T4期舌鳞状细胞癌全舌或近全舌切除术后腹直肌垂直肌皮瓣与股前外侧皮瓣重建的功能与肿瘤学结局比较

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中文摘要

目的： 比较T4期舌鳞状细胞癌患者全舌或近全舌切除术后，腹直肌垂直肌皮瓣（VRAM）与股前外侧皮瓣（ALT）重建的功能与肿瘤学结局。
方法： 本比较性研究纳入2019年2月至2023年2月期间治疗的75例患者（A组：VRAM，n=30；B组：ALT，n=45）。皮瓣选择基于术前股前外侧皮下脂肪厚度捏提试验（<1.5 cm选用VRAM，≥1.5 cm选用ALT）。采用经验证的量表在术后1个月及放疗结束后6个月评估功能结局（言语与吞咽）。采用Kaplan-Meier法及Cox比例风险回归分析无病生存期（DFS）。
结果： B组在术后1个月及6个月时的言语和吞咽功能均显著更优（p < 0.05）。然而，在V型（全舌）切除患者的亚组分析中，功能差异仅在1个月时显著，至6个月时已相当。总体中位随访时间为21.0个月，无病患者中为34.5个月。A组和B组的估计2年DFS率分别为50.9%和43.0%（p = 0.557）。多因素分析确定较低的BMI、阳性结外侵犯（ENE）及较大的浸润深度（DOI >20 mm）为DFS较差的独立预测因素。皮瓣类型并非独立预后因素。
结论： 当皮瓣适当超量设计时，VRAM与ALT皮瓣均可提供相当的长期功能结局。浸润深度>20 mm是该T4期舌鳞状细胞癌队列中强有力的独立不良预后因素，并与显著更差的无病生存期相关。该发现具有假说生成性，值得进一步研究，作为T4期疾病风险分层潜在细化的依据。

英文摘要

OBJECTIVE: To compare functional and oncologic outcomes between vertical rectus abdominis musculocutaneous (VRAM) and anterolateral thigh (ALT) flap reconstruction following total or near-total glossectomy in patients with T4 tongue squamous cell carcinoma.
METHODS: This comparative study included 75 patients (Group A: VRAM, n=30; Group B: ALT, n=45) treated between February 2019 and February 2023. Flap selection was based on preoperative pinch test of anterolateral thigh subcutaneous fat thickness (<1.5 cm for VRAM, ≥1.5 cm for ALT). Functional outcomes (speech and swallowing) were assessed at 1 month postoperatively and at 6 months after completion of radiotherapy using validated scales. Disease-free survival (DFS) was analyzed using the Kaplan-Meier method and Cox proportional hazards regression.
RESULTS: Group B demonstrated significantly better speech and swallowing function at 1 month and 6 months postoperatively (p < 0.05). However, in the subgroup analysis of patients with type V (total) glossectomy, functional differences were significant only at 1 month and became comparable by 6 months. The median follow-up was 21.0 months overall and 34.5 months among disease-free patients. The estimated 2-year DFS rates were 50.9% in Group A and 43.0% in Group B (p = 0.557). Multivariate analysis identified lower BMI, positive extranodal extension (ENE), and greater depth of invasion (DOI >20 mm) as independent predictors of worse DFS. Flap type was not an independent prognostic factor.
CONCLUSIONS: Both VRAM and ALT flaps provide comparable long-term functional outcomes when appropriately oversized. Depth of invasion >20 mm was a strong independent adverse prognostic factor in this cohort of T4 tongue squamous cell carcinoma and was associated with significantly worse disease-free survival. This finding is hypothesis-generating and warrants further investigation as a potential refinement to risk stratification within T4 disease.