Salvage Surgery in Advanced Oral Cancer
A 43-year-old male with a history of right buccal mucosa cancer for which he had undergone surgery and radiation therapy in 2019 was on regular follow up at Medanta - Lucknow.
During one of his follow-ups in 2023, a PET scan was done to check for foul smell coming from his mouth and a persistent headache, which revealed two new second primary cancers – one in the tongue and the other in low infratemporal fossa (ITF). Since the patient had a minimal mouth opening pertaining to his previous treatment, it even made the visualisation of the disease difficult. The PET scan indicated two F-fluorodeoxyglucose (FDG) avid lesions – one in the right lateral tongue and another in the supero-medial aspect of the maxillary sinus wall extending to lower half of pterygoid plates.
Simultaneously, we planned an MRI to look for the extent of the tongue lesion and high ITF peri neural invasion. We used a CT-guided biopsy to establish disease in the ITF. Initial investigations showed that a surgical resection was achievable, but reconstruction would be highly complex.
A surgical attempt to resect with an oncologic safe margin in a post-operative, post-radiation patient with minimal mouth opening is challenging; the effect of radiation on neck vessels and two completely separate sites of primary defect also make the reconstruction difficult. Hence, in case of such recurrences, it is important to counsel the patient about survival. It is also important for the treating surgeon to evaluate their decision making for the way forward. Whether or not to operate in such cases is defined not only by the surgeon’s calibre to resect, but also eclipsed by their potential to reconstruct.
In this case, we were aware that we might not be able to reach an oncologic safe margin and that reconstruction at two separate surgical sites would require two different free flaps. Considering a high ITF stage-4 disease versus the young age of the patient, even a 30%-40% chance of 5-year survival was worth striving for.
After counselling the family, we reached a unanimous decision to operate.
Intraoperatively, he underwent right subtotal maxillectomy along with right extended hemiglossectomy through an angle split incision after raising a cheek flap. We were able to achieve a good resection with a considerable margin, but ended up with a huge defect to reconstruct. The gross defect measured 6.5cmx4cmx5cm and included maxilla, buccal mucosa and the tongue.
The initial plan for reconstruction was a double free flap, using free ALT flap to close the ITF defect followed by free radial forearm flap for tongue reconstruction. Following left neck dissection and identification of sizable vessels on opposite side for anastomosis in the neck, we decided to proceed with the ALT flap plan. The flap is often harvested on the descending branches of the lateral femoral circumflex artery and on its distribution territory the skin paddles are designed.
We found two strong direct perforators to the overlying skin paddles, which, with meticulous dissection, were separated helping us island overlying skin paddle. One half of the flap was used to reconstruct buccal mucosa and the other half for tongue. The flap was ipsilaterally anastomosed and a satisfactory reconstruction with good clinical outcome was achieved.
Considering large defects and a bulky flap, which presents immediate post-operative airway obstruction, difficulty swallowing and chances of aspiration, the patient underwent tracheostomy and was observed in the ICU for post-operative care. The patient was discharged from the hospital on Day 10 of the surgery. In post-operative week 3, he was able to vocalise and swallow.
Patient further underwent adjuvant radiation, which he tolerated well.
The patient, who was advised palliative chemotherapy as the resection and reconstruction in his case looked far-fetched, is now disease-free and continues to be on follow up.
