The role of clinical versus histopathological staging in patients with advanced oral squamous cell carcinoma treated with neoadjuvant radiochemotherapy followed by radical surgery

Improved recurrence rates and progression-free survival in primarily surgically treated oral squamous cell carcinoma - results from a German tertiary medical center

OBJECTIVES

This study aimed to explore survival and recurrence patterns in patients undergoing primarily surgical treatment for oral squamous cell carcinoma (OSCC) at a high-volume tertiary medical center in Germany.

MATERIALS AND METHODS

The study included 421 patients with primary OSCC who underwent radical tumor resection, neck dissection, and reconstruction with a free flap. Prognostic relevance of clinicopathological characteristics was assessed using Cox proportional-hazards models. Kaplan-Meier method estimated local recurrence-free survival, progression-free survival (PFS), and overall survival (OS), while the log-rank test compared survival outcomes between groups.

RESULTS

Recurrence manifested in 16.63% of the patients (70 patients), encompassing local recurrence in 54 patients (77.14%) and distant metastasis in 24 patients (34.28%). Neck recurrence occurred in only 1 patient (0.24%) on the contralateral side. The majority of recurrences occurred within the initial twelve months following primary tumor surgery (64.29%). Overall, the 5-year OS stood at 58.29%, while the 5-year PFS reached 72.53%. Patients with early recurrence within ≤ 12 months showed the least favorable prognosis (log-rank, all p < 0.001).

CONCLUSIONS

Our findings show a significant decrease in recurrence rates and enhanced PFS at a high-volume tertiary medical center in Germany compared to previous studies. Local recurrence was the primary form observed, with most recurrences happening within the initial twelve months post-surgery. Opting for treatment at a high-volume center and devising therapy plans in interdisciplinary tumor boards may not only enhance OS but also contribute to improved PFS.

CLINICAL RELEVANCE

These findings offer valuable insights for physicians regarding the post-treatment care of patients with OSCC. The results underscore the importance of frequent follow-up appointments, particularly during the initial year, and highlight the critical need for vigilance in monitoring for local recurrence.

Neoadjuvant Chemoradiotherapy for Oral Cavity Cancer: Predictive Factors for Response and Interim Analysis of the Prospective INVERT-Trial

Background

To study neoadjuvant chemoradiotherapy (nCRT) and potential predictive factors for response in locally advanced oral cavity cancer (LA-OCC).

Methods

The INVERT trial is an ongoing single-center, prospective phase 2, proof-of-principle trial. Operable patients with stage III-IVA squamous cell carcinomas of the oral cavity were eligible and received nCRT consisting of 60 Gy with concomitant cisplatin and 5-fluorouracil. Surgery was scheduled 6-8 weeks after completion of nCRT. Explorative, multiplex immunohistochemistry (IHC) was performed on pretreatment tumor specimen, and diffusion-weighted magnetic resonance imaging (DW-MRI) was conducted prior to, during nCRT (day 15), and before surgery to identify potential predictive biomarkers and imaging features. Primary endpoint was the pathological complete response (pCR) rate.

Results

Seventeen patients with stage IVA OCC were included in this interim analysis. All patients completed nCRT. One patient died from pneumonia 10 weeks after nCRT before surgery. Complete tumor resection (R0) was achieved in 16/17 patients, of whom 7 (41%, 95% CI: 18-67%) showed pCR. According to the Clavien-Dindo classification, grade 3a and 3b complications were found in 4 (25%) and 5 (31%) patients, respectively; grade 4-5 complications did not occur. Increased changes in the apparent diffusion coefficient signal intensities between MRI at day 15 of nCRT and before surgery were associated with better response (p=0.022). Higher abundances of programmed cell death protein 1 (PD1) positive cytotoxic T-cells (p=0.012), PD1+ macrophages (p=0.046), and cancer-associated fibroblasts (CAFs, p=0.036) were associated with incomplete response to nCRT.

Conclusion

nCRT for LA-OCC followed by radical surgery is feasible and shows high response rates. Larger patient cohorts from randomized trials are needed to further investigate nCRT and predictive biomarkers such as changes in DW-MRI signal intensities, tumor infiltrating immune cells, and CAFs.

Nomograms predicting the overall and cancer-specific survival of patients with buccal mucosa cancer

OBJECTIVES

To construct predictive models for predicting overall survival (OS) and cancer-specific survival (CSS) of patients with buccal mucosa cancer (BMC).

STUDY DESIGN

Data of 936 patients with BMC were extracted from the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2015. Nomograms were constructed based on multivariate Cox regression analyses, and validated using calibration plots, time-dependent receiver operating characteristic curves, and decision curve analyses.

RESULTS

Age at diagnosis, marital status, grade, histopathology, SEER stage, tumor size, and surgery were associated with OS, whereas age at diagnosis, grade, histopathology, SEER stage, tumor size, and surgery were associated with CSS (all P < .05). The concordance indexes for OS and CSS were 0.79 and 0.80 in the training cohort, respectively, and those in the validation cohort were 0.78 and 0.80. Time-dependent receiver operating characteristic curves showed great predictability in nomograms. Decision curve analyses demonstrated good clinical value for OS (4%-88%) and CSS (3%-77%) nomograms. Patients were stratified into 3 risk groups, with the worst prognosis in the high-risk subgroup (P < .001).

CONCLUSIONS

We developed and validated 2 nomograms predicting OS and CSS and established the corresponding risk classification systems in patients with BMC. These models assisted in precise administration of individual therapeutic regimens.

Nonsurgical management of resectable oral cavity cancer in the wake of COVID-19: A rapid review and meta-analysis

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COVID-19 resource constraints have resulted in treatment delays for oral cancer.

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Non-surgical treatment may be necessary to provide timely access to care.

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Definitive CCRT is associated with an increased rate of death in early oral cancer.

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Neoadjuvant regimens have not shown survival benefit in resectable oral cancer.

Objective

Surgery is the preferred treatment modality for oral squamous cell carcinoma (OSCC). However, due to limited resources, re-assessment of treatment paradigms in the wake of the Coronavirus Disease 2019 (COVID-19) pandemic is urgently required. In this rapid review, we described contemporary oncological outcomes for OSCC using non-surgical modalities.

Methods

A systematic literature search was conducted for articles published between January 1, 2010 and April 1, 2020 on MEDLINE and Cochrane CENTRAL. Studies were included if they contained patients with OSCC treated with either neoadjuvant, induction, or definitive radiotherapy, chemotherapy, immunotherapy, or combination thereof, and an outcome of overall survival.

Results

In total, 36 articles were included. Definitive radiotherapy or chemoradiotherapy were the focus of 18 articles and neoadjuvant chemotherapy or chemoradiotherapy were the focus of the other 18 articles. In early stage OSCC, definitive radiotherapy, with or without concurrent chemotherapy, was associated with a significantly increased hazard of death compared to definitive surgery (HR: 2.39, 95% CI: 1.56–3.67, I²: 63%). The hazard of death was non-significantly increased with definitive chemoradiotherapy in studies excluding early disease (HR: 1.98, 95% CI: 0.85–4.64, I²: 84%). Two recent randomized control trials have been conducted, demonstrating no survival advantage to neoadjuvant chemotherapy.

Conclusion

This review suggests that primary radiotherapy and chemoradiotherapy are inferior to surgical management for OSCC. Strategies for surgical delay warranting consideration are sparse, but may include several neoadjuvant regimens, recognizing these regimens may not offer a survival benefit over definitive surgery alone.

Pretreatment tumor volume and tumor sphericity as prognostic factors in patients with oral cavity squamous cell carcinoma

PURPOSE

This study was designed as a retrospective observational study, focusing on the correlation between the preoperative CT-scan tumor volume, tumor sphericity, and the disease-related prognosis.

METHODS

A total of 30 consecutive patients, affected by primary oral cancer, were retrospectively identified from our oral cancer database. The preoperative images (DICOM data) for the study population were uploaded into a modular software package designed to convert patients' medical images into 3D digital models. Multislice interpolation and threshold segmentation tools were used to segment the tumor mass. This was then converted into a 3D mesh and exported in STL format, in order to calculate the corresponding volume. We applied the concept of sphericity - a measurement of how closely the shape of an object approaches that of a mathematically perfect sphere - to the segmented tumor mass.

RESULTS

Mean tumor volume was larger in patients with tumor recurrence and/or who had died than in patients who were disease free/alive. Tumor sphericity was influential on clinical outcomes. It appeared to be lower in patients who had tumor recurrence and/or who had died (0.54 ± 0.09 and 0.53 ± 0.05) than in patients who were disease free/alive (0.65 ± 0.07). This difference was statistically significant (p < 0.05). Cumulative recurrence-free survival was 86.2% for patients with a tumor volume lower than the cut-off value. Otherwise, it was 0% for those with a tumor volume higher than the cut-off value (p < 0.01; log rank test). Cumulative recurrence-free survival was 86.3% for patients with a higher sphericity index, compared with 13.6% for those with a lower sphericity index.

CONCLUSION

The prognostic model, based on a tridimensional, CT-based characterization of the tumor size, which includes both tumor volume and tumor sphericity, uses readily available information and could be considered when formulating prognoses for patients with oral cancer.

Early death among head and neck cancer patients

PURPOSE OF REVIEW

Management of advanced head and neck cancer (HNC) is characterized by high mortality. Furthermore, the treatment involves significant burden to patients and high costs to healthcare systems. Recognizing the risks of early death in patients with a high probability of noncurable disease is important for each individual treatment decision-making. It is thus critical to consider the benefits and side-effects of the planned treatment in relation to the expected survival and to discuss these factors with the patient. However, only few studies have documented early death in HNC patients, that is, during the first posttreatment 6 months. We performed a systematic literature review to find the incidence of this phenomenon and to outline the probable cause.

RECENT FINDINGS

Early mortality in patients with HNC can be explained either by direct effect of malignant disease, may be related to comorbidities, or secondary to the treatment. These factors act together resulting in expected or unexpected early death.

SUMMARY

The present review provides information on the mechanisms leading to early phase mortality (<6 months) after management of HNC. It also reports the incidence of this phenomenon among Finnish and Swedish patient populations.

Analysis of clinicopathological characteristics associated with the outcome of oral squamous cell carcinoma and the establishment of tissue microarrays

The aim of this study was to evaluate clinicopathological risk factors associated with the fatal outcome of oral squamous cell carcinoma (OSCC) in a large cohort of Chinese patients, and to construct tissue microarrays (TMAs) using this cohort. Univariate and multiple logistic regression analyses were performed to evaluate the predictors of poor prognosis in a cohort of 232 patients with OSCC, after which the patient tumor tissues were used to construct TMAs. Univariate logistic regression analysis indicated that a poor outcome of OSCC was associated with the male gender, a history of smoking, the tumor-node-metastasis stage and lymph node metastasis. Multiple logistic regression analysis demonstrated that an increased risk of mortality in patients with OSCC was significantly and independently associated with lymph node metastasis (odds ratio, 3.421; 95% confidence interval, 1.609-7.273). Therefore, the results of the present study suggested that lymph node metastasis is an independent risk factor associated with a poor prognosis of OSCC patients. TMAs of OSCC were successfully constructed, and are the first TMAs to be reported in mainland Chinese patients.

Tumor thickness and risk of lymph node metastasis in patients with squamous cell carcinoma of the tongue

OBJECTIVES

Oral squamous cell carcinomas, and tongue malignancies in particular, are among the most common tumors of the oral cavity. Classification for therapeutic and prognostic purposes is routinely made using the tumor, node, metastasis (TNM) system; however, current definitions do not include tumor thickness. We therefore aimed to identify variables associated with survival, and to evaluate the correlation between tumor thickness and the occurrence of lymph node metastasis.

PATIENTS AND METHODS

All patients undergoing radical tumor resection for squamous cell carcinomas of the tongue between 2000 and 2012 were included. Specimens were analyzed histopathologically and co-variables were interpreted. Follow-up was performed clinically and radiologically for at least 3years according to current guidelines.

RESULTS

We included 492 patients who had a median follow-up of 70months. Variables associated with survival (p<0.05) were age, tumor stage, N stage, UICC (Union for International Cancer Control) stage, tumor grade, and recurrence. In the receiver operating characteristic curve and Youden-Index analyses, the optimal tumor thickness cut-off was 8mm to detect significant differences in overall survival.

CONCLUSION

We highlight the importance of tumor thickness as a predictive variable in tongue cancer. Specifically, a cut-off point of 8mm allowed for a more accurate and statistically precise prediction of lymph node metastasis. These findings could supplement the current classification of tongue cancers and form the basis for treatment.

Operative margin control with high-resolution optical microendoscopy for head and neck squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

High-resolution microendoscopy (HRME) provides real-time visualization of the mucosal surface in the upper aerodigestive tract. This technology allows noninvasive discrimination of benign and neoplastic epithelium and has potential applications for intraoperative margin detection.

STUDY DESIGN

Single institution, prospective, feasibility trial (phase I) of in vivo optical imaging.

METHODS

The study was conducted on patients with squamous cell carcinoma of the upper aerodigestive tract. High-resolution microendoscopy images obtained during surgery were correlated with histopathologic diagnosis to determine the ability of HRME to differentiate between benign and malignant mucosa. Blinded reviewers evaluated HRME images and made determinations of the status of the mucosa. Accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and interrater agreement between multiple raters were calculated to determine the accuracy of HRME imaging.

RESULTS

The mean accuracy of reviewers in differentiating neoplastic or benign mucosa was 95.1% (95% confidence interval [CI], 94%-96%). Sensitivity and specificity were 96% (95% CI, 94%-99%) and 95% (95 % CI, 90%-99%), respectively. The NPV was 98% (95% CI, 97%-99%), and PPV was 91% (95% CI, 85%-98%). The Fleiss kappa statistic for interrater reliability was 0.81, with a standard error of 0.014 and a 95% CI (0.78-0.84).

CONCLUSION

High-resolution microendoscopy allows real-time discrimination between benign and neoplastic mucosa. High levels of sensitivity and specificity can be obtained with this technology when interrogating mucosal surfaces. Despite several technical limitations, HRME shows promise as a technique for intraoperative margin control and platform for molecular imaging technologies.

LEVEL OF EVIDENCE

3b.

Significance of post-resection tissue shrinkage on surgical margins of oral squamous cell carcinoma

BACKGROUND

Resecting oral squamous cell carcinoma (SCC) with an appropriate margin of uninvolved tissue is critical in preventing local recurrence and in making decisions regarding postoperative radiation therapy. This task can be difficult due to the discrepancy between margins measured intraoperatively and those measured microscopically by the pathologist after specimen processing.

MATERIAL AND METHODS

A total of 61 patients underwent resective surgery with curative intent for primary oral SCC were included in this study. All patients underwent resection of the tumor with a measured 1-cm margin. Specimens were then submitted for processing and reviewing, and histopathologic margins were measured. The closest histopathologic margin was compared with the in situ margin (1 cm) to determine the percentage discrepancy.

RESULTS

The mean discrepancy between the in situ margins and the histopathological margins of all close and positive margins were 47.6% for the buccal mucosa (with a P value corresponding to 0.05 equaling 2.1), which is statistically significant, 4.8% for the floor of mouth, 9.5% for the mandibular alveolus, 4.8% for the retromolar trigon, and 33.3% for the tongue.

CONCLUSION

There is a significant difference among resection margins based on tumor anatomical location. Margins shrinkage after resection and processing should be considered at the time of the initial resection. Tumors located in the buccal mucosa show significantly greater discrepancies than tumors at other sites. These findings suggest that it is critical to consider the oral site when outlining margins to ensure adequacy of resection. Buccal SCC is an aggressive disease, and should be considered as an aggressive subsite within the oral cavity, requiring a radical and aggressive resective approach.

A 22 years survival and prognostic factors analysis in a homogeneous series of 64 patients with advanced cancer of the tongue and the floor of the mouth

PURPOSE

The aim of this study is to evaluate patients with advanced tongue and floor of the mouth carcinoma evaluating clinical and histopathologic parameters as prognostic factors for survival.

METHODS

We studied retrospectively 64 patients with squamous cell carcinomas of the tongue and floor of the mouth in stage III and IV, treated by surgery at first and followed them for at least 22 years or until death, with a median follow-up of 67 months (range, 3-290 months). The prognosis factors evaluation included tumor, patient and treatment related factors using univariate and multivariate statistical analysis.

RESULTS

The overall 5-year and 22-year survival rates were 34.4% and 6.3%, respectively; and the specific 5-year and 22 years survival rates 35.9%. Eleven patients (17.2%) had died of a second primary tumor and 8 (12.5%) of intercurrent diseases. Multivariable Cox regression analysis showed node capsular invasion, number of metastatic nodes and malignancy grading as the main factors associated with survival (p < 0.001).

CONCLUSION

A very long-term follow-up allowed for the observation of the specific and the overall survival, influenced by age and comorbidities. The prognosis was strongly influenced by the ganglionar status and the histopathological characteristics of the primary tumor.

Influence of tumor volume on survival in patients with oral squamous cell carcinoma

PURPOSE

The TNM classification is used to assess cancers of the oral cavity, and advancements in imaging techniques have revealed clear variations in tumor volume at presentation. This study therefore aimed to clarify whether preoperative imaging, with exact measurements of the tumor, could affect post-surgery survival after controlling for demographic, clinical, and tumor characteristics.

METHODS

We included 437 patients with histologically confirmed, stage T1-4, N1-3, M0, invasive squamous cell carcinoma of the tongue. Participants were assessed for recurrence every 3 months for the first 2 years, every 6 months for another 2 years, and annually thereafter; routine computed tomography was performed annually. Associations were determined using the Kaplan-Meier estimator, univariate log-rank test, and Cox proportional hazards regression models.

RESULTS

The mean survival of all patients was 68.1 ± 48.2 months. The 2- and 5-year overall survival rates were 82.2 and 66.7 %, respectively. The mean primary tumor volume was 7.14 cm(3) with a range of 1.3-24.21 cm(3). The ROC curve and Youden Index analysis revealed that the optimal cutoff volume was between ≤5.9 and ≤18.3 cm(3) for three different volume groups (p < 0.0001). Large tumor volume was associated with a significantly poorer overall survival (p < 0.0001).

CONCLUSIONS

Tumor volume was significantly associated with the overall survival of patients. This has both prognostic and reconstructive implications that will affect health-related quality of life. In addition, this will inform surgical planning and the allocation of resources.

Influence of epidermal growth factor receptor expression on the cetuximab and panitumumab response rates of head and neck carcinoma cells

OBJECTIVES

To examine the impact of epidermal growth factor receptor (EGFR) expression level on the efficacy of monoclonal antibodies against the EGFR.

METHODS

In four human head and neck carcinoma cell lines, epidermal growth factor expression was knocked down by lentiviral RNA interference. Next, the efficacies of cetuximab and panitumumab at concentrations of 4, 40, and 400 μg/ml were measured by real time cell analysis for a 48-h duration. Finally, the different response rates to the drugs were statistically analyzed.

RESULTS

The lentiviral EGFR knockdown efficiency ranged from 18 to 54 % across all of the cell lines. All original cell lines exhibited rather poor or inverse responses with regard to EGFR-AB treatment. In contrast, inhibiting EGFR expression in the same cell lines yielded statistically significant better responses to cetuximab or panitumumab treatment.

CONCLUSIONS

The cell lines used in this study responded poorly to cetuximab and panitumumab. Better anti-EGFR treatment efficacy was related to lower EGFR expression in head and neck cancer cell lines. These findings might influence the selection of patients to receive cetuximab and panitumumab treatment for head and neck cancer.

[Renaissance of pedicled flaps in oral and maxillofacial surgery]

A retrospective analysis in the period 2007 to 2011 included 71 surgically treated patients for carcinoma of the head and neck region and subsequent reconstruction with 36 pedicled distant flaps and 47 free flaps. Patient specific parameters of data collection with SPSS 17.0 were age and sex distribution, TNM stage and treatment. The specific type of flap reconstruction, duration of surgery, complications, intensive care and inpatient treatment were recorded. The results showed that the healing process was uneventful in 26 (72.2 %) pedicled flaps, 14 (38.9 %) pedicled flaps were transplanted in a preoperatively irradiated area of the head and neck region and in 86.0 % with a positive healing process. Tumor stage, general physical condition of the patient and type of therapy are the key parameters for the choice of reconstruction.

Imaging angiogenesis: perspectives and opportunities in tumour research - a method display

The growth of solid tumours necessitates angiogenesis. The aim of this paper is the presentation and evaluation of different ex vivo methods for analysing tumour angiogenesis. Oral squamous cell carcinomas (SCC) were induced in mice by subcutaneous injection of tumour cells in the groin region and processed for histology and microvascular corrosion casting. Vascularization was analysed light microscopically using CD31 immunochemistry. Corrosion casts were analysed by scanning electron microscopy (SEM), micro computed tomography (μCT) and synchrotron radiation-based micro computed tomography (SRμCT). Immunochemistry allows for a simple and authentic detection and stereological quantification of the SCC vascularization. μCT imaging of the corrosion casts gives a high-quality overview over the three-dimensional (3D) microvascular architecture. SEM and SRμCT allow a high-definition display of the vessel morphology, providing magnificent detail recognition down to the capillary level enabling imaging of different forms of tumour angiogenesis, e.g., sprouting and intussusceptive angiogenesis. Immunochemistry and SEM are regarded as suitable for most of the morphometrical and morphological assessments because of the simple procedure and the high explanatory power, especially in combination with each other. High resolution SRμCT helps answering specialized questions, however, requires sophisticated data processing for visualization and is of limited availability.

Influence of formalin fixation on tissue dimensions in palatal tonsils

AIM

To investigate the change of tissue dimensions after formalin fixation, and to determine the optimal time of fixation.

HYPOTHESIS

Formalin fixation may lead to shrinkage in tissue dimensions and may thus alter tumor stages.

BACKGROUND

It is often observed in tumor surgery that the dimensions in vivo seem larger than after resection, and tissue appears to shrink further after formalin fixation. This might alter dimensions and assessment of spread of the tumor and thus lead to a lesser tumor classification and stage. In cases where the decision for adjuvant chemoradiation is based upon the stage, it may thus be of relevance for the patient to evaluate the pathologic and not the in vivo dimensions of the tumor.

MATERIAL AND METHODS

In order to obtain comparable tissues, we investigated 100 palatal tonsils after cold steel dissection tonsillectomy for chronic tonsillitis. There were four time points investigated: directly after excision in the operating room and after four, 24 and 72 h of fixation in formaldehyde (4% Formaldehyde in phosphate buffer pH 7.4). The tissue was measured in the following dimensions: volume (ml), weight (g) and length, broadness and width (mm).

RESULTS

The tissue size did not change significantly in dimensions except for an increase in length. The time of fixation did not influence the size.

DISCUSSION

Formalin fixation does not significantly influence the tissue dimensions of palatal tonsils in comparison to direct ex vivo measurements. A minimal time of fixation of 20 h is required in order to stop all degenerative processes; however, longer fixation does not change the dimensions of the specimen.

CONCLUSION

The null hypothesis has to be withdrawn that tissue dimensions are altered by formalin fixation. Thus, the histopathological measurements do not influence TNM staging.

MRI pre-treatment tumour volume in maxillary complex squamous cell carcinoma treated with surgical resection

Tumour volume (Tv) measurements obtained from pre-treatment CT and MRI have increasingly shown to be more reliable predictors of outcome than TNM stage. The aim of this study was to determine the correlation of MRI calculated maxillary complex tumour volume with patient outcome.

METHODS

The medical records of 39 patients with squamous cell carcinoma involving the maxillary sinus, maxilla, hard palate and maxillary alveolus were reviewed and tumour volume measurements completed on pre-treatment MRI.

RESULTS

The mean tumour volume was 12.79 ± 24.31 cm(3). Independent samples t test was significant for increasing overall all-cause survival and decreasing tumour volume (1 year: p = 0.003; 5-year: p = 0.031). Cox regression was significant for stratified tumour volume, nodal involvement and peri-neural invasion for predicting disease-free survival.

CONCLUSIONS

MRI measured tumour volume assessment appears to be a reliable predictor of survival in patients with maxillary complex SCC treated by surgical resection.