Predictors of Mandibular Involvement in Cancers of the Oromandibular Region

doi:10.1016/j.joms.2008.06.059

Journal of Oral and Maxillofacial Surgery

Volume 67, Issue 5, May 2009, Pages 1069-1073

https://doi.org/10.1016/j.joms.2008.06.059 Get rights and content

Purpose

Invasion of the mandible by oral squamous carcinoma is not only a relative contraindication to mandible conservation but also an indicator of poor prognosis. This study looks at clinical, radiologic, and operative variables that may help in predicting mandibular bone involvement.

Patients and Methods

A prospective study was carried out to evaluate the mandibular involvement and its predictors in 51 cases of oral squamous carcinoma located in the mandibular region. All patients underwent segmental- or hemimandibulectomy. A detailed clinical examination was followed by radiologic assessment and operative assessment. Statistic analysis was carried out by χ² test (odds ratio [OR] with a significance level of 5%). Multivariate analysis was carried out by logistic regression analysis.

Results

Univariate analysis identified location of tumor on lower alveolus (OR = 8.5), sensory disturbances of inferior alveolar nerve (OR = 16.2), location of tumor within 1 cm of mandible (OR = 1.4), presence of findings on periosteal striping (OR = 2.0) like subperiosteal reaction (OR = 3.5), cortical expansion (OR = 8.8) and presence of pathologic fracture (OR = 2.3) as predictor of bone invasion. Grade of tumor (P = .05) and radiologic bone involvement (P = .02) were found to be significant independent predictors of pathologic bone involvement on multivariate analysis.

Conclusions

It is possible to identify mandibular invasion in almost all cases of oral squamous carcinoma by combining clinical examination, radiologic findings, and findings on periosteal stripping. This helps surgeons to make an informed preoperative and intraoperative decision about mandibular conservation. However, one should be careful when evaluating bone involvement on periosteal stripping as this cannot be recommended as a method of choice due to fear of tumor dissemination and violation of oncologic principles.

Section snippets

Patients and Methods

In an open prospective study between September 2000 and May 2001, mandible invasion of squamous cell carcinoma of the oromandibular region was assessed in 51 consecutive patients. Patients with tumors located within 2 cm of the mandible that were scheduled to undergo either segmental- or hemimandibulectomy were included in the study. The study was approved by the Institutional Review Board and Ethics Committee (Regional Cancer Center, Trivandrum, India).

A comprehensive history was taken

Results

The mean age of the patients was 53.4 years and 41% of the patients were female. The detailed demographic and tumor characteristics are described elsewhere⁷ and in Table 1, Table 2. The mandibular invasion was identified in 25 of 51 patients (49%). The involvement was seen primarily on tumors of lower alveolus (89%) followed by tumors of buccal mucosa (35%). Thirty-five patients had tobacco or alcohol use habits of which majority (n = 31) were tobacco chewers a total of 19 (37.3%) had

Discussion

Involvement of mandible by tumor not only alters the management strategies but also affects the prognosis6, 13, 14, 18 and quality of life of patients with oral squamous cell carcinoma of the mandibular region. On the other hand, other studies failed to find an effect of degree of mandibular resection on survival.15, 16, 17 A combination of clinical examination with radiologic assessment is often accurate in predicting mandibular involvement, however, knowledge of additional factors that may

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Evaluation of the Bone Margin in Oral Squamous Cell Carcinoma
2017, Oral and Maxillofacial Surgery Clinics of North America
Citation Excerpt :
Despite this finding, there are lacking data as to the true effect of radiation and increased risk of bone invasion. In the series by Pandey and colleagues,12 a total of 23 recurrent cancers had received prior radiotherapy, were not found to be at higher risk of mandibular bone invasion as compared with 28 patients never having received irradiation. Contrary to the previously mentioned series, Namin and colleagues18 reported on a series of 51 patients undergoing mandibular resection and concluded that patients with prior radiation did have a significantly higher incidence in bone invasion compared with nonradiated patients.
Mandibular conservation in oral cancer
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They recommended the assessment of macroscopic invasion of the mandible after periosteal stripping as a helpful and worthwhile addition in planning the resection of the mandible in oral cancer surgery. Pandey et al., (2009) too have reported on the findings on periosteal stripping namely subperiosteal reaction, cortical expansion, and presence of pathologic fracture as significant predictors of bone invasion [30]. Forrest et al. (1995) advocated frozen- section analysis of cancellous bone to confirm the adequacy of bony margins [74].
Surgery is one of the established modes of initial definitive treatment for a majority of oral cancers. Invasion of bony or cartilaginous structures by advanced upper aero-digestive tract cancer has been considered an indication for primary surgery on the basis of historic experience of poor responsiveness to radiation therapy [1]. The mandible is a key structure both in the pathology of intra-oral tumours and their surgical management. It bars easy surgical access to the oral cavity, yet maintaining its integrity is vital for function and cosmesis. Management of tumours that involve or abut the mandible requires specific understanding of the pattern of spread and routes of tumour invasion into the mandible. This facilitates the employment of mandibular sparing approaches like marginal mandibulectomy and mandibulotomy, as opposed to segmental or hemimandibulectomy which causes severe functional problems, as the mandibular continuity is lost. Accurate preoperative assessment that combines clinical examination and imaging along with the understanding of the pattern of spread and routes of invasion is essential in deciding the appropriate level and extent of mandibular resection in oral squamous cell carcinoma. Studies have shown that local control rates achieved with marginal mandibulectomy are comparable with that of segmental mandibulectomy. In carefully selected patients, marginal mandibulectomy is an oncologically safe procedure to achieve good local control and provides a better quality of life. This article aims to review the mechanism of spread, evaluation and prognosis of mandibular invasion, various techniques and role of mandibular conservation in oral squamous cell carcinoma.
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2010, Journal of Oral and Maxillofacial Surgery
Tumor stage and resection margins not the mandibular invasion determines the survival in patients with cancers of oro-mandibular region
2009, European Journal of Surgical Oncology
Citation Excerpt :
An open prospective study was conducted to evaluate the mandibular invasion in 51 patients with oral squamous carcinoma between September 2000 and May 2001. The study evaluated the clinical–radiological–pathological bone involvement,2 patterns of spread3 and predictors of mandibular involvement.21 The study recorded the patient's demography, past medical history, social and family history followed by a detailed clinical examination that recorded the maximum size, site, type of lesion, fixity, involvement of skin and neck nodes.
Mandibular involvement in patients with oro-mandibular cancers is very common and is seen in up to 50% of the patients. Evidence suggests that preservation of uninvolved mandible does not reduce survival; however, evidence on effect of mandibular involvement on survival is sparse. We carried out this study to evaluate the effect of various factor including mandibular bone involvement on survival in patients with oro-mandibular cancers.
In an open prospective study 51 patients with oral cancer undergoing mandibular excision were studied. Five year later, the survival information was collected on these patients from computerized database. Survival analysis was carried out by Kaplan Meier method and difference in survival was estimated using log-rank test. Predictors of survival were estimated using Cox proportional hazard model.
The 3 and 5 year survival was 62.6% and 46.9% respectively. Tumor stage (HR 8.7, p = 0.02), margin of surgical excision (HR 1.8, p = 0.007) and nodal stage (HR 2.2, p = 0.04) were found to be significant independent predictors of survival.
In absence of randomized controlled trial which are difficult to design and conduct, the results of present study shows that mandibular conservation may be carried out, even in presence of involved mandible if negative resection margins could be achieved.
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2019, Clinical and Experimental Otorhinolaryngology
What is a safe distance for preservation of the inferior alveolar nerve in lower gingival squamous cell carcinoma? A radiographic and histopathological study
2019, Journal of Craniofacial Surgery

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Basic and patient-oriented researchPredictors of Mandibular Involvement in Cancers of the Oromandibular Region

Purpose

Patients and Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Discussion

J Oral Maxillofac Surg

J Maxillofac Surg

Int J Oral Maxillofac Surg

Am J Surg

J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

J Oral Maxillofac Surg

Mandibular invasion in carcinoma of the lower alveolus

Am J Otolaryngol

Basic and patient-oriented research
Predictors of Mandibular Involvement in Cancers of the Oromandibular Region