Facial-submental island flap for reconstruction of hemitongue defects in young, middle-aged and elderly patients with early and middle stage oral tongue squamous cell carcinoma

Oral tongue squamous cell carcinoma (OTSCC) is the most common primary tumor of the oral cavity; it accounts for 87% of all cases of oral SCC [1]. OTSCC predominantly affects older adults, but its prevalence in younger patients is increasing worldwide [2]. Younger patients are often diagnosed at a later stage of cancer than older patients, and have higher rates of regional metastases and delayed relapse. Furthermore, recurrent disease is more aggressive than the initial disease [3]. A study of multihospital claims database from > 1000 patients aged < 45 years reported that tongue cancer was not associated with a poor prognosis [4]. In addition, treatment decision-making is particularly challenging in older patients with comorbidities, such as cardiovascular, endocrine, and musculoskeletal diseases. The Adult Comorbidity Evaluation-27 (ACE-27) [5] is used to assess comorbidities and correlates with the overall survival of head and neck cancer patients older than 70 years [6]. Several factors are associated with poor outcomes in elderly OTSCC patients, including their clinicopathological characteristics and surgical management [7]. It is unclear whether the prognosis of OTSCC differs between young and elderly patients. We previously reported that the facial-submental artery island flap (FSAIF) can be reliably used to reconstruct oral and maxillofacial defects following cancer ablation [8], particularly in older patients [9]. In the present study, we evaluated the outcomes of hemitongue reconstruction using FSAIF following cancer ablation in young, middle-aged, and elderly patients with early and middle-stage OTSCC.

Patients and methods

This retrospective observational study was conducted from June 2011 to May 2021 at the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, China. The Institutional Review Board of Sun Yat-sen University approved the study. Data on age, sex, comorbidities, clinical staging, flap size, length of surgery, flap survival, complications, swallowing and speech functions, aesthetic outcome, and survival status were extracted from patients’ medical records. The study included primary T1–T3 stage OTSCC patients; there were no N0 stage patients. We excluded patients with cachexia, severe congestive cardiac failure, severe chronic obstructive pulmonary disease, and/or missing follow-up data.

We enrolled 122 OTSCC patients (64 males [52.5%] and 58 females [47.5%]) aged 23–90 years (median age, 58.3 years). The patients were categorized as young (< 45 years, n = 18, 14.8%) (Fig. 1), middle-aged (≥ 45 to < 65 years, n = 63, 51.6%) (Fig. 2), or elderly (≥ 65 years, n = 41, 33.6%) (Fig. 3). The 8th edition of the American Joint Committee on Cancer (AJCC) staging manual [10] was used for the clinical staging of OTSCC. Int total, 3, 11, and 4 patients in the young group, 8, 36, and 19 patients in the middle-aged group, and 4, 22, and 15 in the elderly group were classified as stage I (T1N0), II (T2N0), and III (T3N0 and T3N1), respectively.

Fig. 1figure 1

A 23-year-old female patient with stage II oral tongue squamous cell carcinoma (OTSCC). Incision for the submental artery island flap (FASIF) (A) and the tongue tumor (B). Flap harvested (C) through FASIF reconstruction of the hemitongue (D). Hemitongue reconstruction (E) and a well-hidden horizontal scar at the donor site (F, G) at 18 months postoperatively

Fig. 2figure 2

A 64-year-old female patient with stage II OTSCC. Incision for FASIF (A) and tongue tumor (B). The harvested flap (C). FASIF reconstruction of the hemitongue. The donor area was largely closed (D). Hemitongue reconstruction (E) and a well-hidden horizontal scar (F) at 60 months postoperatively

Fig. 3figure 3

A 90-year-old male patient with stage II OTSCC. Incision plan for FASIF (A) and the harvested flap (B). Hemitongue reconstruction (C) leaving a well-hidden horizontal scar (E) at 16 months postoperatively

The ACE-27 index was used to evaluate comorbidities including alcohol abuse, hypertension, respiratory disease, congestive heart failure, diabetes mellitus, arrhythmia, myocardial infarction, coronary artery disease/angina, stroke, renal insufficiency, dementia, paralysis, other solid tumors, obesity, leukemia/myeloma, lymphoma, illicit drug use, and peripheral arterial, gastrointestinal, psychiatric, liver, neuromuscular, venous, pancreatic, rheumatological, and immunological (e.g., AIDS) diseases. The diseases and conditions were categorized into grades 1–3 (mild, moderate, and severe, respectively) according to the severity of organ decompensation and prognosis. Based on the highest-ranked ailment among the diseases and comorbidities, we assigned patients to comorbidity classes (none, mild, moderate, or severe). Patients with two or more moderate ailments affecting different organ systems, or belonging to different groups, were classified into the severe comorbidities group [11]. The comorbidities were extracted from the medical records, as stated above. In total, 67 (54.9%) patients had at least one comorbidity. Based on the ACE-27 index, 37 (30.3%), 20 (16.4%), and 10 (8.2%) patients had mild, moderate, and severe comorbidities, respectively.

Surgery, including hemiglossectomy, ipsilateral selective neck dissection, and hemitongue reconstruction using FSAIF, was performed in 122 patients. Ipsilateral selective neck dissection was performed in 15 and 69 patients with stage I and II disease, respectively, and radical neck dissection was performed in 38 patients with stage III disease. The submandibular lymph nodes were carefully removed and subjected to the rapid pathological diagnosis during flap elevation. Then, the donor area was largely closed. The details of the surgical technique have been described previously [8]. Six patients with T3N1 disease underwent cobalt-60 adjuvant radiotherapy (60 Gy over 30 days; 2 Gy fractions/day) at the primary site. Table 1 presents the patients’ demographic and clinical characteristics.

Table 1 Demographics, clinical characteristics, and outcomes of facial-submental island flap for reconstruction of tongue defects following cancer ablation in young (< 45 years), middle-aged (≥ 45 to < 65 years) and elderly (≥ 65 years age) patients with early and middle stage oral tongue squamous cell carcinoma

Postoperative complications that occurred within 30 days after surgery were assessed using the Clavien-Dindo classification (Table 2) [12]. The patients were followed to determine their swallowing and speech functions at 6 months postoperatively. Three surgeons assessed the outcomes. Swallowing was classified as normal, soft, liquid, or nasogastric tube feeding. Speech was classified as normal, intelligible, slurred, or tracheostomy requirement. Esthetic outcome was classified as excellent, good, fair, or poor.

Table 2 Clavien-Dindo Classification System for Surgical Complications

Statistical analyses were performed using SPSS software (version 20.0; IBM Corp., Armonk, NY, USA). The chi-square test, independent samples t-test, and Mann–Whitney U test were used to analyze the data. The level of significance was set at p < .05.

留言 (0)

沒有登入
gif