Phd in INNOVATIVE TECHNOLOGIES IN DISEASES OF
SKELETON, SKIN AND ORO-CRANIOFACIAL DISTRICT

Thesis title: Algoritmo chirurgico ricostruttivo nella gestione multidisciplinare dei sarcomi testa-collo

Sarcomas are a rare and heterogeneous group of malignant tumours of mesenchymal origin, accounting for less than 1% of all solid cancers. Within this category, head and neck sarcomas represent approximately 5% of all sarcomas and about 2% of cervicofacial malignancies. Despite their low incidence, they are characterised by locally aggressive behaviour and they frequently involve critical anatomical structures, making the achievement of negative surgical margins - the strongest prognostic determinant - particularly challenging. Surgery remains the cornerstone of treatment as part of a multimodal approach, and reconstructive surgery plays a crucial role in restoring function and aesthetic while enabling adequate oncological resection. The aim of this study was to develop and validate a surgical algorithm integrating reconstructive timing into multidisciplinary treatment planning for head and neck sarcomas. The protocol was designed to guide the appropriate reconstructive approach based on prognostic and surgical considerations. Its clinical applicability was assessed by analysing survival outcomes and surgical margin status. A retrospective review was conducted on 113 patients treated between 2014 and 2024 at the Maxillofacial Surgery Unit of Policlinico Umberto I, University of Rome “La Sapienza”. Patients were stratified according to tumour size and grade, feasibility of achieving clear margins, need for multimodal therapy and suitability for microsurgical reconstruction. Reconstructive timing was categorised as primary: definitive reconstruction immediately after resection; delayed: reconstruction postponed until confirmation of margin negativity; or staged: definitive reconstruction after multimodal therapy. The mean follow-up was 35.9 months (range 6-60). Overall, 5-year overall survival (OS), recurrence-free survival (RFS) and disease-free survival (DFS) were 62.2%, 55.7% and 54.0%, respectively. Negative margins were achieved in 71.7% of cases, with rates of 86.36% in the primary group, 63.89% in the delayed group and 60.61% in the staged group (p=0.034). Kaplan–Meier analyses showed stratified clinical trajectories consistent with the algorithm’s rationale: OS, RFS and DFS were 80%, 75% and 77% in the primary group; 70%, 70% and 67% in the delayed group; and 40%, 30% and 43% in the staged group. Log-rank analyses demonstrated statistically significant differences in survival distributions for mortality (χ²=16.7, df=2, p=0.0002) and recurrence (χ²=21.9, df=2, p=0.00002). In Cox regression, staged reconstruction showed increased mortality (HR 2.66, p=0.015) and recurrence risk (HR 2.47, p=0.0174), reflecting the more advanced disease burden of this subgroup. Positive margins were strongly associated with poorer outcomes (OS HR 6.41, p < 0.0001; RFS HR 7.32, p < 0.0001) and age was an additional independent predictor of mortality (HR 1.023/year, p = 0.0185). This study validated a reproducible, oncologically oriented reconstructive timing algorithm to improve decision-making pathways, supporting standardization in a personalised management of head and neck sarcomas.