Impact of neoadjuvant chemotherapy on perioperative morbidity after major surgery for head and neck cancer

Preoperative neoadjuvant chemotherapy or immunotherapy in head and neck cancer: A systematic review and meta-analysis of surgical risk and pathologic response

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate surgical complications, pathologic responses, and disease progression in patients with head and neck squamous cell carcinoma treated with neoadjuvant chemotherapy or immunotherapy.

METHODS

A comprehensive literature search was conduct across four databases (PubMed, Embase, Cochrane Library, and Scopus) and grey literature sources to identify neoadjuvant therapies in head and neck cancer patients. Only prospective clinical trials were included. The certainty of evidence was appraised using GRADE tool.

RESULTS

A total of 12 clinical trials me the inclusion criteria, comprising, six studies on neoadjuvant chemotherapy (Cisplatin and 5-FU) and six on immunotherapy (Nivolumab, Nivolumab plus Ipilimumab, Pembrolizumab) were analyzed. The mean time from drug administration to surgery ranged from 18 to 29 days. The overall surgical complication rate was 32.8 %, with the lowest observed in the Pembrolizumab group (9 %) and the highest in the Nivolumab plus Ipilimumab group (36.7 %). However, risk ratios for surgical complications were not statistically significant for Nivolumab (RR = 1.68, p = 0.078) or chemotherapy (RR = 1.1, p = 0.70). The complete pathologic response (pCR) rate was low (4 %), highest in the Cisplatin and 5-FU group (11 %). In contrast, the partial pathologic response (pPR) rate reached 58 % with Nivolumab plus Ipilimumab. Disease progression after surgery occurred in 19.4 %, with the lowest progression rate observed in the Nivolumab plus Ipilimumab group (7.7 %). The certainty of evidence was rated as very low for chemotherapy and low for immunotherapy.

CONCLUSION

Combination immunotherapy, particularly Nivolumab with Ipilimumab, demonstrated favorable pPR rates and reduced disease progression but was increased surgical complications. The overall low pCR across all regimen treatments highlight the need for improved therapeutic strategies.

A nuanced review of neoadjuvant therapies in oral cancer

INTRODUCTION

Oral squamous cell carcinoma (OSCC) is a significant global health burden. The goals of neoadjuvant chemotherapy (NACT) are to shrink tumors allowing for more conservative surgeries, improve survival and potentially improve quality of life.

AREAS COVERED

This review explores the current evidence of utility of NACT in OSCC management. We have covered indications of NACT, types of regimens and their associated toxicities, perioperative challenges with regards to margins and complications. We have also reviewed the upcoming regimens for NACT.

EXPERT OPINION

NACT is a potential option for treating borderline resectable and unresectable OSCC. It holds promise for organ preservation (mandibular/tongue). With newer modalities like immunotherapy and targeted therapies, the preferred choice of regimen may evolve. Post NACT, intraoperative margins and choice of adjuvant therapy remain debatable.

Neoadjuvant chemo-immunotherapy with camrelizumab plus nab-paclitaxel and cisplatin in resectable locally advanced squamous cell carcinoma of the head and neck: a pilot phase II trial

Neoadjuvant chemoimmunotherapy has emerged as a potential treatment option for resectable head and neck squamous cell carcinoma (HNSCC). In this single-arm phase II trial (NCT04826679), patients with resectable locally advanced HNSCC (T2‒T4, N0‒N3b, M0) received neoadjuvant chemoimmunotherapy with camrelizumab (200 mg), nab-paclitaxel (260 mg/m2), and cisplatin (60 mg/m2) intravenously on day one of each three-week cycle for three cycles. The primary endpoint was the objective response rate (ORR). Secondary endpoints included pathologic complete response (pCR), major pathologic response (MPR), two-year progression-free survival rate, two-year overall survival rate, and toxicities. Here, we report the perioperative outcomes; survival outcomes were not mature at the time of data analysis. Between April 19, 2021 and March 17, 2022, 48 patients were enrolled and received neoadjuvant therapy, 27 of whom proceeded to surgical resection and remaining 21 received non-surgical therapy. The ORR was 89.6% (95% CI: 80.9, 98.2) among 48 patients who completed neoadjuvant therapy. Of the 27 patients who underwent surgery, 17 (63.0%, 95% CI: 44.7, 81.2) achieved a MPR or pCR, with a pCR rate of 55.6% (95% CI: 36.8, 74.3). Treatment-related adverse events of grade 3 or 4 occurred in two patients. This study meets the primary endpoint showing potential efficacy of neoadjuvant camrelizumab plus nab-paclitaxel and cisplatin, with an acceptable safety profile, in patients with resectable locally advanced HNSCC.

Distal positioning of the skin paddle of pectoralis major myocutaneous flap in head and neck reconstruction

BACKGROUND

To assess outcomes of pectoralis major myocutaneous flap (PMF) wherein the skin paddle (SP) was positioned with its distal portion extending beyond the lower border of pectoralis major by ≥2 cm (PMF-d).

METHODS

Consecutive head and neck reconstructions with PMF-d (n = 110). SP dimensions l2 (distal extent below the lower border of pectoralis major), l1 (proximal extent above lower border of pectoralis major), and b (breadth) were recorded. Endpoints were SP necrosis, recipient dehiscence, early fistula, and persistent fistula.

RESULTS

Median values of l2 , l1 , and b were 3.0, 6.0, and 6.0 cm, respectively. When l2  = 2.0-3.0 cm, SP necrosis occurred in only one (1%) subject (with obesity). When l2 was ≥3.5 cm, necrosis occurred in four (16%) subjects, three of whom also had l1 /l2  < 2.0 (proximal SP < 67% of entire SP). Statistically, increased l2 was the only risk factor for necrosis (p = 0.001). Overall, incidence of recipient dehiscence, early fistula, and persistent fistula were 32 (29%), 20 (20%), and 3 (3%), respectively. Persistent fistula occurred only in the setting of SP necrosis and/or re-irradiation.

CONCLUSION

Careful patient selection, adequate proximal SP, and l2  = 2.0-3.0 cm is associated with a negligible risk of necrosis. The enhanced reach and laxity and additional skin surface area and soft tissue volume conferred with PMF-d facilitate recipient wound healing.

Exercise-based rehabilitation on functionality and quality of life in head and neck cancer survivors. A systematic review and meta-analysis

Head and Neck Cancer (HNC) is a globally rare cancer that includes a variety of tumors affecting the upper aerodigestive tract. It presents with difficulty breathing or swallowing and is mainly treated with radiation therapy, chemotherapy, or surgery for tumors that have spread locally or throughout the body. Alternatively, exercise can be used during cancer treatment to improve function, including pain relief, increase range of motion and muscle strength, and reduce cancer-related fatigue, thereby enhancing quality of life. Although existing evidence suggests the adjunctive use of exercise in other cancer types, no previous studies have examined the effects on HNC survivors. The aim of this meta-analysis was to quantify the effect of exercise-based rehabilitation on functionality and quality of life in HNC survivors who underwent surgery and/or chemoradiotherapy. A systematic review and meta-analysis were carried out following PRISMA statement and registered in PROSPERO (CRD42023390300). The search was performed in MEDLINE (PubMED), Cochrane Library, CINAHL and Web of Science (WOS) databases from inception to 31st December 2022 using the terms "cancer", "head and neck neoplasms", "exercise", "rehabilitation", "complications", "muscle contraction", "muscle stretching exercises" combining with booleans "AND"/"OR". PEDro scale, Cochrane Risk of Bias Tool and GRADE were used to assess methodological quality, risk of bias and grade of recommendation of included studies respectively. 18 studies (n = 1322) were finally included which 1039 (78.6%) were men and 283 (21.4%) were women. In patients who underwent radio-chemotherapy, overall pain [SMD = - 0.62 [- 4.07, 2.83] CI 95%, Z = 0.35, p = 0.72] and OP [SMD = - 0.07 [- 0.62, 0.48] CI 95%, Z = 0.25, p = 0.81] were slightly reduced with exercise in comparison to controls. Besides, lower limb muscle strength [SMD = - 0.10 [- 1.52, 1.32] CI 95%, Z = 0.14, p = 0.89] and fatigue [SMD = - 0.51 [- 0.97, - 0.057] CI 95%, Z = 2.15, p < 0.01] were also improved in those who receive radio-chemoradiation. In HNC survivors treated with neck dissection surgery, exercise was superior to controls in overall pain [SMD = - 1.04 [- 3.31, 1.23] CI 95%, Z = 0.90, p = 0.37] and, in mid-term, on shoulder pain SMD = - 2.81 [- 7.06, 1.43] CI 95%, Z = 1.76, p = 0.08]. No differences in quality of life were found at any of the follow-up periods. There is evidence of fair to good methodological quality, low to moderate risk of bias, and weak recommendations supporting the use of exercise-based rehabilitation to increase functionality. However, no evidence was found in favor of the use of this modality for improving the quality of life of HNC survivors who underwent chemoradiotherapy or surgery.

Comprehensive complication index: A new reporting standard for postoperative complications of free-flap reconstruction in head and neck cancer patients

OBJECTIVE

We aimed to validate and evaluate the comprehensive complication index (CCI) as a measure of postoperative complications (POCs) in the patients with head and neck squamous cell carcinoma (HNSCC) who had undergone free-flap reconstruction.

STUDY DESIGN

A single-center, prospective cohort study was conducted on the patients with primary HNSCC treated between 2015 and 2020.

RESULTS

Of 443 patients, 177 experienced POCs (40.0%). According to the new CCI, 93 patients had severe POCs (score ≥26.2; 21.0%), and only 76 patients were classified as having severe POCs (grade ≥III; 17.2%) according to the traditional Clavien-Dindo classification (CDC). The patients with CCI scores ≥26.2 had a higher rate of major adverse short-term outcomes, such as prolonged length of the hospital stay after surgery, excessive medical costs, and the need for transfusion. Importantly, the Kaplan-Meier analysis revealed a lower overall survival rate for patients with severe complications (CCI score ≥26.2, P = .038). However, no statistically significant differences were observed between CDC grades III or above and overall survival (P = .100).

CONCLUSIONS

The CCI can be used to evaluate POCs of free-flap reconstruction in patients with HNSCC. It performed more accurately than the CDC in short- and long-term outcome prediction and risk factor identification.

Postoperative Complications of Free Flap Reconstruction in Moderate-Advanced Head and Neck Squamous Cell Carcinoma: A Prospective Cohort Study Based on Real-World Data

BACKGROUND

Postoperative complications (POCs) of moderate-advanced head and neck squamous cell carcinoma (HNSCC) after free flap reconstruction have received little attention. We investigated the risk factors that lead to POCs and their impact on management and prognosis.

PATIENTS AND METHODS

A single-center, prospective cohort study was conducted at Beijing Stomatological Hospital on primary HNSCC patients treated between 2015 and 2020.

RESULTS

In total, 399 consecutive HNSCC patients who underwent radical resection of the primary tumor and free flap reconstruction were enrolled in this study, 155(38.8%) experienced POCs. The occurrence of POCs directly led to worse short-term outcomes and poorer long-term overall survival (P=0.0056). Weight loss before the operation (P=0.097), Tumor site (P=0.002), stage T4b (P=0.016), an ACE-27 index of 2-3 (P=0.040), operation time≥8h (P=0.001) and Clindamycin as antibiotic prophylaxis (P=0.001) were significantly associated with POCs.

CONCLUSIONS

The occurrence of POCs significantly leads to worse short-term outcomes and increases the patients' burden.

Delay to surgery after neoadjuvant chemotherapy in head and neck squamous cell carcinoma affects oncologic outcomes

BACKGROUND

Neoadjuvant chemotherapy (NAC) is used in head and neck squamous cell carcinoma (HNSCC) for downstaging advanced disease and decreasing distant metastasis (DM). To the authors' knowledge, no study has specifically examined the impact of a delayed time to surgery (TTS) after NAC on oncologic outcomes. They thus aimed to identify a cutoff for TTS after NAC and its effect on survival indices.

METHODS

This was a retrospective review of all patients with HNSCC receiving NAC followed by surgery with curative intent between March 2016 and March 2019 at the MD Anderson Cancer Center. Receiver operating characteristic analysis was used to identify a cutoff for TTS, and this cutoff was used to analyze the overall survival (OS), locoregional recurrence rate, DM-free rate, and disease-free survival (DFS). A multivariate Cox regression analysis was performed.

RESULTS

One hundred one patients were analyzed with a median follow-up of 24.7 months. The 3-year OS and locoregional recurrence rates did not differ with a TTS ≥ 34 days. However, the 3-year DM-free rate was significantly worse (56% vs 90%; P = .001) in the group with a TTS ≥ 34 days, and the 3-year DFS was significantly lower (26% vs 64%; P = .006). In a multivariate analysis, a TTS ≥ 34 days (hazard ratio [HR], 4.92; 95% confidence interval [CI], 1.84-13.13) and extracapsular extension (HR, 3.01; 95% CI, 1.13-8.00) were significant independent predictors of a poorer DM-free rate. Weight loss > 10% (HR, 5.53; 95% CI, 1.02-30.24) was the only independent predictor for a TTS ≥ 34 days.

CONCLUSIONS

Emphasis should be placed on early definitive locoregional treatment after NAC, particularly in patients who do not respond to NAC. There is a need to validate these findings and establish new benchmarks for the interval between NAC and surgery.