Salvage Treatment for Recurrent Oral Cancer
The surgical treatment of recurrent or previously treated malignancies of the oral cavity presents one of the greatest challenges known to the head and neck surgeon and reconstructive oncologist. These problems are faced with unfortunate frequency and bri
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Mark D. DeLacure and Nicholas J. Sanfilippo
10.1 T he Surgical Treatment and Reconstruction of Recurrent Oral Cavity Malignancy Mark D. DeLacure The surgical treatment of recurrent or previously treated malignancies of the oral cavity presents one of the greatest challenges known to the head and neck surgeon and reconstructive oncologist. These problems are faced with unfortunate frequency and bring oft-devastating functional cost along with the very real threat of death from uncontrolled locoregional disease. The “successful” (long-term locoregional control, effective palliation, the occasional cure) treatment of these cases requires technical expertise and judgment known only to the most experienced head and neck surgeon. Despite this, treatment failure is common and humbling.
10.1.1 Detection of Recurrence When there is apparent delayed failure in the neck, it is incumbent to prove that the primary site in the oral cavity is inactive. While neck failure may represent the clinical emergence of metastatic cells that had been present in the node(s) throughout/ despite treatment, this phenomenon may also represent continued seeding of the
M.D. DeLacure, MD, FACS (*) Department of Otolaryngology-Head and Neck Surgery, Plastic and Reconstructive Surgery, and Neurosurgery, New York University, New York, NY, USA e-mail: [email protected] N.J. Sanfilippo, MD Department of Radiation Oncology, NYU Cancer Institute, New York University, New York, USA © Springer International Publishing Switzerland 2017 M.A. Kuriakose (ed.), Contemporary Oral Oncology, DOI 10.1007/978-3-319-14917-2_10
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neck from a clinically inapparent, uncontrolled, primary. Deep submucosal recurrences or latent persistent tumor is not uncommonly clinically confused with postoperative scar tissue, particularly in the oral tongue. The palpatory exam, while imperfect, is often the most accurate or the sentinel way to detect this unfortunately common circumstance. Regular surveillance postoperative exams during the first several years of posttreatment increase the accuracy and value of this essential tool and allow one to contextualize subtle changes, particularly when coupled with vague evolving or intermittent patient complaints such as pain, or observed misarticulations. Cross-sectional imaging studies, particularly MRI, may be helpful, but are often confusing. Similarly, PET scanning, while overcoming many of the inaccuracies of posttreatment anatomical studies, may render equivocal results, with low SUV values that are non-compelling due to physiologic or background activity (speaking, swallowing), etc. If such studies prove unhelpful, finger-guided dermatologic punch or incisional biopsy under anesthesia may be necessary to reveal the true status of the primary site. Clinically obtained biopsies are often inadequate due to a patient’s ability to cooperate with such efforts due to pain, bleeding, and gag reflex. Unfortunately such biopsy results are often relied upon to reflect disease status an
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