SURGICAL ONCOLOGY AND RECONSTRUCTION
Free Flap Reconstruction Versus Non–Free Flap Reconstruction in Treating Elderly Patients With Advanced Oral Cancer Qi-Gen Fang, MS,* Shuang Shi, MS,y Mengjie Li, MS,z Xu Zhang, MS,x Fa-Yu Liu, MD,k and Chang-Fu Sun, MD{ Purpose:
Our goal was to evaluate whether elderly patients can benefit from free flaps.
Materials and Methods:
The clinical information from the included patients was reviewed, and these patients were asked to complete the University of Washington Quality of Life, version 4, questionnaire. Comparisons of the different scales between the 2 groups were performed.
Results:
The difference in the mouth-opening width before and after surgery did not differ significantly (P = .621) in the patients with and without free flap reconstruction. However, free flap placement tended to preserve the original mouth-opening width. No significant differences were found in recurrence-free survival or disease-specific survival between the 2 groups. The mean quality of life score of the 2 groups was 77.5 10.4 and 72.1 10.8. Significant differences were found in the chewing domain scores between the 2 groups (P = .039). Patients with free flap reconstruction tended to score better in the appearance and taste domains (P = .073 and P = .053, respectively); however, they required longer operative times, and longer postoperative hospital stays and incurred hospital costs. Conclusions: Free flap reconstruction did not benefit elderly patients in mouth-opening width or survival analyses; the only quality of life domain that was significantly improved in patients undergoing free flap reconstruction was chewing. Free tissue transfer should be cautiously suggested for elderly patients with advanced oral cancer. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-5, 2014
increase the complication and mortality rates.1-6 Reconstruction in this patient population has therefore been a challenge for head and neck surgeons. With advances in microsurgery, free flap reconstruction has become the preferred method for repairing medium to large defects after head and neck cancer
The number of elderly patients with head and neck cancer has been increasing owing to an overall increase in life expectancy, leading to greater numbers of aging patients facing complex reconstructive surgery.1-4 The reductions in cardiac, respiratory, renal, and immunologic function that occur with age can *Resident, Department of Oromaxillofacial-Head and Neck Surgery,
{Professor, Department Head, Department of Oromaxillofacial-
China Medical University School of Stomatology, Heping District,
Head and Neck Surgery, China Medical University School of
Shenyang, Liaoning, People’s Republic of China. yResident, Department of Pediatric Dentistry, China Medical
Stomatology, Heping District, Shenyang, Liaoning, People’s Republic of China.
University School of Stomatology, Heping District, Shenyang,
Address correspondence and reprint requests to Dr Sun: Depart-
Liaoning, People’s Republic of China.
ment of Oromaxillofacial-Head and Neck Surgery, China Medical Uni-
zResident, Department of Endodontic Dentistry, Jilin University
versity School of Stomatology, No 117, Nanjing North Street, Heping
School of Stomatology, Dongchang District, Changchun, Jilin,
District, Shenyang, Liaoning 110002, People’s Republic of China;
People’s Republic of China.
e-mail: [email protected]
xResident, Department of Oromaxillofacial-Head and Neck
Received November 5 2013
Surgery, China Medical University School of Stomatology, Heping District, Shenyang, Liaoning, People’s Republic of China.
Accepted January 14 2014 Ó 2014 American Association of Oral and Maxillofacial Surgeons
kProfessor, Department of Oromaxillofacial-Head and Neck
0278-2391/14/00102-5$36.00/0
Surgery, China Medical University School of Stomatology, Heping
http://dx.doi.org/10.1016/j.joms.2014.01.010
District, Shenyang, Liaoning, People’s Republic of China.
1
2
FREE FLAP VERSUS NON–FREE FLAP RECONSTRUCTION AND ADVANCED ORAL CANCER
resection. This technique has many well-known advantages, including a 2-team protocol; the selection of the best-adapted tissue for a given reconstruction type; improved cosmetic and functional outcomes; and 3-dimensional freedom for flap positioning.1-5 However, free flap reconstruction requires an excellent surgical technique and has been associated with prolonged operative times and recovery periods, high hospital costs, and strict general status. Therefore, the use of free flap reconstruction for elderly patients requires additional evaluation. It is unknown whether the clinical results will be significantly different between conservative treatment and free flap reconstruction; it is also unknown whether elderly patients will benefit from free flap reconstruction. However, most related data have only focused on describing the reliability of free flap head and neck reconstruction in the elderly.1-4 Successful surgical treatment should be evaluated in terms of survival and quality of life (QoL) in addition to flap reliability. Therefore, in the present study, we sought to clarify whether the outcomes will differ in elderly patients with advanced oral cancer who receive a free flap reconstruction versus those who do not.
Materials and Methods The China Medical University institutional research committee approved our study, and all participants signed an informed consent agreement. We retrospectively reviewed the medical records from January 2004 to December 2011 in the Department of Oral and Maxillofacial Head and Neck Surgery, China Medical University. The enrolled patients were required to meet the following criteria: age at least 70 years, advanced cancer (stage III or stage IV) at diagnosis according to the American Joint Committee on Cancer 2002 classification, and no preoperative surgical or radiotherapy. These patients were divided into 2 groups. All patients in group A underwent free flap reconstruction, and patients in group B were treated without free flap reconstruction. The clinical information, including age, gender, tumor stage, the presence of systemic disease (cardiovascular disease, hypertension, and diabetes mellitus), length of the postoperative hospital stay, hospital cost, pre- and postoperative mouth-opening width (with postoperative measurements obtained at least 6 months after surgery), interval to recurrence, and interval to death, was reviewed. All these patients underwent primary tumor resection and unilateral or bilateral neck dissection. All the patients included in the present study had no history of cancer and no impairments in communication. The patients were required to complete the Uni-
versity of Washington QoL (UW-QoL), version 4, questionnaire at least 12 months after surgery. The UW-QoL has been proved to be valid and reliable.7 It consists of 12 single-question domains that had 3 to 6 response options, scaled evenly from 0 (worst) to 100 (best). The domains were pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder, taste, saliva, mood, and anxiety. The individual domains were scored according to the UW-QoL guidelines. The c2 test was used to evaluate the significance of the general variables. The Kaplan-Meier method was used to analyze recurrence-free survival (RFS) and disease-specific survival (DSS) rates, and the nonparametric Mann-Whitney U test was used to analyze the UW-QoL scores. P < .05 was considered significant.
Results The final study population consisted of 59 patients. Significant differences were found in systemic disease status, surgery duration, length of postoperative hospital stay, and hospital costs among patients who received free flap reconstruction versus those who did not (all P < .05; Table 1). The flap types were distributed as follows: group A received 2 fibula flaps, 15 radial forearm flaps, and 8 anterolateral thigh flaps; and group B received 7 pectoralis myocutaneous flaps, 12 platysma myocutaneous flaps, 6 submental island flaps, 4 local flaps, and 5 primary closure. Partial necrosis developed in 2 platysma myocutaneous flaps, but the others remained intact. No significant differences were found between the 2 groups in terms of the preoperative (P = .653) and postoperative (P = .909) mouth-opening width. Furthermore, the postoperative change in mouthopening width did not differ significantly between the 2 groups (P = .621). However, the use of free flaps tended to preserve the original mouth-opening width (Table 2). No significant difference was found in the RFS rates between the 2 groups (P = .978; Fig 1). In group A, 14 patients developed a recurrence (5 local and 9 regional) and in group B, 22 patients did so (3 local, 18 regional, and 1 distant). The DSS rates between the 2 groups are shown in Figure 2; no significant differences were found in DSS (P = .834). In groups A and B, 9 and 17 patients died of disease, respectively. Of the 59 patients, 49 (83.1%) returned the questionnaire (Table 3). The mean composite QoL score for the 2 groups was 77.5 10.4 and 72.1 10.8, respectively (Table 4). This difference was not significant (P = .231). However, the differences in the chewing domain scores were significant (P = .039). The patients in group A tended to score better in the
3
FANG ET AL
Table 1. GENERAL PATIENT INFORMATION
Group A Group B P (n = 25) (n = 34) Value
Variable Age (yr) Mean Range Gender Male Female Tumor stage T2 T3 T4 Node stage N0 N1 N2 Primary cancer site Gingiva Tongue Floor of the mouth Buccal Lip Systemic disease Operation duration (minutes) >480 #480 Postoperative stay (days) Hospital cost (RMB) Postoperative radiotherapy
.747 74.2 70-84
73.7 70-89
18 7
27 7
3 9 13
9 12 13
16 8 1
16 14 4
.508
.360
.348
.981 9 5 5 3 3 5 22 3 12.6 42,000 12
12 6 6 4 6 27
FIGURE 1. Comparison of recurrence-free survival rates in patients with and without a free flap (P = .978). Fang et al. Free Flap Versus Non–Free Flap Reconstruction and Advanced Oral Cancer. J Oral Maxillofac Surg 2014.
Free Flap Reconstruction Versus Non–Free Flap Reconstruction in Treating Elderly Patients With Advanced Oral Cancer Qi-Gen Fang, MS,* Shuang Shi, MS,y Mengjie Li, MS,z Xu Zhang, MS,x Fa-Yu Liu, MD,k and Chang-Fu Sun, MD{ Purpose:
Our goal was to evaluate whether elderly patients can benefit from free flaps.
Materials and Methods:
The clinical information from the included patients was reviewed, and these patients were asked to complete the University of Washington Quality of Life, version 4, questionnaire. Comparisons of the different scales between the 2 groups were performed.
Results:
The difference in the mouth-opening width before and after surgery did not differ significantly (P = .621) in the patients with and without free flap reconstruction. However, free flap placement tended to preserve the original mouth-opening width. No significant differences were found in recurrence-free survival or disease-specific survival between the 2 groups. The mean quality of life score of the 2 groups was 77.5 10.4 and 72.1 10.8. Significant differences were found in the chewing domain scores between the 2 groups (P = .039). Patients with free flap reconstruction tended to score better in the appearance and taste domains (P = .073 and P = .053, respectively); however, they required longer operative times, and longer postoperative hospital stays and incurred hospital costs. Conclusions: Free flap reconstruction did not benefit elderly patients in mouth-opening width or survival analyses; the only quality of life domain that was significantly improved in patients undergoing free flap reconstruction was chewing. Free tissue transfer should be cautiously suggested for elderly patients with advanced oral cancer. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-5, 2014
increase the complication and mortality rates.1-6 Reconstruction in this patient population has therefore been a challenge for head and neck surgeons. With advances in microsurgery, free flap reconstruction has become the preferred method for repairing medium to large defects after head and neck cancer
The number of elderly patients with head and neck cancer has been increasing owing to an overall increase in life expectancy, leading to greater numbers of aging patients facing complex reconstructive surgery.1-4 The reductions in cardiac, respiratory, renal, and immunologic function that occur with age can *Resident, Department of Oromaxillofacial-Head and Neck Surgery,
{Professor, Department Head, Department of Oromaxillofacial-
China Medical University School of Stomatology, Heping District,
Head and Neck Surgery, China Medical University School of
Shenyang, Liaoning, People’s Republic of China. yResident, Department of Pediatric Dentistry, China Medical
Stomatology, Heping District, Shenyang, Liaoning, People’s Republic of China.
University School of Stomatology, Heping District, Shenyang,
Address correspondence and reprint requests to Dr Sun: Depart-
Liaoning, People’s Republic of China.
ment of Oromaxillofacial-Head and Neck Surgery, China Medical Uni-
zResident, Department of Endodontic Dentistry, Jilin University
versity School of Stomatology, No 117, Nanjing North Street, Heping
School of Stomatology, Dongchang District, Changchun, Jilin,
District, Shenyang, Liaoning 110002, People’s Republic of China;
People’s Republic of China.
e-mail: [email protected]
xResident, Department of Oromaxillofacial-Head and Neck
Received November 5 2013
Surgery, China Medical University School of Stomatology, Heping District, Shenyang, Liaoning, People’s Republic of China.
Accepted January 14 2014 Ó 2014 American Association of Oral and Maxillofacial Surgeons
kProfessor, Department of Oromaxillofacial-Head and Neck
0278-2391/14/00102-5$36.00/0
Surgery, China Medical University School of Stomatology, Heping
http://dx.doi.org/10.1016/j.joms.2014.01.010
District, Shenyang, Liaoning, People’s Republic of China.
1
2
FREE FLAP VERSUS NON–FREE FLAP RECONSTRUCTION AND ADVANCED ORAL CANCER
resection. This technique has many well-known advantages, including a 2-team protocol; the selection of the best-adapted tissue for a given reconstruction type; improved cosmetic and functional outcomes; and 3-dimensional freedom for flap positioning.1-5 However, free flap reconstruction requires an excellent surgical technique and has been associated with prolonged operative times and recovery periods, high hospital costs, and strict general status. Therefore, the use of free flap reconstruction for elderly patients requires additional evaluation. It is unknown whether the clinical results will be significantly different between conservative treatment and free flap reconstruction; it is also unknown whether elderly patients will benefit from free flap reconstruction. However, most related data have only focused on describing the reliability of free flap head and neck reconstruction in the elderly.1-4 Successful surgical treatment should be evaluated in terms of survival and quality of life (QoL) in addition to flap reliability. Therefore, in the present study, we sought to clarify whether the outcomes will differ in elderly patients with advanced oral cancer who receive a free flap reconstruction versus those who do not.
Materials and Methods The China Medical University institutional research committee approved our study, and all participants signed an informed consent agreement. We retrospectively reviewed the medical records from January 2004 to December 2011 in the Department of Oral and Maxillofacial Head and Neck Surgery, China Medical University. The enrolled patients were required to meet the following criteria: age at least 70 years, advanced cancer (stage III or stage IV) at diagnosis according to the American Joint Committee on Cancer 2002 classification, and no preoperative surgical or radiotherapy. These patients were divided into 2 groups. All patients in group A underwent free flap reconstruction, and patients in group B were treated without free flap reconstruction. The clinical information, including age, gender, tumor stage, the presence of systemic disease (cardiovascular disease, hypertension, and diabetes mellitus), length of the postoperative hospital stay, hospital cost, pre- and postoperative mouth-opening width (with postoperative measurements obtained at least 6 months after surgery), interval to recurrence, and interval to death, was reviewed. All these patients underwent primary tumor resection and unilateral or bilateral neck dissection. All the patients included in the present study had no history of cancer and no impairments in communication. The patients were required to complete the Uni-
versity of Washington QoL (UW-QoL), version 4, questionnaire at least 12 months after surgery. The UW-QoL has been proved to be valid and reliable.7 It consists of 12 single-question domains that had 3 to 6 response options, scaled evenly from 0 (worst) to 100 (best). The domains were pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder, taste, saliva, mood, and anxiety. The individual domains were scored according to the UW-QoL guidelines. The c2 test was used to evaluate the significance of the general variables. The Kaplan-Meier method was used to analyze recurrence-free survival (RFS) and disease-specific survival (DSS) rates, and the nonparametric Mann-Whitney U test was used to analyze the UW-QoL scores. P < .05 was considered significant.
Results The final study population consisted of 59 patients. Significant differences were found in systemic disease status, surgery duration, length of postoperative hospital stay, and hospital costs among patients who received free flap reconstruction versus those who did not (all P < .05; Table 1). The flap types were distributed as follows: group A received 2 fibula flaps, 15 radial forearm flaps, and 8 anterolateral thigh flaps; and group B received 7 pectoralis myocutaneous flaps, 12 platysma myocutaneous flaps, 6 submental island flaps, 4 local flaps, and 5 primary closure. Partial necrosis developed in 2 platysma myocutaneous flaps, but the others remained intact. No significant differences were found between the 2 groups in terms of the preoperative (P = .653) and postoperative (P = .909) mouth-opening width. Furthermore, the postoperative change in mouthopening width did not differ significantly between the 2 groups (P = .621). However, the use of free flaps tended to preserve the original mouth-opening width (Table 2). No significant difference was found in the RFS rates between the 2 groups (P = .978; Fig 1). In group A, 14 patients developed a recurrence (5 local and 9 regional) and in group B, 22 patients did so (3 local, 18 regional, and 1 distant). The DSS rates between the 2 groups are shown in Figure 2; no significant differences were found in DSS (P = .834). In groups A and B, 9 and 17 patients died of disease, respectively. Of the 59 patients, 49 (83.1%) returned the questionnaire (Table 3). The mean composite QoL score for the 2 groups was 77.5 10.4 and 72.1 10.8, respectively (Table 4). This difference was not significant (P = .231). However, the differences in the chewing domain scores were significant (P = .039). The patients in group A tended to score better in the
3
FANG ET AL
Table 1. GENERAL PATIENT INFORMATION
Group A Group B P (n = 25) (n = 34) Value
Variable Age (yr) Mean Range Gender Male Female Tumor stage T2 T3 T4 Node stage N0 N1 N2 Primary cancer site Gingiva Tongue Floor of the mouth Buccal Lip Systemic disease Operation duration (minutes) >480 #480 Postoperative stay (days) Hospital cost (RMB) Postoperative radiotherapy
.747 74.2 70-84
73.7 70-89
18 7
27 7
3 9 13
9 12 13
16 8 1
16 14 4
.508
.360
.348
.981 9 5 5 3 3 5 22 3 12.6 42,000 12
12 6 6 4 6 27
FIGURE 1. Comparison of recurrence-free survival rates in patients with and without a free flap (P = .978). Fang et al. Free Flap Versus Non–Free Flap Reconstruction and Advanced Oral Cancer. J Oral Maxillofac Surg 2014.
