achieve negative margin resection, most alveolar tumors will require resection of the underlying bone. Determining the extent of the mandibulectomy required to achieve negative margins can be challenging.
It is accepted that if there is no bone erosion on CT or MRI, and there is enough height of the bone, marginal mandibulectomy can achieve negative margin resection. The remaining mandible should have at least a height of 1 cm.
If there is bone erosion on CT imaging or MRI shows changes in the bone marrow signal, segmental mandibulectomy is recommended.
There is no level I data on the best method to determine bone involvement. Cone beam CT is considered a very sensitive method.
In good risk candidates, osseous reconstruction with fibula, scapula, or iliac crest free flap is recommended.
Osteocutaneous radial forearm or vascularized rib graft has been described and used in patients who are not good candidates for fibula or scapula. However, the harvested bone is not thick enough to host implants.
CASE 3
Michael G. Moore
History of Present Illness
A 68‐year‐old white male presents with a chief complaint of a painful sore around his right lateral maxillary teeth. He states he initially thought it was related to a dental infection, but after having a tooth pulled, the area has continued to enlarge.
Question: What are the other important points in history taking?
Answer:
Presence of other adjacent loose teeth.
Facial numbness.
Difficulty in opening the mouth.
Dysphagia, odynophagia.
Voice changes.
Presence of neck mass.
For maxillary lesions, it is always important to determine the extent of the disease. Signs such as loose teeth, difficulty in opening the mouth (trismus), and facial numbness (perineural invasion) could provide critical clinical clues to the extent of disease and aggressive behavior.
Question: What additional aspects of the history and risk factors should be investigated?
Answer:
Tobacco or alcohol use.
Any history of head and neck cancers.
Past medical history for significant diseases: peripheral vascular disease, diabetes, autoimmune diseases, chronic kidney disease, coagulation disorders, to name a few.
This patient has a history of 10 pack‐year smoking but quit 25 years ago. He drinks alcohol socially with no history of excessive drinking. There is no history of significant diseases or malignancy.
Physical Examination
Oral cavity examination shows a 3 × 2 cm ulcerative lesion on the buccal aspects of teeth #2 to #4 with slight extension onto the palatal aspect of these teeth. No obvious loose teeth, but there is fleshy tissue at the site of the previously extracted tooth #3. His upper teeth are otherwise intact.
Neck exam revealed a 1.5 cm, firm, mobile, slightly tender right level 1b neck mass. No other neck masses were noted. No trismus or paresthesias noted. The rest of the examination is within the normal limits. Cranial nerves II–XII are intact.
Management
Question: What would you recommend next?
Biopsy of the lesion is the first step and is recommended even before imaging.
An office biopsy is performed and shows a moderately differentiated invasive SCC.
Question: What is the clinical stage at this point?
Answer: T2N1M0, stage III, based on a larger than 2 cm lesion and one palpable node. However, in alveolar lesions, it is important to evaluate the involvement of the bone, and these lesions could be upstaged to T4. Therefore, it is better to obtain imaging before assigning a clinical stage.
Question: What imaging modality would be an appropriate next step in the evaluation and management of this patient?
Answer: A CT of the neck and chest with IV contrast is an excellent next step as this will allow for evaluation of the extent of the primary lesion and to look for bone erosion as well as for any pathologic lymphadenopathy. CT of the chest helps to complete the staging. Alternatively, a PET/CT would be reasonable, but it may not allow for as good of resolution of the primary lesion to evaluate for bone involvement. Given that there is no evidence of neural deficits or concern for orbital or infratemporal fossa extension on physical exam, an MRI is probably not necessary (see Figures 3.1 and 3.2).
Chest CT demonstrated no evidence of metastatic disease.
Oromaxillofacial prosthodontics is consulted to assist with a dental impression and the production of an obturator if maxillectomy is considered.
Question: Based on your current assessment, what would be this patient's clinical stage?
Answer: This patient has oral cavity cancer. The primary lesion is staged based on size and depth of invasion. Here, depth is not known. Size puts it in the T2 category. Of note, minor bone erosion or maxillary involvement through a tooth socket alone does not upstage it to T4a. The patient has multiple ipsilateral pathologic nodes, none of which are larger than 6 cm in size, making him cN2b. Therefore, the stage is T2N2bM0: stage IVa.
Question: Given the above information, what would be the most appropriate management approach for this patient?
Answer: This patient has stage IVa oral cavity cancer. The optimal treatment strategy in patients who are amenable to surgery is for upfront surgical resection of the primary lesion with a concomitant neck dissection. Given the N2b neck dissection, he would benefit from adjuvant radiation therapy (RT ) or chemoradiation therapy, depending on the final margin status and the presence or absence of extracapsular spread.
Question: Figure 3.3 shows an intraoperative photo of the oral cavity defect after surgical resection of the primary tumor. What would you recommend for the reconstruction of the defects? What are the factors that should be considered in the reconstruction of the maxillary defect?
FIGURE 3.1 Axial (a) and coronal (b) cut of the primary lesion. Note there is minor bone erosion – no obvious extension into the pterygoid plates or muscles.
FIGURE 3.2 Axial cut of the neck portion of the CT demonstrating the pathologic node felt