Long-term outcomes in oral cavity squamous cell carcinoma with adjuvant and salvage radiotherapy after surgery

Oncologic outcomes of microscopic tumor cut through in locally advanced oral squamous cell carcinoma

OBJECTIVE

This study aims to determine the impact of MTCT on local recurrence and disease-specific survival in patients with locally advanced T3-T4 OCSCC and compare it with other clinicopathological variables.

METHODS

A retrospective database analysis of patients diagnosed with locally advanced T3-T4 OCSCC surgically treated and submitted to intraoperative frozen section guiding the margin status. Survival was analyzed using the Kaplan-Meier estimator followed by the Cox model for multivariate analysis.

RESULTS

We analyzed 475 patients who met inclusion criteria: MTCT occurred in 29 patients (6.11%) and local recurrence was observed in 131 patients (27.6%). MTCT had an impact on univariate (HR = 2.205; 95% CI 1.243-3.914; p = 0.007) and multivariate (HR = 1.851; 95% CI 1.285-2.666; p = 0.001) analyses. Similar results were found for disease-specific survival: univariate (HZ = 1.669; 95% CI 1.056-2.635; p = 0.028) and multivariate (HZ = 1.307; 95% CI 0.816-2.092; p = 0.265) analyses. A total of 231 patients (48.6%) had died of cancer by the end of follow-up. The best predictor for compromised frozen sections was tumor depth of invasion.

CONCLUSION

Even after negative final margins, MTCT is an important factor associated with poorer outcome, and treatment intensification should be considered in these patients.

LEVEL OF EVIDENCE

Level III.

Long-term outcomes of patients with oral cavity cancer receiving postoperative radiotherapy after salvage neck dissection for cervical lymph node recurrence

BACKGROUNDS

We aimed to clarify the outcomes of postoperative radiotherapy (PORT) after salvage neck dissection for cervical lymph node (LN) recurrence in oral cavity cancer.

METHODS

We retrospectively evaluated overall survival (OS), recurrence-free survival (RFS), recurrence patterns, and adverse events of 51 patients with high-risk features receiving PORT after salvage neck dissection between 2009 and 2019.

RESULTS

After a median follow-up of 7.4 years from PORT initiation, the 7-year OS and RFS rates were 66.3% (95% CI: 54.0-81.3) and 54.6% (95% CI: 42.1-70.9), respectively. Age <70 years and isolated LN recurrence were significantly associated with longer OS and RFS. Among the 22 patients who experienced recurrence, 14 experienced recurrence within the radiation field. PORT-related grade 3 acute mucositis (35%) and late adverse events (osteoradionecrosis [4%] and laryngeal stenosis [2%]) were observed.

CONCLUSIONS

PORT after salvage neck dissection for cervical LN recurrence achieved good survival with acceptable toxicity.

Post-operative PET/CT improves the detection of early recurrence of squamous cell carcinomas of the oral cavity

BACKGROUND

We evaluate the impact of post-operative 18-fluorodeoxyglucose positron emission tomography with computed tomography (PET/CT) for radiation planning on the detection of early recurrence (ER) and treatment outcomes in oral squamous cell carcinoma (OSCC).

METHODS

We retrospectively reviewed the records of patients treated with post-operative radiation between 2005 and 2019 for OSCC at our institution. Extracapsular extension and positive surgical margins were classified as high risk features; pT3-4, node positivity, lymphovascular invasion, perineural invasion, tumor thickness >5 mm, and close surgical margins were considered intermediate risk features. Patients with ER were identified. Inverse probability of treatment weighting (IPTW) was used to adjust for imbalances between baseline characteristics.

RESULTS

391 patients with OSCC were treated with post-operative radiation. 237 (60.6%) patients underwent post-operative PET/CT planning vs. 154 (39.4%) who were planned with CT only. Patients screened with post-operative PET/CT were more likely to be diagnosed with ER than those planned with CT only (16.5 vs. 3.3%, p < 0.0001). Among patients with ER, those with intermediate features were more likely than those high risk features to undergo major treatment intensification, including re-operation, the addition of chemotherapy, or intensification of radiation by ≥ 10 Gy (91% vs. 9%, p < 0.0001). Post-operative PET/CT was associated with improved disease-free and overall survival for patients with intermediate risk features (IPTW log-rank p = 0.026 and p = 0.047, respectively) but not high risk features (IPTW log-rank p = 0.44 and p = 0.96).

CONCLUSIONS

Use of post-operative PET/CT is associated with increased detection of early recurrence. Among patients with intermediate risk features, this may translate to improved disease-free survival.

Salvage Surgery in Recurrent Oral Squamous Cell Carcinoma

More than half of patients with oral cancer recur even after multimodality treatment and recurrent oral cancers carry a poorer prognosis when compared to other sites of head and neck. The best survival outcome in a recurrent setting is achieved by salvage surgery; however, objective criteria to select an ideal candidate for salvage surgery is difficult to frame, as the outcome depends on various treatment-, tumor-, and patient-related factors. The following is summarizes various tumor- and treatment-related factors that guide our decision-making to optimize oncologic and functional outcomes in surgical salvage for recurrent oral cancers. Short disease-free interval, advanced tumor stage (recurrent and primary), extracapsular spread and positive tumor margins in a recurrent tumor, regional recurrence, and multimodality treatment of primary tumor all portend worse outcomes after surgical salvage. Quality of life after surgical intervention has shown improvement over 1 year with a drastic drop in pain scores. Various trials are underway evaluating the combination of immunotherapy and surgical salvage in recurrent head and neck tumors, including oral cavity, which may widen our indications for salvage surgery with improved survival and preserved organ function.

Survival and risk factors of adenosquamous carcinoma in the oral and maxillofacial region: a population-based study

BACKGROUND

The features and prognosis of adenosquamous carcinoma (ASC) in oral and maxillofacial region have not thoroughly investigated, the purpose of this study is to describe clinicopathologic characteristics, treatment, and prognostic factors of this disease.

METHODS

The data of 276 patients diagnosed with ASC in oral and maxillofacial region between 1975 and 2016 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. The prognostic factors influencing overall survival (OS) and disease-specific survival (DSS) were identified by the Kaplan-Meier analysis and Cox regression analysis. The nomograms for OS and DSS were constructed to predict the prognosis of these patients.

RESULTS

Of 276 included patients, 62.7% were male and 37.3% were female, with an average age at diagnosis of 63.5 years. The most common primary site is oral cavity (170/276), followed by salivary gland (106/276). The 3-, and 5-year OS of patients with ASC in oral and maxillofacial region were 49.0% and 38.9%, while the 3-, and 5-year DSS were 67.7%, and 60.4%, respectively. Patients who underwent surgery had longer OS (mOS: 58 m vs. 8 m) and DSS (mDSS: 193 m vs. 18 m) than those who did not. Age, AJCC-T/N/M category as well as surgery were independently associated with OS. Advanced T stage, distant metastases, and surgery were independent factors for DSS. The prognostic nomograms for OS and DSS were constructed, and the C-indexes were 0.71 (95% CI 0.66-0.76) and 0.76 (95% CI 0.67-0.85), respectively.

CONCLUSION

Surgery was the favorable prognostic factor for both OS and DSS among patients with ASC in oral and maxillofacial region.

TERT Promoter Mutations Are Enriched in Oral Cavity Cancers and Associated With Locoregional Recurrence

Telomerase reverse transcriptase (TERT) promoter mutations are prognostic in many cancers and have been observed in human papillomavirus (HPV)-negative head and neck squamous cell carcinomas (HNSCCs). However, the role of TERT promoter mutations in HPV-negative HNSCCs remains poorly understood in these cancers, which have increased risk for locoregional failure (LRF).

PATIENTS AND METHODS

We retrospectively identified patients who were diagnosed with HNSCC between July 1, 2004, and October 12, 2017, at Memorial Sloan Kettering Cancer Center and whose tumors underwent next-generation sequencing using the MSK-IMPACT panel. Patients with HPV-positive oropharyngeal squamous cell carcinoma (SCC) were excluded. Cumulative incidence of LRF, patterns of failure, and overall survival were measured.

RESULTS

We identified 117 patients with SCC of the oral cavity (OSCC), larynx, hypopharynx, or HPV-negative oropharynx whose tumors underwent next-generation sequencing. Sequencing was performed on 95 tumors that were obtained after recurrence and 22 that were obtained before recurrence. TERT promoter mutations were enriched in OSCC compared with laryngopharyngeal cancers (81.1% v 7.0%; P < .001), which was the largest genetic difference between these anatomic disease subsites. TERT promoter mutations were associated with LRF in OSCCs (Gray's test, P < .001) and in the overall cohort (Gray's test, P < .001). On multivariate analysis, TERT promoter mutations were associated with an increased risk for LRF (subdistribution hazard ratio, 2.82; 95% CI, 1.47 to 5.42; P = .0019), independent of oral cavity primary site and TP53 mutation status.

CONCLUSION

TERT promoter status is associated with the cumulative incidence of LRF and patterns of failure. TERT promoter mutations may define a subset of OSCCs with unique pathogenesis that is associated with an increased risk of LRF. Validation in prospective cohorts is warranted.

Progressive muscle loss is an independent predictor for survival in locally advanced oral cavity cancer: A longitudinal study

BACKGROUND AND PURPOSE

To investigate the association between progressive muscle loss and survival outcomes of patients with advanced-stage oral squamous cell carcinoma (OSCC) undergoing surgery and adjuvant (chemo)radiotherapy.

METHODS

We analyzed the computed tomography (CT) scans of 155 patients with stage III-IVB OSCC at baseline, at simulation CT for radiotherapy, and at 3- and 9-months post-treatment. Skeletal muscle index (SMI) was measured using CT at the C3 vertebral level. The predictors of overall survival (OS) and recurrence-free survival (RFS) were evaluated using Cox regression models.

RESULTS

The median follow-up period was 75.0 months. Fifty-one patients (32.9%) developed recurrence, with the median time from the fourth CT to recurrence being 9.1 months. The SMI progressively decreased from baseline to simulation CT by 1.1% (p = 0.006), to 3 months post-treatment by 5.1% (p < 0.001), and to 9 months post-treatment by 15.6% (p < 0.001) in patients developing recurrence. Patients without recurrence lost SMI at the simulation CT by 0.7% (p = 0.001) and at 3 months post-treatment by 2.1% (p < 0.001); their SMI returned to the baseline level at 9 months post-treatment. SMI changes were weakly correlated with changes in body mass index (BMI) (Spearman ρ, 0.13; p = 0.11). In multivariate analysis, SMI changes (per 5% decrease) were independently associated with significantly worse OS (hazard ratio: 1.88, 95% confidence interval: 1.58-2.23; p < 0.001) and RFS (hazard ratio: 1.89, 95% confidence interval: 1.61-2.20; p < 0.001).

CONCLUSION

Progressive muscle loss was independently associated with worse survival outcomes in patients with stage III-IVB OSCC. Muscle loss might not be detected by changes in BMI.

Pathological responses to low-dose irradiation and Pepleomycin in Oral squamous cell carcinoma are predictive of Locoregional control

BACKGROUND

The prognosis of advanced oral cancer remains dismal. While multimodal therapy is beneficial, maintaining the quality of life of long-term survivors is important. Therefore, risk-adapted treatment regimens need to be designed. We herein investigated whether pathological responses in oral cancer patients treated with preoperative chemoradiotherapy predict locoregional recurrence.

METHODS

We retrospectively reviewed the data of 51 oral cancer patients who received preoperative radiotherapy and concurrent pepleomycin, followed by curative surgery at our institution between January 2009 and June 2018. Each patient received preoperative external beam irradiation to the primary tumor and lymphatics (2 Gy per day for approximately 3 weeks) concurrent with pepleomycin (2.5 mg/day). Surgery was performed approximately 3-4 weeks after the completion of preoperative chemoradiotherapy. Pathological responses were defined based on the grading system of Oboshi and Shimosato.

RESULTS

Eight, 22, 16, and 5 patients had Oboshi and Shimosato grades 2a, 2b, 3, and 4, respectively. Favorable pathological responses (grades 3 and 4) were observed in 41.2% of patients (21 out of 51 patients). The pathological response and number of pathological lymph node metastases were identified as significant prognostic factors for locoregional control in the univariate analysis. Three-year locoregional control rates were 100 and 56.6% in patients with favorable and unfavorable pathological responses, respectively.

CONCLUSIONS

The present study demonstrated that pathological tumor responses to preoperative chemoradiotherapy are a useful predictive factor for locoregional control.

Sarcopenia and Systemic Inflammation Synergistically Impact Survival in Oral Cavity Cancer

OBJECTIVES

Sarcopenia and systemic inflammation can affect survival of advanced-stage oral squamous cell carcinoma (OSCC) patients; however, their reciprocal associations with survival outcomes are yet to be investigated.

STUDY DESIGN

Retrospective review at a tertiary cancer center.

METHODS

Patients with stage III-IVB OSCC that underwent surgery and (chemo)radiotherapy at our institution between 2010 and 2015 were reviewed. Skeletal muscle index (SMI) was assessed using computed tomography scans at the C3 vertebra. Sarcopenia was defined at the lowest sex-specific tertile for SMI. Systemic inflammation was estimated using the modified Glasgow prognostic score (mGPS), which ranges from 0 to 2 based on serum C-reactive protein and albumin levels. The predictors of overall survival (OS) were evaluated using Cox regression models.

RESULTS

A total of 174 patients were included in the study. The cut-off values for sarcopenia were set at SMI <52.4 cm² /m² (men) and < 36.2 cm² /m² (women) corresponding to the lowest sex-specific tertile. An mGPS 1-2 was independently associated with sarcopenia (odds ratio: 2.05; 95% confidence interval: 1.06-3.97; P = .03). On multivariate analysis for OS, sarcopenia and mGPS 1-2 independently predicted OS (hazard ratio: 2.12; 95% confidence interval: 1.17-3.85; P = .01 and hazard ratio: 7.85; 95% confidence interval: 3.7-16.65; P < .001, respectively). Patients with both sarcopenia and mGPS 1-2 (vs. neither) had worse OS (hazard ratio: 16.80; 95% confidence interval: 6.01-46.99; P < .001).

CONCLUSIONS

Sarcopenia and systemic inflammation may exert a negative synergistic prognostic impact in advanced-stage OSCC patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1530-E1538, 2021.

The role of adjuvant (chemo-)radiotherapy in oral cancers in the contemporary era

Squamous cell carcinoma of oral cavity (OSCC) is predominantly managed with surgery. Post-operative radiotherapy (PORT) and chemoradiotherapy (POCRT) enhance disease control in OSCC patients with adverse anatomic and pathologic primary and nodal features. Knowledge about disease behavior, surgery and radiotherapy advances, and the emergence of new systemic agents prompt refinement of PORT volumes and POCRT regimens. Traditional and emerging prognostic models that include adverse histopathological features underpin such approaches. This review summarizes research over recent decades with emphasis on the 2015 to Feb 2019 period describing: (1) Indications for PORT and/or POCRT, addressing surgical "margin status" including the definition of a "clear" margin to permit withholding PORT/POCRT; these concepts include characterizing the specimen yielding these measurements, the optimal time point to assess these findings, and the putative value of a "revised margin" performed during the same operative procedure, (2) Emerging prognostic factors including nodal burden (total number of involved lymph nodes) and perineural invasion, (3) PORT volume design, dose/fractionation and optimal surgery-to-PORT interval, (4) Chemotherapy dose, schedule, and agents, and (5) On-going clinical trials involving systemic agents and combinations of chemotherapy with immunotherapy.

Predictors of Early Recurrence Prior to Planned Postoperative Radiation Therapy for Oral Cavity Squamous Cell Carcinoma and Outcomes Following Salvage Intensified Radiation Therapy

PURPOSE

To determine predictors and outcomes for oral squamous cell carcinoma (OSCC) patients who had early recurrence before commencement of postoperative radiation therapy (PORT).

METHODS

Retrospective review was performed for patients with OSCC treated with PORT between 2003 and 2015 after curative-intent surgery. Early recurrence was defined as tumor recurrence after surgical resection and before initiating planned PORT. Patients were classified into the following groups: (1) adjuvant PORT group (no early recurrence), (2) salvage PORT group (locoregional early recurrence), and (3) palliative PORT group (locoregional and distant early recurrence). For the whole cohort, multivariable analysis (MVA) was applied to identify predictors of early recurrence. In the salvage group, the post-PORT recurrence-free rate was estimated, and MVA was used to identify predictors of recurrence-free rate, disease-free survival, and overall survival (OS).

RESULTS

Six hundred and one patients were identified, of whom 513 (85%) were treated with adjuvant PORT. Eighty-eight patients (15%) had early recurrence (28 of 88; 32% were biopsy proven) before PORT (70 in the salvage group and 18 in the palliative group). On MVA, oral tongue subsite, microscopic positive resection margin, pT3-4, and pN2-3 were associated with the development of early recurrence (P < .05 for all). The 3-year OS rates for patients with OSCC treated with adjuvant and salvage PORT were 71% (95% confidence interval [CI], 67%-75%) and 41% (95% CI, 30%-56%), respectively (P < .001; median follow-up was 3.4 and 2.9 years, respectively). After salvage PORT, the 3-year recurrence-free rate was 36% (95% CI, 23%-47%). On MVA, extranodal extension and volume of early recurrent gross disease were associated with poor recurrence-free rate, disease-free survival, and OS (P < .05 for all).

CONCLUSION

Early recurrences are not uncommon in patients with high-risk features, Further study is required to improve prediction and outcomes of this very high-risk group.