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

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.

Depth of Invasion as an Independent Indication for Postoperative Radiation Therapy in Oral Tongue Squamous Cell Carcinoma

PURPOSE

Over the years, scientific literature has highlighted the importance of depth of invasion (DOI) in managing oral squamous cancers, particularly its association with nodal metastasis. However, determining the role of DOI in postoperative radiation therapy (PORT) remains a clinical challenge. This study aimed to evaluate PORT with a DOI cutoff of 5 mm.

METHODS AND MATERIALS

Patients diagnosed with oral tongue squamous cell carcinoma (and restaged as per American Joint Cancer Committee 2018) with pT1,2 and pN0 were selected. Baseline characteristics were collected and divided into 2 groups using a DOI cutoff of ≤5 versus >5 mm. The study endpoints were overall survival (OS), disease-free survival (DFS), and locoregional control (LRC).

RESULTS

The study included 255 patients, with comparable baseline characteristics between groups. A significantly higher incidence of perineural invasion (PNI) was noted among patients receiving PORT in both cohorts. After a median follow-up of 37 months, no statistically significant differences were observed in median OS, DFS, or LRC in patients with a DOI ≤5 mm, irrespective of PORT. Conversely, for patients with a DOI >5 mm, the median OS was 48 months for those not receiving PORT, whereas it was not reached for those receiving PORT (P = .03). Furthermore, patients with a DOI >5 mm who received PORT showed significantly improved median DFS and LRC compared with those who did not receive PORT (36 months vs not reached, P = .001 for DFS; 37 months vs not reached, P < .001 for LRC]. In penalized multivariable Cox regression analysis, PORT emerged as the independent prognostic factor for DFS (hazard ratio [HR], 0.50; 95% CI, 0.31-0.82; P = .01) and LRC (HR, 0.34; 95% CI, 0.20-0.60; P < .001) with statistically insignificant OS benefit (HR, 0.58; 95% CI, 0.33-1.02; P = .06) in patients with a DOI >5 mm.

CONCLUSIONS

Despite a significantly higher distribution of PNI in patients with DOI >5 mm, the use of PORT significantly improved median OS, DFS, and LRC in this retrospective analysis. The penalized Cox proportional hazard model also suggested that the use of PORT in patients with DOI >5 mm increases survival endpoints irrespective of PNI and lymphovascular invasion positivity, especially for DFS and LRC.

Adjuvant therapy for intermediate risk factors in oral cancer: Can we reach a consensus?

Oral carcinoma is a common disease that poses challenges in treatment management, especially for advanced cases. Adjuvant therapies, such as radiation and chemoradiation therapy, are typically used for advanced oral cancer patients. However, there is uncertainty regarding the use of adjuvant therapy for early-stage patients with certain soft histological parameters. The UICC manual of clinical oncology suggests that adjuvant therapy for such parameters is desirable but not essential. These parameters include perineural invasion, lymphovascular invasion, single nodal positivity, and patterns of invasion, which complicate the decision-making process for including adjuvant therapy. This review aims to provide evidence-based literature for effectively managing this patient group and developing treatment protocols based on current evidence.

Improved survival of locoregional-advanced larynx and hypopharynx cancer patients treated according to the DeLOS-II protocol

Introduction

Larynx organ preservation (LOP) in locoregional-advanced laryngeal and hypopharyngeal squamous cell carcinoma (LA-LHSCC) being only R0-resectable (clear margins > 5 mm) by total laryngectomy (TL) is desirable. Based on tumor-specific survival (TSS) and overall survival (OS) data from the RTOG 91-11 trial and meta-analyses of randomized clinical trials (RCTs), cisplatin-based concurrent radiochemotherapy (CRT) is discussed being superior to cisplatin-based induction chemotherapy followed by radiotherapy (IC+RT) and TL followed by postoperative RT (TL+PORT) or radiochemotherapy (TL+PORCT). Outside of RCTs, T4 LHSCC treated with TL+PORCT demonstrated improved OS and TSS compared to CRT alone; comparisons with docetaxel plus cisplatin (TP)-based IC+RT are unpublished. Head-to-head comparisons in RCTs of these four alternatives are missing.

Materials and methods

We utilized monocentric registry data to compare the outcome in the LOP trial DeLOS-II (NCT00508664) and propensity score (PS)-matched LHSCC patients. DeLOS-II utilized endoscopic tumor staging after one cycle of TP-based IC for selecting TL+R(C)T for non-responders versus IC+RT for responders. Main risk factors for survival (localization hypopharynx, T4, N+, tobacco smoking >30 pack years, alcohol consumption >60 g/day, age, sex) were used to calculate the individual PS for each DeLOS-II patient and 330 LHSCC patients suitable for DeLOS-II according to eligibility criteria in Leipzig by CRT (78), TL+PORT (148), and TL+PORCT (104). We performed PS matching with caliper width 0.2.

Results

The 52 DeLOS-II patients (whole intent-to-treat cohort) and three PS-matched cohorts (52 LHSCC patients each) had equal distribution regarding risk factors including Charlson comorbidity score (CS; all p > 0.05) but differed in outcome. During 12,498.6 months of follow-up, 162 deaths (36/41/43/42 in DeLOS-II/TL+PORCT/TL+PORT/CRT, p = 0.356) occurred; DeLOS-II patients had superior OS and TSS. Compared to DeLOS-II, the HR (95% CI) observed in TL+PORCT, TL+PORT, and CRT for OS and TSS were 1.49 (0.92-2.43), 1.49 (1.15-3.18), and 1.81 (1.11-2.96) for OS; and 2.07 (0.944-4.58), 3.02 (1.32-6.89), and 3.40 (1.58-7.31) for TSS.

Conclusion

In addition potential LOP, LA-LHSCC suitable for LOP according the DeLOS-II protocol may achieve improved survival.

Surgical margins in head and neck squamous cell carcinoma: A narrative review

Head and neck squamous cell carcinoma (HNSCC), a prevalent and frequently recurring malignancy, often necessitates surgical intervention. The surgical margin (SM) plays a pivotal role in determining the postoperative treatment strategy and prognostic evaluation of HNSCC. Nonetheless, the process of clinical appraisal and assessment of the SMs remains a complex and indeterminate endeavor, thereby leading to potential difficulties for surgeons in defining the extent of resection. In this regard, we undertake a comprehensive review of the suggested surgical distance in varying circumstances, diverse methods of margin evaluation, and the delicate balance that must be maintained between tissue resection and preservation in head and neck surgical procedures. This review is intended to provide surgeons with pragmatic guidance in selecting the most suitable resection techniques, and in improving patients' quality of life by achieving optimal functional and aesthetic restoration.

Reconstructive flap surgery in head and neck cancer patients: an interdisciplinary view of the challenges encountered by radiation oncologists in postoperative radiotherapy

Background

Major advances have been made in reconstructive surgery in the last decades to reduce morbidity in head and neck cancer. Flaps are now present in 80% of patients with oral cavity cancer to cover anatomic, functional, and cosmetic needs. However, gaps in interdisciplinary innovation transfer from surgery to postoperative radiotherapy (poRT) remain challenging. We aimed to provide an interdisciplinary view of the challenges encountered by radiation oncologists in planning head and neck postoperative radiotherapy.

Methods

A systematic and critical review was conducted to address areas of optimization in surgery and radiology that may be relevant to poRT.

Results

Despite extensive surgical literature on flap techniques and salvage surgery, 13 retrospective series were identified, where flap outcomes were indirectly compared between surgery alone or poRT. These low-evidence studies suggest that radiotherapy accelerates flap atrophy, fibrosis, and osteoradionecrosis and deteriorates functional outcomes. Preliminary evidence suggests that tumor spread occurs at the flap-tissue junction rather than in the flaps. One prospective 15-patient study showed 31.3% vs. 39.2% flap volume reduction without or with poRT. In an international consensus, experts recognized the needs for optimized flap-sparing poRT against flap-related functional deterioration and bone damage. CT, MRI, and PET-CT modalities show potential for the delineation of the junction area between native tissues and flap for flap segmentation and to characterize flap-specific changes quantitatively and correlate them with patterns of relapse or complications.

Conclusion

Flap management in poRT is insufficiently documented, but poRT seems to damage flaps. Current gaps in knowledge underscore the need for prospective flap assessment and interdisciplinary trials investigating flap morbidity minimization by flap-sparing poRT planning.

Outcome of Adjuvant Radiotherapy and Adjuvant Chemoradiation for Oral Cancers with Close Margins of Resection

Oral cancers comprise 50% of all head and neck malignancies in India which can be attributed to tobacco chewing. Advanced oral cancers are managed with surgery followed by adjuvant radiotherapy or adjuvant chemoradiation. There is paucity of studies regarding need for adjuvant treatment in oral cancers with close margins i.e. ≤ 0.5 cm after formalin fixation. This study aims at documenting the oncological outcome with regards to loco-regional control, disease-free survival, overall survival and complications of adjuvant radiotherapy and adjuvant chemoradiation in operated oral cancer patients having close margins of resection. In this Retrospective cohort study, 163 patients with stage T1-T4 oral cancers operated between 2015 and 2019 who have fulfilled the inclusion and exclusion criteria, received adjuvant treatment and could be followed up for at least one year were included. At the end of 45 months, the overall survival was 74.7% and disease specific survival was 82.7%. Among the 7 patients who defaulted radiotherapy, 4 patients succumbed to the disease. Complications were bone marrow depression (2 patients), dysphagia (17) and Trismus (1). Adjuvant radiotherapy should be given in oral cancer patients with close margins of resection since it improves the oncological outcome and disease specific survival and the benefit often outweighs the risk.

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.

Temporal and spatial patterns of recurrence in oral squamous cell carcinoma, a single-center retrospective cohort study in China

BACKGROUND

Oral squamous cell carcinoma (OSCC) is an invasive cancer with a high recurrence rate. Most clinical studies have focused on the prognosis of patients with OSCC, few have investigated the causes and interventions that affect the recurrence. Our study is to explore the temporal and spatial patterns of recurrence in OSCC.

METHODS

234 OSCC patients with recurrence in our hospital and 64 OSCC patients with recurrence in TCGA database were included in the study. Log-rank test and Multivariate Cox Regression Analysis were used to determine whether there was a significant difference between each selected demographic or clinical factors and recurrence. The Kaplan-Meier method was used to plot survival curves for each recurrence interval.

RESULTS

The proportion of OSCC patients in clinical and TCGA with early recurrence was 93.6% and 84.4%, respectively. Age, chewing betel nut, previous radiotherapy, histopathological grading of the primary tumor (poorly differentiated), lymph node metastasis and postoperative infection were found to be associated with the timing of recurrence. It was found that tongue cancer has more regional recurrences, while buccal cancer is mostly local and loco-regional recurrences. The earlier the recurrence, the greater the possibility of local-regional recurrence and the worse the prognosis.

CONCLUSION

Most of recurrent OSCC patients present early recurrence (< 18 months) with poor prognosis, and early recurrence is more prone to local recurrence. Moreover, recurrence site is related with primary site of OSCC.

Adding Concomitant Chemotherapy to Postoperative Radiotherapy in Oral Cavity Carcinoma with Minor Risk Factors: Systematic Review of the Literature and Meta-Analysis

When presenting with major pathological risk factors, adjuvant radio-chemotherapy for oral cavity cancers (OCC) is recommended, but the addition of chemotherapy to radiotherapy (POCRT) when only minor pathological risk factors are present is controversial. A systematic review following the PICO-PRISMA methodology (PROSPERO registration ID: CRD42021267498) was conducted using the PubMed, Embase, and Cochrane libraries. Studies assessing outcomes of POCRT in patients with solely minor risk factors (perineural invasion or lymph vascular invasion; pN1 single; DOI ≥ 5 mm; close margin < 2−5 mm; node-positive level IV or V; pT3 or pT4; multiple lymph nodes without ENE) were evaluated. A meta-analysis technique with a single-arm study was performed. Radiotherapy was combined with chemotherapy in all studies. One study only included patients treated with POCRT. In the other 12 studies, patients were treated with only PORT (12,883 patients) and with POCRT (10,663 patients). Among the patients treated with POCRT, the pooled 3 year OS rate was 72.9% (95%CI: 65.5−79.2%); the pooled 3 year DFS was 70.9% (95%CI: 48.8−86.2%); and the pooled LRFS was 69.8% (95%CI: 46.1−86.1%). Results are in favor of POCRT in terms of OS but not significant for DFS and LRFS, probably due to the heterogeneity of the included studies and a combination of different prognostic factors.

Prognostic impact of perineural invasion in oral cancer: a systematic review

Introduction

Numerous studies have evaluated the prognostic significance of perineural invasion (PNI) in oral cancer; however, the results are inconclusive.

Purpose

To identify the prognostic value of PNI in oral cancer through a metanalysis.

Methods

A literature review was carried out, searching the MedLine databases via Pubmed, Scielo, Lilacs, Cochrane and Websco.

Results

A total of 56 studies were included. The results indicate that PNI in oral cancer has an incidence of 28% (95% confidence interval (CI) 24-31%); 5-year survival with relative risk (RR) 0.67 (0.59-0.75); 5-year disease-free survival RR 0.71 (0.68-0.75); locoregional recurrence with RR 2.09 (1.86-2.35).

Conclusions

PNI is a negative prognostic factor in oral cancer.

Improved prognostic stratification of patients with pN3b oral cavity cancer based on maximum standardized uptake value of metastatic nodes, lymph node ratio, and level of cervical nodal metastases

OBJECTIVES

The prognosis of pN3b oral cavity squamous cell carcinoma (OCSCC) remains heterogeneous. We sought to improve the prognostic stratification of patients with pN3b OCSCC through a combined analysis of FDG-PET parameters and clinicopathological risk factors (RFs).

METHODS

From 2001 to 2019, complete data on maximum standardized uptake values derived from FDG-PET of neck metastatic nodes (SUV-nodal-max) and clinicopathological RFs were available for 257 patients with pN3b disease.

RESULTS

Using the 5-year disease-free survival (DFS) as the outcome of interest, the optimal cutoff points for SUV-nodal-max and lymph node ratio (LNR) were 15.9 and 0.17, respectively. The 5-year DFS rates/(number of cases) for patients with pN3b disease were as follows: SUV-nodal-max < 15.9 versus ≥ 15.9, 49%(226)/21%(31), p = 0.000003; LNR < 0.17 versus ≥ 0.17, 49%(230)/17%(27), p = 0.000117; absence versus presence of neck level IV/V metastases, 49%(230)/15%(27), p = 0.000004. Multivariable analyses revealed that SUV-nodal-max ≥ 15.9, LNR ≥ 0.17, and level IV/V metastases were independent prognosticators for 5-year distant metastases (DM), DFS, disease-specific survival (DSS), and overall survival (OS) rates. Based on these variables, we devised a scoring system that identified three distinct prognostic subgroups at low (score 0, n = 190), intermediate (score 1, n = 51), and high (scores 2-3, n = 16) risk. The 5-year rates of patients with pN3b disease deemed to be at low/intermediate/high risk were as follows: DM, 31%/52%/89%; DFS, 54%/26%/0%; DSS, 59%/36%/8%; OS, 42%/31%/6%, respectively; all p < 0.001.

CONCLUSIONS

A scoring system based on SUV-nodal-max, LNR, and level IV/V metastases improves the prognostic stratification of OCSCC patients with pN3b disease.

cN+pN0 disease does not portend a less favorable prognosis compared with cN0pN0 in patients with resected oral cavity squamous cell carcinoma

Background

We compared the clinical outcomes of patients with oral cavity squamous cell carcinoma (OCSCC) with cN+pN0 versus cN0pN0 disease.

Methods

A total of 1309 OCSCC patients with pN0 disease were included. Of them, 1019 and 290 cases had cN0pN0 and cN+pN0 disease, respectively. For comparison purposes, we also examined 799 patients with pN+disease (cN0pN+/cN+pN+, n = 239/560). Subgroup analysis was performed in a propensity score‐matched cohort with cN0pN0 and cN+pN0 disease (n = 284 each).

Results

Compared with cN0pN0, patients with cN+pN0 had a higher prevalence of the following variables: betel chewing, pT3−4, depth ≥10 mm, perineural invasion, and treatment with surgery and adjuvant therapy. The prognosis of patients with cN+pN0 (mean: 52 nodes) and cN0pN0 (mean: 39 nodes) disease was similar both in the original cohort and after propensity score matching. However, the 5‐year outcomes were more favorable for cN+pN0/cN0pN0 compared with cN0pN+/cN+pN+ (local control, 88%/88%/83%/81%; neck control, 94%/93%/82%/76%; distant metastases, 4%/3%/13%/31%; disease‐free survival, 84%/83%/68%/52%; disease‐specific survival, 92%/92%/77%/57%; overall survival, 81%/82%/59%/42%; all p values <0.001; cN+pN0 versus cN0pN0, all p values >0.05). cN+pN0 disease (vs. cN0pN0) was not significantly associated with local control, neck control, distant metastases, and survivals either in univariable or multivariable analyses.

Conclusions

Despite a higher risk factor burden, the prognosis of patients with cN+pN0 disease did not differ from that of cases with cN0pN0. The higher nodal yield and the more frequent use of adjuvant therapy in cN+pN0 disease may explain the lack of significant differences in terms of neck control compared with cN0pN0 disease.

Poor tumor differentiation is an independent adverse prognostic variable in patients with locally advanced oral cavity cancer--Comparison with pathological risk factors according to the NCCN guidelines

Methods

We sought to compare the prognostic impact of tumor differentiation with respect to adverse risk factors (RFs) identified by the National Comprehensive Cancer Network (NCCN) guidelines––including extranodal extension (ENE), positive/close margins, perineural invasion, lymphatic invasion, and vascular invasion––in patients with locally advanced oral cavity squamous cell carcinoma (OCSCC).

Results

Between 1996 and 2018, 1179 consecutive patients with first primary pT3–4 OCSCC were included. A three‐level grading system was adopted––in which the final classification was assigned according to the most prevalent tumor grade. We identified 382/669/128 patients with well/moderately/poorly differentiated tumors, respectively. Compared with well/moderately differentiated tumors, poorly differentiated OCSCC had a higher prevalence of the following variables: female sex (4%/6%/11%), ENE, (14%/36%/61%), positive margins (0.5%/2%/4%), close margins (10%/14%/22%), perineural invasion (22%/50%/63%), lymphatic invasion (2%/9%/17%), vascular invasion (1%/4%/10%), and adjuvant therapy (64%/80%/87%). The 5‐year rates of patients with well/moderately/poorly differentiated OCSCC were as follows: local control (LC, 85%/82%/84%, p = 0.439), neck control (NC, 91%/83%/70%, p < 0.001), distant metastases (DM, 6%/18%/40%, p < 0.001), disease‐free survival (DFS, 78%/63%/46%, p < 0.001), disease‐specific survival (DSS, 85%/71%/49%, p < 0.001), and overall survival (OS, 68%/55%/39%, p < 0.001). Multivariable analysis identified the following variables as independent prognosticators for 5‐year outcomes: ENE (LC/NC/DM/DFS/DSS/OS), poorly differentiated tumors (NC/DM/DFS/DSS/OS), positive margins (LC/DFS), lymphatic invasion (DFS/DSS/OS), perineural invasion (DM), and age ≥65 years (OS).

Conclusions

In addition to ENE, poor tumor differentiation was identified as the second most relevant adverse RF for patients with pT3–4 OCSCC. We suggest that the NCCN guidelines should include poor tumor differentiation as an adverse RF to refine and tailor clinical management.

Prognostic stratification of patients with AJCC 2018 pStage IVB oral cavity cancer: Should pT4b and pN3 disease be reclassified?

OBJECTIVES

pStage IVB oral cavity squamous cell carcinoma (OCSCC) is defined as either pT4b or pN3 disease. We sought to devise an improved prognostic stratification of this patient group.

METHODS

Between December 2003 and January 2018, we retrospectively reviewed the clinical records of 1331 consecutive patients with OCSCC who received tumor excision and neck dissection. The number of patients with pT4a/pT4b, pT1N3b/pT2N3b/pT3N3b/pT4N3b, and pStage IVA/IVB was 370/83, 3/49/42/142, and 332/295, respectively.

RESULTS

The 5-year rates of disease-free survival (DFS) and disease-specific survival (DSS) for patients with pT4a/pT4b disease were 64%/63% (p = 0.973) and 72%/69% (p = 0.672), respectively. The 5-year DFS and DSS rates for patients with pT1N3b/pT2N3b/pT3N3b/pT4N3b disease were 67%/65%/40%/42% (p < 0.001; pT1-2N3b versus pT3-4N3b, p = 0.002) and 100%/68%/45%/49% (p < 0.001; pT1-2N3b versus pT3-4N3b, p = 0.002), respectively. We devised a new definition for pStage IV by considering patients with pT4bN0-2 and pT1-2N3b diseases as pStage-IVA. The number of patients with pStage IVA/IVB (pT3-4N3b) was 443/184. The 5-year rates of AJCC pStage IVA/IVB and the newly proposed pStage IVA/IVB (pT3-4N3b) were as follows: DFS, 74%/52% and 72%/42%; DSS, 83%/58% and 81%/47%; respectively, all p value < 0.001.

CONCLUSIONS

The clinical outcomes of pT4b and pT4a OCSCC are similar. However, patients with pT3-4N3b disease have a less favorable 5-year prognosis compared with cases with pT1-2N3b. In light of the unfavorable outcomes, pT3-4N3b disease should continue to be classified as pStage IVB. Conversely, pT4bN0-2 and pT1-2N3b diseases portend a less adverse prognosis and should therefore be downstaged to pStage IVA.

Excision repair cross-complementing group 2 upregulation is a potential predictive biomarker for oral squamous cell carcinoma recurrence

Oral cancer is the fourth most common type of cancer among males in Taiwan, and the prognosis for patients with advanced-stage oral squamous cell carcinoma (OSCC) remains poor. The present study investigated the prognostic value of three DNA repair genes, namely excision repair cross-complementing group 1 (ERCC1), ERCC2 and X-ray repair cross-complementing group 1 (XRCC1) in OSCC. The protein expression levels of XRCC1, ERCC1 and ERCC2 in oral cell lines were analyzed via western blotting and immunohistochemistry using samples from 98 patients with biopsy-proven OSCC, while the χ2 test was used to analyze the clinicopathological association. Kaplan-Meier estimates were used to determine the prognostic value of XRCC1, ERCC1 and ERCC2 for overall survival, and the log-rank test was used to evaluate the significance of differences. Multivariate analysis revealed a positive association between ERCC2 expression and OSCC recurrence (19.64-fold; 95% CI, 5.00-77.1; P<0.001). In addition, the high protein expression levels of XRCC1, ERCC1 and ERCC2 were associated with poor disease-free and overall survival rates. Therefore, the present study suggested that high ERCC2 expression may be a risk factor for OSCC recurrence.

Postoperative radiotherapy is associated with improved overall survival for alveolar ridge squamous cell carcinoma with adverse pathologic features

BACKGROUND

Alveolar ridge squamous cell carcinoma (ARSCC) is poorly represented in randomized trials.

METHODS

Adults in the National Cancer Database diagnosed with ARSCC between 2010 and 2014 who should be considered for postoperative radiotherapy (PORT) based on National Comprehensive Cancer Network (NCCN)-defined risk factors were identified.

RESULTS

Eight hundred forty-five (58%) of 1457 patients meeting the inclusion criteria received PORT. PORT was associated with improved overall survival (OS) on unadjusted (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.70-0.98, P = .02) and multivariable (HR 0.78, 95% CI 0.64-0.94, P = .002) analyses. PORT was associated with significantly improved 5-year OS for patients with 1 (68% vs 58%, P < .001), 2 (52% vs 31%, P < .001), and ≥3 (38% vs 24%, P < .001) NCCN-defined risk factors. Prognostic variables significantly associated with worse OS on multivariable analysis included advanced age, primary tumor size ≥3 cm, high grade, positive margin(s), stage N2-3, level IV/V nodal metastasis, and extranodal extension.

CONCLUSION

PORT for resected ARSCC with adverse pathologic features is associated with significantly improved OS.

A retrospective investigation of minor risk factors as prognostic predictors and treatment indications in oral squamous cell carcinoma

Abstract

Background/purpose

The clinical significance of minor risk factors remins uncertain in oral squamous cell carcinoma (OSCC) patients. The purpose of this study was to investigate the clinical impact of minor risk factors in OSCC patients.

Materials and methods

The cases of OSCC patients that underwent surgery were retrospectively analyzed. Patients with major risk factors for recurrence, such as positive surgical margins or extracapsular spread, were excluded. The impact of possible minor risk factors on treatment outcomes was analyzed. One hundred and seventy-five patients with primary OSCC that underwent surgery were included in this study.

Results

The 5-year overall survival (OS), cancer-specific survival (CSS), and relapse-free survival (RFS) rates were 81.2%, 91.0%, and 72.4%, respectively. In multivariate analyses, RFS exhibited a significant association with the pattern of invasion (grade 4 vs. grades 1–3: hazard ratio: 3.096, 95% confidence interval: 1.367–6.884, p < 0.01), OS exhibited a tendency towards associations with the pattern of invasion and perineural invasion, and CSS displayed a tendency towards an association with perineural invasion. The prognosis of the patients with ≥2 minor risk factors was significantly worse than that of the patients with 0 or 1 minor risk factor(s) (OS: 91.6% vs. 64.5%, respectively, p < 0.01; CSS: 98.9% vs. 78.9%, respectively, p < 0.001; and RFS: 81.2% vs. 58.5%, respectively p < 0.05).

Conclusion

Grade 4 invasion and perineural invasion might be significant minor risk factors in OSCC patients. The presence of ≥2 minor risk factors might be a predictor of a poor prognosis in OSCC patients.

Influence of Hyperglycemia on Treatment Outcomes of Oral Cavity Squamous Cell Carcinoma

PURPOSE

The present study investigated the association between perioperative hyperglycemia and the treatment and survival outcomes of patients with oral cavity squamous cell carcinoma (OSCC).

PATIENTS AND METHODS

From 2004 to 2016, 385 patients with OSCC were enrolled and stratified into normoglycemic (<180 mg/dL) and hyperglycemic (≥180 mg/dL) groups. The clinicopathologic characteristics and treatment outcomes of OSCC were subsequently analyzed.

RESULTS

Of the 385 patients, 61 (15.8%) were in the hyperglycemic group. Hyperglycemia was significantly associated with pT stage, pN stage, overall pathologic stage, extranodal extension, albumin level, and tumor depth (P = .004, P = .042, P = .008, P = .001, P = .004, and P = .011, respectively). Patients with hyperglycemia also required a longer hospital stay (P = .003). The 5-year overall survival and disease-specific survival were poorer in the hyperglycemic group than in the normoglycemic group (P = .001 and P = .002, respectively). Multivariate analysis revealed that hyperglycemia is a significant adverse prognostic indicator for OSCC (hazard ratio, 1.709; 95% confidence interval, 1.003 to 2.912; P = .049).

CONCLUSIONS

Hyperglycemia is associated with more advanced disease and poorer survival rates in patients with OSCC. It correlates with adverse clinicopathologic characteristics and longer hospital stay. Screening for hyperglycemia and maintenance of normal glycemic status during the treatment course is imperative in the treatment of OSCC.

Time patterns of recurrence and second primary tumors in a large cohort of patients treated for oral cavity cancer

INTRODUCTION

Routine follow-up after curative treatment of patients with oral squamous cell carcinoma (OSCC) is common practice considering the high risk of second primaries and recurrences (ie second events). Current guidelines advocate a follow-up period of at least 5 years. The recommendations are not evidence-based and benefits are unclear. This is even more so for follow-up after a second event. To facilitate the development of an evidence- and personalized follow-up program for OSCC, we investigated the course of time until the second and subsequent events and studied the risk factors related to these events.

MATERIALS AND METHODS

We retrospectively studied 594 OSCC patients treated with curative intent at the Head and Neck Cancer Unit of the Radboud University Medical Centre from 2000 to 2012. Risk of recurrence was calculated addressing death from intercurrent diseases as competing event.

RESULTS

The 1-, 5- and 10-year cumulative risks of a second event were 17% (95% CI:14%;20%), 30% (95% CI:26%;33%), and 37% (95% CI:32%;41%). Almost all locoregional recurrences occurred in the first 2 years after treatment. The incidence of second primary tumors was relatively stable over the years. The time pattern of presentation of third events was similar.

DISCUSSION

Our findings support a follow-up time of 2 years after curative treatment for OSCC. Based on the risk of recurrence there is no indication for a different follow-up protocol after first and second events. After 2 years, follow-up should be tailored to the individual needs of patients for supportive care, and monitoring of late side-effects of treatment.

A combined analysis of maximum standardized uptake value on FDG-PET, genetic markers, and clinicopathological risk factors in the prognostic stratification of patients with resected oral cavity squamous cell carcinoma

OBJECTIVE

Clinical outcomes of patients with resected oral cavity squamous cell carcinoma (OCSCC) chiefly depend on the presence of specific clinicopathological risk factors (RFs). Here, we performed a combined analysis of FDG-PET, genetic markers, and clinicopathological RFs in an effort to improve prognostic stratification.

METHODS

We retrospectively reviewed the clinical records of 2036 consecutive patients with first primary OCSCC who underwent surgery between 1996 and 2016. Of them, 345 underwent ultra-deep targeted sequencing (UDTS, between 1996 and 2011) and 168 whole exome sequencing (WES, between 2007 and 2016). Preoperative FDG-PET imaging was performed in 1135 patients from 2001 to 2016. Complete data on FDG-PET, genetic markers, and clinicopathological RFs were available for 327 patients.

RESULTS

Using log-ranked tests based on 5-year disease-free survival (DFS), the optimal cutoff points for maximum standardized uptake values (SUV-max) of the primary tumor and neck metastatic nodes were 22.8 and 9.7, respectively. The 5-year DFS rates were as follows: SUVtumor-max ≥ 22.8 or SUVnodal-max ≥ 9.7 (n = 77) versus SUVtumor-max < 22.8 and SUVnodal-max < 9.7 (n = 250), 32%/62%, P < 0.001; positive UDTS or WES gene panel (n = 64) versus negative (n = 263), 25%/62%, P < 0.001; pN3b (n = 165) versus pN1-2 (n = 162), 42%/68%, P < 0.001. On multivariate analyses, SUVtumor-max ≥ 22.8 or SUVnodal-max ≥ 9.7, a positive UDTS/WES gene panel, and pN3b disease were identified as independent prognosticators for 5-year outcomes. Based on these variables, we devised a scoring system that identified four distinct prognostic groups. The 5-year rates for patients with a score from 0 to 3 were as follows: loco-regional control, 80%/67%/47%/24% (P < 0.001); distant metastases, 13%/23%/55%/92% (P < 0.001); DFS, 74%/58%/28%/7% (P < 0.001); and disease-specific survival, 80%/64%/35%/7% (P < 0.001) respectively.

CONCLUSIONS

The combined assessment of tumor and nodal SUV-max, genetic markers, and pathological node status may refine the prognostic stratification of OCSCC patients.

Predicting individualized mortality probabilities for patients with squamous cell carcinoma of the maxilla: Novel models with clinical and histopathological predictors

BACKGROUND

The aim of this article was to develop prediction models that calculate postoperative 2- and 5-year mortality probabilities of patients with squamous cell carcinoma of the maxilla (MSCC).

METHODS

Data were collected from the medical records of patients who had been operated between 2000 and 2015 for MSCC. Potential clinical and histopathological predictors were identified. Confounding-(un)adjusted multivariate Cox and logistic regression models were computed with stepwise backward selection. Internal validation was performed to assess calibration and discriminatory ability.

RESULTS

Ninety-five patients with MSCC were included. Two-year follow-up was complete, and 85 patients had 5-year follow-up. Age, neck treatment, surgical margins, bone invasion, spindle growth, and vasoinvasive growth were associated with mortality. Models were adjusted for confounding with Charlson's comorbidities index. C-indexes were .841 and .770 respectively, and .838 and .749 after bootstrapping.

CONCLUSION

The MSCC-specific mortality probability can be calculated with new prediction models.

Prognostic impact of extratumoral perineural invasion in patients with oral cavity squamous cell carcinoma

PURPOSE

Perineural invasion (PNI) is an adverse prognostic factor in patients with oral cavity squamous cell carcinoma (OCSCC). The American Joint Committee on Cancer Staging Manual, eighth edition, introduced a subdivision of PNI into two distinct forms, that is, extratumoral and intratumoral PNI (EPNI and IPNI, respectively). We designed the current study to assess whether EPNI and IPNI have different prognostic implications in terms of disease control and survival outcomes in patients with OCSCC.

MATERIALS AND METHODS

We retrospectively examined 229 consecutive patients with OCSCC and PNI who underwent radical surgery between July 2003 and November 2016. EPNI and IPNI were identified in 76 and 153 patients, respectively. The 5-year locoregional control (LRC), distant metastasis, disease-free survival (DFS), and overall survival (OS) rates served as the main outcome measures.

RESULTS

Compared with patients showing IPNI, those with EPNI had a higher prevalence of worst pattern of invasion type-5 (P < 0.001), alcohol consumption (P = 0.03), and close margins (P = 0.002). Univariate analysis revealed that EPNI was a significant predictor of 5-year LRC (P = 0.024), DFS (P = 0.007), and OS (P = 0.034) rates. After allowance for potential confounders in multivariable analysis, ENPI was retained in the model as an independent predictor of 5-year LRC (P = 0.028), DFS (P = 0.011), and OS (P = 0.034) rates.

CONCLUSION

Compared with IPNI, the presence of EPNI in OCSCC portends less favorable outcomes. Patients with EPNI are potential candidates for definite aggressive treatment modalities aimed at improving prognosis.

Impact of postoperative radiation therapy for deeply invasive oral cavity cancer upstaged to stage III

BACKGROUND

This article is about the eighth edition staging guidelines for upstaged patients with oral cavity squamous cell carcinoma (OCSCC) with >10 mm depth to pT3. This upstages some patients from stage I-II to stage III, a point at which patients are traditionally considered for postoperative radiation therapy (PORT). The role of PORT in patients upstaged for >10 mm depth is unknown.

METHODS

We identified patients with surgically resected stage I-II OCSCC with >10 mm depth who were upstaged to stage III. We used Cox proportional hazard modeling to compare patients who received PORT to those who did not (median follow-up 38.6 months).

RESULTS

We observed that 3.6% of patients with OCSCC were upstaged to stage III for depth >10 mm including 823 eligible patients. On adjusted analyses, PORT was associated with improved overall survival in patients upstaged to stage III (adjusted hazard ratio [aHR] 0.47, 95% confidence interval [CI] 0.30-0.73).

CONCLUSION

PORT is associated with improved survival for patients with OCSCC upstaged to stage III for >10 mm depth.

Prediction of head and neck squamous cell carcinoma survival based on the expression of 15 lncRNAs

Recent evidence suggests that long noncoding RNAs (lncRNAs) are essential regulators of many cancer-related processes, including cancer cell proliferation, invasion, and migration. There is thus a reason to believe that the detection of lncRNAs may be useful as a diagnostic and prognostic strategy for cancer detection, however, at present no effective genome-wide tests are available for clinical use, constraining the use of such a strategy. In this study, we performed a comprehensive assessment of lncRNAs expressed in samples in the head and neck squamous cell carcinoma (HNSCC) cohort available in The Cancer Genome Atlas database. A risk score (RS) model was constructed based on the expression data of these 15 lncRNAs in the validation data set of HNSCC patients and was subsequently validated in validation data set and the entire data set. We were able to stratify patients into high- and low-risk categories, using our lncRNA expression panel to determine an RS, with significant differences in overall survival (OS) between these two groups in our test set (median survival, 1.863 vs. 5.484 years; log-rank test, p < 0.001). We were able to confirm the predictive value of our 15-lncRNA signature using both a validation data set and a full data set, finding our signature to be reproducible and effective as a means of predicting HNSCC patient OS. Through the multivariate Cox regression and stratified analyses, we were further able to confirm that the predictive value of this RS was independent of other predictive factors such as clinicopathological parameters. The Gene set enrichment analysis revealed potential functional roles for these 15 lncRNAs in tumor progression. Our findings indicate that an RS established based on a panel of lncRNA expression signatures can effectively predict OS and facilitate patient stratification in HNSCC.

Depth of invasion alone as an indication for postoperative radiotherapy in small oral squamous cell carcinomas: An International Collaborative Study

BACKGROUND

We aimed to investigate whether depth of invasion (DOI) should be an independent indication for postoperative radiotherapy (PORT) in small oral squamous cell carcinomas (SCC).

METHODS

Retrospective analysis of DOI (<5, 5 to <10, ≥10 mm) and disease-specific survival (DSS) in a multi-institutional international cohort of 1409 patients with oral SCC ≤4 cm in size treated between 1990-2011.

RESULTS

In patients without other adverse factors (nodal metastases; close [<5 mm] or involved margins), there was no association between DOI and DSS, with an excellent prognosis irrespective of depth. In the absence of PORT, the 5-year disease-specific mortality was 10% with DOI ≥10 mm, 8% with DOI 5-10 mm, and 6% with DOI <5 mm (P = .169), yielding an absolute risk difference of only 4%.

CONCLUSION

The deterioration in prognosis with increasing DOI largely reflects an association with other adverse features. In the absence of these, depth alone should not be an indication for PORT outside a clinical trial.

Oral cancers: Current status

Oral cancer is a global disease. Despite a well elucidated tumour progression model, these cancers present late. Attempts at early detection by way of adjunctive diagnostic technologies and screening have not lived up to expectations in spite initial promise. Surgery is the mainstay of treatment. Treatment intensification by way of adjuvant radiation/chemo radiation is warranted for those with high risk features. Recent studies have explored intensification in those with intermediate risk factors in an attempt to improve outcomes. There has been generation of recent robust evidence that has influenced the need and extent of neck dissection. Neoadjuvant chemotherapy (NACT) may have a potential role in organ preservation and borderline resectable oral cancers. Recurrent tumours should be offered surgery whenever feasible while the addition of biological agents to chemotherapy gives best results in the palliative settings.

Pathological risk factors stratification in pN3b oral cavity squamous cell carcinoma: Focus on the number of positive nodes and extranodal extension

OBJECTIVE

According to the AJCC 2017 Staging Manual, oral cavity squamous cell carcinoma (OCSCC) with pN2 disease (based on the AJCC 2010 criteria) and extra-nodal extension (ENE) should be classified as pN3b. We performed a detailed outcome analyses in this patient subgroup.

MATERIAL AND METHODS

We retrospectively reviewed the clinical records of consecutive OCSCC patients who underwent radical surgery between 1996 and 2017. Patients with pN3b disease (n = 365) were divided into a pN+ ≥8/ENE ≥5 subgroup (defined by the presence of pN+ ≥8 nodes or ENE ≥5 nodes, n = 77) and a pN+ ≤7/ENE ≤4 subgroup (defined by the presence of pN+ ≤7 nodes and ENE ≤4 nodes, n = 288). Patients with pN0/pN1/pN2 (n = 1192/179/197) disease were included for comparison purposes.

RESULTS

Patients in the pN+ ≥8/ENE ≥5 subgroup had less favorable 5-year outcomes than those in the pN+ ≤7/ENE ≤4/pN2/pN1/pN0 groups (local control, 64%/79%/86%/83%/88%, p < 0.001; neck control, 55%/75%/80%/86%/93%, p < 0.001; distant metastases, 67%/28%/20%/12%/3%, p < 0.001; disease-free survival, 21%/51%/64%/72%/82%, p < 0.001; disease-specific survival, 25%/55%/71%/82%/92%, p < 0.001; overall survival, 19%/40%/54%/64%/82%, p < 0.001; respectively). Among patients with pN3b disease, multivariable analysis identified the pN+ ≥8/ENE ≥5 subgroup, lower neck (level IV/V) metastases, and depth of invasion ≥25 mm as independent adverse prognostic factors for 5-year distant metastases and survival rates.

CONCLUSIONS

Patients in the pN+ ≥8/ENE ≥5 subgroup have an unfavorable prognosis and their classification as pN3b is advisable. In contrast, patients in the pN+ ≤7/ENE ≤4 subgroup should be classified as pN3a.

Impact of postoperative radiotherapy on survival and loco-regional control in node-negative oral cavity tumours classified as T3 using the AJCC Cancer Staging Manual eighth edition

According to the eighth edition of the AJCC Cancer Staging Manual (AJCC8), a depth of invasion (DOI) >10mm is classified as pT3, representing a locally advanced tumour requiring postoperative radiotherapy (PORT). When node-negative, however, evidence regarding whether PORT improves loco-regional control or survival is unclear. To clarify this, two cohorts of patients were studied: (1) patients classified as pT3N0 by the seventh edition of the AJCC manual (AJCC7), with DOI >10mm and a tumour diameter >4cm (17 patients who received PORT), and (2) patients classified as pT1N0 and pT2N0 by AJCC7, with DOI >10mm and a tumour diameter <4cm (55 patients who did not receive PORT). Loco-regional control and survival were analysed. PORT was found not to impact overall survival or disease-free survival. It was also found not to impact local, regional, or distant recurrence. Although the two subsets of patients considered here (DOI >10mm with tumour diameter below or above 4cm) were previously distinct, they are both considered pT3 in AJCC8. Data from this study indicate that the routine administration of PORT to patients with a DOI >10mm may not be warranted in the absence of other risk features such as nodal disease or close margins.

Multi-center retrospective study of the prognosis and treatment outcomes of Japanese oral squamous cell carcinoma patients with single lymph node metastasis and extra nodal extension

BACKGROUND

Oral squamous cell carcinoma (OSCC) containing single lymph node metastasis (pN1) with extra nodal extension (ENE) is a rare clinical situation. Therefore, it is unclear whether pN1 with ENE is at high risk of recurrence among the OSCC population, or whether postoperative radiotherapy (RT)/concomitant chemoradiotherapy (CCRT) is effective in these cases.

OBJECTIVES

The purpose of this retrospective study was to investigate the prognosis and compare between no postoperative therapy and postoperative RT/CCRT in pN1 with ENE OSCC patients.

METHODS

Clinicopathological data and treatment modalities were investigated. The evaluated endpoints were overall survival (OS) and type of recurrence.

RESULTS

The 3-year cumulative OS rates for the pN1 only, multiple lymph node metastasis (MLM) only, ENE + MLM, and ENE + pN1 groups were 77.2%, 66.8%, 43.3%, and 66.6%, respectively. In the ENE + pN1 group, the most common cause of death in the surgery only group was from regional failure. The surgery + RT/CCRT group was associated with better disease-specific survival and OS rates than the surgery only groups (P < 0.05).

CONCLUSIONS

The prognosis of ENE + pN1 was not as poor as that of ENE + MLM, although both these groups feature ENE. Adjuvant therapy (RT/CCRT) after surgery is recommend for cases of ENE + pN1.

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

OBJECTIVE

Early-stage oral cavity squamous cell carcinoma (OCSCC) represents a heterogeneous group of patients, and locoregional recurrence rates are as high as 25% with surgery alone. Radiotherapy (RT) is typically reserved as part of salvage multimodality therapy after salvage surgery because it is generally thought that there is no significant detriment to salvage therapy. Our aim was to examine outcomes for recurrent OCSCC treated with salvage surgery and radiation and compare them to outcomes for patients treated with adjuvant postoperative RT upfront.

METHODS

We identified 425 patients with OCSCC treated with postoperative RT at our institution. The 5-year rates of local failure, locoregional failure (LRF), survival, and distant metastasis (DM) were the main outcome measures. We performed a landmark analysis and examined the same outcomes in the adjuvant versus salvage cohorts using Cox proportional hazards and Fine-Gray competing risk method.

RESULTS

The adjuvant cohort had higher tumor (T) (P < 0.0001) and nodal (N) (P < 0.0001) stage than the salvage cohort's stage at initial presentation. On multivariate analysis, a strategy of salvage RT experienced poorer overall survival (OS) compared to upfront adjuvant RT (hazard ratio [HR] 1.84; 95% confidence interval [CI], 1.26-2.70; P = 0.002). Moreover, salvage surgery followed by RT patients experienced increasing risk of LRF (HR 1.56; 95% CI, 1.18-2.06; P = 0.002) and (DM) (HR 1.53; 95% CI, 1.08-2.17; P = 0.02) on multivariate analysis. Additional analysis was performed excluding salvage cohort with advanced disease at initial presentation (T3-T4 and N2). Salvage RT treatment selection for early-stage OCSCC continued to experience significantly poorer OS as compared to adjuvant RT (HR 1.48; 95% CI, 1.002-2.19; P = 0.049).

CONCLUSION

Early-stage OCSCC patients who are observed and experienced recurrence requiring salvage therapy (surgery and RT) have worse oncologic outcomes than locally advanced patients receiving upfront adjuvant RT. Prospective randomized studies are needed to identify high-risk subset of early-stage OCSCC comparing adjuvant RT versus observation, followed by salvage surgery and RT at recurrence.

LEVEL OF EVIDENCE

4. Laryngoscope, 2539-2545, 2018.

Molecular and serologic markers of HPV 16 infection are associated with local recurrence in patients with oral cavity squamous cell carcinoma

Human papillomavirus (HPV) infections predict mortality in Taiwanese patients with oral cavity squamous cell carcinoma (OCSCC). To address their prognostic significance for local recurrence (LR), in this retrospective cohort study we investigated different serologic and molecular markers of HPV 16 infection in 85 consecutive patients with primary OCSCC who received standard treatment and had their sera stored before treatment. Resected tumor specimens were examined with PCR-based assays for HPV 16 E6/E7 mRNA expression. Sera were tested with suspension arrays for the presence of HPV-specific antibodies using synthetic L1 and E6 peptides as well as a synthetic E7 protein. HPV 16 E6/E7 mRNA, anti-L1, anti-E6, and anti-E7 antibodies tested positive in 12%, 25%, 38%, and 41% of the study patients, respectively. Multivariate analysis identified pathological T3/T4, E6/E7 mRNA, and anti-E7 antibodies as independent risk factors for LR, whereas anti-E6 antibodies were an independent protective factor. In patients with ≥ 3 (high-risk group), 2 (intermediate-risk), and ≤ 1 (low-risk) independent risk factors (predictors), the 5-year LR rates were 75%, 42%, and 4%, respectively. Results were validated in an independent cohort. Together, our preliminary data indicate that HPV 16 infections as well as low and high serum levels of anti-E6 and anti-E7 antibodies, respectively, can serve as biomarkers of LR in patients with OCSCC, whereas the clinical usefulness of anti-HPV 16 antibodies for risk stratification of newly diagnosed cases deserves further scrutiny.

Postoperative radiotherapy with or without concurrent chemotherapy for oral squamous cell carcinoma in patients with three or more minor risk factors: a propensity score matching analysis

Background

To investigate the advantage of concurrent chemotherapy with postoperative radiotherapy (RT) of oral squamous cell carcinoma (OSCC) in patients with three or more minor risk factors.

Methods

Minor risk factors included pT4 disease, pN1 disease, margin ≤ 4 mm, poor differentiation, perineural invasion, vessel or lymphatic invasion, and tumor invasion depth ≥ 11 mm. Surgery was the primary treatment, followed by RT or concurrent chemoradiation (CCRT). After propensity score matching, 34 patients in each treatment group were selected for comparison.

Results

The median follow-up for living patients was 86.4 months (range: 47–189 months). The 5-year overall survival of the RT and CCRT groups was 35.3% and 67.2% (p = 0.018), respectively. The 5-year recurrence-free survival of the RT group and CCRT group was 42.6% and 75.4% (p < 0.01).

Conclusion

Postoperative CCRT for patients with three or more minor risk factors increased recurrence-free and overall survival.

Clinical Outcomes in pT4 Tongue Carcinoma are Worse than in pT3 Disease: How Extrinsic Muscle Invasion Should be Considered?

BACKGROUND

The identification of extrinsic tongue muscle invasion in oral cavity cancer remains challenging. Notably, the most recent American Joint Committee on Cancer (AJCC 2017, 8th edition) staging manual indicates that extrinsic muscle invasion does not lead to the diagnosis of a T4 tumor. Because this approach carries the risk of tumor downstaging, we compared the clinical outcomes of patients with oral tongue squamous cell carcinoma (SCC) staged as pT3 vs. pT4 according to the AJCC 2010, 7th edition criteria.

METHODS

We retrospectively examined the records of consecutive patients with pT3 (n = 135) and pT4 (n = 68) tongue SCC who underwent radical surgery. Of the 68 pT4 tongue SCC, 63 (93%) had extrinsic muscle involvement alone. The 5-year locoregional control (LRC), distant metastasis (DM), and disease-free survival (DFS) rates served as outcome measures.

RESULTS

Compared with pT3 tongue SCC, pT4 patients presented significantly more frequently with pN2 disease, extranodal extension, poor tumor differentiation, tumor depth >15 and >20 mm, margin status ≤4 mm, perineural invasion, vascular invasion, and were more frequently treated with surgery plus concurrent chemoradiotherapy. Less favorable 5-year outcomes were observed in patients with pT4 than pT3 tumors (LRC 50 vs. 75%, p < 0.001; DM 27 vs. 14%, p = 0.013; DFS 43 vs. 69%, respectively, p < 0.001). We identified pT4 disease (vs. pT3) as an independent adverse prognostic factor for LRC and DFS.

CONCLUSIONS

We suggest classifying patients with tongue SCC and extrinsic muscle invasion as having pT4 disease.

Adverse pathologic features in early oral squamous cell carcinoma and the role of postoperative radiotherapy-a review

The use of postoperative radiotherapy (PORT) in early stage oral cancer with adverse pathologic features (APFs) is controversial. Prognostically relevant APFs reviewed were perineural invasion, lymphovascular invasion, depth of invasion, worst pattern of invasion, and margin status. The current literature remains divided with regard to the benefit of treatment escalation in these patients; although these patients are at high risk for recurrence, the morbidity of PORT needs to be balanced against the likely benefit in disease control. A wide heterogeneity in the literature exists, likely as a result of differences in treatment protocols. We performed a literature review of the role of PORT in early-stage oral cancer with APFs. Based on the current evidence, the decision to administer adjuvant therapy needs to be made on an individual basis; patients with >1 APF are likely to benefit from PORT, and the use of risk-scoring systems may help in decision making.

A Model for Perineural Invasion in Head and Neck Squamous Cell Carcinoma

Perineural invasion (PNI) is found in approximately 40% of head and neck squamous cell carcinomas (HNSCC). Despite multimodal treatment with surgery, radiation, and chemotherapy, locoregional recurrences and distant metastases occur at higher rates, and overall survival is decreased by 40% compared to HNSCC without PNI. In vitro studies of the pathways involved in HNSCC PNI have historically been challenging given the lack of a consistent, reproducible assay. Described here is the adaptation of the dorsal root ganglion (DRG) assay for the examination of PNI in HNSCC. In this model, DRG are harvested from the spinal column of a sacrificed nude mouse and placed within a semisolid matrix. Over the subsequent days, neurites are generated and grow in a radial pattern from the cell bodies of the DRG. HNSCC cell lines are then placed peripherally around the matrix and invade preferentially along the neurites toward the DRG. This method allows for rapid evaluation of multiple treatment conditions, with very high assay success rates and reproducibility.

Does Medullary Versus Cortical Invasion of the Mandible Affect Prognosis in Patients With Oral Squamous Cell Carcinoma?

PURPOSE

Whether mandibular involvement by oral squamous cell carcinoma (OSCC) could be identified as a factor for cancer staging and prognosis prediction remains a subject of debate. In addition, the influence of different types of mandibular invasion (cortical or medullary invasion) on patients' prognosis remains unclear. The aim of this systematic review was to establish whether mandibular invasion or its subset should be considered an independent prognostic factor for patients with OSCC.

MATERIALS AND METHODS

The search for eligible studies was performed according to the predesigned inclusion criteria for a systematic review. Mandibular invasion and invasion depth were considered the primary and secondary predictor variables, respectively. The electronic search was performed using 12 databases. Manual searching covered 14 related journals and references of the included studies were scanned. The risk of bias assessment was evaluated by 2 reviewers using risk-of-bias assessment tools recommended by Saltaji et al (Angle Orthod 82:1115, 2012). Two reviewers extracted the data in duplicate. RevMan 5.2 was used for meta-analysis to assess the primary outcomes (disease-free survival and overall survival) and the secondary outcomes (2- and 5-year survival rate and local control).

RESULTS

Eighteen studies (total, 3,756 participants) were included and used as the study sample. Among these included studies, 7 had an unclear risk of bias and the remaining showed a high risk. The results of the meta-analyses showed a significant relation between mandibular invasion and overall survival (P = .04) and, most importantly, that medullary involvement (P = .0001), but not cortical involvement (P = .66), could decrease overall survival. When focusing on disease-specific survival, mandibular medullary involvement predicted a poor disease-specific survival (P < .0001), but cortical involvement showed no effect (P = .66).

CONCLUSION

This review showed that OSCC mandibular medullary invasion, and not mandibular invasion or mandibular cortical invasion, could be an independent prognostic factor for patients.

Outcome and fewer indications for adjuvant therapy for patients with oral squamous cell carcinomas under standardized tumor board conditions

PURPOSE

The aim of our study was to review the outcome of patients with oral squamous cell carcinoma (OSCC) treated according to the current diagnostic and treatment protocols ["Tumor Board Group" (TBG)] compared to patients diagnosed before the introduction of standardized and certified guidelines ["Conventional Group" (CG)]. We also analyzed the influence of prognostic factors on overall survival (OS), disease-free survival (DFS) and recurrence-free survival (RFS) rates.

METHODS

A total of 321 patients (TBG 95 patients and CG 226 patients) with histologically confirmed OSCC were included in our study. RFS, DFS and OS rates were analyzed by Kaplan-Meier estimates. Cox regression was performed for multivariate analysis of prognostic factors. Results were statistically significant with a p value of <0.05.

RESULTS

T, N, AJCC stage, age and therapy resulted to be independent risk factors for OS and DFS. We were not able to identify statistically significant prognostic factors for RFS apart from grading. 31.58% of patients from the TBG received postoperative adjuvant treatment compared to 74.78% within the CG. The OS rate was 79.63% at 30 months for patients from the TBG in comparison with 65.54% for patients from the CG.

CONCLUSION

The implementation of standardized guidelines including the establishment of the "Tumor Board Conference" results in a higher percentage of patients receiving surgery as only treatment and in better OS rates. To further support this positive trend, patients shall be followed longer and analyzed in future. T, N and M as well as AJCC stage were identified as most important prognostic factors for OS and DFS in our study.

Predictive factors of occult neck metastasis in patients with oral squamous cell carcinoma

INTRODUCTION

It is well established that cervical lymph node metastasis is the most important prognostic factor in patients with oral squamous cell carcinoma of the upper aerodigestive tract. The definition of parameters and classifications that could separate patients in groups of low, intermediate and high-risk is being attempted for several years.

OBJECTIVE

The objective of this study was to determine possible predictive factors related to the occurrence of occult cervical lymph node metastasis through the analysis of histopathological reports of surgical specimens obtained after oral squamous cell carcinoma resection and selective neck dissections of patients initially classified as N0.

METHODS

This was a primary, retrospective, observational, case-control study. Histopathological reports were reviewed to determine if some findings were related to the occurrence of occult lymph node metastasis. The events analyzed were oral cavity subsites, pT-stage, muscular infiltration, desmoplasia, vascular emboli, perineural infiltration, tumor thickness and compromised margins.

RESULTS

Occult cervical metastasis accounted for 19.10 percent of the cases. Desmoplasia, perineural infiltration, tumor thickness and pT4a stage are predictive factors of occult neck metastasis (p-value=0.0488, 0.0326, 0.0395, 0.0488, respectively).

CONCLUSION

The accurate definition of predictive factors of occult cervical metastasis may guide the selection of patients that should be referred to radiotherapy, avoiding the unnecessary exposure of low-risk patients to radiation and allowing a better regional control of the disease in those of moderate or high risk.

Clinical Outcomes of Patients with Resected Oral Cavity Cancer and Simultaneous Second Primary Malignancies

Objectives

Simultaneous second primary tumors (SSPT) are not uncommon in patients with oral cavity squamous cell carcinoma (OSCC) living in areas where the habit of betel quid chewing is widespread. We sought to identify the main prognostic factors in OSCC patients with SSPT and incorporate them into a risk stratification scheme.

Methods

A total of 1822 consecutive patients with primary OSCC treated between January 1996 and February 2014 were analyzed for the presence of SSPT. The 18-month and 5-year overall survival (OS) rates served as the main outcome measures.

Results

Of the 1822 patients, 77 (4%) were found to have SSPT (i.e, two malignancies identified within one month of each other). The 18-month and 5-year OS rates in patients without SSPT and with SSPT were 82% and 69%, and 72% and 53%, respectively (p = 0.0063). Patients with SSPT were further divided into patients with either esophageal cancer or hepatocellular carcinoma (eso-HCC subgroup, n = 8) and other tumors (NO eso-HCC subgroup, n = 69). After multivariate analysis, neck nodal extracapsular spread (ECS, n = 18) and the presence of eso-HCC were identified as independent adverse prognostic factors. The 18-month OS rates of SSPT patients with both eso-HCC and ECS (n = 5) vs. the remaining patients (n = 72) were 0% and 78%, respectively (p < 0.0001).

Conclusion

OSCC patients with neck nodal ECS and esophageal cancer or hepatocellular carcinoma as SSPT have a dismal short-term prognosis.

Autofluorescence imaging in recurrent oral squamous cell carcinoma

The survival of patients with oral cancer is decreased by locoregional recurrence after an initial multimodal treatment. In order to identify lesions in the oral cavity for a possible recurrence, clinical evaluation as well as MRI or CT scanning is advised. The evaluation of mucosa lesions is hampered by changes related to radio- and chemotherapy as well as reconstruction with tissue flaps. Several techniques for easier identification of tissue abnormalities in the oral cavity have been advocated as adjuncts in order to facilitate identification. Especially methods using altered tissue fluorescence have gained much interest during the last decade. The aim of our prospective study was to evaluate fluorescence properties of undiagnosed mucosa lesions with the VELscope device in patients with multimodal treated oral cancer prior to histological confirmation. In total, 41 patients with a history of oral squamous cell carcinomas (OSCC) (19 females and 22 males) with undiagnosed mucosa lesions where included in the study. After clinical evaluation, examination and documentation using the VELscope® device were performed. Then, an incisional biopsy was performed. An autofluorescence loss indicating a malignant or dysplastic mucosa condition could be detected in six patients (14.6 %); however, only one OSCC and one SIN revealed a complete autofluorescence loss. In four patients, OSCC was present in lesions with retained autofluorescence. Sensitivity and specificity for the VELscope® examination to identify malignant oral lesions by autofluorescence were 33.3 and 88.6 %, respectively. The positive and negative predictive values were 33.3 and 88.6 %, respectively. No statistical correlation between gender and lesion appearance versus autofluorescence loss could be detected. In contrast to mucosa lesions in patients with no prior treatment, the autofluorescence evaluation with the VELscope reveals no additional information in our analysis. Accordingly, invasive biopsies as gold standard are still needed to get sufficient evidence regarding potential malignancy in patients after multimodal treatment for oral cancer.

Impact of indication-shift of primary and adjuvant chemo radiation in advanced laryngeal and hypopharyngeal squamous cell carcinoma

Based on level I evidence, postoperative platinum-based radiochemotherapy (PORCT) is the recommended standard of care in defined risk situations after resection of squamous cell carcinomas of the larynx and hypopharynx (LHSCC). The value of the addition of chemotherapy to adjuvant radiation in intermediate and high risk situations other than extracapsular spread or R1-/R2 resection is still debated. From 1993 to 2009, 555 patients (median follow-up: 24.4 months) with advanced LHSCC (UICC stages III-IVB) were treated in a curative intent. Patient data were continuously documented in the county of Leipzig cancer registry and were retrospectively analyzed as mono institutional survey. PORCT was introduced into the standard procedures in 2004, but also applied before in selected cases. Based on this paradigm shift, the patient population was divided into two comparative groups treated before and after 2004. 361 patients were treated before 2004. 43.8 % received primary surgery (OP) + postoperative radiotherapy (PORT) and 20.2 % OP + PORCT. 194 patients were treated after 2004: 21.1 % received OP + PORT and 35.6 % OP + PORCT. Regarding the PORCT groups, 20.6 % received cisplatin plus 5FU before 2004 which shifted to 59.4 % after 2004. The 3-year tumor-specific-survival rate of the whole cohort was improved from 47 to 60 % (p = 0.006). The subgroup treated with OP + PORT or PORCT improved from 56.1 to 68.5 % (p = 0.028). Localization proved to be a significant and independent factor. Only patients with advanced laryngeal cancer had significant improved survival (p < 0.01), while the improvement for hypopharyngeal cancer patients was not significant (p < 0.2). After 2004, there was a slight increase (+10.2 %) of primary radiochemotherapy (pRCT) due to stronger selection if R0 > 5 mm-resectability is unlikely. Standardised use of PORCT and pRCT considering clear indications showed to be significantly involved in improved survival in advanced LHSCC.

Clinical evidence of field cancerization in patients with oral cavity cancer in a betel quid chewing area

OBJECTIVES

We sought to investigate whether there is evidence of field cancerization in patients with oral cavity squamous cell carcinoma (OSCC) enrolled in a betel quid chewing area. We also assessed whether betel quid chewing is an independent risk factor for field cancerization in OSCC patients.

METHODS

We retrospectively examined the records of 1570 OSCC patients who underwent radical tumor resection between 1996 and 2011. A total of 1243 study participants (79%) had a positive history of betel quid chewing before surgery. Of the 767 patients treated with surgery alone, 599 (78%) were preoperative chewers, whereas a history of preoperative betel quid chewing was identified in 644 (80%) of the 803 patients who received adjuvant therapy. The 5-year control, survival, and second primary tumors (SPTs) rates served as the main outcome measures.

RESULTS

Regardless of the treatment modality, more than 70% of the SPTs were located in the oral cavity or soft palate. Despite a similar risk profile in terms of tumor depth, lymph node metastasis, and pathological margin status, preoperative chewers showed a significantly higher incidence of 5-year SPTs and local recurrences compared with non-chewers. Moreover, multivariate analysis demonstrated that preoperative betel quid chewing was an independent prognostic factor for 5-year local control and SPTs occurrence rates.

CONCLUSIONS

Our results demonstrate that preoperative betel quid chewers had a higher incidence of local recurrence and SPTs than non-chewers, suggesting that field cancerization may occur in OSCC patients with a history of betel quid chewing.

Postoperative concomitant chemoradiotherapy improved treatment outcomes of patients with oral cavity cancer with multiple-node metastases but no other major risk factors

Purpose

To investigate the results of postoperative radiotherapy (PORT) for the treatment of pathologic N2b/c squamous cell carcinoma of the oral cavity (OSCC).

Materials and Methods

This study reviewed cancer registry data collected in our hospital from 1998 to 2009 with the following inclusion criteria: primary OSCC, treatment with radical surgery, and multiple nodal metastases. Patients who had extracapsular spreading of the lymph node metastases or positive resection margins or who refused to undergo PORT were excluded. The prescribed dose of PORT was 60–66 Gy. Concurrent chemotherapy was optional. Patient characteristics, treatment parameters and clinical outcome were recorded. The primary end point was overall survival, and the secondary endpoint was disease status.

Results

There were 138 eligible cases, and the median follow-up period was 35 months. The 3-year overall survival rate was 56%. Univariate analysis revealed that pathologic T4 status (pT4), bone marrow invasion, and lymphatic invasion were significantly correlated with poor outcome (p<0.05). Multivariate analysis showed that pT4, lymphatic invasion, and the no concurrent chemotherapy were independent poor prognostic factors (p<0.05). Fifty-four patients had tumor recurrence. The 3-year recurrence-free survival rate was 59%. Skin invasion, pT4, and bone marrow invasion were correlated with poor prognosis in the univariate analysis (p<0.05). Only pT4 (p<0.01) and no concurrent chemotherapy (p = 0.03) were independently correlated with poor recurrence-free survival.

Conclusion

For OSCC patients with multiple-node metastases without extracapsular spreading or positive resection margins, PORT without concurrent chemotherapy correlated to inferior outcome. Multiple lymph node metastases might be considered an indication for concurrent chemotherapy.