Second salvage surgery with extended vertical lower trapezius island myocutaneous flap reconstruction for advanced re-recurrent oral and oropharyngeal squamous cell carcinoma

Abstract

The purpose of this study was to evaluate the outcomes of second salvage surgery with extended vertical lower trapezius island myocutaneous flap (TIMF) reconstruction for patients with re-recurrent oral cavity and oropharyngeal squamous cell carcinoma (SCC). The subjects were 23 patients with advanced re-recurrent oral and oropharyngeal SCC undergoing second salvage surgery and reconstruction with a TIMF. A TIMF with a skin paddle measuring 6 cm × 7 cm to 10 cm × 22 cm was used to reconstruct the major defects. Three patients experienced minor complications: minor flap failure ( n = 1), wound dehiscence at the donor site ( n = 1), and an orocutaneous fistula ( n = 1). The patients were followed for 3–72 months. Fifteen patients were alive with no evidence of disease, two were alive with disease, and six died of local recurrence or distant metastases. Second salvage surgery remains an effective treatment modality for select patients with advanced re-recurrent oral and oropharyngeal SCCs, and the extended vertical lower TIMF is a large, simple, and reliable flap for reconstructing the major defect following second salvage surgery.

Locoregional recurrences are the most frequent cause of treatment failure in patients with squamous cell carcinoma (SCC) of the oral cavity and oropharynx. Salvage surgery remains the only curative treatment option for patients with failure after primary radiation and/or surgery. Unfortunately, 39.7–54.9% of patients who undergo salvage surgery will develop further locoregional recurrence.

Second salvage surgery can be considered a potentially curative therapeutic approach for a select group of patients with re-recurrent oral SCC. In these cases, following wide resection of the tumours where the major defects were present, reconstructing the inevitable defect is challenging. We have previously reported the use of the extended vertical lower trapezius island myocutaneous flap (TIMF) in the reconstruction of large defects following salvage surgery for patients with recurrent head and neck SCC, and consider it to be a large, simple, and reliable flap. The purpose of this study was to review the functional and survival outcomes of second salvage surgeries with an extended vertical lower TIMF, including a folded pattern reconstruction, for advanced re-recurrent oral cavity and oropharyngeal SCC.

Patients and methods

The subjects were 23 patients with advanced re-recurrent oral and oropharyngeal SCC who underwent second salvage surgeries and reconstruction with an extended lower vertical TIMF between January 2008 and October 2012. The institutional review board approved the study. There were 17 males and six females; their ages ranged from 16 to 85 years (median 59.9 years). The site of the primary tumour was the oral cavity (buccal mucosa, tongue, floor of mouth, palate, gingiva) in 19 patients (82.6%) and the oropharynx (base of tongue, soft palate, retromolar trigone) in four (17.4%). The clinical staging of re-recurrence (rCS) was classified as advanced rCS III in two patients (8.7%) and rCS IV in 21 patients (91.3%). As the initial treatment, 15 patients were treated with surgery, including ipsilateral radical neck dissection (nine cases) and reconstruction with a pectoralis major myocutaneous flap (three cases) or forearm free flap (two cases), four patients underwent radiotherapy alone, and four patients underwent surgery and adjuvant radiotherapy. As first salvage treatment, 11 patients were treated with salvage surgery including ipsilateral radical neck dissection (four cases) and reconstruction with a pectoralis major myocutaneous flap (two cases) or submental flap (one case), 10 patients underwent radiotherapy, and two underwent surgery and adjuvant radiotherapy ( Table 1 ).

Table 1
Origin of the tumour, initial and first salvage treatments, second salvage surgery, and reconstruction with the extended lower vertical trapezius island myocutaneous flap (TIMF) in 23 patients with advanced re-recurrent oral and oropharyngeal squamous cell carcinoma.
Patient
Age, gender
Tumour site, clinical staging of recurrence Initial treatment/first salvage treatment Time to re-recurrence (months) Second salvage treatment Skin paddle of the flap (cm) Complications Adjuvant treatment Follow-up (months) Functional outcomes/status
1.
49, M
Buccal mucosa, IV Tumour resection/RT 4 Tumour resection, Man, Max, IND 6 × 10 None 11 Soft diet, normal speech/alive no disease
2.
42, F
Floor of mouth, IV Tumour resection/RT 12 Tumour resection, Man, BND 9 × 25 None Chemotherapy 9 Soft diet, normal speech/alive no disease
3.
60, M
Floor of mouth, IV RT/tumour resection 5 Tumour resection, Man, BND 6 × 9 None 4 Liquid diet, slurred speech/alive no disease
4.
78, M
Base of tongue, IV Tumour resection/tumour resection 7 Tumour resection, total glossectomy, Man, IND 7 × 9 None 8 Nasogastric tube feeding, intelligible speech/died of disease
5.
68, F
Retromolar trigone, IV Tumour resection/tumour resection 10 Tumour resection, Man, Max, IND 6 × 9 None Chemotherapy/RT 18 Soft diet, slurred speech/alive no disease
6.
64, M
Soft palate, III Tumour resection/RT 10 Tumour resection, Max, IND 7 × 9 None 36 Soft diet, intelligible speech/alive no disease
7.
56, F
Base of tongue, IV Tumour resection, IND/RT 5 Tumour resection, total glossectomy, Man, CND 6 × 8 None 3 Nasogastric tube feeding, permanent tracheostomy/died of disease
8.
16, M
Buccal mucosa, IV Tumour resection/tumour resection, RT 11 Craniofacial resection, IND 10 × 15 Wound dehiscence at donor site 38 Solid diet, normal speech/alive no disease
9.
60, F
Buccal mucosa, IV Tumour resection, IND/RT 3 Tumour resection, Max, Man 9 × 20 None 8 Nasogastric tube feeding, permanent tracheostomy/died of disease
10.
69, M
Palate, IV Tumour resection, RT/tumour resection 7 Craniofacial resection, Man, IND 10 × 20 None Chemotherapy 12 Soft diet, normal speech/alive no disease
11.
74, M
Tongue, III RT/tumour resection, IND 9 Tumour resection, hemiglossectomy, Man 6 × 7 None 72 Solid diet, normal speech/alive no disease
12.
63, F
Buccal mucosa, IV Tumour resection, IND/RT 5 Tumour resection, Man, IND 6 × (9 + 14) a None Chemotherapy 14 Solid diet, intelligible speech/alive no disease
13.
43, F
Tongue, IV Tumour resection, RT/total glossectomy, submental flap, IND 6 Tumour resection, Man, CND 6 × (12 + 8) a None 18 Soft diet, intelligible speech/died of disease
14.
47, M
Tongue, IV Hemiglossectomy, IND, PMPF/RT 13 Tumour resection, Man, CND 7 × (10 + 9) a None 25 Soft diet, normal speech/alive no disease
15.
75, M
Buccal mucosa, IV Tumour resection, RT/tumour resection, IND 3 Tumour resection, Man, IND 10 × (10 + 12) a Minor flap failure 3 Nasogastric tube feeding, permanent tracheostomy/died of disease
16.
82, M
Buccal mucosa, IV Tumour resection, RT/tumour resection 5 Tumour resection, hemiglossectomy, Man, IND 6 × (9 + 13) a None 12 Liquid diet, intelligible speech/alive no disease
17.
48, M
Tongue, IV Hemiglossectomy, IND, FFF/RT 3 Tumour resection, total glossectomy, Man 7 × (15 + 8) a Orocutaneous fistula Chemotherapy 8 Soft diet, intelligible speech/alive no disease
18.
56, M
Buccal mucosa, IV Tumour resection, IND, FFF/tumour resection, PMPF 4 Tumour resection, total glossectomy, Man, Max 9 × (11 + 8) a None RT, chemotherapy 6 Soft diet, normal speech/alive with disease
19.
85, M
Buccal mucosa, IV RT/tumour resection 8 Tumour resection, Man, Max, IND 7 × (7 + 9) a None 19 Soft diet, normal speech/alive no disease
20.
60, M
Tongue, IV RT/hemiglossectomy, IND, PMPF 5 Tumour resection, total glossectomy, Man, CND 7 × 13 None RT 9 Soft diet, intelligible speech/alive no disease
21.
63, M
Tongue, IV Hemiglossectomy, IND, PMPF/RT 6 Tumour resection, total glossectomy, Man, CND 7 × 9 None 11 Liquid diet, slurred speech/alive with disease
22.
35, M
Tongue, IV Hemiglossectomy, IND, PMPF/tumour resection, RT 5 Tumour resection, total glossectomy, Man, CND 6 × 15 None Chemotherapy 6 Liquid diet, intelligible speech/died of disease
23.
85, M
Gingiva, IV Tumour resection, IND/RT 4 Tumour resection, Man 6 × (13 + 10) a None RT 10 Soft diet, normal speech/alive no disease
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Jan 19, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Second salvage surgery with extended vertical lower trapezius island myocutaneous flap reconstruction for advanced re-recurrent oral and oropharyngeal squamous cell carcinoma
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