Abstract
Purpose
Squamous cell carcinoma is a common entity among adult head and neck cancer patients, with many requiring reconstruction post resection. Conversely, this entity is rare among children with major reconstruction even more unique. This case and the concomitant review of literature highlight the intricacies of pediatric facial reconstruction.
Methods
The case described is of a 6-year-old African-American boy with poor dentition and a painful, 1.5 cm epiphytic lesion on the alveolar ridge of the left mandible. Incisional biopsy and computerized tomography were employed to obtain diagnosis and extent of disease. Surgical resection and reconstruction followed.
Results
Incisional biopsy confirmed the diagnosis of squamous cell carcinoma. Maxillofacial computerized tomography confirmed the extent of the mandibular lesion. After interdisciplinary discussion and weighing options with the family, a segmental mandibulectomy, neck dissection, and right fibula free flap reconstruction with titanium 2.0 mm metal plate fixation was performed. Re-examination post-operatively showed complete coverage of the defect and the ability to restore excised dentition.
Conclusion
Squamous cell carcinoma within the pediatric population occurs less often than sarcomas, but may necessitate major reconstruction. Without rigid reconstruction, contracture may result. The current consensus favors microvascular bone reconstruction. However, a lack of consensus exists regarding the timing of dental rehabilitation.
1
Introduction
The major accomplishments in mandibular reconstructive surgery are to restore mastication, deglutition, and cosmesis. The advent of the vascularized fibular free flap in 1975 provided an avenue for mandibular reconstruction in adults that has become commonplace, especially at academic centers . However, these reconstructions rarely occur in children . In contrast to adults, the pediatric mandible needs to develop synchronously with the maxilla and basicranium. Discrepancy in craniofacial growth following fibular free flap may necessitate further procedures, including orthognathic surgery as the facial skeleton matures . Other surgical issues may arise due to anastomotic vessel diameter and growth over time, as well as inconsistent landmarks of the growing pediatric facial structure. Further, the growth of the limb at the donor site must be taken into consideration as a potential complicating factor . These added challenges create a necessity for multidisciplinary care and surgical planning unique to pediatric patients. Pediatric head and neck cancers are rare, and are usually rhabdomyosarcoma, osteosarcoma or chondrosarcoma. SCC is rarely seen in the pediatric population, and has unique prognostic and treatment factors. We here describe a case of pediatric alveolar ridge SCC and free fibula reconstruction, with a review of the literature.
2
Case report
A six-year-old African-American boy was noted to have poor dentition and a 1.5 cm exophytic lesion on the alveolar ridge of the left mandible extending to the buccal surface of first deciduous left mandibular molar ( Fig. 2 A). The painful lesion had been present at least two months. He presented after being unable to tolerate chips and other hard, crunchy foods due to increased tenderness at the site of the lesion. Physical examination yielded mixed dentition, with a 1.5 cm exophytic lesion on the alveolar ridge of the left mandible, which extended to the buccal surface of the first deciduous left mandibular molar. The lesion was tender to palpation with overlying edema and erythema. There was post-auricular lymphadenopathy present on the left; otherwise, the neck was WNL. Both DP and PT pulses were 2 + in bilateral lower extremities. A CT scan demonstrated a 1.5 cm mandibular lesion adjacent to the first deciduous left mandibular molar, with associated osteolysis and no pathologic lymphadenopathy present ( Fig. 1 ). The incisional biopsy demonstrated a pathological diagnosis of moderate to well differentiated squamous cell carcinoma, favoring primary odontogenic/intraosseous origin. Multiple cervical lymph nodes in levels I–III were negative for malignancy. An inter-disciplinary team evaluated and discussed at length this patient’s options for management. The care team incorporated the patient and family into the decision making process where the final decision was to undertake segmental mandibulectomy, neck dissection, and right fibula free flap reconstruction with titanium 2.0 mm metal plate fixation ( Fig. 2 B ). Surgical resection margins were free of tumor.
2
Case report
A six-year-old African-American boy was noted to have poor dentition and a 1.5 cm exophytic lesion on the alveolar ridge of the left mandible extending to the buccal surface of first deciduous left mandibular molar ( Fig. 2 A). The painful lesion had been present at least two months. He presented after being unable to tolerate chips and other hard, crunchy foods due to increased tenderness at the site of the lesion. Physical examination yielded mixed dentition, with a 1.5 cm exophytic lesion on the alveolar ridge of the left mandible, which extended to the buccal surface of the first deciduous left mandibular molar. The lesion was tender to palpation with overlying edema and erythema. There was post-auricular lymphadenopathy present on the left; otherwise, the neck was WNL. Both DP and PT pulses were 2 + in bilateral lower extremities. A CT scan demonstrated a 1.5 cm mandibular lesion adjacent to the first deciduous left mandibular molar, with associated osteolysis and no pathologic lymphadenopathy present ( Fig. 1 ). The incisional biopsy demonstrated a pathological diagnosis of moderate to well differentiated squamous cell carcinoma, favoring primary odontogenic/intraosseous origin. Multiple cervical lymph nodes in levels I–III were negative for malignancy. An inter-disciplinary team evaluated and discussed at length this patient’s options for management. The care team incorporated the patient and family into the decision making process where the final decision was to undertake segmental mandibulectomy, neck dissection, and right fibula free flap reconstruction with titanium 2.0 mm metal plate fixation ( Fig. 2 B ). Surgical resection margins were free of tumor.
