胸大肌肌皮瓣在舌再造术中的应用

报告舌癌行全舌,或舌大部或舌根广泛切除术后,应用胸大肌皮瓣行舌再造术的经验。方法 自１９８４年１２月至１９９５年９月,我院对８６例Ｔ３或Ｔ４舌癌根治术后的舌缺损,应用带蒂胸大肌肌皮瓣同期进行了舌再造术。结果 肌皮瓣全坏死１例。术后吞咽和语言功能恢复正常分别为５９例和４４例。     

Retrospective study on cancer of the base of the tongue

From Feb. 1962 to Feb. 1982, 54 patients with cancer of the base of tongue were treated in our hospital. There were 44 squamous cell carcinomas and 10 adeno-cystic carcinomas. 46 patients were treated by radiotherapy only, 6 by surgery plus radiotherapy, 1 by surgery and 1 by chemotherapy alone. The 5 year survival rate was 27.1%. The result indicates that radiotherapy alone is poor. The author suggests that for cancer of the base of tongue, a combination of radiotherapy and surgery be used and prospective randomized study be carried out. The defect can be repaired using skin or myocutaneous flaps. In extensive lesions, glossectomy plus laryngectomy should be considered. For the healthy and young patients, the lesions of the base of tongue together with a part of the larynx should be extirpated but for the older man, selective glossectomy is advised.     

Functional and sensitive outcomes after tongue reconstruction: about a series of 30 patients

Few studies reported both functional and sensitive long-term evaluations after tongue reconstruction. The aim of this study was to assess functional outcomes and sensitive recovery after tongue reconstruction with fasciocutaneous free flap (FCFF) or musculocutaneous pedicled flap (MCPF) without nerve anastomosis. We enrolled 30 patients having no recurrence from a consecutive series of 79 tongue reconstructions as part of a cancer treatment. All patients were submitted to functional and sensitive tests. The functional study included intelligibility, tongue motility, food, and swallowing scores. Flap sensibility was evaluated too. Male-to-female sex ratio was 6.5 with a mean age of 52 years old. The lesions were mainly advanced (T3-T4 73%). Mobile tongue and base of tongue resection was carried out in 43% of cases, and resection was limited to the oral tongue for 53%. Twenty-one FCFF and nine MCPF were performed. The mean follow-up was 2 years and 11 months. Swallowing (slightly impaired 63%), food (normal 40%), and intelligibility (excellent 77%) assessments were satisfactory. Spontaneous sensory recovery was regularly observed (mean response 62%). The two groups FCFF and MCPF were similar regarding population and tumors characteristics. Functional results were higher in case of FCFF (food score p=0.05; intelligibility p=0.04). No difference was observed on sensitive recovery. This study emphasizes good functional results either for swallowing or intelligibility, with higher scores for the FCFF, strengthening the opinion that FCFF is the best choice for tongue reconstruction whenever possible.     

The difference between delayed extubation and tracheostomy in post-operative sleep apnea after glossectomy or laryngectomy

BACKGROUND: Patients with cancer of the tongue or larynx require glossectomies or laryngectomies and subsequent reconstruction. These procedures remove part of the patient's upper airway. In cancer of the tongue, the removed part of the airway is substituted by a flap of their skin. Post-operatively, it is possible that the patients have problems respiring comfortably. In addition to this, long surgical procedures may simply interfere with their circadian rhythm. To elucidate the possible change in their post-operative respiration, we monitored the patient's respiratory pattern with an apnea monitor. METHODS: We attached an apnea monitor to the patients and recorded their respiratory pattern and arterial oxygen saturation. The patients were monitored for a total of five days: three days prior to the operation, one day before the operation, the day of operation, two days after, and on the fourth day after the operation. The period of monitoring was from 8:00 p.m. to 6:00 a.m. the next morning. RESULTS: Sixteen patients completed this study. The patients whose tube was extubated after glossectomy showed frequent apnea, low mean oxygen saturation and low comfort score as compared to the patients with tracheostomy after laryngectomy. Because two failed cases of free skin flap were among the former, it is possible that the frequent apnea is a factor of failed free skin graft after glossectomy and laryngectomy. CONCLUSION: Further studies are required to improve the patient's respiration during their sleep after tracheal extubation in glossectomy.     

Organ preservation with interstitial radiation for base of tongue cancer

Management options for squamous cell carcinoma of the base of tongue include surgical resection (often with adjuvant radiation), definitive external radiation and external combined with interstitial radiation. The reported series is a single institution experience with interstitial radiation for base of tongue cancer. Twenty patients were treated definitively with interstitial radiation as a boost to external radiation, and four patients were treated palliatively with interstitial radiation alone for recurrent base of tongue cancers or disease arising in a previously irradiated base of tongue. Patient, tumor, and treatment details were analyzed relative to disease control and posttreatment patient function. The 5-year actuarial local control, locoregional control, distant metastasis-free survival, overall disease-free survival, and actuarial overall survival of the definitively treated patients were 86%, 84%, 57%, 41%, and 30%, respectively. The 5-year actuarial rate of tolerating a normal diet was 86%, and all long-term survivors had normal speech function. Of the four patients treated palliatively with interstitial implant alone for recurrent disease (three patients), or a second primary cancer in a previously irradiated site (one patient), local control was obtained in three and long-term disease-free survival was obtained in one. Interstitial implantation combined with external radiation is associated with a high rate of disease eradication with preservation of speech and swallow function. Interstitial radiation alone can achieve effective palliation.     

Results of surgical treatment of tongue cancer

Fourty-four patients with squamous cell carcinoma of the tongue have been treated by surgery. Twenty-two out of 44 patients were treated by a glossectomy alone and the remaining 22 by en bloc dissection with a glossectomy and neck dissection. The 5-year cumulative survival rate of these 44 cases was 86.1%, broken down as follows: stage I (20 cases), 100%; stage II (9 cases), 88.9%; stage III (11 cases), 72.7%; and, stage IV (4 cases), 50%. Four cases had a recurrence in the primary site, and 6 in the cervical region. Five out of 44 cases died (4 from tongue cancer, and one from other causes). Further, 3 out of 5 cases died of a recurrent cancer in the primary focus or in the neck. Thus, it has been concluded that control of the primary focus and neck metastasis is important for the treatment of tongue cancer, and that surgery also is an excellent therapy for tongue cancer.     

Radiation doses to structures within and adjacent to the larynx are correlated with long-term diet- and speech-related quality of life

PURPOSE: To test the hypothesis that radiation dose to key sites in the upper aerodigestive tract is associated with long-term functional outcome after (chemo)radiotherapy for head-and-neck cancers. METHODS AND MATERIALS: This study examined the outcome for 27 patients treated with intensity-modulated radiotherapy for definitive management of their head-and-neck cancer who were disease free for at least 1 year after treatment. Head-and-neck cancer-specific quality of life (QoL) was assessed before treatment and at 1 year after treatment. Type of diet tolerated, presence of a feeding tube, and degree of weight loss 1 year after treatment were also used as outcome measures. Radiation doses delivered to various points along the upper aerodigestive tract, including base of tongue, lateral pharyngeal walls, and laryngeal structures, were determined from each treatment plan. Radiation doses for each of these points were tested for correlation with outcome measures. RESULTS: Higher doses delivered to the aryepiglottic folds, false vocal cords, and lateral pharyngeal walls near the false cords correlated with a more restrictive diet, and higher doses to the aryepiglottic folds correlated with greater weight loss (p < 0.05) 1 year after therapy. Better posttreatment speech QoL scores were associated with lower doses delivered to structures within and surrounding the larynx. CONCLUSION: Our data show an inverse relationship between radiation dose delivered to laryngeal structures and speech and diet and QoL outcomes after definitive (chemo)radiation treatment. These findings suggest that efforts to deliver lower doses to laryngeal structures may improve outcomes after definitive (chemo)radiation therapy.     

Deep inferior epigastric artery perforator free flaps in head and neck reconstruction

The advantage of free perforator flaps versus free musculocutaneous flaps is the reduced morbidity of the donor site with preservation of nerves, muscles and deep fascia. In this study, we evaluated the reconstruction results of deep inferior epigastric artery perforator (DIEAP) free flaps in the head and neck. A retrospective review was performed of 12 patients with head and neck tumor ablation defects that were reconstructed with the deep inferior epigastric artery perforator (DIEAP) free flaps between January 2004 and December 2006. Reconstruction outcomes and complications were measured. Recipient sites were subdivided into defects of total or subtotal glossectomy (N=6), three-dimensional defects of midface (N=3), through and through defects of the cheek (N=2), and anterior skull base resection with an external skin component defect (N=1).The overall free flap success rate was 92% (11/12). One DIEAP free flap was lost because the draining jugular vein thrombosed. No complications were observed in the donor site, including abdominal bulge or hernia. Due to the advantage of minimum donor site morbidity, the DIEAP free flap is a new and reliable reconstruction choice for head and neck surgical defects.     

Long-term functional outcome of brachytherapy for carcinoma of the mobile tongue: focus on the atrophic change of irradiated tongue

OBJECTIVE: To assess tongue atrophy and long-term functional outcome of mobile tongue cancer patients after interstitial radiotherapy. METHODS: Of 493 patients whose squamous cell carcinoma of the mobile tongue had been treated with low dose rate brachytherapy, there were 57 patients evaluated between July 2002 and April 2004 whose tongue had not been modified by surgical procedures and who had no primary recurrence. The median time from treatment to evaluation was 96 months (range: 9-214 months). Almost all of the patients belonged to the early stage tongue cancer (T1/T2/T3/T4=30:24:3:0), and all had received interstitial radiotherapy with a single-plane implant. To evaluate the deformity of the tongue, we used a grading system that classified the atrophic changes of the tongue into four categories (G0-G3). RESULTS: Thirty-nine patients (70%) showed mild tongue hemiatrophy (G1 or G2) in the irradiated side. However, no patients showed severe atrophy where the tongue cannot be made to protrude beyond the incisors (G3). The length of time after brachytherapy was >72 months and the age of the patients at brachytherapy had the same statistical significance (P=0.0366). As for functional outcome, understandability of speech and a normal diet were preserved for almost all patients. CONCLUSION: The progression of atrophic change in the irradiated tongue occurred over a long term after brachytherapy. However, most patients could maintain their activities of daily life without severe restriction.     

Use of the double-paddle anterolateral thigh flap for locally advanced tongue carcinoma requiring second site reconstruction

BackgroundAdvanced oral tongue carcinoma can present with extension beyond the oral cavity. Operative defects after resection may involve multiple anatomical sites and significantly impact speech and swallowing. Dependence on long-term enteral feeding is not uncommon for these patients. The anterolateral thigh (ALT) flap is one of the most reliable and flexible flaps used in the reconstruction of total and subtotal tongue defects. The double-paddle flap modification may be a more suitable option for complex oral tongue defects after advanced tumor ablation.MethodsCase series of 31 patients with oral tongue squamous cell carcinoma that were classified as stage IV. The age of patients ranged from 32 to 63 years. We designed the double-paddle ALT flaps to reconstruct the two-site surgical defects (tongue defect and pharynx or neck skin defect). Postoperative viability of the flap was checked by clinical observation. The last examination was performed at 3-months after the completion of adjuvant chemoradiotherapy. The functional capacity of our patients was evaluated by three physicians (Head and Neck Surgeon, Radiation Oncologist, and Physiatrist) using a Speech Intelligibility Score and the Functional Oral Intake Scale.ResultsA total of 31 patients with surgical defects after total or subtotal tongue resection for cancer underwent double-paddle ALT flaps for reconstruction from March 2018 to December 2019. The dimension of flaps from 8 × 12 cm to 10 × 18 cm were divided into double-paddle from 8 × 5 cm to 10 × 10 cm. There was one case of pedicle thrombosis, one case of postoperative bleeding, three cases of neck infection, and six cases of salivary fistula. Our patients were seen in follow up from 6 to 36 months, with median follow-up of 23.5 months. The survival rate of ALT flap was 100%. All of our patients achieved an oral diet by 9 months after surgery. The mean score speech intelligibility was 2.74 ± 0.68 (4-point ordinal scale). The 2-year disease-free survival rate was 61.3%.ConclusionsThe double-paddle ALT flap is a reliable flap suitable for oral defects involving multiple subsites after ablative procedures. The majority of patients demonstrated acceptable functional rehabilitation.Clinical question/ level of evidenceTherapeutic, IV.     

舌癌根治术后游离前臂皮瓣一期舌再造术的改进

背景与目的：舌癌根治术造成半舌缺损,严重影响患者的生存质量。术中行一期舌再造术可保证手术创面的Ⅰ期愈合,使患者的吞咽及语言功能早日恢复,然而游离皮瓣再造舌时常发生的血管危象问题一直阻碍着这项手术的广泛开展。本文报告在应用游离前臂皮瓣行一期舌再造术中所做的一些改进方法,旨在提高其成功率。方法：对32例舌鳞癌患者在根治术中应用游离前臂皮瓣行一期舌再造,在皮瓣设计、制备和血管吻合等方面加以改进。结果：术后口腔和颈部创面均一期愈合,无涎瘘、乳糜漏、口底颌下瘘和感染等并发症发生;术后出现血管危象6例,5例抢救成功,1例失败,最终放弃皮瓣,移植成活率为96．9％。再造舌外形大部分良好,语言和吞咽功能恢复良好。结论：改进的游离前臂皮瓣舌再造术再造舌的成功率较高。     

Changes in Oral Function and Quality of Life in Tongue Cancer Patients Based on Resected Area

Objective: Treatment of tongue cancer caused oral morbidities such as oral dryness, and dysphagia. The purpose of this study is to examine the time course of oral function and QOL based on resected area for patients after tongue cancer resection. Methods: 31 patients who underwent tongue cancer resection at the Showa University Head and Neck Oncology Center. The participants were divided into two groups; 24 participants in partial/hemi glossectomy group (PG), and seven in subtotal/total glossectomy group (TG). Participants were evaluated swallowing function (FOIS and MASA-C), tongue pressure (TP: kPa), BMI, whole body muscle mass (kg), and QOL evaluation (EORTC QLQ-C30, H & N35). Participants were measured at baseline (before surgical treatment), 1, 3, and 6 months after surgical treatment (1M, 3M, and 6M). Results: At baseline, tongue pressure and FOIS score of PG were significant higher than that of TG. At 1M, TP, MASA-C, and FOIS score of PG were significant higher than that of TG. At 3M, TP, MASA-C, and FOIS score of PG were significant higher than that of TG. At 6M, TP and MASA-C were significantly higher than that of TG. QOL measurements did not noted any significant difference between groups before 6M. At 6M, Some QOL measurements of TG related tongue function (Swallowing, Senses, Speech, Social contact) were significantly lower than PG. Conclusions: The resected area had significant effects on oral morbidities and feeding function. It is necessary to develop more effective rehabilitation methods to improve patients QOL who had functional impairment remained.     

Social perception of speech in individuals with oropharyngeal reconstruction

Oral cancer affects approximately 5% of the Canadian population every year. One option for treatment of oropharyngeal cancer includes resection of the diseased tissue with primary reconstruction of the defect using a microvascular free flap, followed by post-operative adjuvant radiation therapy. The aim of reconstructive surgery is to maintain functional speech and swallowing. While the literature provides support for the maintenance of speech intelligibility following reconstructive procedures, certain aspects of resonance may be altered when the palatal structures are involved. Little is known about the effect of such alterations on the perception of speakers who have been treated with microvascular free flap reconstruction. Social perception is a process in which we infer attributes of others, with the speech signal playing an integral part in attribution. The purpose of this study was to explore the social perceptions formed about speakers both before and after surgery for oropharyngeal cancer. The results of this study revealed that positive perceptions of speakers significantly diminished as a result of surgery and negative perceptions increased. Certain variables, such as degree of resection of the soft palate and base of tongue, and sex of the speaker, had influence on the results. This research suggests that intelligibility measurements of speech, although useful, do not provide a complete indication of the social impact of reconstructive surgery on patients with oropharyngeal resections.     

Free flap reconstruction in the treatment of tumors involving the hard palate.

AIM: To report our experience in free flap reconstruction of the hard palate after malignant tumor resection, in terms of reconstruction method, immediate post-operative course and subjective functional results. PATIENTS AND METHODS: Files from 1988 to 1999 were reviewed for patients having undergone microvascular reconstruction of the hard palate. The immediate post-operative course (during the first month) was reviewed to determine the occurrence of complications. The surgeon's evaluation 1 year post-operatively was used to determine the intelligibility of speech, type of diet and the quality of nasal permeability. RESULTS: Thirty eight patients (28 men and 10 women) with malignant tumors involving the hard palate had undergone surgical reconstruction using microvascular free flap techniques: free radial forearm flap (13 cases), scapular flap (24 cases) or fibular flap (five cases). Two different flaps were employed in two cases (scapula plus fibula). A second flap was used with success in two cases of failure of the first flap, for a total of 42 free flaps for 38 patients. Complications occurred in seven cases, with two cases of flap necrosis. At 1 year, 33 patients achieved a normal diet and 35 normal or easily intelligible speech. CONCLUSIONS: Microsurgical reconstruction using free tissue transfer allows reconstruction of large defects of the hard palate, with low morbidity and an excellent functional outcome. We propose criteria for free flap reconstruction and choice of flap.     

Proposal of a new grading system for evaluation of tongue hemiatrophy as a late effect of brachytherapy for oral tongue cancer.

PURPOSE: To evaluate tongue hemiatrophy as a late effect of brachytherapy, a new grading system was designed and applied to patients who had received low dose rate (LDR) or high dose rate (HDR) brachytherapy for early tongue cancer. METHODS AND MATERIALS: Between December 1998 and April 1999, 49 patients who had received brachytherapy for early tongue cancer (T1/T2=22:27) at Osaka University Hospital were investigated. All patients had undergone either LDR or HDR brachytherapy with Ir-192 (LDR/HDR=30:19) between 1980 and 1998. Atrophic changes in their tongue were classified into four categories (G0-G3): G3, not able to protrude the tongue beyond incisors; G2, hemiatrophy is seen on the irradiated side in the resting position of the tongue; G1, deviation of the tip of the tongue to the irradiated side is seen when protruded; and G0, none of these signs. The relationship between tongue hemiatrophy and tumor factors, treatment factors, and patients' functional impairment was then investigated. The median time from treatment to assessment was 75 months (range 8-219 months). Volume index was defined as the number of needles that were implanted vertically into the tongue. RESULTS: Fourteen patients were classified as G0, 29 as G1, five as G2, and one as G3. None of the G0 patients showed any speech or swallowing dysfunction, pain or contracted feeling, or general dissatisfaction with post-treatment tongue status. There was a tendency for such problems to increase with the tongue hemiatrophy grade. The frequency of T2 and non-superficial type tumors also tended to increase with the tongue hemiatrophy grade. The volume index of the G2-3 hemiatrophy group was significantly larger than that of the G0-1 group (P=0.041). CONCLUSION: This new grading system makes evaluation of atrophic changes in the tongue after brachytherapy easy and effective.     

Human papillomavirus is more common in base of tongue than in mobile tongue cancer and is a favorable prognostic factor in base of tongue cancer patients

The frequency of human papilloma virus (HPV) and its influence on clinical outcome was analyzed retrospectively in pre-treatment paraffin embedded biopsies from 110 patients with tongue cancer. The presence of HPV DNA was examined in 85 mobile tongue tumors and 25 base of tongue tumors by a polymerase chain reaction (PCR) with 2 general primer pairs, GP5+/6+ and CPI/IIG. When HPV-DNA was found, HPV-type specific primers and direct sequencing were used for HPV sub-type verification. Twelve of 110 (10.9%) samples were HPV-positive; 9 for HPV-16, 1 for HPV-33, 1 for HPV-35 and 1 could not be analyzed because of shortage of DNA. HPV was significantly more common in base of tongue tumors (10/25, 40.0%) compared to tumors of the mobile tongue (2/85, 2.3%). The influence of HPV on clinical outcome in mobile tongue cancer could not be studied, due to that HPV was present in too few cases. Of the 19 patients with base of tongue cancer that were included in the survival analysis, however, 7 patients with HPV-positive base of tongue cancer had a significantly favorable 5-year survival rate compared to the 12 HPV-negative patients. In conclusion, HPV is significantly more common in base of tongue cancer than in mobile tongue cancer, and has a positive impact on disease-specific survival in patients with base of tongue cancer.     

Advanced squamous cell carcinoma of the base of the tongue treated with surgery and post-operative radiotherapy.

BACKGROUND: Early stage squamous cell carcinoma of the base of the tongue has been successfully treated with radiotherapy and brachytherapy. However, the vast majority of these tumours seen in Western Europe are already at an advanced stage. Medical records of 79 patients with squamous cell carcinoma of the base of the tongue treated between 1980 and 1994 were examined. METHODS: Eighty-three per cent of the primary tumours were stage T3 or T4. Fifty-nine patients were treated with surgery and post-operative radiotherapy. Quality of life assessment amongst the survivors was performed by means of a questionnaire. RESULTS: Five year disease free survival in patients undergoing excision for T3-T4 tumours was 59%. Patients with T2-T3 tumours undergoing partial excision of the tongue base had a 3 year recurrence free survival rate of 68%. Distant metastasis occurred in 16%. Seventy-eight per cent of the patients judged their quality of life to be near normal. CONCLUSION: Surgery and post-operative radiotherapy offer a reasonably good survival in advanced carcinoma of the base of the tongue with preservation of quality of life.     

Deltopectoral Flap Reconstruction of the Posterior Pharyngeal Wall: A Single Stage Pedicle Flap Alternative Solution to the Free Flap Reconstruction of Circumferential Laryngopharyngeal Defects

The first option for reconstruction of a circumferential pharyngeal defect following extensive pharyngo-laryngectomy is free tissue transfer. Despite that, pedicled flaps can be used when microsurgical expertise is not available or if other patient related or region related issues deem free tissue transfer unfavourable. The aim of this study was to review the operative feasibility and functional outcomes following dual flap reconstruction of circumferential pharyngeal defects.This was a retrospective study of all patients (n = 8) who underwent either primary (n = 5) or salvage (n = 3) circumferential laryngopharyngectomy + /– cervical oesophagectomy, followed by dual flap reconstruction, with a deltopectoral flap to reconstruct the posterior wall from 2005 to 2020. The main outcome measures were operative complications, hospital stay and functional outcomes (speech and swallowing). The operation was feasible in all patients, with dual flap reconstruction using a deltopectoral flap, combined with a pectoralis major flap (n = 5) or a supraclavicular flap (n = 3). All patients developed a small, lateralised, self-healing fistula at the site of the deltopectoral flap 3-point junction. This did not require any intervention, or impact on adjuvant treatment. Functional outcomes were favourable, with all patients achieving oral diet. One patient required gastrostomy diet supplementation, and one patient required stricture dilatation. Of the patients able to receive a speech valve (n = 4), all achieved intelligible speech. Dual flap reconstruction of circumferential pharyngeal defects represents a feasible alternative option for a complex reconstructive problem. The predictable operative recovery and favourable functional outcomes indicate that the use of both a deltopectoral flap and a second flap is a robust reconstructive solution.     

Larynx preservation surgery for advanced posterior pharyngeal wall carcinoma with free flap reconstruction: a critical appraisal

To report the functional and oncologic results of larynx preservation surgery with free flap reconstruction for posterior pharyngeal wall carcinoma. Retrospective medical chart review. Tertiary care referral center. We present a series of seven patients, who were treated for an advanced stage posterior pharyngeal wall carcinoma between 1995 and 1998. All patients underwent posterior pharyngectomy with larynx preservation via a suprahyoidal approach for carcinoma of the posterior pharyngeal wall, with radial forearm free flap reconstruction. Complications occurred in three patients with grade 3 comorbidity, one of whom suffered flap loss. After a mean follow-up of 48 months, three patients are alive without disease. One patient is alive with a second primary tongue carcinoma. Two patients died of disease, whereas one patient died of another cause. All patients could be decannulated and maintain their voice. Six out of seven patients were able to take oral nutrition, although four patients needed additional PEG-tube feeding. Posterior pharyngectomy with larynx preservation and radial forearm free flap reconstruction is feasible in selected patients, with acceptable functional results and survival. However, the patient must be aware of the risk of chronic aspiration and the possibility of long-term PEG feedings.