- Email: [email protected]
Reconstruction of mandibular defects in irradiated patients
178 ma1 in most seropositive patients. These findings suggest that infection with HIV may be responsible for some the otoneurologic findings. In separate observations, HIV particles have been detected in microglial cells and endothelial central nervous system cells. These data do not necessary imply that subclinical electrophysiologic abnormalities place a patient at increased risk for dementia. Nor is there any direct link between electrophysiologic measurements and the results of neuropsychological testing. However, since otolaryngologists are often the first physicians to see individuals with features of peripheral or central vestibular disorders, it is important to be aware that such disorders may be the first manifestation of HIV infection.
Long-term Effects of Radiotherapy in Childhood and Adolescence. DL Larson, S Kroll, N Jaffe, et al. Am J Surg 1990; 160:348-351 Malignant tumors in children are often treated with radiation therapy in addition to different combinations of chemotherapy. However, the long-term complications of such therapy in cured survivors is not known. This study examined the records of 50 selected pediatric patients treated at M. D. Anderson Cancer Center to rate the late effects of nonsurgical cancer treatment. Patients with head and neck cancer received chemotherapy and radiotherapy for rhabdomyosarcoma, retinoblastoma, or nasopharyngeal tumors. Median follow-up for this group was 13 years. The most severe side effects noted in the field of radiation were hypoplasia of the jaw, orbit, or hemi-face, with varying degrees of atrophy of the overlying soft tissues. In some of these children, attempts at reconstruction with bone grafts or other significant surgery were compromised by prior radiation therapy. Retardation of growth and development of bone and soft tissue may occur as a result of the impaired secretion of various hormones, including thyroid hormone (secondary to pituitary radiation) or a direct inhibition from soft tissue and blood vessel fibrosis. The data in this report suggest that children can psychologically adapt and can become productive members of society following radiation. Adolescent children with soft tissue tumors treated with chemotherapy suffer from the further problem of having tissues more greatly sensitized to radiation by the chemotherapy. In addition, the risk of developing future sarcomas is 10 to 20 times greater than that of a first neoplasm after head and neck irradiation. Radiation of the thyroid gland in doses as small as 120 cGy may also increase thyroid cancer risk 100-fold. Today, one in 1,000 adults older than 20 years is a survivor of childhood cancer. These patients need to be evaluated in an ongoing fashion for endocrine disorders.
Definitive Mandibular Replacement Using Reconstruction Plates. JR Saunders, RM Hirata, DA Jaques. Am J Surg 1990; 160:387-389 Large defects can result from radical mandibular surgery for head and neck cancers. A variety of reconstructive techniques have been proposed, including micro-
ABSTRACTS vascular transfer. More recently, stainless steel and titanium reconstruction plates without free flaps have also been used. This report examines the results of mandibular reconstruction in 27 patients following mandibular resection. The surgical technique is briefly described and involves shaping the plate to the existing mandible prior to extirpative surgery. In 78% of the patients, reconstruction was successful, with primary soft tissue healing. Postoperatively, six of the 21 patients, approximately 30%. required removal of the plates. Two of the patients had reconstruction plates replaced as a secondary procedure. Twenty-three of 27 patients (85%) had final mandibular reconstruction with plates. However, there were 16 complications in 14 patients. In seven patients, oral exposure of plates occurred. Small areas of dehiscence were also noted in five patients, although all healed with nonoperative measures. The location of the reconstruction plate did not appear to be a factor in plate retention. This study confirms the results of several other series which show that reconstruction plates can be used following tumor resection, with success rates ranging from 73% to 90%. Plates may be the ideal form of reconstruction in advanced tumor patients, especially if microvascular transfer of tissue is not available. The authors note that large anterior resections frequently have a minor tissue dehiscence, particularly in the lateral junction of flap and gingiva. The downward pull of a pectoralis flap combined with the opposing action of the plate with jaw motion may be a source of late failure. None of the nine patients with anterior resections were able to wear dentures. The authors propose that the use of plates reduces the need for microvascular flaps, although they still reserve microvascular osseous free flaps for patients requiring dental rehabilitation following radiotherapy. For most patients with advanced stage disease, reconstruction plates can be used immediately and with a low morbidity rate.
Reconstruction of Mandibular Defects in Irradiated Patients. DW Klotch, J Gump, L Kuhn. Am J Surg 1990; 160:396-398 Mandibular reconstruction using titanium plates is a well-described technique. Several authors have questioned whether this technique can be used in patients who have had prior radiotherapy. This study was a prospective nonrandomized clinical trial designed to evaluate the outcome of patients who underwent reconstruction with plates and who had or were to have radiotherapy. Thirty-one patients were treated. Reconstruction was performed using titanium reconstruction plates. All patients received a 7-day course of antibiotics. Forty-two percent of patients had prior radiotherapy and 51% received postoperative radiotherapy. Thirty-five percent of patients had standard therapy and 16% had accelerated fractionation. Sixty-one percent of the 31 patients healed without complications. However, in 39% of patients, major complications developed, including plate exposure or fistula formation. The most common cause of plate exposure was disease recurrence, with all of these patients dying. Infection related to plate exposure occurred in three of 12
ABSTRACTS patients. Of the 12 patients who developed plate exposure, seven had no evidence of disease and were potential candidates for secondary repair. Follow-up in this report is short, with a minimum of 13 months. However, this does not detract from the study since its goal was to evaluate the outcome of reconstruction. Potential risk factors identified for reconstruction failure include poor nutrition, prior radiation, prior surgery, recurrence, and standard or accelerated postoperative therapy. Multiple regression analysis demonstrated that poor nutrition was a significant contributor to both extraoral and intraoral plate exposure. Plates were not removed when exposed, even when postoperative radiation therapy was still required. Patients tolerated plate exposure and were still able to take oral alimentation. This prospective study in conjunction with the previous study shows that reconstruction plates are a good alternative to mandibular reconstructive surgery. They are rapid, reliable, and effective. Prior or postoperative radiation therapy does not adversely affect the outcome of reconstruction plates. These two papers should be compared with another paper by Colman et al in the same issue of the American Journal of Surgery addressing the efficacy of microvascular reconstruction. In areas in which microvascular reconstruction are not available, reconstruction plates should be considered to close mandibular defects following extirpative surgery.
Significance of Positive Margins in Oral Cavity Squamous Carcinoma. TR Loree. EW Strong. Am J Surg 1990; 160:410-414 The treatment of head and neck squamous cell carcinoma is predicated in part on obtaining clear surgical margins. Although this does not guarantee a low rate of local recurrence, it is accepted that an involved margin carries with it a poorer prognosis. Several unresolved questions exist: (1)What is the risk of recurrence with a positive margin? [z) What is the role of postoperative radiotherapy in the presence of the positive margin? In an attempt to clarify these issues, these investigators analyzed the significance of positive margins on survival in a large group of patients with primary oral cavity carcinomas. Three hundred ninety-eight patients were studied at the Memorial Sloan-Kettering Institute. The margin was classified as positive according to four criteria: (1) close margin, (2)premalignant change in the margin, (3) in situ carcinoma of the margin, and (4) invasive microscopic cancer at the margin. Using these criteria, 32% of patients had positive margins. The incidence of positive margins was directly proportional to the increasing size of the primary tumor. Surgical treatment consisted of primary tumor resection with or without a neck dissection. Not surprisingly, it was found that positive margins increase the risk of local recurrence. The overall local recurrence rate in the entire positive margin group was twice the negative margin group, 36% versus 18%. respectively. Positive margins also adversely affected survival; the s-year survival rates of the positive and negative margin groups were 52% and SO%, respectively, a statistically significant difference. When the impact of postoperative adjuvant therapy was examined, none of the observed differ-
179
ences in survival rates between the patients with surgery alone and those with combined therapy was significant. A major finding of this study is that whereas postoperative radiation therapy to 6,000 cGy successfully reduced the local recurrence rate in patients with positive margins, this benefit did not translate to an improved !&year survival. The patterns of recurrence may change, but the overall risk of failure is increased. Adjuvant postoperative radiation therapy does not appear to decrease the risk of local recurrence in patients with positive margins to a level similar to patients with negative margins not treated with radiation therapy. Surgeons should continue aggressively to obtain pathologically negative margins and not to rely on radiation therapy to “clean up” microscopic disease.
Squamous Carcinoma of the Posterior Pharyngeal Wall. RH Spiro, J Kelly, AL Vega, et al. Am J Surg 1990; 160:420-423 The posterior pharyngeal wall is not a common primary site for squamous cell tumors. Survival rates have been poor and delays in diagnosis are common. This is a retrospective analysis of 78 patients treated at the Memorial Sloan-Kettering Hospital. Dysphagia and odynophagia were the most common presenting symptoms followed by the appearance of a neck mass or hoarseness. Treatment included surgery alone, surgery with radiation therapy, or a variation thereof. Surgery was the primary modality in 76% of patients and 24% had definitive radiation therapy. Most often, combination therapy was used. In 54% of the surgically treated patients, laryngeal preservation procedures were used. Significant treatment complications were recorded in 50% of all patients treated, and the incidence was similar in both surgically treated and radiation-treated patients. Common postoperative complications included fistula formation, infection, and sepsis. Overall, the absolute 2-year survival rate was 32%. Results were better in those who had lesions that were mostly confined to the posterior wall and in those whose nodes were clinically negative on admission. Local recurrence occurred in approximately 41% of patients and was directly related to initial tumor stage. Distant metastases and neck failure were relatively uncommon. Radiation therapy alone appears to have limited effectiveness in posterior pharyngeal tumors due to technical problems posed by the proximity of the radiation-sensitive spinal cord, even when this area is properly shielded and adequate doses are delivered. For unknown reasons, tumors arising in the posterior pharyngeal wall do not respond as well as nasopharyngeal tumors. Notably, laryngeal preservation was possible in 54% of resected patients. Ultimately, alimentation was achieved although it was not always per oral. It appears that survival is not compromised when a normal, uninvolved larynx is preserved. Several reconstruction options are available in these tumors, including pectoralis flaps or restoring continuity using transposed stomach or free jugural flaps. The role of radiotherapy and surgery in the treatment of posterior pharyngeal tumor remains in flux, but aggressive treatment using both of these modalities is necessary.
Long-term Effects of Radiotherapy in Childhood and Adolescence. DL Larson, S Kroll, N Jaffe, et al. Am J Surg 1990; 160:348-351 Malignant tumors in children are often treated with radiation therapy in addition to different combinations of chemotherapy. However, the long-term complications of such therapy in cured survivors is not known. This study examined the records of 50 selected pediatric patients treated at M. D. Anderson Cancer Center to rate the late effects of nonsurgical cancer treatment. Patients with head and neck cancer received chemotherapy and radiotherapy for rhabdomyosarcoma, retinoblastoma, or nasopharyngeal tumors. Median follow-up for this group was 13 years. The most severe side effects noted in the field of radiation were hypoplasia of the jaw, orbit, or hemi-face, with varying degrees of atrophy of the overlying soft tissues. In some of these children, attempts at reconstruction with bone grafts or other significant surgery were compromised by prior radiation therapy. Retardation of growth and development of bone and soft tissue may occur as a result of the impaired secretion of various hormones, including thyroid hormone (secondary to pituitary radiation) or a direct inhibition from soft tissue and blood vessel fibrosis. The data in this report suggest that children can psychologically adapt and can become productive members of society following radiation. Adolescent children with soft tissue tumors treated with chemotherapy suffer from the further problem of having tissues more greatly sensitized to radiation by the chemotherapy. In addition, the risk of developing future sarcomas is 10 to 20 times greater than that of a first neoplasm after head and neck irradiation. Radiation of the thyroid gland in doses as small as 120 cGy may also increase thyroid cancer risk 100-fold. Today, one in 1,000 adults older than 20 years is a survivor of childhood cancer. These patients need to be evaluated in an ongoing fashion for endocrine disorders.
Definitive Mandibular Replacement Using Reconstruction Plates. JR Saunders, RM Hirata, DA Jaques. Am J Surg 1990; 160:387-389 Large defects can result from radical mandibular surgery for head and neck cancers. A variety of reconstructive techniques have been proposed, including micro-
ABSTRACTS vascular transfer. More recently, stainless steel and titanium reconstruction plates without free flaps have also been used. This report examines the results of mandibular reconstruction in 27 patients following mandibular resection. The surgical technique is briefly described and involves shaping the plate to the existing mandible prior to extirpative surgery. In 78% of the patients, reconstruction was successful, with primary soft tissue healing. Postoperatively, six of the 21 patients, approximately 30%. required removal of the plates. Two of the patients had reconstruction plates replaced as a secondary procedure. Twenty-three of 27 patients (85%) had final mandibular reconstruction with plates. However, there were 16 complications in 14 patients. In seven patients, oral exposure of plates occurred. Small areas of dehiscence were also noted in five patients, although all healed with nonoperative measures. The location of the reconstruction plate did not appear to be a factor in plate retention. This study confirms the results of several other series which show that reconstruction plates can be used following tumor resection, with success rates ranging from 73% to 90%. Plates may be the ideal form of reconstruction in advanced tumor patients, especially if microvascular transfer of tissue is not available. The authors note that large anterior resections frequently have a minor tissue dehiscence, particularly in the lateral junction of flap and gingiva. The downward pull of a pectoralis flap combined with the opposing action of the plate with jaw motion may be a source of late failure. None of the nine patients with anterior resections were able to wear dentures. The authors propose that the use of plates reduces the need for microvascular flaps, although they still reserve microvascular osseous free flaps for patients requiring dental rehabilitation following radiotherapy. For most patients with advanced stage disease, reconstruction plates can be used immediately and with a low morbidity rate.
Reconstruction of Mandibular Defects in Irradiated Patients. DW Klotch, J Gump, L Kuhn. Am J Surg 1990; 160:396-398 Mandibular reconstruction using titanium plates is a well-described technique. Several authors have questioned whether this technique can be used in patients who have had prior radiotherapy. This study was a prospective nonrandomized clinical trial designed to evaluate the outcome of patients who underwent reconstruction with plates and who had or were to have radiotherapy. Thirty-one patients were treated. Reconstruction was performed using titanium reconstruction plates. All patients received a 7-day course of antibiotics. Forty-two percent of patients had prior radiotherapy and 51% received postoperative radiotherapy. Thirty-five percent of patients had standard therapy and 16% had accelerated fractionation. Sixty-one percent of the 31 patients healed without complications. However, in 39% of patients, major complications developed, including plate exposure or fistula formation. The most common cause of plate exposure was disease recurrence, with all of these patients dying. Infection related to plate exposure occurred in three of 12
ABSTRACTS patients. Of the 12 patients who developed plate exposure, seven had no evidence of disease and were potential candidates for secondary repair. Follow-up in this report is short, with a minimum of 13 months. However, this does not detract from the study since its goal was to evaluate the outcome of reconstruction. Potential risk factors identified for reconstruction failure include poor nutrition, prior radiation, prior surgery, recurrence, and standard or accelerated postoperative therapy. Multiple regression analysis demonstrated that poor nutrition was a significant contributor to both extraoral and intraoral plate exposure. Plates were not removed when exposed, even when postoperative radiation therapy was still required. Patients tolerated plate exposure and were still able to take oral alimentation. This prospective study in conjunction with the previous study shows that reconstruction plates are a good alternative to mandibular reconstructive surgery. They are rapid, reliable, and effective. Prior or postoperative radiation therapy does not adversely affect the outcome of reconstruction plates. These two papers should be compared with another paper by Colman et al in the same issue of the American Journal of Surgery addressing the efficacy of microvascular reconstruction. In areas in which microvascular reconstruction are not available, reconstruction plates should be considered to close mandibular defects following extirpative surgery.
Significance of Positive Margins in Oral Cavity Squamous Carcinoma. TR Loree. EW Strong. Am J Surg 1990; 160:410-414 The treatment of head and neck squamous cell carcinoma is predicated in part on obtaining clear surgical margins. Although this does not guarantee a low rate of local recurrence, it is accepted that an involved margin carries with it a poorer prognosis. Several unresolved questions exist: (1)What is the risk of recurrence with a positive margin? [z) What is the role of postoperative radiotherapy in the presence of the positive margin? In an attempt to clarify these issues, these investigators analyzed the significance of positive margins on survival in a large group of patients with primary oral cavity carcinomas. Three hundred ninety-eight patients were studied at the Memorial Sloan-Kettering Institute. The margin was classified as positive according to four criteria: (1) close margin, (2)premalignant change in the margin, (3) in situ carcinoma of the margin, and (4) invasive microscopic cancer at the margin. Using these criteria, 32% of patients had positive margins. The incidence of positive margins was directly proportional to the increasing size of the primary tumor. Surgical treatment consisted of primary tumor resection with or without a neck dissection. Not surprisingly, it was found that positive margins increase the risk of local recurrence. The overall local recurrence rate in the entire positive margin group was twice the negative margin group, 36% versus 18%. respectively. Positive margins also adversely affected survival; the s-year survival rates of the positive and negative margin groups were 52% and SO%, respectively, a statistically significant difference. When the impact of postoperative adjuvant therapy was examined, none of the observed differ-
179
ences in survival rates between the patients with surgery alone and those with combined therapy was significant. A major finding of this study is that whereas postoperative radiation therapy to 6,000 cGy successfully reduced the local recurrence rate in patients with positive margins, this benefit did not translate to an improved !&year survival. The patterns of recurrence may change, but the overall risk of failure is increased. Adjuvant postoperative radiation therapy does not appear to decrease the risk of local recurrence in patients with positive margins to a level similar to patients with negative margins not treated with radiation therapy. Surgeons should continue aggressively to obtain pathologically negative margins and not to rely on radiation therapy to “clean up” microscopic disease.
Squamous Carcinoma of the Posterior Pharyngeal Wall. RH Spiro, J Kelly, AL Vega, et al. Am J Surg 1990; 160:420-423 The posterior pharyngeal wall is not a common primary site for squamous cell tumors. Survival rates have been poor and delays in diagnosis are common. This is a retrospective analysis of 78 patients treated at the Memorial Sloan-Kettering Hospital. Dysphagia and odynophagia were the most common presenting symptoms followed by the appearance of a neck mass or hoarseness. Treatment included surgery alone, surgery with radiation therapy, or a variation thereof. Surgery was the primary modality in 76% of patients and 24% had definitive radiation therapy. Most often, combination therapy was used. In 54% of the surgically treated patients, laryngeal preservation procedures were used. Significant treatment complications were recorded in 50% of all patients treated, and the incidence was similar in both surgically treated and radiation-treated patients. Common postoperative complications included fistula formation, infection, and sepsis. Overall, the absolute 2-year survival rate was 32%. Results were better in those who had lesions that were mostly confined to the posterior wall and in those whose nodes were clinically negative on admission. Local recurrence occurred in approximately 41% of patients and was directly related to initial tumor stage. Distant metastases and neck failure were relatively uncommon. Radiation therapy alone appears to have limited effectiveness in posterior pharyngeal tumors due to technical problems posed by the proximity of the radiation-sensitive spinal cord, even when this area is properly shielded and adequate doses are delivered. For unknown reasons, tumors arising in the posterior pharyngeal wall do not respond as well as nasopharyngeal tumors. Notably, laryngeal preservation was possible in 54% of resected patients. Ultimately, alimentation was achieved although it was not always per oral. It appears that survival is not compromised when a normal, uninvolved larynx is preserved. Several reconstruction options are available in these tumors, including pectoralis flaps or restoring continuity using transposed stomach or free jugural flaps. The role of radiotherapy and surgery in the treatment of posterior pharyngeal tumor remains in flux, but aggressive treatment using both of these modalities is necessary.