Treatment of Squamous Cell Carcinoma from Posterior Maxilla with Wide Local Excision of the Tumor and Total Alveolectomy, Reconstruction with Buccal Fat Pad Advancement, Placement of Surgical Obturator, and an Ipsilateral Supraomohyoid Neck Dissection

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. The treatment plan included wide local excision of the tumor with total alveolectomy, reconstruction with a buccal fat pad advancement, and placement of 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

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.¹

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.^2–6 Transoral tumor resection, can be performed in two ways—en bloc or piecemeal, depending on the location and size of the tumor. However, as of now, there are no established guidelines suggesting the use of either en bloc or piecemeal methods for transoral surgery.^7-8

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.² 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.^2–6

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.^2–6

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.^2-6 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 node 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.