Successful Mandibulectomy with PMMC Flap Reconstruction for Oral Cancer

Chief Complaints

A 73-year-old male patient with a body mass index (BMI) of 18 presented to the Oncology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of a non-healing ulcer in the left lower jaw region for three months. The lesion had initially been small but gradually increased in size and was associated with pain and a burning sensation.

He had previously been evaluated at a private hospital, where a PET-MR scan revealed an ill-defined lesion in the left lower alveolus involving the premolar and molar region (SUV max 9.9), along with an FDG-avid left level IB lymph node measuring 13 × 9 mm (SUV 4.0), raising suspicion of malignancy. A biopsy was performed, which showed pseudoepitheliomatous hyperplastic squamous epithelium with mild to moderate dysplasia and suspicious foci of invasion.

He subsequently presented to PACE Hospitals for further evaluation and management.

The patient had a significant past medical history of cerebrovascular events, having suffered strokes in the past and was on regular treatment for secondary prevention. He was also a known case of hypertension on ongoing medical management. Additionally, he had been recently diagnosed with type 2 diabetes mellitus and was on treatment for glycemic control.

On examination, the patient was conscious, coherent, and cooperative. Extraoral examination showed no obvious facial deformities and no clinically significant cervical lymphadenopathy. Intraoral examination revealed an ulceroproliferative lesion in the left lower alveolus, extending anteriorly toward the canine region and posteriorly to the retromolar trigone, with lateral extension toward the gingivobuccal sulcus and medially confined to the alveolar ridge without involvement of the floor of the mouth. On palpation, the lesion was tender with surrounding induration. Systemic examination was normal.

Upon admission to PACE Hospitals, the patient underwent a comprehensive evaluation, including a detailed review of his medical history and physical examination by the Oncology team. The patient presented with a non-healing ulcer in the left lower jaw region associated with pain and progressive increase in size, and clinical examination revealed an ulceroproliferative lesion in the left lower alveolus, raising a high suspicion of malignancy.

A complete diagnostic workup was performed, including imaging, biopsy, and laboratory investigations. Imaging studies demonstrated an ill-defined lesion in the left lower alveolus with extension toward adjacent mandibular and retromolar regions, along with an FDG-avid left level IB lymph node suggestive of possible nodal involvement. Histopathological examination initially showed features of dysplastic squamous epithelium with suspicious invasive changes, which was later confirmed on frozen section as squamous cell carcinoma. Laboratory investigations revealed anemia, low serum albumin levels, and abnormal arterial blood gas values indicating mild respiratory compromise, while renal function and serum electrolytes were within acceptable limits. Glycemic assessment showed elevated HbA1c consistent with diabetes mellitus.

Based on the confirmed findings, the patient was advised to undergo Oral Cancer Treatment in Hyderabad, India, under the expert care of the Oncology Department.

After a thorough consultation with Dr. B Arvind, Consultant Oral and Maxillofacial OncoSurgeon, and cross-consultation with Dr. Seshi Vardhan Janjirala (Cardiologist), Dr. Pradeep Kiran Panchadi (Pulmonologist), Dr. S Pramod Kumar (Neurologist), and Dr. Tripti Sharma (Endocrinologist), a comprehensive evaluation was conducted to determine the most appropriate treatment for the patient's condition,, diagnosed with carcinoma of the left lower alveolus (Squamous Cell Carcinoma, T2 N1 M0).

Based on patient symptoms and diagnostic findings, it was determined that a wide local excision, left segmental mandibulectomy, selective neck dissection (I-IV), and PMMC flap reconstruction were identified as the appropriate approach for the condition. The decision was based on a detailed clinical assessment, including the patient's biopsy and imaging reports, and aimed at achieving optimal outcomes through timely surgical intervention.

The patient and his family were counselled in detail about the condition, including the risks and potential complications associated with the surgery. They were also informed about the importance of surgical intervention in preventing further disease progression and ensuring the best possible outcomes. 

Following the multidisciplinary decision, the patient was scheduled for Wide Local Excision with Left Segmental Mandibulectomy, Selective Neck Dissection (Levels I–IV), and PMMC flap reconstruction Surgery in Hyderabad at PACE Hospitals, under the expert care and supervision of the Oncology team.

The following steps were carried out during the procedure:

• Preoperative Preparation: The patient was assessed by multiple specialists, including a cardiologist, pulmonologist, and neurologist, to ensure their medical stability. A pre-anesthetic checkup was conducted to confirm the patient's fitness for general anesthesia. The surgical site was marked, and the patient was positioned for optimal access to the affected areas.

• Wide Local Excision: A transverse neck incision was made on the left side, combined with a midline lip split incision for better access to the tumor site. A safe surgical margin was established around the primary tumor located in the left lower alveolus. The tumor, along with any affected surrounding tissues, was excised completely.

• Left Segmental Mandibulectomy: The affected portion of the mandible, including part of the lower jaw, was removed to ensure all cancerous tissue was excised. This procedure was necessary to achieve clear margins, particularly since the tumor involved the bone structure.

• Selective Neck Dissection (I-IV): The lymph nodes in levels I through IV of the neck were carefully removed to address potential metastasis. This step was crucial for staging and preventing the spread of cancer to surrounding lymphatic tissues.

• PMMC Flap Reconstruction: A pectoralis major myocutaneous (PMMC) flap was raised for the reconstruction of the surgical defect, particularly in areas where soft tissue had been removed. The flap was inset into the defect to restore both function and appearance, providing coverage for the area that was surgically altered. The procedure concluded with hemostasis to ensure no excessive bleeding occurred, and the wound was closed layer by layer. Drains were placed to prevent fluid accumulation. The patient was then transferred to the ICU for postoperative monitoring and later moved to the ward once stable.
  

Postoperatively, the patient was shifted to the ICU, where he was extubated and closely monitored. Following this, he was transferred to the ward. Due to low oxygen saturation, Dr. Pradeep Kiran Panchadi (Pulmonologist) was consulted, and appropriate advice was followed, which included nebulization and oxygen support. Additionally, Dr. Tripti Sharma (Endocrinologist) was consulted for glycemic control, and her recommendations were implemented. Dr. Seshi Vardhan Janjirala (Cardiologist) was also consulted for elevated blood pressure, and his guidance was followed. Other supportive treatments included administering intravenous fluids, managing pain, and monitoring for any signs of complications.

Upon discharge, the patient was prescribed medications to manage various post-operative conditions. The patient was advised to take medications for infection prevention, pain relief, and managing nausea and vomiting. Medication was recommended to reduce stomach acid and aid in recovery. A supplement was prescribed to support nutrition, and another medication was provided to relieve constipation. For sleep management, a medication was prescribed as needed for insomnia. Oral antiseptic mouthwash was recommended for oral hygiene to prevent infection in the sutured area. A topical ointment was suggested for wound care at the sutured site. Additionally, a syrup was prescribed to support recovery and improve hemoglobin levels.

Supportive treatments included nebulization for respiratory support and oxygen therapy to maintain adequate oxygen saturation levels. The patient was advised to continue oxygen support intermittently during the day and overnight for 15 days to enhance respiratory function.

Advice on discharge was provided by the multidisciplinary team. The Endocrinology team advised continuation of oral medication for blood sugar control, along with regular fasting and post-meal blood glucose monitoring twice weekly to ensure proper diabetes management. The Neurology team advised continuation of medication to reduce cholesterol levels and a medicine to prevent blood clots in order to lower the risk of further stroke events.

The Cardiology team advised continuation of medication to control blood pressure and reduce overall heart-related risks. The Pulmonology team advised inhalational therapy to improve breathing and lung function, along with supplemental oxygen support via nasal prongs intermittently during the day and continuously during the night to maintain adequate oxygen levels.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any concerning symptoms, including fever, abdominal pain, or vomiting.

The patient was advised to schedule a follow-up appointment with the Oncologist in Hyderabad at PACE Hospitals one week after discharge. Additionally, review after 1 week with the Endocrinology team, along with sugar charting for assessment of glycemic control. Review after 2 weeks with the Cardiology team for evaluation and continuation of cardiac care. Review after 3 weeks with the Neurology team for neurological assessment and continuation of stroke-related management.

This case highlights carcinoma of the left lower alveolus managed with wide local excision, segmental mandibulectomy, selective neck dissection (I–IV), and PMMC flap reconstruction after confirmation of squamous cell carcinoma. Cross consultations from cardiology, pulmonology, endocrinology, and neurology were obtained for optimal perioperative management of comorbid conditions. The patient had a stable postoperative recovery and was discharged in a hemodynamically stable condition with planned multidisciplinary follow-up.