局部晚期复发口腔癌挽救性手术近期疗效分析

Salvage surgery with extended vertical lower trapezius island myocutaneous flap reconstruction for advanced recurrent oral and oropharyngeal squamous cell carcinoma

目的 :挽救性手术是复发口腔口咽癌一种有可能根治的治疗方法。肿瘤复发灶切除后巨大缺损的修复重建是治疗的难点,本研究对局部晚期复发口腔口咽癌行挽救性手术切除及延长下斜方肌皮瓣修复,并评估其近期疗效。方法:选取中山大学孙逸仙纪念医院23例局部晚期复发口腔口咽癌患者,男17例,女6例,行挽救性手术切除肿瘤并以延长下斜方肌皮瓣修复缺损。19例口腔癌,4例口咽癌;复发癌临床分期为3例r CS III期,20例r CS IV期;在首次治疗方面,15例行手术治疗,4例放疗,4例手术后辅以放疗;之后的再次治疗方面,11例患者进行手术治疗,10例进行根治性放疗,2例行手术治疗辅以术后放疗。所有患者均无远处转移。其中21例患者行肿瘤复发灶的广泛切除,2例患者进行颅颌面切除。肿瘤切除术后缺损采用延长下斜方肌皮瓣修复,皮岛大小6 cm×7 cm^10 cm×22 cm,9例患者采用折叠延长下斜方肌皮瓣修复颌面洞穿性缺损。采用SPSS 12.0软件包对数据进行统计学分析。结果:所有患者术后均未出现严重并发症,出现远端皮瓣局部坏死、供区切口裂开及口内外瘘道各1例。4例患者(17.4%)术后可正常进食固体食物,11例患者(47.8%)可进食软食,4例患者(17.4%)可进食流质食物,4例患者(17.4%)需留置经鼻胃管,鼻饲流质饮食。9例患者(39.2%)术后发音正常,8例患者(34.8%)术后发音尚清楚,3例患者(13.0%)术后语音不清,3例患者(13.0%)术后需永久性气管造瘘。随访3~72个月(中位时间15.7个月),15例患者(65.2%)无复发生存,2例患者(8.7%)复发生存,6例患者(26.1%)在随访3~18个月时死于肿瘤复发和转移。无复发生存患者的第二次治疗至复发时间为7.40±0.53个月,复发、转移、死亡患者的时间为4.83±0.42个月,两者间差异显著。结论:挽救性手术治疗局部晚期复发口腔口咽癌是一种有效的治疗方案,延长下斜方肌皮瓣是修复此类手术后巨大缺损简单、可靠的大型组织瓣。

PURPOSE： Salvage surgery can be considered as a potentially curative therapeutic approach for a selected group of patients with re-recurrent oral and oropharyngeal squamous cell carcinoma（SCC）. Reconstructing the major defects following wide resection of the tumors is challenging. We evaluated the outcomes of a second salvage surgery with extended vertical lower trapezius island myocutaneous flap（TIMF） reconstruction for selected patients with re-recurrent oral cavity and oropharyngeal SCC. METHODS： The subjects were 23 patients with advanced re-recurrent oral and oropharyngeal SCC undergoing second salvage surgery and reconstruction with extended lower vertical TIMF（17 males, 6females）. The site of the primary tumor was the oral cavity in 19 patients and the oropharynx in 4 patients. The clinical staging of re-recurrence（r CS） was classified as advanced r CS III in 3 patients and r CS IV in 20 patients. In initial treatment, fifteen patients were treated with surgery, four with radiotherapy alone, and 4 with surgery and adjuvant radiotherapy. In the first salvage treatment, eleven patients were treated with salvage surgery, ten with radiotherapy, and 2with surgery and adjuvant radiotherapy. All patients had locoregional re-recurrence without distant metastasis and underwent a second salvage surgery. Of them, twenty one patients underwent wide resection of the tumor. A craniofacial resection was performed in 2 patients. An extended vertical lower TIMF, with a skin paddle measuring 6 cm ×7 cm to 10cm×22 cm, was used to reconstruct the major defects; among them, there were 9 folded extended vertical lower TIMFs for reconstructing through-and-through defects. RESULTS： Minor flap failure, wound dehiscence in the donor site, and an orocutaneous fistula occurred in 3 patients, but there was no major complication in any patients. Four patients（17.4%）could manage a solid diet, eleven（47.8%） could manage a soft diet, four（17.4%） remained on a liquid diet, and 4（17.4%）required nasogastric tube feeding. Nine patients（39.2%） achieved normal speech, eight（34.8%） achieved intelligible speech, three（13.0%） had slurred speech, and 3（13.0%） required a permanent tracheostomy. The patients were followed up for 3-72 months（median, 15.7 months）. Fifteen patients（65.2%） were alive with no evidence of disease, two（8.7） were alive with disease, and 6（26.1%） died of local recurrence or distant metastases at 318 month. The time interval between the first salvage surgery and the date of the second recurrence in those alive with no disease and those who died of disease were 7.40±0.53 and 4.83±0.42 months, respectively. A significant difference（P〈0.05） was noted between those alive with no disease and those who died of disease. CONCLUSIONS： Salvage surgery remains an effective treatment modality for selected 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 salvage surgery.