Surgical treatment of oral cavity cancer

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Surgical treatment of oral cavity cancer

• Tod C. Huntley, MD FACS
• Center for Ear Nose Throat Allergy,
  Indianapolis, Indiana
• tod.huntley_at_centadocs.com
• 800-283-1056
• Statewide Campus System of Michigan State COM
• Genoa Woods Conference Center
• January 19, 2008

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Surgical treatment of oral cavity cancer

• Introduction
• Multidisciplinary team approach
• Surgical approaches
• Reconstructive options
• Algorhythms and case examples

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Oral CA

• Unique challenges for treatment
• Integral part of upper aerodigestive tract
• Multiple functions
• Speech, swallowing, immune, respiration
• Wide range of behaviors and presentations
• Diverse treatment options
• Prevention and early diagnosis crucial
• Serious health problem

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Oral CA treatment Multidisciplinary approach
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Oral CA treatmentMultidisciplinary approach

• Surgeons
• Cancer resection
• Reconstruction
• Speech and swallowing therapist
• Prosthodontist
• Oral Surgeons

• Medical oncologist
• Radiation oncologist
• Dentist
• Social worker
• Specialized nurses

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Oral CA

• Incidence
• 390,000 new cases per year worldwide
• Highest South Central Asia, South Africa, Europe
• U.S. 11.9/100,000 39,000 new cases/yr.
• Increasing faster than any other HN site
• Increases with age
• Men gt women by 31 margin

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Oral cancer
Surgical considerations
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Surgical considerations

• Goals
• Adequate exposure
• Wide negative margins
• Preserve normal functions
• Proper incision planning
• Neck dissection frequently needed
• Avoid the tracheotomy site
• Reconstruction to optimize cosmesis function

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Surgical considerations

• Difficult anatomy
• Inferior and posterior oropharynx difficult to
  expose
• Proximity of mandible
• Complex vascular and neural anatomy of the
  parapharyngeal space
• Narrow oropharyngeal introitis

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Oral cavity Surgical approaches

• Transoral
• Mandibular swing
• Visor flap
• Lateral pharyngotomy
• Suprahyoid
• Any of the above approaches can also include
  mandibular resection

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Oral cavity Surgical approaches

• Transoral approach

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Oral cavity Transoral approach

• Small to moderate sized lesions
• Oral cavity (palate, tonsils), orophx, tongue
  base, larynx
• Good exposure mouth gags
• Laser, electrocautery, cold knife

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Oral cavity Transoral approach

• Advantages
• Least invasive, no external incisions
• Sparing of pharyngeal nerves
• sensation, function
• Earlier swallowing
• Less chance for fistula
• Less need for flap for reconstruction
• Disadvantages
• Limited exposure
• Poorer visualization of deeper structures

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Oral cavity Transoral approach
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Oral cavity Transoral approach
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Oral cavity Transoral approach
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Oral cavity Transoral approach
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Oral cavity Surgical approaches

• Lip/mandibular split approach

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Oral cavity Lip/mandibular split

• Mandibulotomy with preservation of bone
• Advantages
• Widest exposure of oropharynx--Extensive tumors
• Disadvantage
• Cosmesis
• Wound breakdown over chin/lip

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Oral cavity Lip/mandibular split
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Oral cavity Lip/mandibular split

• Mandibulotomy
• Parasymphyseal
• Stair-stepped
• Plate fixation
• Avoid damage to
• Tooth roots
• Nerves mental, lingual, XII
• TMJs

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Oral cavity Lip/mandibular split
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Oral cavity Surgical approaches

• Visor flap approach

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Oral cavity Visor flap approach

• Similar to mandibular swing approach
• Advantages over lip split
• Improved cosmesis by avoiding external incision
• Avoids notching of lower lip
• Disadvantages compared to lip split
• Access limited by mental nerves may drill out
  for improved access
• Lip chin ptosis if chin not carefully fixed to
  mandible or reconstruction plate

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Oral cavity Visor flap approach
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Oral cavity Visor flap approach
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Oral cavity Visor flap approach
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Oral cavity and oropharynx Surgical approaches

• Lateral pharyngotomy approach

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Biopsy techniques

• Fine needle aspiration (FNA)
• Cup forceps
• Excision
• Brush biopsy

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Biopsy-brush
Not recommended
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Biopsy-FNA
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Biopsy-FNA
Dont traumatize the cells!
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Biopsy-FNA
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Biopsy-cup forceps
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Biopsy
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Oral pathology examples
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Leukoplakia
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Leukoplakia
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Proliferative verrucous leukoplakia
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Lichen planus
Erosive
Atrophic
Reticular
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Aphthous stomatitis
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Candidiasis
Angular cheilitis
Acute erythematous
Pseudomembranous (thrush)
Candidal leukoplakia
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Herpes
Primary gingivostomatitis
Recurrent--neurotropic
Recurrent intraoral
Recurrent labialis
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Melanoma
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Melanoma look-alikes
Focal smokers melanosis
Melanotic macules
Amalgam tattoo
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Lip cancer
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Lip cancer
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Lip cancer
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Buccal cancer
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Buccal cancer
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Buccal cancer
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Floor of mouth cancer
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Floor of mouth cancer
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Palate cancer
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Palate cancer
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Palate cancer
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Palate cancer
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Palate--tori
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Mandible--tori
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Mandible cancer
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Mandible cancer
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Mandible cancer
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Mandible cancer
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Mandible cancer
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Mandible cancer
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Mandible cancer
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Mandible cancer
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Mandible cancer 3-D CT images
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Tongue cancer
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Tongue cancer
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Tongue cancer
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Tongue cancer
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Tongue cancer
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Tonsil cancer
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Cancer of everything
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Cancer resectionsExamples
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Cancer resectionExamples

• Tongue
• and
• floor of mouth

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Tongue and FOM resectionsTransoral
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Tongue and FOM resectionsTransoral
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Tongue and FOM resectionsTransoral
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Tongue and FOM resectionsTransoral
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Tongue and FOM resectionsTransoral
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Cancer resectionsExamples

• Tongue,
• floor of mouth, mandible

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Mandibular resections
Marginal resection
Segmental resection
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Tongue, FOM, mand resectionTransoral
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Tongue, FOM, mand resectionTranscervical
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Cancer resectionsExamples

• Palate

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Palate resections
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Maxillectomy
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Maxillectomy
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Maxillectomy
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Cancer resectionsExamples

• Neck dissections

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Neck dissection
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Neck dissection
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Reconstruction

• Skin grafts
• Local flaps
• Regional flaps
• Microvascular free flaps

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Reconstruction ladder
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Reconstruction ladder

• Considerations
• Size and type of defect
• Bone, mucosa, tongue, etc.
• Functional considerations
• Articulation
• Deglutition
• Oral competence
• Cosmesis
• Prior treatments (surgery, XRT)
• Comorbidities

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Reconstruction ladder

• Considerations
• Keep it simple when possible
• Multidisciplinary approach
• Oral surgery
• Maxillofacial prosthodontics
• Good communication with resection team
• Big picture
• Comorbidities
• Goals

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Primary closure

• Examples
• Anterior mobile tongue
• Marginal mandibulectomy defects
• Floor of mouth
• Advantages
• Quick and easy
• No additional dissection
• Drawbacks
• Tethering
• Dehiscence (XRT, tension)

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Skin grafting

• Examples
• Tongue, floor of mouth, buccal
• Skin vs. Alloderm
• Advantages
• Quick and easy
• Disadvantages
• Non-irradiated tissue beds only
• Sloughing bone exposure, granulations
• Correct insetting is tedious.
• Need for bolster / tissue immobilization
• Buccal scarring with trismus
• Donor site of STSG painful

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Skin grafting
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Skin grafting
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Flaps factors affecting choice

• Tissue needs
• Bone
• Muscle
• Skin or fascia
• Vascularity
• Pedicled
• Free
• Other factors
• Prior treatment (XRT, surgery)
• Pt health (comorbidities, obesity, etc.)

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Flaps types

• Localimmediate vicinity blood supply left
  intact flap is still attached to the donor site
• Regionaloutside of local vicinity blood supply
  still uninterrupted
• Free--flap is disattached, blood vessels cut and
  hooked up to vessels in head and neck

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Local flaps

• Donor site considerations
• Limited to non-irradiated donor sites
• Donor site functional morbidity
• Limited choices

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Local flap techniques
Bilateral advancement flaps
Pedicle advancement flap
Rotational flap
Interpolated flap
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Local flap techniques
Transposition flap
B
A
V-Y advancement flaps
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Local flap examplesLip reconstruction
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Local flap examplesLip reconstruction
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Local flap examplesLip reconstruction
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Local flap examplesLip reconstruction
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Local flap examplesGreater palatine flap
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Local flap examplesGreater palatine flap
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Other local and regional flaps of interest

• Pedicled flaps
• Pectoralis Major (PM)
• Deltopectoral (DP)
• Sternocleidomastoid (SCM)
• Temporalis
• Greater Palatine
• Trapezius

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Regional flaps
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Pectoralis major
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Pectoralis major
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Pectoralis major

• Uses and advantages
• Reliable workhorse
• Bulk
• Oropharynx, lateral defects
• Disadvantages
• Bulk
• Limited length
• Donor site chest wall weakness
• No bone

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Deltopectoral

• Primary use external neck
• Disadvantages
• Limited arc of rotation
• Unreliable if prior PM flap used
• Donor site skin graft needed

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Sternocleidomastoid

• Use precluded by
• Prior neck dissection
• Neck XRT
• Concurrent neck dissection in level IIB
• Limited arc or rotation
• No bone

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Trapezius system
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Trapezius systemsuperiorly based

• Uses
• Lateral neck
• Temporal bone, parotid region
• Unaffected by neck dissection
• Disadvantages
• Donor site skin graft
• Positioning
• Limited arc or rotation

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Trapezius systemlower island

• Uses
• Neck and intraoral soft tissue
• Disadvantages
• Positioning
• Neck dissection can put transverse cervical
  vessels at risk
• Bone unreliable

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Temporalis
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Microvascular free flaps
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Microvascular free flaps
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Microvascular free flaps

• Advantages
• Multiple tissue choices
• size, type of tissue, donor site
• Non irradiated
• 2 teams
• Disadvantages
• Time and expertise

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Free flaps
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Radial forearm

• The new workhorse?
• Thin, pliable tissue
• Reliable anatomy
• Internal or external defects or both
• Donor site morbidity minimal
• Ideal for 2 teams

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Radial forearm
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Radial forearm

• Uses
• Tongue
• Phayrnx
• Floor of mouth
• Sensation
• Bone?
• Risk of pathologic fracture of radius
• Cannot osteointegrate
• Allen test to assess ulnar system

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Rectus abdominus
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Rectus abdominus
Bulk advantageous and disadvantageous Total
glossectomy or extensive external soft tissue
defects No pt. repositioning needed
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Latissimus dorsi
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Latissimus dorsi

• Advantages
• Large amount of soft tissue
• Multiple paddles
• Reliable anatomy
• Can also be used as pedicled flap
• Disadvantages
• Patient positioning

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Fibula

• Advantages
• Greatest bone length of any flaps angle to angle
• Multiple osteotomies
• Can be osteointigrated
• 2 teams without repositioning
• Minimal donor site morbidity
• Disadvantages Limited soft tissue paddle arc of
  rotation, may require site graft to donor site
• Need to assess peroneal arterial system
  radiographically

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Fibula
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Fibula
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Fibula
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Fibula
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Fibula
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Fibula
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Fibula
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Fibula
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Iliac crest
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Iliac crest

• Advantages
• Thickest bone stock of any free flap
• Easily osteointigrated
• Disadvantages
• Donor site morbidity
• Bulk
• Cannot osteotomize as much as fibula

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Jejunum

• Uses
• Cervical esophagus
• Mucosal defects
• Disadvantages
• Mucus production
• Short pedicle
• Serosa prevents
• neovascularization

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Free flap salvage
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Oral and oropharyngeal defects

• Our preferences

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Segmental lateral mandible

• Issues
• Bone reconstruction less critical than with
  anterior defects
• Less chance of plate erosion
• Choices
• Primary closure without bone reconstruction
• Reconstruction plate with PM flap
• Nonvascularized bone if no XRT
• Composite free flap fibula, iliac crest

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Segmental anterior mandible

• Issues
• High chance of plate erosion if no bone
• Cosmesis Andy Gump
• Choices
• Recon plate with PM poor long term choice
• Bone free flap best option
• Fibula 1 choice

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Anterior mandibleanchor the chin!
Lip ptosis
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Mandible defects

• Marginal mandibulectomy
• Primary closure usually OK
• Later need for vestibuloplasty?
• Dental rehabilitation
• Tissue borne denture
• Neo-alveolus Vestibuloplasty
• Save anchoring teeth
• Osteo-integrated implants
• Expense, extrusion

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Tongue

• Primary closure when possible
• Skin graft/Alloderm when no XRT
• Larger subtotal defects
• RFFF best choice for form, function
• PM flap bulky
• Total glossectomy
• Aspiration laryngectomy, laryngeal stent?
• RFFF, rectus, PM flap

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Buccal mucosa

• Primary closure, skin graft
• Scarring, contracture
• Trismus
• RFFF best choice

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Oropharynx, tonsil

• RFFF
• Best choice
• PM flap

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Palate

• Prosthesis generally best choice
• If need to resect ½ soft palate then resect
  entire soft palate
• RFFF advantages over prosthesis not enough to
  justify cost and risk
• Bone free flap for hard palate difficult

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Palate
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Oral oropharyngealfree flap reconstructionexam
ples

• Mandibular defect
• Mandibular, lip, cheek defect
• Maxillary and palatal defect
• Maxillary defect
• Tongue and tonsillar fossa defect

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Patient 1

• Right lateral floor of mouth squamous cell
  carcinoma
• Invaded mandibular body, lateral tongue, and
  tonsil
• Palpable neck metastases
• Reconstructed with fibular free flap

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Mandibular defectFibula free flap
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Mandibular defectFibula free flap
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Mandibular defectFibula free flap
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Patient 2

• Large buccal cancer with involvement of
• Lateral oral commissure
• Full thickness of cheek to overlying skin
• Mandible
• Failed prior reconstruction with pectoralis major
  myocutaneous flap and titanium reconstruction
  plate
• Reconstructed with fibula free flap and local
  rotational flaps for oral commissure

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Complex oral defectFibula and local flaps
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Complex oral defectFibula and local flaps
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Complex oral defectFibula and local flaps
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Complex oral defectFibula and local flaps
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Complex oral defectFibula and local flaps
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Complex oral defectFibula and local flaps
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Complex oral defectFibula and local flaps
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Complex oral defectFibula and local flaps
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Patient 3

• Large maxillary alveolar sarcoma
• Involved premaxilla and ventral alveolus
• Facial soft tissues uninvolved
• Reconstructed with fibula free flap

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Complex maxillary defectFibula free flap
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Complex maxillary defectFibula free flap
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Complex maxillary defectFibula free flap
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Complex maxillary defectFibula free flap
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Complex maxillary defectFibula free flap
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Complex maxillary defectFibula free flap
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Patient 4

• No cancer
• Multiple failed oral surgical procedures (gt 30!)
  for cosmetic dental rehabilitation
• Complete loss of premaxilla, ventral hard palate,
  support to nose
• Large oro-nasal fistula
• Reclusive
• Reconstructed with fibula free flap

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Maxillary and palatal defectFibula free flap
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Maxillary and palatal defectFibula free flap
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Maxillary and palatal defectFibula free flap
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Patient 5

• Large right tongue CA
• Ant. tongue to base
• Right tonsillar fossa
• Palpable neck mets
• Prior XRT and chemo
• Lip/mandibular split
• Reconstructed with radial forearm free flap

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Large tongue cancer
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Large tongue cancer
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Large tongue cancer
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Large tongue cancer
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Large tongue cancer
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The end

• Questions?

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Surgical treatment of oral and oropharyngeal
cancer

• Tod C. Huntley, MD FACS
• Center for Ear Nose Throat Allergy,
  Indianapolis, Indiana
• tod.huntley_at_centadocs.com
• 800-283-1056
• Statewide Campus System of Michigan State COM
• Genoa Woods Conference Center
• January 19, 2008