Surgery as a single modality therapy for squamous cell carcinoma of the oral tongue

CT predictors of sub-centimeter occult lymph node metastases in oral cavity squamous cell carcinoma: A case-control study

BACKGROUND

For patients with oral cavity squamous cell carcinoma (OCSCC) without evidence of nodal metastasis (cN0) on pre-operative evaluation, there are no clear guidelines who should undergo elective neck dissection (END) versus clinical surveillance.

OBJECTIVE

To identify CT imaging characteristics of sub-centimeter lymph nodes that would help predict the likelihood of nodal metastases on pathology.

METHODS

Retrospective review of cN0 OCSCC patients at a tertiary academic medical center was performed. Inclusion criteria included elective neck dissection, pre-operative CT imaging and presence of metastatic disease within lymph nodes. Control group consisted of patients without nodal metastases on pathology. CT features that were evaluated included asymmetric size, disrupted fatty hilum, asymmetric number, presence of cortical nodule, cortical nodule size, and round/oval shape. We evaluated the associations between CT LN features and the presence of metastases using multi-level mixed-effects logistic regression models. Model evaluation was performed using 5-fold cross-validation. The positive predictive value (PPV) and negative predictive value (NPV) were calculated.

RESULTS

26 patients in each study and control groups were included. Three-level mixed-effects logistic regression models indicated round/oval shape (OR = 1.39, p = .01), asymmetric number (OR = 7.20, p = .005), and disrupted fatty hilum (OR = 3.31, p = .04) to be independently predictive in a 3-variable model with sensitivity = 38.0%, specificity = 92.0%, and PPV = 93.8%.

CONCLUSIONS

In cN0 OCSCC patients undergoing END, round/oval shape, asymmetric number, and disrupted fatty hilum of lymph nodes on pre-operative CT imaging are novel and highly predictive of occult nodal disease.

Surgical Extent for Oral Cancer: Emphasis on a Cut-Off Value for the Resection Margin Status: A Narrative Literature Review

The optimal cut-off point of the resection margin was recently debated in oral cancer. To evaluate the current evidence of the dynamic criteria of the resection margin, a review of the available literature was performed. Studies were sourced from PubMed and EMBASE by searching for the keywords "mouth neoplasm", "oral cancer", "oral cavity cancer", "oral squamous cell carcinoma", "tongue cancer", "margins of excision", "surgical margin" and "resection margin". We found approximately 998 articles on PubMed and 2227 articles on EMBASE. A total of 3225 articles was identified, and 2763 of those were left after removing the duplicates. By applying advanced filters about the relevance of the subjects, these were narrowed down to 111 articles. After the final exclusion, 42 full-text articles were reviewed. The universal cut-off criteria of 5 mm used for determining the resection margin status has been debated due to recent studies evaluating the impact of different margin criteria on patient prognosis. Of note, the degree of the microscopic extension from the gross tumor border correlates with tumor dimensions. Therefore, a relatively narrow safety margin can be justified in early-stage oral cancer without the additional risk of recurrence, while a wide safety margin might be required for advanced-stage oral cancer. This review suggests a surgical strategy to adjust the criteria for risk grouping and adjuvant treatments, according to individual tumor dimensions or characteristics. In the future, it might be possible to establish individual tumor-specific surgical margins and risk stratification during or after surgery. However, the results should be interpreted with caution because there is no strong evidence (e.g., prospective randomized controlled studies) yet to support the conclusions. Our study is meaningful in suggesting future research directions and discussions.

Multicentre study on resection margins in carcinoma of the oral cavity, oro-hypopharynx and larynx

Objective

The prognostic significance of the resection margins is still subject of conflicting opinions. The purpose of this paper is to report the results of a study on the margins in carcinoma of the oral cavity, oro-hypopharynx and larynx.

Methods

A multicentre prospective study was carried out between 2015 and 2018 with the participation of 10 Italian reference hospitals. The primary objective was to evaluate local control in patients with well-defined clinical characteristics and comprehensive histopathological information.

Results

During the study period, 455 patients were enrolled; the minimum follow-up was 2 years. Previous treatment, grading and fresh specimen examination were identified as risk factors for local control in multivariate analysis. On the basis of these results, it seems possible to delineate “risk profiles” for different oncological outcomes.

Discussion

The prognostic significance of the margins is reduced, and other risk factors emerge, which require diversified treatment and follow-up.

Conclusions

Multidisciplinary treatment with adjuvant therapy, if indicated, reduces the prognostic importance of margins. Collaboration with a pathologist is an additional favourable prognostic factor and quality indicator.

An appendix with literature review is present in the online version.

Prognostic outcomes of OSCC derived from proliferative verrucous leukoplakia: a systematic review

OBJECTIVE

This study aimed to evaluate prognostic outcomes of PVL-derived oral squamous cell carcinomas (P-OSCC) based on recurrence, new primary tumour, metastasis and survival information.

STUDY DESIGN

Five databases and grey literature were searched electronically with the following main keywords (proliferative verrucous leukoplakia, squamous cell carcinoma and malignant transformation) to answer the following review question: 'Are survival outcomes for P-OSCC worse?' based on the PECOS principle. The Joanna Briggs Institute Critical Appraisal tool was used to identify possible biases and assess the quality of each of the primary studies.

RESULTS

A total of 21 articles met the inclusion criteria, and the results of this systematic review suggest that P-OSCC can recur and generate new primary tumours; however, metastases are rare. Thus, most patients remain alive for an average period of 5 years.

CONCLUSION

Apparently, P-OSCC has better clinical prognostic characteristics than conventional OSCC. There is a lack of information on the main prognostic outcomes of P-OSCC; therefore, specific studies must be performed to achieve a better comparison between P-OSCC and conventional OSCC progression.

The role of postoperative radiotherapy in pN1 oral cavity cancer without extranodal extension

Background

The administration of postoperative radiotherapy remains controversial in pN1 oral cavity cancer patients without extranodal extension. The aim is to determine whether postoperative radiotherapy reduces the neck recurrence rate and improves the survival outcomes of pN1 patients.

Methods

This study consecutively enrolled 1056 patients with newly diagnosed oral squamous cell carcinoma who underwent tumor wide excision and neck dissection from September 2002 to November 2019. One hundred two pN1 patients without extranodal extension were eligible for analysis. Then, a subgroup analysis of 40 patients was performed after patients with other adverse risk factors (positive margins, close margins, lymphovascular invasion, perineural invasion, tumor depth ≥ 10 mm, and poor histological differentiation) were excluded.

Results

Of the 102 eligible pN1 patients, 26 patients received surgery alone, and 76 received postoperative radiotherapy. No significant differences were observed in the neck recurrence rate (7.7% vs. 15.8%, p = 0.30). Similarly, in patients without other adverse risk factors, no significant differences were observed in the neck recurrence rate (5% vs. 20%, p = 0.15) between surgery alone group and postoperative radiotherapy group. Moreover, no significant difference was found in the neck recurrence-free survival rate, overall survival, and disease-specific survival (77.1% vs. 52.5%, p = 0.42, 83.5% vs. 64.5%, p = 0.81, and 88.2% vs. 67.9%, p = 0.34, respectively).

Conclusion

Postoperative radiotherapy did not significantly decrease the probability of neck recurrence and survival outcomes in pN1 patients without extranodal extension. Radical surgery alone may be considered sufficient treatment for pN1 patients without other adverse risk factors.

Use of Indocyanine Green Fluorescent Imaging in the Assessment of a Tongue Flap After Lateral Hemiglossectomy

Indocyanine green (ICG) angiography is a real-time imaging modality that can be used to assess intraoperative tissue perfusion. ICG dye has proven to be feasible, safe, and cost-effective, especially for muscle flaps during complex reconstructions. To our knowledge, we discuss the first use of ICG angiography for the real-time assessment of a tongue flap following left lateral hemiglossectomy. ICG angiography showed excellent perfusion of the tongue and tongue flap, which subsequently led to an uncomplicated postoperative recovery.

Impact of histological Oral Tongue Cancer margins on locoregional recurrence: A multi-centre retrospective analysis

OBJECTIVES

To assess the effect of the histological margins (HM) upon locoregional failure (LRF) and overall survival (OS) for oral tongue squamous cell carcinoma (OTSCC).

MATERIALS AND METHODS

We undertook a retrospective review of 258 patients, across two institutions, treated for OTSCC between 2007 and 2016. A Cox-proportional hazards model was used to compare the relative hazard ratio of HM to the accepted standard of 5 mm margins for LRF and OS.

RESULTS

The median follow up period was 4.8 years. The 5 year OS and freedom from LRF were 69% and 75% respectively. The Cox-proportional hazards model adjusted for age, DOI and LVI showed increasing risk of mortality and LRF with decreasing HM widths of <5 mm.

CONCLUSION

HM >5 mm were associated with a risk reduction of both LRF and mortality in OTSCC. This study supports >5 mm HM being the oncologic goal of surgery.

Patient-Reported Quality of Life After Resection With Primary Closure for Oral Tongue Carcinoma

OBJECTIVES/HYPOTHESIS

For early-stage oral tongue carcinoma and carcinoma in situ (ESOTCCIS), we evaluated patient-reported quality-of-life (QOL) outcomes following resection with primary closure (R-PC).

STUDY DESIGN

Retrospective review at an academic cancer center.

METHODS

Thirty-nine ESOTCCIS patients (Tis, T1, T2) who underwent R-PC without radiation completed the University of Washington Quality of Life Questionnaire Version 4 (UW-QOL) at least 6 months since R-PC (mean = 2.39 years; range = 0.5-6.7 years). We compared UW-QOL scores for pain, swallowing, chewing, speech, and taste to established normative population scores. Multivariable regression analysis evaluated factors associated with QOL impairment.

RESULTS

ESOTCCIS patients who underwent R-PC in comparison to the normative population reported significantly worse mean speech (87.7 vs. 98, P < .001) and taste (85.6 vs. 95, P = .002) scores and no significant differences in mean pain (91.7 vs. 86, P = .96), swallowing (100 vs. 98, P = .98), chewing (97.4 vs. 94, P = .98) scores. For speech and taste, 59% (23/39) reported no postoperative change from baseline, whereas 41% (16/39) and 35.9% (14/39) reported mild impairment, respectively. Overall, postoperative QOL was reported as good, very good, or outstanding by 87.2% (34/39). Higher American Society of Anesthesiologists class, cT1 compared to CIS, and ventral tongue involvement were independently associated with worse speech. Age < 60 years was independently associated with worse taste.

CONCLUSIONS

ESOTCCIS patients who undergo R-PC without radiation can expect long-term swallowing, chewing, and pain to be in the normative range. Although a majority of patients can expect to achieve normative speech and taste outcomes, R-PC carries the risks of mild speech and/or taste impairments.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:312-318, 2021.

The economic burden of oral squamous cell carcinoma in Australia

OBJECTIVES

The financial burden of treatment for oral squamous cell carcinoma in Australia has never been reported, and there is a paucity of international data. Here, we report the direct costs of treatment of surgically resectable oral cancer in a tertiary public hospital in Australia over a 15-year period.

MATERIALS AND METHODS

Pathology department records, records of hospital attendance and hospital finance department records were interrogated to determine the direct costs of inpatient and outpatient treatment. Costs were adjusted using the total health price index so that all costs were equivalent to costings for the 2016/2017 financial year.

RESULTS

A total of 113 cases were identified as suitable for inclusion. Complete inpatient and outpatient hospital attendance and costing data for treatment and subsequent 2-year follow-up was available for 29 cases. The average total cost over the 2-year period was $92 958AUD (median $102 722, range $11 662-$181 512). On average, 92.8% of costs were incurred in the first year post-diagnosis. Inpatient costs, outpatient costs and total costs increased with increasing pathological cancer stage. Both 1- and 2-year post-diagnosis overall cost for patients with Stage 4 oral cavity cancer were more than two times greater than for patients with Stage 1 oral cancer.

CONCLUSION

It is well documented that patients diagnosed at an earlier stage will have better survival outcomes, and it is assumed that the economic burden of their treatment will be less. We have shown that there is a direct correlation between cancer stage and cancer treatment cost. The findings provide clear economic support for oral cancer screening initiatives to detect earlier stage cancers, and the need to investigate novel techniques and technologies to detect oral squamous cell carcinoma early and reduce recurrence and mortality rates.

Surgical Margins: The Perspective of Pathology

Neoplasms of the head and neck constitute a broad spectrum of benign and malignant entities. When treatment involves resection, assessment of the surgical margins represents an important component of the pathologic examination. Margin status is an important indicator of a complete surgical resection. The ability to generalize conclusions such as 'safe distance' measurements from work performed mSCCa or cutaneous malignancy to other types of neoplasms in the head and neck region seems limited. This article reviews conditions and considerations for reliable margin assessment and interpretation.

Long-term outcome of high-dose-rate brachytherapy and perioperative brachytherapy in early mobile tongue cancer

Purpose

To evaluate long-term outcome of high-dose-rate brachytherapy and perioperative brachytherapy in early mobile tongue cancer.

Material and methods

Seventy-three patients with clinically staged T1/T2 N0 M0 of mobile tongue cancer were studied retrospectively. Between January 2000 and September 2010, 47 patients underwent high-dose-rate brachytherapy (HDR-BT) alone and 26 patients underwent perioperative brachytherapy (PB). Endpoints were overall survival, disease-free survival, loco-regional control, and late side effects.

Results

Median age was 52 years and median follow-up was 74 months (range, 60-180). There were no local recurrences in the PB group. Overall survival at 6 years was 74.7% vs. 92.3% in HBR BT and PB group, respectively (p = 0.032). Disease-free survival at 6 years was 55.3% vs. 92.3% respectively in HDR-BT and PB (p = 0.002). Disease-free survival at 6 years in tumor histologic grade 1/2 patients was 76.3 months versus 40% in grade 3 patients. Nodal recurrence-free rate at 6 years was 67.5% with HDR-BT only, and 96.2% with PB (p = 0.007). In HDR BT only group, nodal recurrence-free rate at 6 years in T1 patients was 89.8% versus 29.4% in T2 patients. 16% and 7% patients developed soft tissue necrosis and osteoradionecrosis, respectively. Multivariate Cox proportional hazards analysis revealed significant correlation of local recurrence with tumor grade (p = 0.029), nodal recurrence with T-stage (p = 0.007), and disease-free survival with age (p = 0.003) and T stage (p = 0.026).

Conclusions

HDR-BT alone gives acceptable loco-regional control in T1 tumors. T2 stage tumors should not be treated by brachytherapy alone in view of high failure rates in nodal regions and should undergo either neck dissection or nodal irradiation. Perioperative brachytherapy is investigational and can be considered in patients who are at high-risk for local recurrence in patients undergoing surgery alone.

A 16-gene signature predicting prognosis of patients with oral tongue squamous cell carcinoma

Background

Oral tongue squamous cell carcinoma (OTSCC) is the most common subtype of oral cancer. A predictive gene signature is necessary for prognosis of OTSCC.

Methods

Five microarray data sets of OTSCC from the Gene Expression Omnibus (GEO) and one data set from The Cancer Genome Atlas (TCGA) were obtained. Differentially expressed genes (DEGs) of GEO data sets were identified by integrated analysis. The DEGs associated with prognosis were screened in the TCGA data set by univariate survival analysis to obtain a gene signature. A risk score was calculated as the summation of weighted expression levels with coefficients by Cox analysis. The signature was used to distinguish carcinoma, estimated by receiver operator characteristic curves and the area under the curve (AUC). All were validated in the GEO and TCGA data sets.

Results

Integrated analysis of GEO data sets revealed 300 DEGs. A 16-gene signature and a risk score were developed after survival analysis. The risk score was effective to stratify patients into high-risk and low-risk groups in the TCGA data set (P < 0.001). The 16-gene signature was valid to distinguish the carcinoma from normal samples (AUC 0.872, P < 0.001).

Discussion

We identified a useful 16-gene signature for prognosis of OTSCC patients, which could be applied to clinical practice. Further studies were needed to prove the findings.

Distribution of cervical metastasis in tongue cancer: Are occult metastases predictable? A retrospective study of 117 oral tongue carcinomas

PURPOSE

The aims of this study were to evaluate the pattern of distribution of cervical metastasis in tongue cancer and to analyze the various therapeutic options available. Moreover, numerous histological features were analyzed to assess the impact of each factor on overall survival.

MATERIALS AND METHODS

A retrospective analysis was conducted using the records of patients diagnosed with oral tongue cancer between 2004 and 2010 in the Virgen de las Nieves University Hospital (HUVN). A total of 117 patients with squamous cell carcinoma of the tongue treated with glossectomy and selective neck dissection were included in the study. The pattern of distribution of cervical metastases and numerous histological features such as T-stage, N stage, surgical margins, tumor thickness, extracapsular spread (ECS) and vascular invasion were analyzed.

RESULTS

Level IIA was the most affected, followed by level III. The rate of skip metastasis was 7,4%. T and N stage, tumor thickness, ECS, surgical margins and nerve and vascular invasion were associated with poorer outcomes in terms of overall survival (p < 0,001).

CONCLUSION

Cervical nodal involvement represents the major prognostic factor in tongue cancer. A total of 51,2% of N+ patients presented T1 and T2 tumors in this series. We recommend performing neck dissection at the early stages in clinically N0 patients when a tumor thickness >0,4 cm is suspected. Level IV should be included in the neck dissection of clinically N0 tongue cancer.

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.

Natriuretic peptide receptor A is related to the expression of vascular endothelial growth factors A and C, and is associated with the invasion potential of tongue squamous cell carcinoma

Natriuretic peptide receptor A (NPRA) is one of the natriuretic peptide receptors. NPRA has been reported to play a role in the carcinogenesis of various tumours, as well as functional roles in renal, cardiovascular, endocrine, and skeletal homeostasis. The clinicopathological significance of NPRA in tongue squamous cell carcinoma (TSCC) was examined in this study. The overexpression of NPRA was more frequent in TSCC (21/58, 36.2%) than in the normal oral epithelium (0/10, 0%) (P<0.05). It was also more frequently observed in cancers with higher grades according to the pattern of invasion (grades 1-2 vs. grades 3-4, P<0.01). Additionally, there was a tendency towards an association between the N classification and NPRA expression (N0 vs. N1-2, P=0.06). Significant correlations were also observed between the expression of NPRA and that of VEGF-A (P<0.001) and VEGF-C (P<0.001). The high-NPRA expression group had a significantly poorer prognosis, with a 5-year disease-specific survival rate of 39.7%, compared to 97.0% in the low-expression group (P<0.001). Multivariate analysis suggested that the overexpression of NPRA may also be an independent prognostic factor (P<0.05). In conclusion, NPRA is associated with VEGF expression levels, invasion, and metastasis, and may be a prognostic factor in TSCC patients.

Association of Lymphovascular Space Invasion With Locoregional Failure and Survival in Patients With Node-Negative Oral Tongue Cancers

Importance

The indications for adjuvant therapy in resected oral tongue cancers are based on both clinical and pathological factors, with clear evidence for adjuvant radiation in patients with pathologically positive neck lymph nodes, positive margins, and extracapsular extension, but the data for patients with no nodal disease are sparse.

Objective

To investigate determinants of failure and survival in patients with node-negative oral tongue cancer.

Design, Setting, and Participants

Medical records for patients with oral tongue cancer treated with definitive surgery from 2003 to 2013 were reviewed. All patients were cN0 negative and classified as pathologically node-negative (pN0) if a neck dissection was performed. Patients received adjuvant radiotherapy (RT) or chemoradiotherapy (CRT) based on standard clinical and pathological determinants.

Main Outcomes and Measures

Kaplan-Meier and multivariable (MVA) logistic regression and Cox proportional hazard regression analyses were performed to identify patient, tumor, and treatment characteristics predictive of locoregional control (LRC) and overall survival (OS).

Results

A total of 180 patients met entry criteria, with a median follow-up time of 4.9 years (range, 0.9-12.5 years); 102 patients (56.7%) were female and 42 patients (23.3%) were younger than 45 years at diagnosis. One hundred fifty-three patients (85%) had T1/T2 tumors, and 112 patients (62%) had elective neck dissections with confirmed pN0. Lymphovascular space invasion (LVSI) was present in 36 patients (20%). On MVA, LVSI (OR, 0.06; 95% CI, 0.02-0.19; P < .01) was associated with worse LRC. Elective neck dissection (odds ratio [OR], 2.99; 95% CI, 1.16-7.73; P = .02) and receipt of RT (OR, 7.74; 95% CI, 2.27-26.42; P < .01) were associated with improved LRC. Three-year LRC rates were significantly lower for patients with LVSI (38.8%; 95% CI, 22.8%, 54.6%) than those without LVSI (81.9%; 95% CI, 74.4%, 87.4%). On MVA, only LVSI (hazard ratio, 2.20; 95% CI, 1.19-4.06; P = .01) and age greater than 44 years (hazard ratio, 4.38; 95% CI, 1.34-14.27; P = .01) were associated with worse OS. Three-year OS rates were significantly lower in patients with LVSI (71.3%; 95% CI, 53.2%-83.4%) than those without LVSI (90.3%; 95% CI, 83.8%-94.3%).

Conclusions and Relevance

Lymphovascular space invasion in patients with node-negative oral tongue cancer treated with upfront definitive surgery is associated with worse LRC and OS. Node-negative oral cavity cancers with LVSI warrant consideration of further adjuvant therapy, which should be further evaluated in a prospective setting.

Skp2 Regulates the Expression of MMP-2 and MMP-9, and Enhances the Invasion Potential of Oral Squamous Cell Carcinoma

Oral squamous cell carcinoma (OSCC) is the most common malignant tumor of the head and neck regions and accounts for more than 90 % of cancers in the oral cavity. S-phase kinase-associated protein-2 (Skp2) is a member of the F-box protein family and the substrate recognition subunit of the Skp1-Cullin-F box protein E3 ubiquitin ligase complex. Skp2 is oncogenic and overexpressed in human cancers. The aims of the present study were to determine the clinicopathological significance of Skp2 in OSCC and clarify its function in OSCC cell lines in vitro. Multiple methods including immunohistochemical staining, RT-PCR, western blotting, migration and invasion assays, and siRNA transfection were employed in order to investigate the clinicopathological significance and molecular function of Skp2 in OSCC. The overexpression of Skp2 was more frequent in OSCC than in the normal oral epithelium. It was also more frequently detected in cancers with higher grades according to the T classification, N classification, and pattern of invasion. The high-Skp2 expression group had a significantly poorer prognosis, at 30.1 %, than that of the low-expression group, at 63.0 %. The downregulation of Skp2 decreased migration and invasion potentials in HSC3 cells. Moreover, the suppression of Skp2 reduced the enzyme activities of MMP-2 and MMP-9 via Sp1. Skp2 may be a prognostic factor in OSCC patients, and may also play crucial roles in the migration and invasion potentials of OSCC cells.

A meta-analysis of margin size and local recurrence in oral squamous cell carcinoma

OBJECTIVES

Excision margins for oral squamous cell carcinoma (OSCC) are poorly understood. Close (<5mm) and involved (<1mm) pathological margins are key indicators of the need for adjuvant treatment. This review aimed to assess the impact of pathological margin size on local recurrence rates.

METHODS

MEDLINE and EMBASE were searched for studies that looked at local recurrence following excision of primary OSCC without adjuvant therapy. Five studies met the inclusion criteria.

RESULTS

Recurrence rates were pooled to give a 21% absolute risk reduction (95% confidence interval 12-30%, p=<0.00001) in local recurrence with margins clear by more than 5mm. Unweighted pooled recurrence rates were 20% in patients with margins clear by more than 5mm.

CONCLUSION

These findings suggest that a 5mm pathological margin is the minimum acceptable margin size in OSCC.

FOXC2 expression is associated with tumor proliferation and invasion potential in oral tongue squamous cell carcinoma

Forkhead box protein C2 (FOXC2) is a gene encoding a transcription factor that controls the generation of mesodermal tissue including vascular and lymphatic tissues. FOXC2 has previously been associated with EMT and tumor angiogenesis in various cancers. Moreover, a relationship between the expression of FOXC2 and poor prognosis has been reported in various cancers. We herein examined the clinicopathological significance of FOXC2 in oral tongue squamous cell carcinoma (OTSCC) and attempted to clarify the function of FOXC2 in OTSCC cell lines in vitro. The overexpression of FOXC2 was more frequent in cancers with higher grades according to the pattern of invasion (grade 4 vs. 1-3; p < 0.05). A correlation was observed between the expression of FOXC2 and that of VEGF-A and -C (VEGF-A; p < 0.05, VEGF-C; p < 0.001). The high-FOXC2 expression group had a significantly poorer prognosis than that of the low-expression group (p < 0.001). Multivariate analysis indicated that the overexpression of FOXC2 may also be an independent prognostic factor, similar to N classification (N0 vs 1/2; p < 0.05), stage classification (stage I/II vs III/IV; p < 0.05), pattern of invasion (grade 1-3vs 4; p < 0.05), local recurrence (local recurrence (+) vs (-); p < 0.01), and the overexpression of FOXC2 (FOXC2 overexpression (-) vs.(+); p < 0.05). In the OTSCC cell line analysis, the expression of FOXC2 was also associated with proliferation and invasion potential. These results strongly suggest that the overexpression of FOXC2 may be a potent predictor of survival in OTSCC patients.

Survival after curative surgical treatment for primary oral squamous cell carcinoma

The purpose of this retrospective study was to review recurrence rate and survival of patients with primary oral squamous cell carcinoma (OSCC) that have received surgical treatment and adjuvant radio-therapy with curative intent in our clinic over a 6-year period. A total of 106 patients were included. The 5-year overall survival (OS) was 41%, 5-year disease-specific survival (DSS) was 77%, 5-year disease-free survival (DFS) was 72%. DSS was significantly different between early and advanced stage, 87% and 67% respectively (p = 0.04). Recurrence significantly affected survival: OS with or without recurrence at 20 months was 24% and 87% respectively (p < 0.001). Although a guideline based approach for the treatment of OSCC might provide an advantage, more data are needed for these guidelines to be based on.

Tumor thickness as an independent risk factor of early recurrence in oral cavity squamous cell carcinoma

The aim is to determine if tumor thickness is a risk factor related to the development of early recurrences in surgically treated oral cavity squamous cell carcinoma (SCC). Retrospective cohort study conducted at Instituto do Câncer do Estado de São Paulo (ICESP). Fifty-seven patients with oral cavity SCC (excluding lip tumors and patients previously submitted to any treatment) were analyzed regarding the occurrence of an early disease progression (locoregional or distant metastasis) within the first 12 months after initial treatment. Tumor thickness and other histological characteristics related to the development of recurrence up to 1 year after treatment were tested. Results demonstrated that tumor thickness greater than 10 mm (P = 0.034), as well as angiolymphatic invasion (P = 0.001), perineural invasion (P = 0.041) and lymph-node metastasis (P = 0.021) was associated with a worse 12-month disease-free survival (Log-Rank test). In multivariate analysis, tumor thickness greater than 10 mm emerged as an independent risk factor for early recurrence in oral cavity tumors (HR = 3.4, 95% CI: 1.005-11.690; P = 0.049--Cox regression). Post-operative radiotherapy seems to be a protective factor for early recurrences in patients with tumor thickness greater than 10 mm (P = 0.017--Log-Rank test; HR = 0.32, 95% CI: 0.12-0.87, P = 0.026--Cox regression). The results of the present research suggest that tumor thickness greater than 10 mm may be an independent adverse factor for early progression of surgically treated oral cavity SCC. Adjuvant therapies, in particular post-operative radiotherapy, should be advocated in this group of patients, regardless of the co-existence of other well-described histological risk factors.

Overexpression of CRKII increases migration and invasive potential in oral squamous cell carcinoma

CT10 regulator of kinase (CRK) was originally identified as an oncogene product of v-CRK in a CT10 chicken retrovirus system. Overexpression of CRKII has been reported in several human cancers. CRKII regulates cell migration, morphogenesis, invasion, phagocytosis, and survival; however, the underlying mechanisms are not well understood. In the present study, we evaluated the possibility of CRKII as an appropriate molecular target for cancer gene therapy. The expression of CRKII in 71 primary oral squamous cell carcinomas and 10 normal oral mucosal specimens was determined immunohistochemically, and the correlation of CRKII overexpression with clinicopathological factors was evaluated. Overexpression of CRKII was detected in 41 of 70 oral squamous cell carcinomas, the frequency being more significant than in normal oral mucosa. In addition, CRKII overexpression was more frequent in higher-grade cancers according to the T classification, N classification, and invasive pattern. Moreover, RNAi-mediated suppression of CRKII expression reduced the migration and invasion potential of an oral squamous cell carcinoma cell line, OSC20. Downregulation of CRKII expression also reduced the expression of Dock180, p130Cas, and Rac1, and the actin-associated scaffolding protein cortactin. These results indicate that the overexpression of CRKII is tightly associated with an aggressive phenotype of oral squamous cell carcinoma. Therefore, we propose that CRKII could be a potential molecular target of gene therapy by RNAi-targeting in oral squamous cell carcinoma.

Aesthetic and functional radical surgery in young patients with stage one or two tongue cancer: a preliminary report

INTRODUCTION

The effect of an initial radical cure and the post-operative quality of life in young patients with stage one or two tongue cancer seems to be more important than in old patients. The aim of this study was to achieve both optimal surgical effectiveness and improved post-operative quality of life for young patients with stage one or two tongue cancer.

MATERIALS AND METHODS

7 patients under 40 years of age with T(1)-T(2)N(0)M(0) squamous cell carcinoma of tongue underwent aesthetic and functional radical surgery in which reconstruction of the defect in the oral cavity and conservation of the main functional organs in neck with good scar aesthetics in the face and neck were performed. The outcomes were assessed clinically.

RESULTS

No tumour recurrence was found in the tongue, floor of mouth or neck at the end of follow-up (at least 37 months). The appearance of the tongue and oral function was retained; function in face, neck and shoulder was maintained; a satisfactory cosmetic appearance of the face and neck was achieved.

CONCLUSIONS

Aesthetic and functional radical surgery could ensure radical cure and unchanged, or improved post-operative, quality of life in young patients with stage one or two tongue cancer.

Overexpression of cortactin increases invasion potential in oral squamous cell carcinoma

Cortactin, an F-actin binding protein, stabilizes F-actin networks and promotes actin polymerization by activating the Arp2/3 complex. Overexpression of cortactin has been reported in several human cancers. Cortactin stimulates cell migration, invasion, and experimental metastasis. However, the underlying mechanism is not still understood. In the present study, we therefore evaluated the possibility that cortactin could be appropriate as a molecular target for cancer gene therapy. In 70 primary oral squamous cell carcinomas and 10 normal oral mucosal specimens, cortactin expression was evaluated by immunological analyses, and the correlations of the overexpression of cortactin with clinicopathologic factors were evaluated. Overexpression of cortactin was detected in 32 of 70 oral squamous cell carcinomas; significantly more frequently than in normal oral mucosa. Cortactin overexpression was more frequent in higher grade cancers according to T classification, N classifications, and invasive pattern. Moreover, RNAi-mediated decrease in cortactin expression reduced invasion. Downregulation of cortactin expression increased the expression levels of E-cadherin, β-catenin, and EpCAM. The siRNA of cortactin also reduced PTHrP expression via EGF signaling. These results consistently indicate that the overexpression of cortactin is strongly associated with an aggressive phenotype of oral squamous cell carcinoma. In conclusion, we propose that cortactin could be a potential molecular target of gene therapy by RNAi targeting in oral squamous cell carcinoma.

RNAi-mediated down-regulation of alpha-actinin-4 decreases invasion potential in oral squamous cell carcinoma

alpha-actinin-4, originally identified as an actin-binding protein associated with cell motility, invasion, and metastasis of cancer cells, appears to be overexpressed in various human epithelial carcinomas, including colorectal, breast, esophageal, ovarian, and non-small cell lung carcinomas. The authors evaluated whether alpha-actinin-4 might be appropriate as a molecular target for cancer gene therapy. In 64 primary oral squamous cell carcinomas (OSCCs) and 10 normal oral mucosal specimens, and in seven human OSCC cell lines, alpha-actinin-4 expression was evaluated immunologically and correlations with clinicopathologic factors were examined. Overexpression of alpha-actinin-4 was detected in 38 of 64 oral squamous cell carcinomas (70%); significantly more frequently than in normal oral mucosa. The expression of alpha-actinin-4 was significantly associated with invasion potential defined by the Matrigel invasion assay. Cancer cell lines with higher alpha-actinin-4 expression had greater invasive potential. An RNAi-mediated decrease in alpha-actinin-4 expression reduced the invasion potential. These results indicated that the overexpression of alpha-actinin-4 was associated with an aggressive phenotype of OSCC. The study indicated that alpha-actinin-4 could be a potential molecular target for gene therapy by RNAi targeting for OSCC.

Poor prognosis in patients with stage I and II oral tongue squamous cell carcinoma

BACKGROUND

The objective of this study was to compare survival in patients with squamous cell carcinoma (SCC) of the oral tongue with that in patients with SCC in other oral cavity subsites.

METHODS

Patients with stage I and II (T1-T2N0M0) SCC of the oral cavity diagnosed between 1988 and 2004 were queried by using the Surveillance, Epidemiology, and End Results (SEER) database. The log-rank test was used to compare the overall survival (OS) and cause-specific survival (CSS) of patients who had oral tongue SCC with those of patients who had SCC of other oral cavity subsites. A Cox proportional hazards multivariate analysis was performed to evaluate the influence of covariates on the risk of CSS and OS.

RESULTS

Between 1988 and 2004, 6791 patients with stage I and II SCC of the oral cavity were identified. Among them, 40% had oral tongue SCC, and 60% had SCC of other oral cavity subsites. The median patient age was 64 years. The 5-year OS and CSS rates were 60.9% and 83.5%, respectively, for patients with oral tongue SCC versus 64.7% and 94.1%, respectively, for patients with SCC of other oral cavity subsites (OS: hazard ratio, 1.24; P< .0001; CSS: hazard ratio, 3.04; P< .0001). On multivariate analysis, OS and CSS were influenced significantly by T classification, age, sex, and oral tongue subsite. The CSS for patients who had stage I and II oral tongue SCC also was unfavorable compared with the CSS for stage-matched patients who had SCC of other head and neck sites.

CONCLUSIONS

Oral tongue SCC was associated with poor survival compared with other oral cavity and head and neck sites. These data suggested a potential benefit for multimodality therapy in this cohort of patients.

Clinicopathologic significance of EpCAM expression in squamous cell carcinoma of the tongue and its possibility as a potential target for tongue cancer gene therapy

Epithelial adhesion molecule (EpCAM) is a transmembrane glycoprotein involved in intercellular adhesion. In particular, EpCAM appears to be overexpressed by the majority of human epithelial carcinomas, including colorectal, breast, head and neck, and hepatic carcinomas. We therefore hypothesized that EpCAM would be a good molecular target for cancer gene therapy. EpCAM protein expression in 48 primary tongue cancers and 10 normal oral mucosa was evaluated using anti-EpCAM immunohistochemistry, and correlation was examined with the clinicopathologic factors. In four human tongue cancer cell lines (SAS, HSC-2, OSC19 and OSC20), we investigated EpCAM expression by reverse transcription-polymerase chain reaction (RT-PCR). The invasive potential of cancer cells was evaluated using Matrigel invasion assay. Moreover, the effect of EpCAM inhibition was analyzed using RNA interference (RNAi). EpCAM overexpression was detected in 30 of 48 tongue cancers (62.5%), and was significantly higher in primary squamous cell carcinoma (SCC) of the tongue than in normal oral mucosa. The expression of EpCAM was significantly associated with tumor size, regional lymph node metastasis, histological differentiation and invasion pattern. Cancer cell lines with higher EpCAM expression had more invasive potential. Moreover, RNAi-mediated EpCAM reduction decreased the invasion potential and proliferation activity. These results indicated that the overexpression of EpCAM was correlated with a more aggressive phenotype of tongue cancer. Moreover, we suggested that EpCAM could be a molecular target, and that RNAi targeting EpCAM could be useful for tongue cancer gene therapy.

Management of the node negative early carcinoma tongue

OBJECTIVE

To determine the role of thickness of the primary lesion in early Squamous Cell Carcinoma (SCC) of the oral tongue for decision-making regarding the management of possible occult cervical node metastases.

SETTING

Tertiary referral centre

PATIENTS

Patients who were treated by the authors for early (T1, T2) primary lesions in the oral tongue in two malignancy treatment centres of the Armed Forces Medical Services were included in this prospective study. Where the primary lesion was less than 04 mm in depth, the neck was not addressed electively. Those who developed nodal disease in the neck on follow up were subjected to comprehensive neck dissection. In those patients where the tumour thickness was more than 04 mm, the neck was addressed with at least a supra-omohyoid neck dissection. Postoperative radiotherapy was given as per standard indications. The patients were followed up as per standard protocol.

RESULTS

Disease free survival rate achieved was 86% and this compares well with survival rates achieved by other workers.

CONCLUSION

Treatment of neck nodes in early (T1,T2) SCC of the oral tongue can be expectant in cases where tumour thickness is less than 04 mm, but where it is more than 04 mm elective treatment of the neck is recommended.

Unilateral, clinically T2N0, squamous cell carcinoma of the tongue: surgical outcome analysis

To determine the survival rate and analyse the predicting factors of recurrence in patients with unilateral, clinically T2N0 squamous cell carcinoma (SCC) of the tongue which does not cross the midline, a retrospective analysis of 32 such consecutive, previously untreated, cases was performed. All patients were initially treated by surgery between January 1992 and May 2004. All patients had neck dissections: 12 continuous, 20 discontinuous, 24 bilateral and 8 unilateral. Fourteen patients (44%) received adjunctive postoperative radiotherapy. Occult metastatic rates were 34% and 4% in ipsilateral and contralateral neck, respectively. Patients with pN0 cancer had a better 5-year disease-specific survival rate than those with pN+ cancer (85% versus 41%, P=0.005). Twelve patients (38%) had recurrences after the initial treatment. The recurrence rate was significantly higher in patients with pathologic nodal metastasis, peroral resection of the primary tumour or discontinuous neck dissection. The results suggest that the most effective surgical methods for treating unilateral T2N0 SCC of the tongue which does not cross the midline are: pull-through approach for primary lesion instead of peroral approach; continuous rather than discontinuous neck dissection and ipsilateral elective rather than bilateral routine elective neck dissection.

[Preoperative radiochemotherapy for advanced oral cavity tumours : the Kiel DOSAK experience regarding curability and quality of life]

BACKGROUND

According the guidelines of the German-Austrian-Swiss Council for maxillary and facial tumours (DOSAK), patients with advanced oral cavity tumours underwent preoperative radiochemotherapy followed by radical surgery. The results were to be evaluated with regard to curability and quality of life and compared with the current literature.

PATIENTS AND METHODS

Between 1993 and 1998, 52 patients were treated. Radiotherapy up to a total dose of 36 Gy was combined with one cycle of cisplatin (12.5 mg/m2, days 1-5) chemotherapy. Besides clinical data concerning radiogenic toxicity and surgical complications, quality of life after therapy was of special interest.

RESULTS

Three years after therapy 33 of 52 patients (63.5%) were alive, and after 5 years 19 of 33 patients (57.6%) were still alive. Seven patients (14.6%) had a local recurrence. Side effects of radiotherapy according RTOG scoring were minor; only one patient (1.9%) had grade 3 toxicity. Of 48 patients, 9 (18.7%) had no surgical complications. Quality of life was good in only 14 patients (29.2%); all the other patients (70.8%) suffered from impaired quality of life.

CONCLUSIONS

Preoperative radiochemotherapy in advanced oralcavity carcinomas with subsequent radical surgery is an effective treatment regarding long-term survival. The treatment is burdened by lasting impaired quality of life. High scientific priority should hence be directed to a steady improvement of quality of life in these patients.

A Novel Approach to Advanced Carcinoma of the Tongue: Cases Successfully Treated with Combination of Superselective Intra-Arterial Chemotherapy and External/High-Dose-Rate Interstitial Radiotherapy

OBJECTIVE

This study sought to evaluate the efficacy and safety of a novel treatment regimen, intra-arterial cisplatin infusion plus external/high-dose-rate radiotherapy.

METHODS

Superselective intra-arterial infusion of cisplatin (100-120 mg) was performed concomitantly with external radiotherapy in four patients with locally advanced carcinoma of the tongue. A high-dose-rate brachytherapy boost was performed after combination therapy in all patients. Brachytherapy was performed after external radiotherapy, and the treatment schedule was twice daily, with a fraction of 600 cGy up to a total of 30-48 Gy.

RESULTS

All patients completed the therapy as scheduled. There were no vascular or neurological complications. Grade III acute radiation mucositis developed in all patients but this did not necessitate a treatment break. With a mean follow-up period of 35 months, loco-regional control was obtained for all patients.

CONCLUSIONS

The combination of weekly administration of intra-arterial cisplatin plus external/high-dose-rate radiotherapy seems effective for advanced carcinoma of the tongue.

Oral tongue carcinoma and its treatment in Finland

Management of oral tongue squamous cell cancer (OTSCC) remains a challenge. This nationwide study reports the used treatment approach and the outcome of OTSCC in Finland. Retrospective study of OTSCC patients in 1995-1999 with a 5-year follow-up. The corresponding data from 1980 to 1989 is also included. About 235 patients (125 M, 110 F; mean age 61.6 years; range 24-90 years) were included, 77% had SCC of lateral border of the tongue and 25% were N+. Treatment with curative intent was given to 224 (95%) patients. Surgery of the primary tumour was performed in 218 (97%) patients and with a reconstruction in 69 (31%) patients. A neck dissection was performed ipsilaterally in 114 (51%) and bilaterally in 9 (4%) cases. Irradiation was given to 131 (58%) patients. The rate for locoregional recurrence was 28%. The 3- and 5-year overall survival (OS) rates were 66 and 47%, respectively. The corresponding disease specific survival (DSS) rates were 74 and 64%, respectively. The mean DSS for patients younger than 40 years and older than 40 years was 111 and 88 months, respectively (P < 0.02). The 3- and 5-year DSS rates were: Stage I, 88 and 74%; Stage II, 74 and 62%; Stage III, 79 and 71% and Stage IV, 36 and 33%, respectively. In the present study the surgical treatment approach seems effective in controlling early stage OTSCC but the modest survival, in spite of combination of radiotherapy and surgery, points out the need to consider new strategies in the management of advanced stage disease.

Treatment results and prognostic factors in oral tongue cancer: analysis of 80 patients

Treatment results and prognostic factors for 80 patients with oral tongue cancer admitted to Istanbul University Oncology Institute between 1987 and 2000 were retrospectively analysed. The patients were treated by surgery and postoperative or curative radiotherapy. Median age was 55 (22-93) out of which 41 patients (51%) were male and 39 (49%) were female. One patient (1%) had stage I disease, 28 patients (36%) stage II, 18 patients (23%) stage III and 32 patients (40%) stage IVA disease. Nineteen patients (24%) were medically inoperable or refused surgical treatment, so were treated with curative radiotherapy to a total dose of 70Gy (group A). The remaining 61 patients (76%) were treated with surgery and postoperative external beam radiotherapy (group B). The median follow-up time was 44 months. The 5-year overall and loco-regional disease-free survival rates were 42% and 46%, respectively. The 5-year overall survival rates were 16% in group A and 49% in group B (P=0.0002). The 5-year disease-specific survival rate was 23% in group A while in group B it was 49%; the difference was statistically significant (P=0.02). Combined treatment improves overall and disease-free survival in patients with stage II, III and IVA oral tongue cancer. In patients who are not candidates for surgery, the effect of radiotherapy may be increased with the use of brachytherapy.

Ablation of advanced tongue or base of tongue cancer and reconstruction with free flap: Functional outcomes

AIM

To evaluate the functional outcomes of patients who underwent total or nearly total glossectomy for advanced tongue or base of tongue cancer.

MATERIAL AND METHODS

We used the radial forearm free flap (RFFF), anterior lateral thigh flap (ALTF) or fibular osteocutaneous flap (FOCF) to reconstruct the oral defect after radical resection in 39 patients undergoing total or nearly total glossectomy with laryngeal preservation.

RESULTS

Good functional outcomes, measured by independent feeding, speech and swallowing were achieved in 35, 36 and 35 patients, respectively. The cumulative 4-year survival rates were 63.8% for tongue cancer and 42.9% for base of tongue cancer.

CONCLUSION

Reconstruction with free flaps is a feasible method to restore the functional outcomes in speech and deglutition among patients who undergo total or nearly total glossectomy with laryngeal preservation.

A comparison of brachytherapy and surgery for the treatment of stage I–II squamous cell carcinoma of the tongue

The treatment method for early stage tongue cancer is still controversial in Japan. The aim of this study is to compare the prognosis for patients with early tongue cancer treated with brachytherapy and surgery. A retrospective study was conducted to compare the efficacy of low-dose-rate brachytherapy (LDR), high-dose-rate brachytherapy (HDR), and surgery for early tongue cancer. A total of 180 patients with stage I-II tongue cancer were divided into three treatment groups: LDR (78), HDR (26), and surgery (71). Local recurrence was seen in thirteen patients (17%) of the LDR, nine (35%) of the HDR, and four (6%) of the surgery group. After salvage therapy, final local cure was obtained for 71 patients (91%) of the LDR, 22 (85%) of the HDR, and 71 (100%) of the surgery group. Neck failure was recorded for eight patients in the LDR, six in the HDR, and three in the surgery group. The respective 5-year overall survival rates for the LDR, HDR and surgery groups were 84.0%, 72.9%, 95.4% for stage I, and 72.2%, 51.5%, 93.8% for stage II. These findings show that surgery is the optimal treatment method for patients with stage I-II tongue cancer.

Prognostic significance of late cervical metastasis and distant failure in patients with stage I and II oral tongue cancers

Stage I and II oral tongue cancers (OTC) generally have a favorable prognosis, but there are some early OTC cases with a poor prognosis. OTC is known for its propensity for subclinical nodal metastasis and, moreover, we must devise a strategy that takes account of the possibility of recurrence and distant metastasis. In the current study, 90 previously untreated patients with stage I or II OTC who underwent surgical treatment were eligible for review. The authors investigated the associations of their clinico-pathologic factors with disease outcomes, and also examined the postoperative course for patients with a poor prognosis. The most common cause of death was distant metastasis and late cervical lymph node metastasis (LCM) was the significantly independent prognostic variable. Since LCM can be treated with salvage surgery, the central issue is to control patients with distant metastises who are free of disease in their loco-regional sites.

Concurrent chemoradiotherapy with pirarubicin and 5-fluorouracil for resectable oral and maxillary carcinoma

OBJECTIVE

We present the response rate and adverse effects of our regimen of concurrent chemoradiotherapy with pirarubicin (THP) and 5-fluorouracil (5-FU) for oral and maxillary carcinoma.

PATIENTS AND METHODS

Fifteen patients with oral (10 cases) or maxillary (5 cases) squamous cell carcinoma who underwent our concurrent chemoradiotherapy with the combination of intraarterial pirarubicin, intravenous continuous 5-fluorouracil, and radiation between March 2001 and February 2003 in our department were entered in this study. THP (5 mg/day) was infused into the lingual or maxillary artery one hour before radiation on days 1-5 and 8-12, while intravenous 5-FU (150 mg/m2/day) was instilled continuously on days 1-5, 8-12, 15-19, and 22-26 in accordance with the radiation schedule (2 Gy/day). Consequently, total doses of THP, 5-FU, and radiation were 50 mg, 3000 mg/m2 and 40 Gy, respectively. After the treatment series, response rate and adverse effects were evaluated.

RESULTS

Response rate achieved 100% (12 cases exhibited a complete response and the remaining 3 a partial response). Notably, all 10 patients with oral carcinoma exhibited complete response. The main adverse effects were leucopenia (6/15) and mucositis (6/15), both of which were acceptable.

CONCLUSIONS

This concurrent chemoradiotherapy is very useful for oral and maxillary carcinoma as a preoperative modality with remarkably high response rate and acceptable adverse events.

Relevance of positive margins in case of adjuvant therapy of oral cancer

Positive or clean surgical margins are of great prognostic interest in the surgical treatment of oral and oropharyngeal cancer with poor survival of patients burdened with positive margins. The impact of postoperative treatment modalities on the survival of these patients is debated. The relevance of positive margins was investigated in three patient populations (a group treated by surgery only, a group with postoperative polychemotherapy, and a group with a multi-modality treatment comprising postoperative radiation with concurrent chemotherapy) which were compared retrospectively. Patients treated with adjuvant regimens following resection in healthy margins had a survival advantage as compared to the surgery only group possibly due to less local relapses and longer relapse latencies. Overall disease-free survival was better in the groups with adjuvant therapy irrespective of free or positive margins. Survival rates following positive surgical margins were worse in all three groups as compared to the respective subgroups with healthy margins. A second resection in patients with positive margins, executed in the group with postoperative radiation with concurrent chemotherapy, did not result in survival improvement. Therefore, radical resection at initial surgery in healthy and clear margins remains indispensable in multi-modality treatment strategies involving surgery. The combination of healthy margins and adjuvant treatment seems to be most favorable for patient survival.