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  • Title
  • 1. Introduction
  • 2. Supraomohyoid Neck Dissection
  • 3. Excision of Squamous Cell Carcinoma from the Right Posterior Maxilla
  • 4. Immediate Surgical Obturator Placement and Adjustments
  • 5. Post-op Remarks

Treatment of Squamous Cell Carcinoma from the Posterior Maxilla with Obturator Placement and Ipsilateral Neck Dissection

5538 views

Daniel Oreadi, DMD
Tufts University

Main Text

Abstract

Surgery has been the first line of treatment for oral cavity cancer. After appropriate workup, the decision to include an ipsilateral or bilateral neck dissection is made. The patient presented here was diagnosed with a posterior maxillary alveolar tumor. Here, Dr. Oreadi at Tufts University performs a wide local excision of the tumor with total alveolectomy, reconstruction with a buccal fat pad advancement, and placement of a surgical obturator. Additionally, an ipsilateral supraomohyoid neck dissection was performed due to the relative risk of regional metastases.

Keywords 

Metastatic disease, lymph node containing fibro-fatty tissue, surgical obturator, buccal fat pad, platysma flap, external carotid artery, internal carotid artery, greater auricular nerve, greater palatine artery, spinal accessory nerve, hypoglossal nerve, marginal mandibular branch of facial nerve, perifacial nodes, submandibular gland, anterior and posterior bellies of digastric muscle, mylohyoid muscle

Case Overview

Details of the case and procedure, including patient history, relevant indications, diagnostics, and technique. The recommended subsections are as follows:

The patient is an 80-year-old female who presented initially with complaints of a growth in her right posterior maxillary gingiva around the area of a previously extracted tooth #2 (Second molar). An incisional biopsy yielded a squamous cell carcinoma diagnosis. Staging via PET/CT was performed, and the patient was stage II. 

Background

Oral and maxillofacial surgeons trained in the management of head and neck cancer are qualified to manage oral cancers. The American Cancer Society’s most recent estimates for oral cavity and oropharyngeal cancers in the United States for 2021 are about 54,010 new cases of oral cavity or oropharyngeal cancer and about 10,850 deaths from such disease.

Focused History of the Patient

The patient shown here had a history of oral lesions associated with an autoimmune condition known as Lichen Planus. She underwent multiple biopsies with some returning as dysplasia (Pre-cancer). She was treated with excision of the dysplasia based on its degree. Unfortunately, she progressed to develop carcinoma.

Physical Exam

The patient presented initially with a mobile tooth in the posterior right maxilla. The tooth was extracted, and a biopsy of the adjacent soft tissue showed severe dysplasia. A second biopsy confirmed alveolar squamous cell carcinoma. 

Imaging and Special Tests

PET/CT for staging revealed a right, mid-posterior palate, 2x2.5-cm lesion with moderate FDG uptake (SUV max 6.5) without abutting the midline. There was no FDG avid neck adenopathy. Remaining studies were negative.

Options for Treatment

Surgery remains the first line of treatment for oral/head and neck cancer. The recommended procedure involves wide local excision with immediate reconstruction when possible in addition to a neck dissection in most cases.

The use of neoadjuvant therapy by means of radiation or chemotherapy is mostly indicated in cases of advanced disease with unresectability. Adjuvant therapy following surgery is indicated when adverse features are identified in the pathology report. This patient is a candidate for adjuvant therapy based on those features found in her final pathology report.

Rationale for Treatment

The main goal in cancer surgery is to achieve disease eradication while treating for cure. Oral/head and neck cancer continues to have a poor prognosis if detected late with a 5-year survival of less than 50% when a single positive lymph node is identified. Early diagnosis and treatment remains with a high survival rate greater than 85% in some cases when clear margins and negative adverse features are present.

Special Considerations

High risk patients for the development of oral cancer include those with a significant history of tobacco and alcohol use, those who are immunocompromised, those with poor oral health, and patients with genetic predisposition for the disease. Early diagnosis remains the single most significant prognostic indicator for success. 

Discussion

Not every oral cancer patient requires a neck dissection. Location of the tumor, staging, and risk stratification will dictate the benefit of such procedure. In this particular case, the patient was stage IV due to maxillary bone involvement and, although the PET/CT did not show any FDG avidity in the neck region, the patient had 1 positive lymph nodes with metastatic involvement justifying the decision to include the neck dissection in the treatment plan.

Equipment

Oral and maxillofacial set

ENT major set

Bovie electrocautery

Bipolar electrocautery

Checkpoint nerve stim

Surgical obturator

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.


Citations

  1. Leiser Y, Yudovich K, Barak M, El Naaj IA. The Management of Maxillary Squamous Cell Carcinoma - A Retrospective Study. J Cancer Ther. 2014 Oct; 5(12):1065-1071. doi: 10.4236/jct.2014.512112.
  2. Zhang WB, Peng X. Cervical metastases of oral maxillary squamous cell carcinoma: A systematic review and meta-analysis. Head Neck. 2016 Apr;38 Suppl 1:E2335-42. doi: 10.1002/hed.24274. Epub 2016 Feb 18. PMID: 26890607
  3. Hakim SG, Steller D, Sieg P, Rades D, Alsharif U. Clinical course and survival in patients with squamous cell carcinoma of the maxillary alveolus and hard palate: Results from a single-center prospective cohort. J Craniomaxillofac Surg. 2020 Jan;48(1):111-116. doi: 10.1016/j.jcms.2019.12.008. Epub 2019 Dec 13. PMID: 31884030 Clinical Trial.
  4. Qu Y, Liu Y, Su M, Yang Y, Han Z, Qin L. The strategy on managing cervical lymph nodes of patients with maxillary gingival squamous cell carcinoma. J Craniomaxillofac Surg. 2019 Feb;47(2):300-304. doi: 10.1016/j.jcms.2018.12.008. Epub 2018 Dec 13. PMID: 30595475
  5. Joosten MHMA, de Bree R, Van Cann EM. Management of the clinically node negative neck in squamous cell carcinoma of the maxilla. Oral Oncol. 2017 Mar;66:87-92. doi: 10.1016/j.oraloncology.2016.12.027. Epub 2017 Jan 21. PMID: 28249653

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Authors

Filmed At:

Tufts University

Article Information

Publication Date
Article ID321
Production ID0321
VolumeN/A
Issue321
DOI
https://doi.org/10.24296/jomi/321