- Email: [email protected]
O150. The current role of the pedicled pectoralis major flap in reconstructive head and neck surgery
Discussion: The ALT flap presents in our study a predictable anatomic pattern in 70% of cases. Flap survival was 100% in the radial branch and 90% in the ALT one. The donor site morbidity by far was higher in the radial branch but when assessed by the patient no significant differences were recorded. Whether the ALT would replace the RF as a main tool for head and neck reconstruction continues to be subject of debate. doi:10.1016/j.oos.2009.06.231
O147. Reconstruction of mid-facial defect with free tissue transfer after surgery of nasal cavity and maxillary sinus cancer Y.H. Joo *, D.I. Sun, J.H. Cho, K.J. Cho, S.H. Cho, M.S. Kim
105
6 months, and 1 year postoperatively).Cosmetic outcome was assessed by naive observers. The cost benefit comparing microvascular reconstruction to obturation was calculated. Results: The average age of the cohort was 62.5. Eighty-five percent were male. Restoration of speech function was achieved, with normal perceptual, acoustic and aeromechanical speech outcomes for all patients across all assessment times. The swallowing results reveal that timely restoration of swallowing function was achieved in all patients. The cosmetic outcomes were rated a good to excellent for all patients. The cost benefit was in favour of obturation in the first four years then in favour of microvascular reconstruction. Conclusions: Microvascular reconstruction of the maxilla results in good cosmetic and functional outcomes. The cost benefit is in favour of obturation in the first four years, then in favour of microvascular reconstruction.
The Catholic University of Korea, Republic of Korea doi:10.1016/j.oos.2009.06.233 Introduction: Post-operative defects of the nasal cavity cancer are difficul to reconstruct because they are large and complicated defects. Large defects of the head and neck are challenging to reconstruct since there may be a three-dimensional requirement of both volume and multiple surfaces of oral lining and external skin. Materials and methods: We conducted a retrospective review of 35 patients who underwent reconstruction between 1999 and 2008. Free flaps were used in 21 patients and local advancement flaps (12 palatal and two temporalis muscle) were transposed in 14 patients. Outcome measures included free flap types, flap success and postoperative functional result. Results: Anterolateral thigh flap were used in 13 of the 20 patients (65%), rectus abdominis free flap in four patients (20%), fibular osteocutaneous free flap in two patients (10%) and radial forearm free flap in one patients (5%), respectively. Free flap survival was 100% with partial flap necrosis in one patient. Return to regular diet was seen in 14 patients (70%), a soft diet in 4 (20%), and a liquid diet in 2 (10%). Speech was accessed as normal in 12 patients (60%), near normal in 6 (30%), intelligible in 2 patients (10%). Conclusions: Free tissue transfer provides the most effective and reliable form of immediate reconstruction for mid-facial defects after maxillectomy. doi:10.1016/j.oos.2009.06.232
O148. Microvascular maxillar reconstruction: functional and cosmetic, cost outcomes H. Seikaly *, J. Rieger, K. Ansari, J.R. Harris University of Alberta, Canada Introduction: Cancer of the maxilla is a devastating disease that affects all aspects of the patients’ life. Treatment has routinely resulted in significant cosmetic and functional deficits. The advent of obturation and more recently free tissue transfer has improved patient outcomes and quality of life. Objective: The purpose of this presentation is to (1) Report the, functional and cosmetic outcomes of a prospective cohort of patients that underwent microvascular reconstruction of the maxilla. (2) Report on the cost benefit of microvascular reconstruction. Methods: Thirty-six consecutive patients that had microvascular reconstruction of the maxilla between 2000 and 2007 were followed prospectively through our Multidisciplinary Head and Neck Surgery Reconstruction Clinic. Swallowing was assessed with videofluoroscopy and a diet questionnaire. Speech was assessed by acoustical, aeromechanical and perceptual measurements. All assessments were performed at four points in time (preoperative and 1 month,
O149. Iliac crest-tensor fascia lata osteomyocutaneous flap for orbitomaxillary reconstruction S. Iyer *, M.A. Kuriakose Amrita Institute of Medical Sciences, Kochi, India The goal of reconstruction of extensive orbital rim and floor following maxillectomy is to provide adequate orbital support to prevent enophthalmos, diplopia and palatal obturation to allow normal speech and swallowing. The existing methods of reconstruction fail to address these two goals simultaneously. A new method of reconstruction of these defects using iliac crest-tensor fascia lata flap is proposed. Results of the cadaver dissection, use of the flap in five clinical cases and its superiority over the existing methods is described. Material and methods: Initial cadaver dissections were carried out to assess the flap and pedicle characteristics. This flap was used in five cases of cancers of the maxilla, which necessitated extensive resection of orbital floor along with maxillectomy. The flap was raised as a muscle and bone flap in three cases and in two, a skin paddle was included. The immediate and delayed outcome at 6month follow up was analyzed. The functional outcome with regard to the ocular position and function, palatal obturation, speech and swallowing were recorded. Results: Cadaver dissection demonstrated that the flap is suitable for reconstructing the orbitomaxillary defects with regard to the tissue and the pedicle characteristics. In the clinical series all the five flaps survived. The pedicle length averaged 7 cm and direct anastomosis was possible to the neck vessels. The delayed outcome assessment showed excellent orbital support with no diplopia. The palatal defect could be obturated successfully in all cases resulting in normal speech and swallowing. The CT scan showed excellent integration in all the cases. Primary closure of the donor site was possible with no evidence of donor site morbidity. Conclusions: Iliac crest-TFL flap is a reliable and safe method of reconstruction of the orbitomaxillary defects. This flap addresses issues of both orbital support and palatal obturation very well. doi:10.1016/j.oos.2009.06.234
O150. The current role of the pedicled pectoralis major flap in reconstructive head and neck surgery C.M.E. Avery *, S.T. Crank, J.P. Hayter University Hospitals of Leicester, United Kingdom
Oral AbstractsPoster ListOrals ListPan. Disc. & Symp. Abs.Keynote Abs.Keynote Bios.ProgramIAOOWelcomeCommittee Listings
Oral abstracts / Oral Oncology Supplement 3 (2009) 56–122
Oral AbstractsPoster ListOrals ListPan. Disc. & Symp. Abs.Keynote Abs.Keynote Bios.ProgramIAOOWelcomeCommittee Listings
106
Oral abstracts / Oral Oncology Supplement 3 (2009) 56–122
Introduction: The pedicled pectoralis major myocutaneous flap has long been superseded as the reconstruction of first choice for major head and neck ablative surgery by the development of free tissue transfer techniques. The aim of this study is to evaluate the current use and indications of the pedicled pectoralis major flap in modern oncological surgical practice. Methods: A 10 year retrospective review between 1997 and 2007. Data recorded included basic demographics, indications for the pectoralis major flap, staging of disease, type of resection, ASA grade, previous surgical treatment and post operative complications. Results: Fifty-two patients were identified and the notes obtained for 50 cases. Seventeen pectoralis major flaps were used to salvage a free flap. The remaining flaps (33) were used as the preferred reconstruction for a variety of indications which included; large volume neck disease with resection of skin (6), salvage surgery (5), in conjunction with free flaps (3), significant medical co-morbidity (8). Twenty-nine patients were treated for a primary SCC of the head and neck of which all patients had Stage IV disease and 15 had recurrent disease. Discussion: The indications for the pectoralis major flap have radically changed but this flap still has an important role in the management of patients with extensive or recurrent disease, and in those compromised by previous radical surgery or significant medical comorbidity. The options for the management of a failed free flap have been evaluated by Wei1 and although a further free flap has been advocated the local wound conditions and/or medical condition may not always favour further free tissue transfer. In this situation the pectoralis major flap is often the preferred option. doi:10.1016/j.oos.2009.06.235 References 1. Wei FC, Demirkan F, Chen HC, et al.. The outcome of failed free flaps in head and neck and extremity reconstruction: What is next in the reconstructive ladder. Plast Reconstr Surg 2001;108:1154–60.
O151. Evaluation of positron-emission and computed tomography (PET-CT) imaging service for patients with malignant cervical lymph nodes and an unknown primary tumour M.J. Monteiro *, K. Altman, J. Herold, G. Burkill, I. Francis, J. Dikomite Brighton and Sussex University Hospitals NHS Trust, United Kingdom Introduction: The prognosis for patients with metastatic cervical lymphadenopathy and an unknown primary tumour is poor. The literature reports a typical survival period of 1 year from diagnosis in these cases. However, a median survival period of 23 months has been documented for such patients who subsequently have the primary tumour site identified and treated with the appropriate therapy. Only 20–27% of primary tumours are identified with conventional radiological imaging, and 24–40% with standard PET scanning. However, a diagnostic rate of 57% has been reported for PET-CT in the detection of all occult primary tumours. This study aims to evaluate the use of PET-CT imaging when applied specifically to the scenario of occult cancer presenting with metastatic cervical lymphadenopathy. Method: All patients with metastatic cervical lymph nodes presenting to the head and neck unit at the Royal Sussex County Hospital between 2004 and 2008, and whose primary tumour could not be identified by standard diagnostic procedures (CT, MRI, EUA), were referred for fast-track whole-body PET-CT by the multi-disciplinary head and neck cancer meeting. The percentage of primary tumours found was calculated.
Results: In 12 (43.5%) of 28 patients referred for PET-CT for metastatic cervical lymphadenopathy of unknown origin, a primary tumour was found. Discussion: These results provide a detection rate higher than that reported with other imaging modalities for occult primary tumours in the head and neck region. This has important implications for treatment and prognosis. Further evaluation in larger patient populations is required. doi:10.1016/j.oos.2009.06.236
O152. Evaluation of molecular markers for the assessment of occult metastasis in lymph nodes in head and neck squamous cell carcinoma A. Suresh, S. Duarah, K.R. Hiran, S. Sundaram, V. Kekatpure, M.A. Kuriakose * Amrita Institute of Medical Sciences, Kochi, India Nodal metastasis is the single most important prognostic marker of head and neck cancer, which determines recurrence, development of distant metastases, and the survival of patients. The management strategies for patients with clinically apparent metastases are now well established while there is no clear consensus on the management of occult nodal metastasis. Attempts were therefore made to identify several clinical, histological and molecular markers that can predict nodal metastasis and enable appropriate treatment of high-risk individuals. Lymphoscintigraphy has now been established as a reliable and a less invasive technique of identifying the first tumor-draining lymph node (sentinel node) and thus providing these sentinel nodes for further analytical studies. Cytokeratin14 has been well investigated as a molecular marker for nodal metastasis and in this study its expression was assessed along with established markers of oral cancer, e1F4E (Eukaryotic translation initiation factor 4E) and Desmoglein 3 (DSG3) in lymph nodes identified by Lymphoscintigraphy in oral cancer patients. Analysis was carried out by the relative quantification using the Quantitative real time PCR and by immunohistochemistry (DSG3 and CK14). 45 nodes were analyzed (40 patients and 5 normals) for the expression of e1F4E and CK14; the combination of both the markers showed a positive predictive value of 0.88 and an increased sensitivity in detecting pathologically negative patients. Comparative analysis of DSG3 expression with CK14 and eIF4E has indicated a higher sensitivity of detection in the nodes and the efficacy of the use of the combination of these markers is currently being evaluated. doi:10.1016/j.oos.2009.06.237
O153. Neck dissections: Factors morbidity R. Walker, V. Bhatt *, N. Barnard
affecting
outcomes
and
Worcestershire Acute Hospitals NHS Trust, United Kingdom Aims and objectives: To study factors affecting morbidity and outcomes following neck dissections in a single head and neck unit. Materials and methods: Retrospective audit of records of all patients who underwent neck dissections at Worcestershire Royal Hospital. One hundred and fifty patients underwent unilateral or bilateral neck dissections in the period between May 2005 and October 2008. Relationship between various demographic and clinico-pathological factors and morbidity will be sought. Outcomes measured in disease
O147. Reconstruction of mid-facial defect with free tissue transfer after surgery of nasal cavity and maxillary sinus cancer Y.H. Joo *, D.I. Sun, J.H. Cho, K.J. Cho, S.H. Cho, M.S. Kim
105
6 months, and 1 year postoperatively).Cosmetic outcome was assessed by naive observers. The cost benefit comparing microvascular reconstruction to obturation was calculated. Results: The average age of the cohort was 62.5. Eighty-five percent were male. Restoration of speech function was achieved, with normal perceptual, acoustic and aeromechanical speech outcomes for all patients across all assessment times. The swallowing results reveal that timely restoration of swallowing function was achieved in all patients. The cosmetic outcomes were rated a good to excellent for all patients. The cost benefit was in favour of obturation in the first four years then in favour of microvascular reconstruction. Conclusions: Microvascular reconstruction of the maxilla results in good cosmetic and functional outcomes. The cost benefit is in favour of obturation in the first four years, then in favour of microvascular reconstruction.
The Catholic University of Korea, Republic of Korea doi:10.1016/j.oos.2009.06.233 Introduction: Post-operative defects of the nasal cavity cancer are difficul to reconstruct because they are large and complicated defects. Large defects of the head and neck are challenging to reconstruct since there may be a three-dimensional requirement of both volume and multiple surfaces of oral lining and external skin. Materials and methods: We conducted a retrospective review of 35 patients who underwent reconstruction between 1999 and 2008. Free flaps were used in 21 patients and local advancement flaps (12 palatal and two temporalis muscle) were transposed in 14 patients. Outcome measures included free flap types, flap success and postoperative functional result. Results: Anterolateral thigh flap were used in 13 of the 20 patients (65%), rectus abdominis free flap in four patients (20%), fibular osteocutaneous free flap in two patients (10%) and radial forearm free flap in one patients (5%), respectively. Free flap survival was 100% with partial flap necrosis in one patient. Return to regular diet was seen in 14 patients (70%), a soft diet in 4 (20%), and a liquid diet in 2 (10%). Speech was accessed as normal in 12 patients (60%), near normal in 6 (30%), intelligible in 2 patients (10%). Conclusions: Free tissue transfer provides the most effective and reliable form of immediate reconstruction for mid-facial defects after maxillectomy. doi:10.1016/j.oos.2009.06.232
O148. Microvascular maxillar reconstruction: functional and cosmetic, cost outcomes H. Seikaly *, J. Rieger, K. Ansari, J.R. Harris University of Alberta, Canada Introduction: Cancer of the maxilla is a devastating disease that affects all aspects of the patients’ life. Treatment has routinely resulted in significant cosmetic and functional deficits. The advent of obturation and more recently free tissue transfer has improved patient outcomes and quality of life. Objective: The purpose of this presentation is to (1) Report the, functional and cosmetic outcomes of a prospective cohort of patients that underwent microvascular reconstruction of the maxilla. (2) Report on the cost benefit of microvascular reconstruction. Methods: Thirty-six consecutive patients that had microvascular reconstruction of the maxilla between 2000 and 2007 were followed prospectively through our Multidisciplinary Head and Neck Surgery Reconstruction Clinic. Swallowing was assessed with videofluoroscopy and a diet questionnaire. Speech was assessed by acoustical, aeromechanical and perceptual measurements. All assessments were performed at four points in time (preoperative and 1 month,
O149. Iliac crest-tensor fascia lata osteomyocutaneous flap for orbitomaxillary reconstruction S. Iyer *, M.A. Kuriakose Amrita Institute of Medical Sciences, Kochi, India The goal of reconstruction of extensive orbital rim and floor following maxillectomy is to provide adequate orbital support to prevent enophthalmos, diplopia and palatal obturation to allow normal speech and swallowing. The existing methods of reconstruction fail to address these two goals simultaneously. A new method of reconstruction of these defects using iliac crest-tensor fascia lata flap is proposed. Results of the cadaver dissection, use of the flap in five clinical cases and its superiority over the existing methods is described. Material and methods: Initial cadaver dissections were carried out to assess the flap and pedicle characteristics. This flap was used in five cases of cancers of the maxilla, which necessitated extensive resection of orbital floor along with maxillectomy. The flap was raised as a muscle and bone flap in three cases and in two, a skin paddle was included. The immediate and delayed outcome at 6month follow up was analyzed. The functional outcome with regard to the ocular position and function, palatal obturation, speech and swallowing were recorded. Results: Cadaver dissection demonstrated that the flap is suitable for reconstructing the orbitomaxillary defects with regard to the tissue and the pedicle characteristics. In the clinical series all the five flaps survived. The pedicle length averaged 7 cm and direct anastomosis was possible to the neck vessels. The delayed outcome assessment showed excellent orbital support with no diplopia. The palatal defect could be obturated successfully in all cases resulting in normal speech and swallowing. The CT scan showed excellent integration in all the cases. Primary closure of the donor site was possible with no evidence of donor site morbidity. Conclusions: Iliac crest-TFL flap is a reliable and safe method of reconstruction of the orbitomaxillary defects. This flap addresses issues of both orbital support and palatal obturation very well. doi:10.1016/j.oos.2009.06.234
O150. The current role of the pedicled pectoralis major flap in reconstructive head and neck surgery C.M.E. Avery *, S.T. Crank, J.P. Hayter University Hospitals of Leicester, United Kingdom
Oral AbstractsPoster ListOrals ListPan. Disc. & Symp. Abs.Keynote Abs.Keynote Bios.ProgramIAOOWelcomeCommittee Listings
Oral abstracts / Oral Oncology Supplement 3 (2009) 56–122
Oral AbstractsPoster ListOrals ListPan. Disc. & Symp. Abs.Keynote Abs.Keynote Bios.ProgramIAOOWelcomeCommittee Listings
106
Oral abstracts / Oral Oncology Supplement 3 (2009) 56–122
Introduction: The pedicled pectoralis major myocutaneous flap has long been superseded as the reconstruction of first choice for major head and neck ablative surgery by the development of free tissue transfer techniques. The aim of this study is to evaluate the current use and indications of the pedicled pectoralis major flap in modern oncological surgical practice. Methods: A 10 year retrospective review between 1997 and 2007. Data recorded included basic demographics, indications for the pectoralis major flap, staging of disease, type of resection, ASA grade, previous surgical treatment and post operative complications. Results: Fifty-two patients were identified and the notes obtained for 50 cases. Seventeen pectoralis major flaps were used to salvage a free flap. The remaining flaps (33) were used as the preferred reconstruction for a variety of indications which included; large volume neck disease with resection of skin (6), salvage surgery (5), in conjunction with free flaps (3), significant medical co-morbidity (8). Twenty-nine patients were treated for a primary SCC of the head and neck of which all patients had Stage IV disease and 15 had recurrent disease. Discussion: The indications for the pectoralis major flap have radically changed but this flap still has an important role in the management of patients with extensive or recurrent disease, and in those compromised by previous radical surgery or significant medical comorbidity. The options for the management of a failed free flap have been evaluated by Wei1 and although a further free flap has been advocated the local wound conditions and/or medical condition may not always favour further free tissue transfer. In this situation the pectoralis major flap is often the preferred option. doi:10.1016/j.oos.2009.06.235 References 1. Wei FC, Demirkan F, Chen HC, et al.. The outcome of failed free flaps in head and neck and extremity reconstruction: What is next in the reconstructive ladder. Plast Reconstr Surg 2001;108:1154–60.
O151. Evaluation of positron-emission and computed tomography (PET-CT) imaging service for patients with malignant cervical lymph nodes and an unknown primary tumour M.J. Monteiro *, K. Altman, J. Herold, G. Burkill, I. Francis, J. Dikomite Brighton and Sussex University Hospitals NHS Trust, United Kingdom Introduction: The prognosis for patients with metastatic cervical lymphadenopathy and an unknown primary tumour is poor. The literature reports a typical survival period of 1 year from diagnosis in these cases. However, a median survival period of 23 months has been documented for such patients who subsequently have the primary tumour site identified and treated with the appropriate therapy. Only 20–27% of primary tumours are identified with conventional radiological imaging, and 24–40% with standard PET scanning. However, a diagnostic rate of 57% has been reported for PET-CT in the detection of all occult primary tumours. This study aims to evaluate the use of PET-CT imaging when applied specifically to the scenario of occult cancer presenting with metastatic cervical lymphadenopathy. Method: All patients with metastatic cervical lymph nodes presenting to the head and neck unit at the Royal Sussex County Hospital between 2004 and 2008, and whose primary tumour could not be identified by standard diagnostic procedures (CT, MRI, EUA), were referred for fast-track whole-body PET-CT by the multi-disciplinary head and neck cancer meeting. The percentage of primary tumours found was calculated.
Results: In 12 (43.5%) of 28 patients referred for PET-CT for metastatic cervical lymphadenopathy of unknown origin, a primary tumour was found. Discussion: These results provide a detection rate higher than that reported with other imaging modalities for occult primary tumours in the head and neck region. This has important implications for treatment and prognosis. Further evaluation in larger patient populations is required. doi:10.1016/j.oos.2009.06.236
O152. Evaluation of molecular markers for the assessment of occult metastasis in lymph nodes in head and neck squamous cell carcinoma A. Suresh, S. Duarah, K.R. Hiran, S. Sundaram, V. Kekatpure, M.A. Kuriakose * Amrita Institute of Medical Sciences, Kochi, India Nodal metastasis is the single most important prognostic marker of head and neck cancer, which determines recurrence, development of distant metastases, and the survival of patients. The management strategies for patients with clinically apparent metastases are now well established while there is no clear consensus on the management of occult nodal metastasis. Attempts were therefore made to identify several clinical, histological and molecular markers that can predict nodal metastasis and enable appropriate treatment of high-risk individuals. Lymphoscintigraphy has now been established as a reliable and a less invasive technique of identifying the first tumor-draining lymph node (sentinel node) and thus providing these sentinel nodes for further analytical studies. Cytokeratin14 has been well investigated as a molecular marker for nodal metastasis and in this study its expression was assessed along with established markers of oral cancer, e1F4E (Eukaryotic translation initiation factor 4E) and Desmoglein 3 (DSG3) in lymph nodes identified by Lymphoscintigraphy in oral cancer patients. Analysis was carried out by the relative quantification using the Quantitative real time PCR and by immunohistochemistry (DSG3 and CK14). 45 nodes were analyzed (40 patients and 5 normals) for the expression of e1F4E and CK14; the combination of both the markers showed a positive predictive value of 0.88 and an increased sensitivity in detecting pathologically negative patients. Comparative analysis of DSG3 expression with CK14 and eIF4E has indicated a higher sensitivity of detection in the nodes and the efficacy of the use of the combination of these markers is currently being evaluated. doi:10.1016/j.oos.2009.06.237
O153. Neck dissections: Factors morbidity R. Walker, V. Bhatt *, N. Barnard
affecting
outcomes
and
Worcestershire Acute Hospitals NHS Trust, United Kingdom Aims and objectives: To study factors affecting morbidity and outcomes following neck dissections in a single head and neck unit. Materials and methods: Retrospective audit of records of all patients who underwent neck dissections at Worcestershire Royal Hospital. One hundred and fifty patients underwent unilateral or bilateral neck dissections in the period between May 2005 and October 2008. Relationship between various demographic and clinico-pathological factors and morbidity will be sought. Outcomes measured in disease