Treatment Results of Postoperative Radiotherapy on Squamous Cell Carcinoma of the Oral Cavity: Coexistence of Multiple Minor Risk Factors Results in Higher Recurrence Rates

Expression of the cancer stem cell markers CD44v6 and ABCG2 in tongue cancer: effect of neoadjuvant chemotherapy on local recurrence

The efficacy of neoadjuvant chemotherapy (NAC) is controversial, and no report supports NAC with a high evidence level. Recently, we showed that a deep surgical margin was resected very close to the tumor site in many NAC-treated oral squamous cell carcinoma patients, suggesting that NAC may lead to local recurrence and poor outcomes. The purpose of this study was to evaluate the effect of NAC on tumor local recurrence using cancer stem cell marker immunohistochemistry. We retrospectively analyzed 89 patients who underwent radical surgery for tongue cancer, and examined the effect of NAC on tumor local recurrence. Cancer stem cell marker (CD44v6 and ABCG2) expression was detected by immunohistochemistry. In our study, the local recurrence rate was 12.4%. CD44v6 and ABCG2 expression was significantly associated with regional lymph node metastasis, pattern of invasion, depth of invasion, perineural invasion and local recurrence, respectively. Tumor local recurrence was a significant independent predictive factor of the 5-year disease specific survival. CD44v6 or ABCG2 positivity in NAC-treated patients was significantly associated with tumor local recurrence. It was suggested that local recurrence in NAC-treated cases is associated with cancer stem-like cells. We propose that NAC leads to the selection and/or residue of more aggressive cancer stem-like cells.

Impact of perineural invasion in the pathologically N0 neck in oral cavity squamous cell carcinoma

OBJECTIVE

Patients with oral cavity squamous cell carcinoma (OCSCC) undergo adjuvant radiation for pathologically high-risk features including positive nodal disease and extracapsular spread (ECS). In the absence of these high-risk features, our objective was to determine if perineural invasion (PNI) is an independent risk factor and if adjuvant radiation (XRT) improves disease control rates.

STUDY DESIGN

Historical cohort analysis.

SETTING

Tertiary university hospital.

METHODS

Eighty-eight OCSCC patients (46 males, 42 females; mean age = 56.7 years; median follow-up = 4.6 years) treated surgically with pathologically N0 (pN0) necks were studied. Overall, 23% (20/88) were pN0/PNI+ and of those with PNI, 70% (14/20) underwent XRT. Survival analysis using Kaplan-Meier followed by multivariable Cox models was performed.

RESULTS

Multivariate analysis verified PNI to be associated with worse disease-free interval (DFI) (P = .012) and local-regional control (LRC) (P = .005) and perivascular invasion (PVI) associated with worse DFI (P = .05). Among pN0/PNI+ patients, those who received XRT demonstrated significantly improved DFI (mean = 6.5 years vs 1.7 years; P = .014) and LRC (mean 6.7 years vs 1.9 years; P = .047). There was no improvement in overall survival (P = .68) or disease-specific survival (P = .8) in those receiving XRT.

CONCLUSIONS

PNI is an independent adverse risk factor in the absence of nodal metastasis and extracapsular spread. We observed a statistically significantly longer DFI and LRC when patients were treated with adjuvant radiation.

Predictors of locoregional recurrence in T1-2N0 tongue cancer patients

Locoregional recurrence of oral tongue squamous cell carcinoma (OTSCC) has been considered a poor prognostic entity in terms of survival rate. The purpose of this study was to evaluate the incidence of locoregional recurrence and to identify significant risk factors for locoregional recurrence in early-stage OTSCC. We retrospectively reviewed the records of 58 patients who underwent radical surgery for T1-2N0 OTSCC. The local recurrence and regional recurrence rates were 10.3 % (6/58 patients) and 15.5 % (9/58 patients) in this study, respectively. The survival rate of patients with local recurrence was 66.7 %, which was significantly lower than that (96.2 %) of patients without local recurrence, whereas the survival rates of patients with or without regional recurrence were not significantly difference. Pattern of invasion (POI), neoadjuvant chemotherapy (NAC) and the status of the surgical margin were identified as factors influencing local recurrence. In particular, the status of the deep surgical margin was a high potential independent risk factor. The deep surgical margin was resected closely in many NAC-treated cases, suggesting that NAC may lead to local recurrence and a poor outcome. No efficacy of NAC was observed, suggesting that the standard treatment for early OTSCC is surgery alone.

Retrospective analysis of survival of patients with squamous cell carcinoma of the maxilla after primary resection and elective bilateral neck dissection: An institutional experience

Background:

A retrospective analysis of the 5-year survival rates of patients who underwent treatment for oral squamous cell carcinoma (OSCC) of the maxillary region was performed to analyse the prognostic factors for patient's survival.

Materials and Methods:

Twenty-four patients with SCC of the maxillary region, who underwent treatment at our hospital between 1999 and 2009 were included in the study. The patients underwent primary surgical resection and elective bilateral neck dissection. The patients with tumor positive margins were referred for chemo-radiotherapy after surgery.

Results:

The overall 5-year survival rate was 25%. The patients who had recurrence had presented with T3 or T4 lesions only. Of the patients who died, 14 out of the 18 were those who had tumor-positive margins and had undergone radiotherapy following surgery.

Conclusions:

Primary surgical treatment of SCCs of the maxillary region along with elective bilateral neck dissection yielded some improvement in survival rates, and can therefore be seen as a valuable strategy. Tumor-free resection margins and early detection of the lesion are the most important indicators for favorable prognosis.

Oral cancer: Current role of radiotherapy and chemotherapy

The term oral cavity cancer (OSCC) constitutes cancers of the mucosal surfaces of the lips, floor of mouth, oral tongue, buccal mucosa, lower and upper gingiva, hard palate and retromolar trigone. Treatment approaches for OSCC include single management with surgery, radiotherapy [external beam radiotherapy (EBRT) and/or brachytherapy], as well as adjuvant systemic therapy (chemotherapy and/or target agents); various combinations of these modalities may also be used depending on the disease presentation and pathological findings. The selection of sole or combined modality is based on various considerations that include disease control probability, the anticipated functional and cosmetic outcomes, tumor resectability, patient general condition, and availability of resources and expertise. For resectable OSCC, the mainstay of treatment is surgery, though same practitioners may advocate for the use of radiotherapy alone in selected "early" disease presentations or combined with chemotherapy in more locally advanced stage disease. In general, the latter is more commonly reserved for cases where surgery may be problematic. Thus, primary radiotherapy ± chemotherapy is usually reserved for patients unable to tolerate or who are otherwise unsuited for surgery. On the other hand, brachytherapy may be considered as a sole modality for early small primary tumor. It also has a role as an adjuvant to surgery in the setting of inadequate pathologically assessed resection margins, as does postoperative external beam radiotherapy ± chemotherapy, which is usually reserved for those with unfavorable pathological features. Brachytherapy can also be especially useful in the re-irradiation setting for persistent or recurrent disease or for a second primary arising within a previous radiation field. Biological agents targeting the epithelial growth factor receptor (EGFR) have emerged as a potential modality in combination with radiotherapy or chemoradiotherapy and are currently under evaluation in clinical trials.

Evaluation of saliva flow rates, Candida colonization and susceptibility of Candida strains after head and neck radiation

Hyposalivation is a long-term effect in patients receiving head and neck radiation. Radiotherapy can predispose oral colonization by Candida species of the mucosa. This study aims to evaluate the correlation between hyposalivation, measured by unstimulated saliva flow rates (SFR) and fungal colonization of the oral cavity, and also the resistance of isolated Candida strains to antimicrobial therapy. Fifty-three consecutive patients with radiotherapy were examined for late radiation damage on dental hard tissue and the salivary glands (SFR over a period of 5 min). The SFR were divided into three different values of hyposalivation: grade I (SFR 0.1-0.25 ml/min), grade II (SFR ≤0.1 ml/min), and grade III (SFR = 0.0 ml/min). Candidal colonization was defined using Sabouraud agar and identified using API 20C AUX (biomerieux) in the patients' rinsing water. Susceptibility was tested with Etest (amphotericin B, ketoconacole, voriconacole, and fluconacole). Hyposalivation grade I was detected in 23% (9.1 × 10(1) colony forming units (cfu); range, 200-5,900 cfu), hyposalivation grade II in 26% (4.3 × 10(1) cfu; range, 110-3,300 cfu), and hyposalivation grade III in 51% (2.0 × 10(3) cfu; range, 300-19,475 cfu) of patients. A significant correlation between the SFR and candidal colonization and clinical presentation (European Organization for Research and Treatment of Cancer (EORTC) score) was detected (Mann-Whitney test, p = 0.031). Twenty Candida albicans and 27 non-albicans species were identified. The resistance of C. albicans was higher than that of non-albicans strains against antimicrobial agents. By comparison, amphotericin B showed the greatest and fluconazole the least effect. A higher value of hyposalivation correlates with a higher risk of candidal colonization in patients who have received radiotherapy and also with a higher EORTC score. The spectrum of Candida is wide and susceptibility against antifungal therapy differs. In long-term examinations of patients with xerostomia after radiotherapy, the EORTC score can be used to measure hyposalivation. Reduced susceptibility of C. albicans might introduce complications to therapy. Findings of more non-albicans strains show a change in colonization which should be examined in further studies.

Oral squamous cell carcinoma: clinicopathological features in patients with and without recurrence

AIM

To compare the clinicopathological profile of oral squamous cell carcinoma (OSCC) in groups with and without recurrence.

METHODS

Records of all patients who underwent surgery for primary OSCC at a single institution during 1999 were identified. Patient demographics, lesion site, clinical and pathologic stage, pathologic grading, pattern of invasion, lymphocytic infiltrate, perineural invasion, and treatment and survival data were collected. Descriptive statistics were calculated for each variable and survival was calculated using Kaplan-Meier and Cox models. Patients were divided into 2 groups: with (n = 25) and without (n = 28) recurrence.

RESULTS

Tongue (p = 0.02) and poorly differentiated (p = 0.04) tumors were associated with recurrence. Kaplan-Meier and Cox models revealed tobacco use and the absence of lymphocytic infiltrate to be associated with the poorest survival in recurrent OSCC.

CONCLUSION

The tumor site, tobacco use, and pathological features were involved in the recurrence of OSCC and should be taken into account for OSCC treatment and follow-up.

Prognostic value of lymph node density in node-positive patients with oral squamous cell carcinoma

BACKGROUND

Lymph node density (LND) is superior to TNM nodal status in predicting survival after surgery for bladder and other cancers. Little is known, however, about whether LND can predict survival in patients with oral squamous cell carcinoma (OSCC). We therefore evaluated the utility of LND for predicting survival for patients with OSCC and positive nodes (pN+).

METHODS

We reviewed the clinical, pathologic, and follow-up data of 211 OSCC patients who underwent surgery. All lymph nodes harvested from neck dissection were carefully examined, with LND calculated as the ratio of positive lymph nodes to total lymph nodes removed. Univariate and multivariate analyses of variables predicting overall survival (OS) and disease-specific survival (DSS) were performed for all patients and in pN+ patients.

RESULTS

Kaplan-Meier analyses showed that the 5-year OS and DSS rates in all patients were 72% and 79%, respectively. Multivariate analysis showed that variables independently prognostic for DSS were T classification (hazard ratio [HR] = 2.97, 95% confidence interval [95% CI] = 1.59-5.57; P = .001), and N classification (HR = 4.91, 95% CI = 2.47-9.75; P < .001). In pN+ patients, univariate analysis showed that T classification, >2 positive nodes, and LND >0.06 (median) were significant predictors of DSS (P < .015 each), and multivariate analysis showed that LND was an independent predictor of DSS (HR = 3.24, 95% CI = 1.61-6.53; P = .001).

CONCLUSIONS

LND may be useful in stratifying the likelihood of survival in patients with OSCC.