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Bone Cancer Treatment, London at the London Bridge Head and Neck Cancer Centre

Tumours that involve bone (T4) are only likely to be treated using surgery.

The amount of bone required to safely resect the tumour will depend on the degree of bone invasion. This can be determined fairly accurately by use of an MRI scan supplemented with plain radiography and if neither of these investigations are diagnostic, a DEXA scan.

At operation the presence of bony invasion can be assessed by stripping the periosteum (a membrane that lines the outer surface of all bones) and using this technique in combination with the pre-operative investigations. Recent work has shown that although in edentulous (toothless) patients 50 percent of bony invasion occurs via the occlusal surface, bony invasion in dentate patients occurs almost entirely at the point of junction between attached and unattached mucosa.

At least 1cm of normal uninvaded bone will be removed from around the tumour. Contrary to earlier belief Squamous Cell Carcinoma (SCC) does not travel along the inferior alveolar nerve to involve the neurovascular bundle outside the extent of cancellous bony invasion. In the mandible therefore if the invasion is small or only affects the periosteum it may be possible to resect a margin of bone leaving the lower border intact (marginal resection).

The soft tissues can be closed primarily or by using a flap. If this is not possible a segment of bone will have to be removed and ideally replaced by a bone graft and as post-operative radiotherapy is almost always a possibility this will be vascularised by recipient vessels in the neck, also comprising of covering soft tissue, constituting a composite flap.
No matter how small bony resection in the maxilla will almost always pass into the nasal or maxillary cavity. Small defects can sometimes be closed by local soft tissue flaps. Most however, will require either obturation with a prosthesis or ideally reconstruction with a vascularised bone graft.

There are three main composite flaps used in orofacial reconstruction:

  • The vascularised iliac crest graft - Pedicled on the deep circumflex iliac artery and its vena comitantes (DCIA) offers the best bone, excellent muscle but a rather bulky skin flap

  • The fibular flap - based on the peroneal vessels offers less bone, no muscle but a versatile skin paddle
  • The scapular flap - based on the subscapular vessels offers similar bone and soft tissue to the fibula with the advantage of a very mobile skin paddle that is not tethered to the bone like the previous flaps. It offers the lowest co-morbidity to the patient in terms of function as the other two flaps may affect gait. Unfortunately it cannot be harvested at the same time as the resection increasing the operating time by as much as three hours.

Vascularised bone grafts even after radiotherapy offer an excellent platform on which to place dental implants and all patients undergoing this type of reconstruction are likely to obtain immense benefits from implant retained fixed or removable prosthesis.

When considering a patient for free tissue transfer, coexistent disease will always be considered. Generally only those patients who are considered fit (therefore not having systemic disease that restricts their daily activity) are candidates for this technique and age in itself is no bar to this type of surgery.

Where the prognosis is extremely poor and surgery is to be carried out complex reconstruction that might cause the patient to spend a long time in hospital will not be contemplated.

Pedicle flaps such as the pectoralis major or nasolabial and even primary closure may offer a less satisfactory functional result but will be quicker to carry out cause less co-morbity and hence often best overall for the patient.
Even patients with hemimandibular defects do surprisingly well in terms of appearance, eating and speech without bony reconstruction.

All patients requiring surgical resection may require a temporary tracheostomy to allow safe airway management. Patients with large tumours particularly affecting the tongue and oropharynx are highly likely to require this and the patients will be warned that they will require this.