Dra. Karyna Vargas Alvarado.

Oral and Maxillofacial Surgeon.
Specializing in the Instituto Mexicano del Seguro Social IMSS.
And at the National Autonomous University of Mexico.
rvpaloma77@hotmail.com

Dr. José F. Gallegos Hernandez.

Surgical Oncologist Dr.'s National Medical Center Siglo XXI, IMSS Mexico.
Head of Service of the Department of Head and Neck Siglo XXI, IMSS Mexico.

Abstract

The squamous cell carcinoma is the increased incidence of malignancy of the oral cavity. Represents 5% of all tumors of this region. The 68-72% of patients had locoregionalmente advanced stage at diagnosis. Treatment is decided on clinical and radiological. The aim of this paper is to present a series of oral cancer patients with mandibular bone infiltration, mandibulectomia treated with segmental and / or marginal, and the persistence of disease after surgical treatment.

This is an observational study, retrospective and longitudinal. We reviewed records of 91 patients treated at the Oncology Hospital Siglo XXI, in the service of head and neck diagnosed with cancer of the oral cavity, between the years 2001 to 2005 who were treated with mandibulectomia and showed infiltration mandibular bone.

The most common tumor was Epidermoid Ca (64%), the male: female ratio 5:3, the average age of presentation was 55 years with a significant increase in the frequency (65.9%) in the interval between ages 36 -75 years.

The segmental mandibulectomía was performed in 67% of cases and marginal in 16.5%, because most of the patients had advanced stage IV-A.


Summary

Epidermal Cancer is the malignant neoplasm's oral cavity with the highest incidence. It has a rate of 5% of all tumors of that region. From 68% to 72% of all patients have advanced local and regional states at the time diagnosis. The treatment is selected on clinical and radiological basis. The objective of this study is to show a series of patients with oral cancer and bone treated with segmental mandibular infiltration and / or marginal mandibulectomy and the persistence of the disease after the surgical treatment.

This is an observational, retrospective, and longitudinal study. Clinical charts of 91 patients with a diagnosis of oral cancer were revised, from 2001 to 2005, treated in the Head and Neck Department of the Oncology Hospital Siglo XXI, with mandibulectomy and mandibular bone infiltration.

The more frequent was the skin cancer tumor (64%) with a male: female ratio of 5:3, mean age at presentation was 55 years old with a meaningful increase of frequency (65.9%) in the ages from 36 to 75 years old.

Segmental mandibulectomy was made in the 67% of the cases and marginal mandibulectomy in the 16.5%, due to the advanced states IV-A of the majority of the patients.


Introduction

The most common cancer of the oral cavity is the squamous cell carcinoma, which constitutes approximately 5% of all malignancies. Most of these tumors are diagnosed in loco-regionally advanced stages that require multimodal treatment (surgery, radiotherapy, and / or chemotherapy) .1,2,3.

Statistics from the National Cancer Institute of Mexico indicate that 65% of invasive tumors of the oral cavity are squamous cell carcinomas, mucoepidermoid carcinomas 8%, 8% carcinomas adenoideoquísticos, and 2% adenocarcinomas.3, 4,5,6.

This neoplasm, despite being in a place accessible to the diagnosis, is diagnosed at advanced stages in 68 to 72% of cases. Half is metastatic cervical lymphadenopathy, which implies a worse prognosis for survival and control. Like other tumors of the upper aero, cancers of the oral cavity and oropharynx characterized by a loco-regional invasive behavior. The tumors spread in a local, and invade and destroy adjacent structures, such as the jaw and the base of the skull, almost in parallel with the lymphatic pathway. Nodal chains affected by tumors of the oral cavity is regions submental, submandibular, jugular-jugular digastric and middle (levels I-II-III). Tumors of the oropharynx more frequently affect the jugular ganglia high, medium and inferior (II, III, IV), in addition to the retropharyngeal. Early hematogenous route is uncommon. Distant metastases of cancer of the oral cavity are rare, but occur with some frequency in advanced and recurrent tumors (15-20%), whites are the organs lung, liver and hueso2 14.
     
With regard to the location of the tumors in the oral cavity has been observed that the sites most affected are the tongue (lateral edges), gingiva, floor of mouth, hard palate, buccal mucosa and retromolar trigone. In the oropharynx, the sites most affected are the base of the tongue and tonsillar fossa, soft palate and posterior wall amigdalina.2, 3.
     
The staging is described based on the TNM classification and clinical stages, according to the Board of the American Cancer (AJCC) in 1997.4,5,6,7,8,

The objectives of the classification of tumors has been to unify criteria and to allow decisions on treatment. Therefore, in stage I-II (T1-T2) surgery may be a curative treatment, but as mentioned before, the vast majority of tumors presented in advanced stages (65%). In recent years advances in surgical techniques using microvascular grafts have significantly reduced the morbidity of the reconstruction mandibulectomía very successful in allowing these pacientes.9, 10.11.
         
The jaw is the structural support of the oral cavity and lips, providing oral continence and avoid unintended leakage of saliva, provides support for the closure during speech and stabilizes the soft tissues during swallowing, it is important to properly select Patients mandibulectomía segmental or marginal and offer an immediate reconstruction. The jaw works well as a point of resistance to the progression tumoral.12, 13.14.
        
There are two types of mandibular resection useful for patients with cancer of the oral cavity:
Marginal resection: The alveolar border which includes the mylohyoid line to the inner side of the jaw, without affecting the cortical bottom and 1 cm. mandibular thickness to avoid interrupting irrigation mandibular.15 bone, 16,17
Segmental resection: The means of continuous bone loss and, according to the site of bone defect, can be divided into five groups: 1) Sinfisiario. 2) Lateral. 3) of the ramus; 4) condyle and 5) combined (two or more of the foregoing) .15,16,17,18.
     
The marginal mandibulectomía and surgical treatment of cancers of the oral cavity has been discussed in the literature over the past 40 years, its main advantage is that it preserves the segmental mandibular continuity and avoids the need for complex reconstruction. Despite this treatment remains controversial because it could mean a higher rate of tumor persistence, hence the need to make a thorough preoperative evaluation, including a clinical examination, imaging, scanning under anesthesia, intraoperative findings, and so on. to choose the surgical procedure apropiado.19, 20
     
Contraindications for Marginal Mandibulectomía are:
Great destruction of the cortex.
Mandibular invasion and the mylohyoid line.
Massive destruction of soft tissue and both cortices.
Presence of tumor in the alveolar process.
Edentulism, and
Radiotherapy mandibular.20, 21.22.

Material and Methods

This study was conducted at the Hospital of Oncology in the Medical Center Siglo XXI, in the Department of Head and Neck. This is an observational study, retrospective, longitudinal. We reviewed the records electronically in patients with cancer of the oral cavity in the years 2001 to 2005.
     
We included all patients who underwent mandibular resection, and that had not previously received radiotherapy. We designed a data collection sheet, which included the following parameters: age, gender, tumor stage (TNM), iconographic studies, surgical procedure and histopathological report.
     
For data analysis we used the statistical package SPSS version 12.0. The results were presented as medians, percentiles and ranges. The differences in percentages were analyzed by Chi square. To assess the influence of different variables simultaneously in tumor activity was used a logistic regression with SPSS 12.0 program and is considered as the dependent variable in the clinical stage and histopathologic outcome, and the presence or absence of lesion studies image as an independent variable and the presence or absence of tumor activity.

Results

Were included in this study 91 cases of patients diagnosed with cancer of the oral cavity in which the analysis of all variables were not found all the values, so the analysis was based on distribution data is not normal.
     
The gender distribution showed a higher prevalence for the male group, representing 58.24% (53 patients) versus 41.76% (38 patients) were females. (Fig.1)
     
For analysis by age were distributed at intervals of 20 years each. The first group of 15-35 years, with a frequency of 17.58% for the group 36-55 years, 32.97%, the group of 56-75 years, 32.97% and the group of 76-95 years, 16.48%. This shows mixed results, with a significant increase between the ages of 36-75 years.
     
Histopathologic analysis of the report and its distribution by gender showed higher frequency of squamous cell carcinoma invasive moderately differentiated (36.6%) for both genders, without significant difference, the second frequency in the squamous cell carcinoma was well differentiated (17.6%), followed by poorly differentiated squamous cell carcinoma (5.5%), osteogenic sarcoma (4.4%), high grade mucoepidermoid carcinoma (3.8%), rhabdomyosarcoma (3.1%) and only several pathologies (29%). (Fig. 2)
     
The clinical stage that was presented more frequently in this analysis were stage IV-A with 33 patients (36.3%) stage II, 23 patients accounted for 25.3%, stage III in 15 patients (16.5%); stage I, 14 patients (15.4%) and without staging 6.5%.
     
Computerized tomography showed a diagnostic method useful for surgical decision making, with the following percentages: TAC infiltration positive for cortical 54%, negative 35.4% TAC, without study, 10.6%. In Orthopantomography found that 61.8% were positive for cortical infiltration and 33.2% were negative and no study, 5%. Cortical infiltration was 62.6% in the body and infiltration in 37.4%. The correlation of variables (Pearson correlation) showed Orthopantomography had low correlation in terms of bodily invasion and cortical (.275 and .306, respectively). For the TAC was a statistically significant correlation to body and cortical infiltration (572 and 664, respectively).
     
As for the type of Mandibulectomía made the segmentary was performed in 67% and the marginal (16.5%. No procedure was found in 16.5%. We looked at the persistence of the disease for each group, finding a 53.9% in the mandibulectomía patients undergoing segmental and 6.6% for the group of marginal mandibulectomía without monitoring, 39.5%. (Fig.3)
     
Logistic regression analysis conducted for the variables (a) cortical infiltration and / or body (b) Histopathological reporting (c) computed tomography showed variable for (a) a Beta value of -1.6117 with a standard error (SE ) of 492 with a p <0.001 for an IC 95% (.076 -. 520). For the variable (b) a Beta value of .183, standard error (TE) of 0.48 with p <0.000 for an IC 95% (.758 -. 916). For the variable (c) a Beta value of 22.209, standard error (SE). Of 13,074.764 with a p <.999 for I.C. 95%. (Pearson Correlation). (Fig.4)

Discussion

According to the results obtained significant differences were observed slightly in relation to generate reports in the literature (5:1) and that found in this study (5:3).
The age of presentation of the tumor is similar to other reports. Epidermoid carcinoma was the entity with the highest incidence, similar to what was found in other research. Most patients in our study at the time of diagnosis were at an advanced stage. The segmental Mandibulectomía procedure was performed in the highest percentage of cases, despite this, there was persistence of disease after the therapy employed. This work is a comparative study of two techniques mandibulectomía exposed, because it would need to conduct a prospective study with the same stage of disease to determine which technique would provide more benefits.

Conclusions

The results of this study are comparable with those of other authors, but do not demonstrate the importance of putting more emphasis on the initial scan to obtain a correct diagnosis and thus be able to offer the patient a curative surgical treatment, not only palliative. Rely on iconographic studies and CT scan is essential for surgical decision making, as means of support are quite sensitive diagnosis and high predictive value.

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