The Submental Flap for Reconstruction of Tongue Defects- Surgical Outcome and Quality of Life Assessment.

Tongue defects following resection of cancers, have a major effect on speech and swallowing, impairing the quality of life. Free flaps such as the free radial artery forearm flap and anterolateral thigh flap have been ideal for the reconstruction of such defects depending upon the volume of tissue loss. Local flaps such as the submental flap and pectoralis major myocutaneous flap serve as an alternative in decreasing morbidity and improving functional outcomes. Surgical outcomes associated with submental flaps used in the reconstruction of tongue defects were evaluated in our study. This is a retrospective analysis of 545 patients, where the submental flap was used for the repair of tongue defects for cancer resections. Oncological safety was studied in 375 patients with a median follow-up of 48 months. 140 patients were studied for their functional outcomes using the parameters, adapted from the University of Washington- Quality of Life questionnaire. Complete flap loss was seen in 15(2.75%) patients while 22(4.03%) patients had partial loss of flap. Locoregional Recurrences, second primary, and distant metastases were noted in 91 of the 375 patients studied. The mean score for swallowing, speech, and taste were 72,71, and 69 respectively. The submental flap is an effective and reliable alternative for the reconstruction of tongue defects. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03858-3.

Does Operable Stage IV Gingivobuccal Cancers Need Further Prognostic Subgrouping?

Background: Operable stage IV gingivobuccal complex cancer is classified as Stage IVA and IVB. Among patients with Stage IVA disease, different subgroups with likely different prognoses are combined. Patients with advanced nodal status tend to have a poorer prognosis. We divided these patients into four groups: group I (T4aN0), group II (T4aN1-2), group III (T1-3N2) constituting stage IVA category, and group IV (TanyN3) representing stage IVB. This study assesses if these patients can be prognostically subgrouped based on nodal status. Methods: It is a prospective observational study done at a tertiary care center from July 2017 to June 2020. This study aims to analyze survival outcomes in these subgroups using Kaplan Meir, univariate and multivariate analysis. Results: The study enrolled 113 patients of operable gingivobuccal complex stage IVA cancer with a median follow up of 26 months, disease-free survival (DFS) was 74% for group 1, while it was 55%, 26% and 32.2% for group 2, group 3 and group 4 respectively. Patients with T4N3 disease had DFS of just 15%. Patients in group 3 and 4 had the worst outcomes in terms of DFS and Overall Survival(OS) with HR-3.7 and 3.3 and 3.3 and 3.8 respectively (p value-0.001). Conclusion: The nodal status is the most important prognostic factor affecting DFS and OS. Patients with small primary but advanced nodal stage do poorly than patients with advanced primary and node-negative disease. There is a need for subgrouping patients with Stage IVA tumors based on nodal status for better prognostication.

Submental Flap in the Reconstruction of Palatal Defects.

Amongst oral cancers, malignancies of the palate and the upper gingivo-buccal complex are relatively uncommon. Following resection, defects in the palate lead to a nasal speech and nasal regurgitation on swallowing. This is best overcome with a prosthetic obturator which occludes the palatal defect and has dentures for the upper alveolus. It may not be possible to fit a prosthetic obturator in edentulous patients and in patients with trismus. Microvascular free flaps though commonly used for such defects, are time consuming, expensive and require a specialised setup. This study assesses the submental flap for its feasibility to repair palatal defects, the sturdiness of the flap, its functional outcome and the oncological safety in using the flap. This is a retrospective analysis of 46 patients, where palatal defects for oral cancers were reconstructed with the submental flap. Oncological safety was studied in 41 patients with a median follow-up of 34.5 months. 20 patients were studied for their functional outcomes using the parameters, adopted from the University of Washington-Quality of Life questionnaire. Complete flap loss was seen in 4 (8.7%) patients while 2 (4.35%) patients had minor dehiscence. No donor site morbidity was reported. Locoregional Recurrences and distant metastasis were noted in 13 of the 41 patients studied. The mean score was highest for speech at 95.5% while the lowest mean score was for mouth opening at 42.5%. The submental flap is an effective and reliable alternative for the reconstruction of palatal defects.

Impact of Depth of Invasion (According to Layer) on Lymph Node Metastasis in Buccal Mucosa Cancers.

(1) To study layer of invasion as predictor of cervical lymph node metastasis. (2) To decide a cut off depth according to layer of invasion for neck dissection. It is a prospective study with sample size of 220 patients at tertiary care hospital with previously untreated operable buccal mucosa carcinoma over period of 21 months. The factors considered under the study were Tumor layer of invasion, lymph node metastasis, Ultrasonography doppler neck, CT scan and gender. Wide excision of the lesion and reconstruction was done. Histopathological analysis of resected specimen were recorded as part of data collection for all the cases. Quantitative data represented using Mean ± SD (Standard Deviation) and median and interquartile range compared using Chi square test. Standard principles of univariate analysis was used according to statistical methods. Depth when measured according to layer of invasion, was significantly associated with lymph node metastasis with 89% of the muscle as layer of invasion being Lymph node positive (p = 0.009). There is 1.39 times chances of lymph nodal metastasis in patients with muscle invasion as compared to submucosal invasion. Tumour layer of invasion plays important role in predicting chances of nodal metastasis in clinically N0 neck in buccal mucosa cancer. According to the study, we should electively proceed with ipsilateral lymph node dissection once the layer of tumour invasion is muscle. This study is limited by sample size and short duration of one year and nine months.

Submental flap: Game changer in oral cancer reconstruction-A study of 1169 cases.

BACKGROUND: Free-flap reconstructions (FFRs) are the standard-of-care following resections for oral cancer. This study assessed an alternative, the pedicled submental flap (SF) for its versatility, oncological outcomes, and comparative operative time and cost. METHODS: This was a longitudinal prospective study of 1169 patients of oral cancer reconstructed with the SF. Oncological outcomes in terms of recurrence rate and disease-free survival (DFS), were analyzed in 730 cases with a minimum of 18 months follow-up. Surgical time and cost were compared between 20 SFs and 14 FFRs performed consecutively. RESULTS: SF was used to reconstruct defects in the cheek (29.2%), mandible (41.6%), tongue (26.3%) and palate (2.7%) with a 94% flap survival. N+ at level 1 did not adversely affect the recurrence rate as compared with N+ at levels other than level 1 (27.52% vs 29.81%). SFs took a shorter time (186 minutes vs 474 minutes) and cost significantly less than FFRs (P < .0001). CONCLUSIONS: SF can reconstruct various oral defects, is sturdy, and esthetically and functionally satisfactory. The procedure time is much shorter than for FFR and costs considerably less. With careful case selection and meticulous clearance, SF reconstruction is oncologically safe even in N+ neck.

Clinical Profile and Quality of Life Assessment of Oral Cancer Patients Following Nasolabial Flap Reconstruction Surgery.

To evaluate the quality of life (QOL) of oral cancer patients who had undergone surgical reconstruction with nasolabial flap. A cross-sectional study was conducted over a period of 1 year at a tertiary care hospital and 128 subjects were included. The subjective assessment of quality of life using The University of Washington QOL Questionnaire including physical, socio-emotional, composite and overall QOL, Objective assessment of functional mouth opening and Nasolabial crease scar assessment using Vancouver scar scale was done. Majority of the subjects, 98.4% were male. Maximum cases were involving the lower gingivobuccal complex and retromolar trigone followed by buccal mucosa. Majority of the tumors were T2, 53.1% followed by T1, 18.8%. Statistically significant (p < 0.05) difference was found in relation to age, tumor size (T1, T2, T3), absence of adjuvant radiation therapy, presence or absence of neck dissection, tumor site; buccal mucosa and lower gingivobuccal complex plus retromolar trigone and intact bone status in physical functional, social-emotional subscores, composite score and overall QOL assessment. Improved mouth opening postoperatively was statistically significant (p < 0.05) in T1 and T2 lesions of buccal mucosa and lower gingivobuccal complex plus retromolar trigone who did not receive radiation and with intact bone status. Majority of the cases, 36.7% had a nasolabial crease scar score 2. Nasolabial flap is a viable option in the reconstruction of small and medium sized oral defects with good quality of life (QOL) outcome and objective outcome as depicted by significantly improved mouth opening. The aesthetic outcome of nasolabial crease scar is good in our study.

Clinical outcome of surgical treatment of T1-2 N0 squamous cell carcinoma of oral tongue with observation for the neck: Analysis of 176 cases.

OBJECTIVE: To analyze various demographic, clinical, and histopathologic factors in T1-2 N0 squamous cell carcinoma (SCC) of the oral tongue to define a high-risk group for regional recurrence that will benefit from elective neck dissection. MATERIALS AND METHODS: Retrospective outcome analysis of a patient cohort without palpable or ultrasound (USG) detectable nodal metastases undergoing per oral wide glossectomy for T1-2 N0 SCC of oral tongue. Patients were followed up using palpation and serial USG neck and fine-needle aspiration cytology. RESULTS: Of the 176 patients, 69 (39%) showed recurrence during follow-up. Fifty-eight cases developed regional neck node metastases, i.e., overall regional node recurrence rate of 33%. Fifty-three (91%) with regional neck node metastases were salvaged successfully with further treatment. In 110 cases with tumor thickness more than 5 mm, 39% cases developed regional neck node metastases. This association was significant with P = 0.0402. Among 44 cases with perineural invasion, 54% developed regional neck node metastases. Similarly in 39 cases with lymphovascular invasion, 61% developed regional neck node metastases. Association of both of these parameters with the development of regional neck node metastases was significant. CONCLUSION: We recommend prophylactic selective neck dissection in early stage SCC of oral tongue, especially with depth of invasion more than 5 mm, perineural and lymphovascular invasion.

Outcome of per oral wide excision of T1-2 N0 localized squamous cell cancer of the buccal mucosa--analysis of 156 cases.

OBJECTIVES/HYPOTHESIS: The purpose of the study was to study the outcomes of per oral wide excision of early T1-2 N0 squamous cell cancer of buccal mucosa. METHODS: This is a retrospective study of early and localized squamous cell cancer of the buccal mucosa treated with peroral wide excision at a tertiary-care hospital. RESULTS: A total of 156 patients were analyzed. One hundred ten patients (70.5%) had no recurrence, whereas 15 (9.6%) had a local recurrence, 24 (15.4%) had regional metastasis, three (1.9%) had locoregional recurrence, and four (2.6%) developed second primary tumors over a median follow-up of 48 months. Most patients with local recurrences (14 patients, 93.3%) and regional metastases (24 patients, 100%) could be salvaged with treatment. In contrast, all three cases with locoregional could not be salvaged. Most of the cases with recurrences, 36 (78%) in this study group, occurred within 2 years of primary treatment. Out of 143 cases with a habit of tobacco/beetel quid chewing, premalignancy was seen in 62 (43.4%) cases, showing a statistically significant association with P-value of 0.012. Fifteen (21.4%) cases with stage T2 developed regional neck nodes, while only 9 (10.5%) cases with stage T1 developed regional neck nodes with P-value of 0.032. Three-year overall survival rate and disease-free survival rates were 91.7% and 70.5%, respectively. CONCLUSIONS: Peroral wide excision seems to be an adequate procedure for T1-2N0 localized squamous cancer of buccal mucosa. Prophylactic selective neck dissection should be considered in only T2 N0 cases as only T stage of the disease could be significantly correlated with the development of the metastatic neck nodes.

Primary pleomorphic adenoma of minor salivary gland in the parapharyngeal space.

BACKGROUND: World literature suggests parapharyngeal space lesions account for only 0.5% head and neck tumours and the majority of the minor salivary gland tumours are malignant. The parapharyngeal space is very rare site for this tumour. CASE PRESENTATION: Two cases of primary pleomorphic adenomas arising de novo from minor salivary glands in the para pharyngeal space are reported. Review of literature, clinical features, pathology, radiological findings and treatment of these tumours are discussed. CONCLUSION: Pleomorphic adenoma arising de novo in the parapharyngeal space is of rare occurrence. High index of suspicion and an adequate clearance of the tumour with a cuff of surrounding dispensable normal tissues is the key to successful treatment of such tumours.