Traumatic ulceration mimicking oral squamous cell carcinoma recurrence in an insensate flap.

Abstract

We report our experience with a patient who developed an ulcer within a free flap 2 months following resection of an oral squamous cell carcinoma. We discuss this clinical problem and the issues it raised, with particular attention to early tumor recurrence and the restoration of sensation in free-flap reconstructions.

Introduction

Surgically treated squamous cell carcinoma (SCC) of the oral cavity frequently recurs after a histologically incomplete excision. Such a recurrence is an early event, as it usually occurs within 2 years of surgery. (1,2) Theoretically, the reconstruction of defects with a flap following oral cavity resection can delay the detection of a recurrence because the deep resection margins are covered. We report the case of a patient who developed a large ulcer within a radial forearm free flap. Clinically, the lesion appeared to be a primary tumor recurrence, despite the fact that clear resection margins had been achieved 2 months earlier.

Case report

A 58-year-old man presented with a T2N0M0 SCC of the left lateral border of his tongue; the mass extended onto the floor of the mouth. His initial management was surgical, and he underwent tumor excision, selective neck dissection, and reconstruction with a noninnervated radial forearm free flap. His immediate postoperative recovery was unremarkable. Histologically, the resection margins were clear, and there were no positive neck nodes.

At follow-up 2 months later, we noted that a large, painless ulcer had formed within the flap (figure 1). We suspected a tumor recurrence, and we obtained biopsy specimens with the patient under local anesthesia. The biopsies showed only superficial slough and necrosis. Subsequent examination under general anesthesia was performed, and further biopsies were taken. At that time, we noted that the patient's only remaining tooth, an upper left molar, fitted perfectly into the ulcer when his mouth was closed. The tooth was removed, and the ulcer healed over the course of the next month (figure 2). All biopsies were negative for tumor recurrence.

[FIGURES 1-2 OMITTED]

Discussion

The patterns of SCC recurrence in the oral cavity have been well described, and these recurrences often arise earlier than they do at other sites in the head and neck. (1) Approximately 90% of recurrences of surgically treated head and neck SCC occur within 2 years of the initial treatment. (2) In the United Kingdom, it is recommended that patients who have been treated for head and neck SCC be initially followed up at monthly intervals throughout the first year. (3) The purpose of these frequent follow-ups is to monitor the primary tumor site and nodal areas for signs of recurrence so that further treatment can be instituted at an early stage if appropriate. Another important aspect of frequent follow-up during the first year is that it can minimize the morbidity related to surgery or radiotherapy. It was during this standard follow-up period that we found the ulceration in our patient's oral cavity.

We did not recognize that the ulceration was a benign condition until we had ruled out recurrent SCC. The ulcer bad not been present on examination in the outpatient department 1 month postoperatively. We presume that as the patient's oral function and intake increased, so did the repeated intraoral trauma involving the flap and the tooth. The progression to obvious ulceration occurred over the next few weeks, abetted by the fact that the patient experienced no pain that would have alerted him to and prevented further trauma.

Placing a radial forearm free flap is an accepted means of reconstructing oral cavity defects following tumor excision. It is a popular technique because the flap is easy to raise on a long vascular pedicle, is thin and pliable, and is associated with a relatively low rate of donor-site morbidity. (4) The importance of maintaining sensation in the flap has been recognized, especially in the context of functional rehabilitation. (5) Several studies have been conducted to assess the recovery of sensation in both innervated and noninnervated free flaps. (6-11) One might postulate that early sensory recovery might have helped our patient avoid the repeated trauma between his tooth and the flap, and this in turn would have prevented the ulcer from developing. However, according to the literature, restoration of sensation would not have helped our patient because the ulcer developed only 2 months postoperatively, and restoration of sensation generally requires 3 to 4 months, even when an innervated flap is used.

References

(1.) Stell PM. Time to recurrence of squamous cell carcinoma of the head and neck. Head Neck 1991;13:277-81.

(2.) Hall SF, Groome PA, Rothwell D. Time to first relapse as an outcome and a predictor of survival in patients with squamous cell carcinoma of the head and neck. Laryngoscope 2000;110: 2041-6.

(3.) Effective head and neck cancer management. Second consensus document. British Association of Otarhinolaryngologists-Head and Neck Surgeons. 2000:34.

(4.) Soutar DS, Scheker LR. Tanner NS, McGregor IA. The radial forearm flap: A versatile method for intra-oral reconstruction. Br J Plastic Surg 1983;36:1-8.

(5.) Urken ML. The restoration or preservation of sensation in the oral cavity following ablative surgery. Arch Otolaryngol Head Neck Surg 1995;121:607-12.

(6.) Kimata Y, Uchiyama K, Ebihara S, et al. Comparison of inner rated and noninnervated free flaps in oral reconstruction. Plast Reconstr Surg 1999;104:1307-13.

(7.) Vriens JP, Acosta R, Soutar DS, Webster MH. Recovery of sensation in the radial forearm free flap in oral reconstruction. Plast Reconstr Surg 1996;98:649-56.

(8.) Shindo ML, Sinha UK, Rice DH. Sensory recovery in non-innervated free flaps for head and neck reconstruction, Laryngoscope 1995;105:1290-3.

(9.) Netscher D, Armenta A, Meade RA, Alford EL. Sensory recovery of innervated and non-innervated radial forearm free flaps: Functional implications. J Reconstr Microsurg 2000;16:179-85.

(10.) Lvoff G. O'Brien CJ, Cope C, Lee KK. Sensory recovery in noninnervated radial forearm free flaps in oral and oropharyngeal reconstruction. Arch Otolaryngol Head Neck Surg 1998;124: 1206-8.

(11.) Close LG, Truelson JM, Milledge RA, Schweitzer C. Sensory recovery in noninnervated flaps used for oral cavity and oropharyngeal reconstruction. Arch Otolaryngol Head Neck Surg 1995;121:967-72.

Anne Hitchings, FRCS 

Andrew Murray, FRCS (ORL)

>From the Department of Otolaryngology-Head and Neck Surgery, Crosshouse Hospital, Kilmarnock. U.K.

Reprint requests: Mr. Andrew Murray, Department of Otolaryngology-Head and Neck Surgery, Crosshouse Hospital, Kilmarnock KA2 0BE, UK. Phone: [phone]; fax: [phone]: e-mail: [e-mail]