marginal mandibulectomy. Studies have shown a local control rate to be comparable in both the two groups.4,5 Segmental mandibulectomy causes severe functional problems, as the mandibular continuity is lost. The tumour can be adequately removed in marginal mandibulectomy without disrupting the mandibular continuity. Marginal mandibulectomy has been studied mainly for the floor of mouth cancers;6 however, in the Indian subcontinent it is the gingivo-buccal complex tumour that is more prevalent due to use of non-smoked tobacco. There is only a thin layer of tissue between the gingiva and the underlying bone. Patients with gingival lesions have a likely possibility of an early bone involvement. The extent of invasion of the bone may not necessarily correlate with the radiological appearance.4 Clinical judgement should be employed in combination with radiology to increase diagnostic reliability.1,5 Local failure free survival in our study is 79% at 2 years, which is similar to the earlier studies which have reported figures ranging from 864 to 94%.4,5 Local recurrence rate as high as 19% has been reported.5 The reason for a lower local recurrence rate (16%) in our study is possibly due the judicious selection of cases without paramandibular soft tissue involvement. The addition of post-operative radiotherapy for those patients with poor prognostic factors like high grade tumour, margin positivity and bone involvement could also be a reason for low recurrence rate. Pradhan (1987)7 has found a local control rate of 79% in buccal cancers and local control rate of 92% in floor of mouth cancers. The reason for poorer control rate in buccal cancers being the inability to get a good soft tissue margin. We had an overall local control rate of 90%. This high figure is probably due to judicious case selection. Overall disease free survival of 69% at end of 2 years and 60% at the end of 5 years was better than that reported earlier.8 We recommend the use of marginal mandibulectomy for oral cavity cancers especially the gingivo-buccal cancers which may be close to the mandible or erode it superficially, but with out extensive soft tissue spread. In properly selected cases marginal mandibulectomy can achieve good disease control without compromising on cosmesis and function of the mandible.
806
K.A. Pathak et al.
References 1. Werning JW, Byers RM, Novas MA, Roberts D. Preoperative assessment for and outcomes of mandibular conservation surgery. Head and Neck 2001;23:1024—30. 2. Brown JS, Lowe D, Kalavrezos N, D’souza J, Mangennis P, Woolgar J. Patterns of invasion and routes of tumor entry into the mandible by oral squamous cell carcinoma. Head Neck 2002;24:370—83. 3. Marchetta FC, Sako K, Murphy JB. The periosteum of mandible and intraoral carcinoma. Am J Surg 1971;122:711—13. 4. Totsuka Y, Usui Y, Tei K, et al. Results of surgical treatment
5.
6.
7.
8.
for squamous carcinoma of the lower alveolus: segmental vs. marginal resection. Head Neck 1991;13:114—20. Dubner S, Heller KS. Local control of squamous cell carcinoma following marginal and segmental mandibulectomy. Head Neck 1993;15:29—32. Shaha AR. Preoperative evaluation of the mandible in patients with carcinoma of the floor of mouth. Head Neck 1991;13: 398—402. Pradhan SA, Rajpal MR. Marginal mandibulectomy in the management of squamous cancer of the oral cavity. Indian J Cancer 1987;24:167—71. Bahadur S. Marginal resection of the mandible in oral cancer. Indian J Cancer 1994;31:235—9.
www.ejso.com
Marginal mandibulectomy for lateral sulcus tumours K.A. Pathak*, R. Agarwal, M.S. Deshpande Head and Neck Service, Department of Surgical Oncology, Tata Memorial Hospital, Dr. E. Borges Road, Mumbai 400 012, India Accepted for publication 11 May 2004 Available online 3 July 2004
KEYWORDS Gingival neoplasms; Mandibular neoplasms; Surgery-oral; Recurrence; Marginal mandibulectomy
Summary Objective. To report a retrospective series of marginal mandibulectomy for cancers of oral cavity, with special reference to squamous cancers of gingival buccal complex. Methods. Retrospective record review of 107 patients who underwent marginal mandibulectomy between 1994 and 2001. Results. Eighty-three marginal mandibulectomies were done for gingivo-buccal complex cancers. Local failure rate was 16%. The 2-year and 5-year disease free survival rates were 69 and 60%, respectively. The local recurrence free survival at the end of 2 and 5 years were 79 and 70%, respectively. Conclusion. In carefully selected patients, marginal mandibulectomy is an oncologically safe procedure to achieve good local control. Q 2004 Elsevier Ltd. All rights reserved.
Introduction Gingivobuccal complex cancers include cancers of the buccal mucosa, alveolus, gingivobuccal sulcus and retro molar trigone. Choosing the appropriate surgical procedure for management of mandible in patients with oral cancer continues to be a challenge for head and neck surgeons. If conservative mandibular resection can achieve cure rates that are comparable to those with segmental mandibulectomy, the less aggressive option is always preferable.1 Marginal mandibulectomy is a mandible preserving procedure for resection of the cancer of the oral cavity involving the mandible superficially or coming close to it. An understanding of the pattern of spread and routes of tumour *Corresponding author. Tel: þ91-22-2417-7177; fax: þ 91-222414-6937. E-mail address: [email protected]
invasion of the mandible is essential in deciding the appropriate level and extent of mandibular resection in oral squamous cell carcinoma.2 The role of marginal mandibulectomy has been extensively studied in cancers of the floor of mouth, which is more common in the western countries. There are few large studies addressing its application in cancers of gingivo-buccal complex.
Patients and methods We report a retrospective survey of 107 patients who underwent marginal mandibulectomy at our hospital from 1994 to 2001. We analysed the data of 92 patients who had squamous cell carcinoma of oral cavity and had follow up of at least 18 months. Fifteen patients with benign or non-squamous cancers of oral cavity (verrucous hyperplasia,
0748-7983/$ - see front matter Q 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2004.05.010
Marginal mandibulectomy for lateral sulcus tumours
myxoma, spindle cell tumour, malignant melanoma) were excluded. The disease free survival curves were calculated using the Kaplan – Meier method and log rank test was used to study the impact of various prognostic factors.
Results Decision of marginal mandibulectomy was based on detailed clinical examination and a panorex X-ray of the mandible. Sixty-two patients had primary tumour in lower gingivo-buccal complex, 14 in lower alveolus, 12 in floor mouth/tongue and four in retromolar trigone. Five patients had T1 tumour, 45 patients had T2, 22 patients had T3 and 18 patients had T4 disease (due to involvement of skin lesion). Primary tumor was not assessable in two patients who had received prior chemotherapy. Thirty-four patients had well differentiated, 49 had moderately differentiated and nine had poorly differentiated squamous carcinoma. On histopathological examination bone involvement was seen in eight patients. Three patients had received preoperative radiotherapy before presenting to this institute. Post-operative radiotherapy was given in 35 patients. Out of them 23 patients had deep muscle involvement, 29 had high-grade tumors and eight had peri nodal spread of disease. In course of follow up 22 patients developed recurrent disease and six had second primary tumour. Local recurrences were most common (12) followed by regional (7) or locoregional (3) recurrences. Out of the 22 recurrences, 15 were considered for salvage, four by radiotherapy alone, eight by surgery alone and three by combination of surgery and radiotherapy. Only six out of the 15 patients had post salvage disease free survival of over 6 months. Overall local control rate inclusive of salvaged recurrences was 90% at the end of 5 years. Positive surgical margins, grade of tumour and the bone involvement did not significantly correlate with local recurrence, probably because of postoperative radiotherapy in these patients. The 2-year and 5-year disease free survival was 69 and 60%, respectively. The local recurrence free survival at the end of 2 and 5 years were 79 and 70%, respectively.
Discussion The management of early oral cancers has gradually changed after Marchetta (1971)3 showed that the mandible is eroded by direct extension of the
805
tumour rather than by the involvement of the periosteal lymphatics. Mandibular arch preserving procedures are used to prevent the cosmetic and the functional problems arising from the segmental mandibular resection. The choice of surgery for the tumours coming close to the mandible would be either a segmental or a marginal mandibulectomy. Studies have shown a local control rate to be comparable in both the two groups.4,5 Segmental mandibulectomy causes severe functional problems, as the mandibular continuity is lost. The tumour can be adequately removed in marginal mandibulectomy without disrupting the mandibular continuity. Marginal mandibulectomy has been studied mainly for the floor of mouth cancers;6 however, in the Indian subcontinent it is the gingivo-buccal complex tumour that is more prevalent due to use of non-smoked tobacco. There is only a thin layer of tissue between the gingiva and the underlying bone. Patients with gingival lesions have a likely possibility of an early bone involvement. The extent of invasion of the bone may not necessarily correlate with the radiological appearance.4 Clinical judgement should be employed in combination with radiology to increase diagnostic reliability.1,5 Local failure free survival in our study is 79% at 2 years, which is similar to the earlier studies which have reported figures ranging from 864 to 94%.4,5 Local recurrence rate as high as 19% has been reported.5 The reason for a lower local recurrence rate (16%) in our study is possibly due the judicious selection of cases without paramandibular soft tissue involvement. The addition of post-operative radiotherapy for those patients with poor prognostic factors like high grade tumour, margin positivity and bone involvement could also be a reason for low recurrence rate. Pradhan (1987)7 has found a local control rate of 79% in buccal cancers and local control rate of 92% in floor of mouth cancers. The reason for poorer control rate in buccal cancers being the inability to get a good soft tissue margin. We had an overall local control rate of 90%. This high figure is probably due to judicious case selection. Overall disease free survival of 69% at end of 2 years and 60% at the end of 5 years was better than that reported earlier.8 We recommend the use of marginal mandibulectomy for oral cavity cancers especially the gingivo-buccal cancers which may be close to the mandible or erode it superficially, but with out extensive soft tissue spread. In properly selected cases marginal mandibulectomy can achieve good disease control without compromising on cosmesis and function of the mandible.
806
K.A. Pathak et al.
References 1. Werning JW, Byers RM, Novas MA, Roberts D. Preoperative assessment for and outcomes of mandibular conservation surgery. Head and Neck 2001;23:1024—30. 2. Brown JS, Lowe D, Kalavrezos N, D’souza J, Mangennis P, Woolgar J. Patterns of invasion and routes of tumor entry into the mandible by oral squamous cell carcinoma. Head Neck 2002;24:370—83. 3. Marchetta FC, Sako K, Murphy JB. The periosteum of mandible and intraoral carcinoma. Am J Surg 1971;122:711—13. 4. Totsuka Y, Usui Y, Tei K, et al. Results of surgical treatment
5.
6.
7.
8.
for squamous carcinoma of the lower alveolus: segmental vs. marginal resection. Head Neck 1991;13:114—20. Dubner S, Heller KS. Local control of squamous cell carcinoma following marginal and segmental mandibulectomy. Head Neck 1993;15:29—32. Shaha AR. Preoperative evaluation of the mandible in patients with carcinoma of the floor of mouth. Head Neck 1991;13: 398—402. Pradhan SA, Rajpal MR. Marginal mandibulectomy in the management of squamous cancer of the oral cavity. Indian J Cancer 1987;24:167—71. Bahadur S. Marginal resection of the mandible in oral cancer. Indian J Cancer 1994;31:235—9.