Survival analysis of 5595 head and neck cancers--results of conventional treatment in a high-risk population

Outcome of Hypofractionated Palliative Radiotherapy Regimens for Patients With Advanced Head and Neck Cancer in Tikur Anbessa Hospital, Ethiopia: A Prospective Cohort Study

PURPOSE

Head and neck cancers (HNCs) are the third most commonly treated cancer with radiation in Ethiopia. Most patients present with advanced stage and are not candidates for curative treatment. The objective of our study is to assess the outcome of hypofractionated palliative radiotherapy (RT) for advanced HNCs in a resource-limited setting.

MATERIALS AND METHODS

Patients with histology-proven advanced HNC candidates for hypofractionated palliative RT were enrolled. Three regimens were allowed: 44.4 Gy in 12 fractions, 30 Gy in 10 fractions, and 20 Gy in five fractions. Response to treatment was assessed at baseline and at 4 weeks after treatment completion. The Kaplan-Meier curve was used to measure the survival.

RESULTS

Between January 2022 and January 2023, 52 patients were enrolled and 25 patients were eligible for outcome assessment. Index symptoms include pain, bleeding, dysphagia, respiratory distress, and others in 25, 13, 10, 6, and 17 patients, respectively. Complete relief of the top three symptoms include pain in 52% of patients, hemostasis in 84% of patients, and dysphagia in 30% of patients. Objectively, 64% of patients attained partial response. For 48% of patients, their quality of life (QoL) improved in one parameter of the physical scores. Moreover, 64% of patients showed improvement in three parameters. The global functional score improved in 80% of patients. One patient had grade 3 xerostomia. At the end of the study period, 44% of patients died. The median survival after radiation was 9 months (95% CI, 7.2 to 10.8).

CONCLUSION

All palliative hypofractionated regimens used were effective in terms of symptom control, tumor response rate, and QoL, and were well tolerated. This makes it appropriate for our setup because the majority of patients require palliation.

Long-term outcomes of neo-adjuvant chemotherapy on borderline resectable oral cavity cancers: Real-world data of 3266 patients and implications for clinical practice

BACKGROUND

Neo-adjuvant chemotherapy (NACT) followed by response assessment is the standard treatment algorithm for locally advanced oral cavity squamous cell carcinomas (OCSCC) in the Indian subcontinent. The 3-drug NACT regimen (Docetaxel-Cisplatin-5-FU) has shown improvement in overall survival over 2-drug regimen (Docetaxel-Cisplatin) in a phase-3 randomised study. We have analysed the 10-year outcomes with this treatment algorithm.

METHODS

This was an institutional review board approved retrospective analysis of a prospectively collected dataset of borderline resectable OCSCC patients who underwent NACT. Patients who became resectable after NACT underwent surgery followed by appropriate adjuvant therapy. Patients who were unresectable received definitive chemoradiation (CTRT), palliative chemotherapy, radiotherapy or best supportive care based on general condition.

RESULTS

A total of 3266 patients were included. The most common subsite was buccal mucosa and the most frequent indication was peri-tumoral edema upto zygoma. More than 2-drugs NACT was offered to 32.9% patients. Overall, 32.5% patients had a response to NACT. A total of 1358 patients were offered curative treatment, of which 929 (32%) underwent surgery and the rest underwent definitive chemo-radiation (14.8%). Patients who received more than 2-drugs NACT versus those who received 2-drugs had a 10-years OS of 21% vs 5.1% (p < 0.001). Patients who underwent surgery versus those who did not had a 10-year OS of 21.8% vs 4.1% (p < 0.001). Patients who achieved pCR had a 5-year OS of 45.3% vs 13.3% for those who did not (p < 0.001).

CONCLUSION

NACT leads to long term survival benefit in patients of borderline resectable oral cavity cancer.

Occult metastases of oral maxillary squamous cell carcinoma: Systematic review and meta-analysis

Squamous cell carcinoma (SCC) is the most common malignant neoplasm of the oral cavity. The performance of END (elective neck dissection) in cases of maxillary SCC is controversial because the literature traditionally classified maxillary tumors as having low metastatic potential. The aim of this systematic review and meta-analysis was to determine the percentage of occult cervical metastases in maxillary SCC to identify in which cases there is the need to perform an END. We searched the PubMed database to select articles dated from 2000 to 2020 that fulfilled our inclusion criteria; finally, we reviewed 27 manuscripts. We show that the overall cervical and occult metastases rate was 35% and 19%, respectively. For T1, the percentage of occult metastasis rate was 11%; for T2, it was 16%; for T3, it was 20%; and for T4, it was 32%. We suggest END (levels I-II-III) as treatment to T3/T4 cN0 patients.

Oral cavity adjuvant therapy (OCAT) -a phase III, randomized controlled trial of surgery followed by conventional RT (5 fr/wk) versus concurrent CT-RT versus accelerated RT (6fr/wk) in locally advanced, resectable, squamous cell carcinoma of oral cavity

BACKGROUND

Limited data exists regarding the impact of intensification of adjuvant therapy in resected Oral Cavity Squamous Cell Carcinomas (OCSCC) with adverse prognostic features on histopathology.

PATIENTS AND METHODS

This was a three-arm phase III, randomised trial including patients with resected advanced OCSCC. Randomisation was done in a 1:1:1 ratio: Arm-A- standard adjuvant radiation therapy (RT) 60Gy/30 fractions over 6 weeks versus Arm-B-concurrent chemoradiation versus Arm-C-accelerated radiation therapy (6 d a week). The trial was powered to detect an absolute difference of 10% in 5-year Locoregional Control (LRC).

RESULTS

The trial was conducted between June 2005 and March 2013. Majority of the patients were males, had T3-T4 disease, had N2-N3 nodal status and had Extra-Capsular Extension (ECE) in nodes. The median follow-up was 95.9 months. There was no difference between the three arms (A versus B versus C) for 10-year locoregional control (LRC): 60.2% versus 61.4% versus 65.7%, p = 0.57; disease free survival (DFS): 37.4% versus 43.9% versus 39.6%, p = 0.40; or Overall Survival (OS): 39.7% versus 46.6% versus 40.4%, p = 0.40. There was no benefit of intensification with either modality in patients with any single adverse pathological factor. A benefit of intensification could be seen in patients with a combination of high-risk features: T3-T4 primary tumours with N2-N3 nodes along with ECE for DFS (Arm B versus Arm A HR) = 0.53, Arm C versus Arm A HR = 0.63) and OS (Arm B versus Arm A HR = 0.58, Arm C versus Arm A HR = 0.60).

CONCLUSIONS

All optimally resected OCSCC with adverse features did not benefit from intensification of adjuvant therapy. Only a cohort of patients with a combination of high-risk features are likely candidates for intensification.

CLINICAL TRIAL REGISTRATION

NCT00193843.

Late toxicities in locally advanced head and neck squamous cell carcinoma treated with intensity modulated radiation therapy

Purpose

The study aims to report late toxicities in locally advanced head-and-neck squamous cell carcinoma (LAHNSCC) treated with intensity-modulated radiation therapy (IMRT).

Materials and Methods

A retrospective study was conducted on 103 patients of LAHNSCC treated with IMRT. We analyzed the cumulative incidence of late xerostomia, dysphagia, and aspiration at an interval of 6-month, 1-year, 2-year, and 3-year from the start of IMRT.

Results

At a median follow up of 4.2 years (interquartile range, 3.5 to 6 years), the cumulative incidence of grade ≥2 late xerostomia was 5.5%, dysphagia was 6.9%, and aspiration was 11.1%. Logistic regression showed that D_mean of ≥26 Gy to parotids had higher risk of xerostomia (hazard ratio [HR] = 5.19; 95% confidence interval [CI], 1.90–14.22; p = 0.001). Late dysphagia was associated with D_mean of ≥45 Gy to pharyngeal constrictors (PC) (HR = 7; 95% CI, 1.84–26.61; p =0.004), ≥55 Gy to larynx (HR = 3.25; 95% CI, 1.15–9.11; p = 0.025), and adjuvant RT (HR = 5.26; 95% CI, 1.85–14.87; p = 0.002). Aspiration was associated with D_mean of ≥45 Gy to larynx (HR = 6.5; 95% CI, 1.93–21.88; p = 0.003), D_mean of ≥55 Gy to PC (HR = 3.54; 95% CI, 1.25–9.98; p = 0.017), and patients having late dysphagia (HR = 4.37; 95% CI, 1.55–12.31; p = 0.005).

conclusions

IMRT is a feasible radiation delivery technique in LAHNSCC with a decreased late toxicity profile.

[Oral and pharyngeal cancer: incidence, mortality, and survival in Germany]

Hintergrund

Die Gruppe der Lippen‑, Mundhöhlen- und Pharynxkarzinome (ICD-10: C00–C14) beschreibt eine heterogene Gruppe bösartiger Tumoren, deren Inzidenz, Mortalität und Überleben sich nach Entität stark unterscheiden.

Ziel der Arbeit

Diese Arbeit gibt eine detaillierte Übersicht epidemiologischer Maßzahlen für diese Tumorentitäten unter Berücksichtigung der Heterogenität bezüglich Alter, Geschlecht, Lokalisation und Stadium.

Material und Methoden

Inzidenz- und Mortalitätsdaten für Deutschland für die Jahre 1999–2016 wurden aus der interaktiven Datenbank des Zentrums für Krebsregisterdaten (ZfKD) extrahiert. Alters- und Stadienverteilungen und altersstandardisiertes relatives 5‑Jahres-Überleben wurden auf dem gepoolten ZfKD-Datensatz (Diagnosejahre 1999–2017) berechnet.

Ergebnisse

Im Jahr 2016 lagen die Inzidenz und Mortalität für alle Entitäten insgesamt bei 17,6 bzw. 7,0 pro 100.000 Männern und 6,5 bzw. 1,8 pro 100.000 Frauen. Das relative 5‑Jahres-Überleben für 2015–2017 lag bei 53 % bzw. 63 %. Es zeigten sich deutliche Unterschiede in der Überlebensrate und in der Alters- und Stadienverteilung zwischen den Entitäten. Im zeitlichen Verlauf zeigte sich ein Anstieg des Alters bei Diagnose, insbesondere bei Männern, aber keine Veränderung in der Stadienverteilung. Trotzdem stieg das relative 5‑Jahres-Überleben zwischen 1999–2002 und 2013–2017 von 45 % (Männer) bzw. 59 % (Frauen) auf 52 % bzw. 63 %.

Diskussion

Die starke Heterogenität der untersuchten Tumoren verdeutlicht die Notwendigkeit einer nach Geschlechtern und Lokalisationen getrennten Betrachtung für eine aussagekräftige Interpretation der epidemiologischen Kennzahlen. Mit Ausbau der klinischen Krebsregistrierung werden in Zukunft zusätzliche Analysen unter Einbezug weiterer wichtiger klinischer Faktoren möglich sein.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00103-021-03368-z) enthalten.

Toxicity syndrome and early competing deaths in head-and-neck cancer undergoing radiation therapy: Observation and hypothesis

Radiotherapy (RT) and/or concurrent chemoradiation (CRT) is the mainstay for the treatment of locally advanced head-and-neck cancer (LAHNC). Sepsis remains a poorly understood and unrecognized event in head-and-neck cancer. The study aims to hypothesize a 'toxicity syndrome' leading to sepsis and subsequent sepsis-related deaths. A retrospective audit of all 125 LAHNC patients treated radically from January 2013 to June 2017 was conducted. A total of fifteen toxic deaths were reported. Thirteen deaths were attributed to sepsis. Individual toxicity for death was ascertained only for three cases. A toxicity syndrome namely 'mucositis-dysphagia-aspiration-sepsis (MDAS) complex' was proposed as the cause of death in the rest ten cases. The authors recommend the surveillance of the 'MDAS complex' for the prevention of early toxicity-related deaths in patients with LAHNC undergoing RT or CRT.

Role of fractal analysis in detection of dysplasia in potentially malignant disorders

Background:

Fractal analysis is, a noninvasive method, used to determine the intricate characteristics of the matter. Oral leukoplakia (OL), a potential malignant disorder, has definite propensity to turn in to malignancy. In such lesions, fractal dimension analysis (FDA) could be helpful in the early detection of malignant transformation.

Objectives:

To determine the efficacy of fractal dimension analysis in detecting malignancy potential of oral leukoplakia.

Materials and Methods:

After ethical clearance, we enrolled 121 patients in our study. Lesions were photographed before and after toluidine staining. Image J software was used to analyze fractal dimensions (FDs) of digital image and results were compared with biopsy.

Results:

Fractal dimension value is significantly higher in leukoplakia with dysplastic changes. FD values increase as age of patients increases. FD value in leukoplakia with different tobacco products showed more positive correlation with surti/khaini abusers.

Conclusion:

Fractal dimension analysis is a useful method in determination of complication in OL cases and can be used as an effective, noninvasive screening tool at primary healthcare centers for early intervention.

Squamous cell carcinoma of upper alveolus: An experience of a tertiary care center of Northeast India

Objective:

The main objective of this study was to analyze the clinical behavior and the impact of nodal metastasis on the prognosis of upper alveolus squamous cell carcinoma (SCC).

Materials and Methods:

The medical records of 110 patients with SCC of the upper alveolus (International Classification of Diseases-10-C03.0) diagnosed during 2010–2015 were reviewed. Survival analysis was done using the Kaplan–Meier method and was compared using log rank-test. P < 0.05 was considered statistically significant.

Results:

Of the 110 patients, 59 were males and 51 were females. Forty-six (41.8%) patients presented with lymph node metastasis. Fifty-three (51.8%) patients presented in Stage IVA, thirty (27.3%) patients in Stage IVB, ten (9.1%) patients in Stage III, 12 (10.9%) patients in Stage II. The 5-year overall survival (OS) was 71.1% in Stage II, in Stage III it was 65.6%, in Stage it was IVA 56.7%, and in Stage IVB it was 19.4% (P = 0.02). The 5-year OS for node negative compared with node positive was 66.3% versus 37.3%, respectively (P = 0.019).

Conclusion:

Presence of lymph node metastasis is associated with lower survival rates. Adequate surgical resection with adjuvant treatment, where necessary, offers the best chance of disease control.

Dentist's Delay or Dexterity to Diagnose the Deadly: A Clinico-radiological Series of Oral Malignancies Exhibiting Varied Presentations in the Tamil Nadu Rural Belt

Oral cancer is the sixth most common malignancy globally with a wide geographic variation. India is the second largest consumer and third largest producer of tobacco in the world. One-third of the global burden of oral cancer is predominantly attributed to high prevalence of tobacco consumption. The highest incidence and prevalence of oral squamous cell carcinoma is found in the Indian subcontinent particularly in the lower socioeconomic strata, due to an increase in the deleterious habits of potent, proven carcinogens like smoking, chewing tobacco, betel quid and areca-nut. Also, there is a delayed presentation of oral cancer in India, as approximately 50% of patients are diagnosed at stage III or IV. In this article, we report five varied presentations of well differentiated oral squamous cell carcinoma from rural belt of Tamil Nadu. All the cases were reported late to diagnose. Clinical and radiological staging plays a pivotal role to stage an oral malignant patient which aids in guiding him to a proper treatment plan. Early diagnosis along with patient counselling is of vital importance for the prognosis of the patients with oral malignancies. Also, it is an utmost important duty of the health care professionals to create awareness on oral cancer especially in rural areas. For this reason, dentists play a very significant role in the early detection and prevention of oral malignancies.

Conventional Fractionation versus Quad Shot in Advanced Head-and-Neck Cancers: A Randomized Controlled Trial

Context:

A significant number of patients with head-and-neck cancers have an incurable disease with limited life expectancy. The objective of the present study was to compare two different short courses of hypofractionated palliative radiotherapy regimens to evaluate symptoms, disease response, and acute toxicity.

Materials and Methods:

Previously untreated 50 patients of Stage IV B and IV C head and neck cancers were randomized to receive conventional hypofractionated palliative radiotherapy 30 Gy/10 fractions/2 weeks (control group) or Quad Shot regimen (study group) 14 Gy in 4 fractions given twice a day at least 6 h apart for 2 consecutive days. This regimen was repeated at 4 weekly intervals for a further two courses if there was no tumor progression.

Results:

Symptom relief was similar among the two schedules for pain (60.86 vs. 57.17), dysphagia (60.86 vs. 52.17%), and hoarseness (43.85 vs. 38.09%). Overall response (that is partial response and stable disease) was seen in majority (>70%) of the patients in both the groups. Treatment was very well tolerated with no patient experiencing more than Grade 3 toxicity in the control group and Grade 2 toxicity in the study group.

Conclusions:

Quad Shot regimen is an effective hypofractionated palliative radiotherapy schedule with minimal toxicity, good symptom relief, and response rate as compared to conventionally used regimen (30 Gy/10 fractions/2 weeks).

Oropharyngeal Squamous Cell Carcinoma Metastasis to Distal Skeletal Muscle on FDG PET/CT

We present a case of a tongue squamous cell carcinoma (SCC) metastasizing to distal skeletal muscle detected on FDG PET/CT imaging. A 48-year-old man with locally recurrent tongue SCC underwent a restaging FDG PET/CT to investigate neck and unilateral leg pain. The PET scan showed large, intensely FDG-avid lesions in the right scalene and left hamstring muscles, which were biopsy proven as metastatic SCC. Skeletal muscle metastases from oropharyngeal SCCs are rare; however, PET/CT has allowed increased detection of atypical metastatic sites. Such cases support the consideration of metastasis for muscular lesions in head and neck cancer patients.

Nuclear survivin promoted by acetylation is associated with the aggressive phenotype of oral squamous cell carcinoma

Defects in apoptotic pathway contribute to development and progression of oral cancer. Survivin, a member of the inhibitors of apoptosis protein (IAP) family, is increased in many types of cancers. However, it is unclear whether increased survivin is associated with oral squamous cell carcinomas (OSCC), and what mechanisms may involve in. In this study, we examined survivin expression in OSCC compared with normal oral tissues via immunohistochemical staining. The results showed that, not only total survivin is increased in OSCCs, but also the subcellular location of survivin is changed in OSCCs compared with normal oral tissues. In most of normal oral tissues, survivin staining was either negative, or cytoplasmic positive/nuclear negative; whereas in most of OSCC tissues, survivin staining was nuclear positive. Statistic analysis indicates that nuclear survivin, rather than total or cytoplasmic one, correlates with tumor TNM stage and differentiation grade. Consistently, in vitro analysis showed that survivin is in cytoplasm in normal human oral kinotinocyte (HOK) cells; whereas it is in nucleus in OSCC HN6 cells. Importantly, treatment of HOK cells with HDAC inhibitor Trichostatin A (TSA) induces survivin acetylation and promotes its nuclear localization. Moreover, nuclear survivin in OSCC cells was acetylated at K129 in its C-terminal, suggesting that the acetylation is important for nuclear location of survivin. Our study demonstrates that it is nuclear survivin, rather than total or cytoplasmic one, associates with TNM stage and tumor grade of OSCC. Thus, we propose nuclear survivin as a prognostic marker for the progression of OSCC.

Survival in Head and Neck Cancers - Results of A Multi- Institution Study

BACKGROUND

The prime output of Hospital Based Cancer Registries is stage and treatment based survival to evaluate patient care, but because of challenges of obtaining follow-up details a separate study on Patterns of Care and Survival for selected sites was initiated under the National Cancer Registry Programme of India. The results of stage and treatment based survival for head and neck cancers by individual organ sites are presented.

MATERIALS AND METHODS

A standardized Patient Information Form recorded the details and entered on-line at www.hbccrindia.org to a central repository - National Centre for Disease Informatics and Research. Cases from 12 institutions diagnosed between 1 January 2006 and 31 December 2008 comprised the study subjects. The patterns of treatment were examined for 14053 and survival for 4773 patients from five institutions who reported at least 70% follow-up as of 31 December 2012.

RESULTS

Surgical treatment with radiation for cancer tongue and mouth showed five year cumulative survival (FCS) of 67.5% and 60.4% respectively for locally advanced stage. Chemo-radiation compared to radiation alone showed better survival benefit of around 15% in both oro and hypo-pharyngeal cancers and their FCS was 40.0%; Hazard Ratio (HR):1.5;CI=1.2-1.9) and 38.7%; (HR):1.7; CI=1.3-2.2).

CONCLUSIONS

The awareness about the requirement of concurrent chemo-radiation in specifically cancers of the oro and hypopharynx has to be promoted in developing countries. The annual (2014) estimate number of new Head and Neck cancers with locally advanced disease in India is around 140,000 and 91,000 (65%) patients do not receive the benefit of optimal treatment with ensuing poorer survival.

Oral tongue cancer in public hospitals in Madrid, Spain (1990-2008)

Background

The cancer which appears in the mobile portion of the tongue is the most common neoplasm of the oral cavity. The objective of this study was to analyse oral tongue cancer epidemiology in a population of 610 patients diagnosed between 1990 and 2008 and detailed in the Tumour Registry of the Madrid region.

Material and Methods

A retrospective analysis based on the following variables provided in the Tumour Registry was achieved: age, gender, histology, stage, location, treatment. Descriptive and analytic statistics with these variables, using Pearson’s Chi-square test to study the relationship between the qualitative variables.

Results

Patients’ mean age was 61.53±13.95 years, with a gender ratio of 2.09:1 (413 males vs 197 females). The lesion was mainly localized in the lateral border of tongue, with other sites (dorsal face, ventral face, lingual tonsil, contiguous sites, tongue NOS) represented at lower rates. Squamous cell carcinomas (94.9%) far outweighted other histologies (salivary gland tumours, soft tissue tumours, haematolymphoid tumours). 59% of the cases appeared in localized stages, versus 35.2% in regional and 4.8% in distant stages. Surgery was the most frequently used treatment, followed by surgery in combination with radiotherapy.

Conclusions

Oral tongue cancer is a disease of the elderly, with a male predominance. It mainly appears in its lateral border, localized squamous cell carcinomas representing the great majority of lingual neoplasms.

Key words:Oral tongue cancer, squamous cell carcinoma, epidemiology, treatment.

Study of Cyfra 21–1, a Tumor Marker, in Head and Neck Squamous Cell Carcinoma

Objectives:

We performed a prospective study to determine the cutoff value and the prognostic value of Cyfra 21–1, a serum tumor marker, in head and neck squamous cell carcinoma (HNSCC).

Methods:

The serum concentration of Cyfra 21–1 was measured in a group of 300 patients (group 1) with HNSCC, in a control group of 71 healthy subjects (group 2), and in a group of 73 patients with a nonmalignant tumor or inflammatory disease (group 3). The concentrations were compared between the various groups and subgroups; the cutoff value was calculated with a receiver operating characteristic curve. Furthermore, the serum concentrations of Cyfra 21–1 before treatment in the group of 300 patients were compared with the stage of the disease and with the evolution of the overall survival rate and the disease-free survival rate. Finally, to determine whether Cyfra 21–1 is an independent prognostic factor, we compared the concentrations, by a Cox model, with the classic prognostic factors of HNSCC.

Results:

At the cutoff value of 1 ng/mL, the specificity was 94% and the sensitivity was 72%. The serum concentrations of Cyfra 21–1 were statistically correlated with the stage of the disease. The overall survival rate and the disease-free survival rate were lower in patients with high serum concentrations, and these differences were statistically significant (p <.001). The Cox model allows us to conclude that Cyfra 21–1 is a prognostic marker that is independent of other classic prognostic factors.

Conclusions:

Cyfra 21–1 is an interesting tumor marker that could be proposed for the early detection of HNSCC with a cutoff value of 1 ng/mL. Furthermore, Cyfra 21–1 can be considered an independent prognostic marker.

Treatment outcome for head and neck squamous cell carcinoma in a developing country: University Malaya Medical Centre, Malaysia from 2003-2010

BACKGROUND

Head and neck cancer (HNC) is the eighth most common cancer as estimated from worldwide data. The incidence of HNC in Peninsular Malaysia was reported as 8.5 per 100,000 population. This study was aimed to determine the treatment outcomes for HNC patients treated in the Oncology Unit of University Malaya Medical Centre (UMMC).

MATERIALS AND METHODS

All newly diagnosed patients with squamous cell carcinoma of head and neck (HNSCC) referred for treatment to the Oncology Unit at UMMC from 2003-2010 were retrospectively analyzed. Treatment outcomes were 5-year overall survival (OS), cause specific survival (CSS), loco-regional control (LRC) and radiotherapy (RT) related side effects. Kaplan-Meier and log rank analyses were used to determine survival outcomes, stratified according to American Joint Committee on Cancer (AJCC) stage.

RESULTS

A total of 130 cases were analysed. Most cases (81.5%) were at late stage (AJCC III-IVB) at presentation. The 5-year OS for the whole study population was 34.4% with a median follow up of 24 months. The 5-year OS according to AJCC stage was 100%, 48.2%, 41.4% and 22.0% for stage I, II, III and IVA-B, respectively. The 5-year overall CSS and LCR were 45.4% and 55.4%, respectively. Late effects of RT were documented in 41.4% of patients. The most common late effect was xerostomia.

CONCLUSIONS

The treatment outcome of HNSCC at our centre is lagging behind those of developed nations. Efforts to increase the number of patients presenting in earlier stages, increase in the use of combined modality treatment, especially concurrent chemoradiotherapy and implementation of intensity modulated radiotherapy, may lead to better outcomes for our HNC patients.

Surgical treatment of glottic cancer: retrospective analysis of 192 cases in a multidisciplinary tertiary care centre in Pune, India

OBJECTIVES

A multidisciplinary team approach is required for the preservation of voice and appropriate management of glottic cancer. This study aimed to investigate the outcomes of surgically treated glottic cancers of all stages. All aspects of surgical management, such as laser cordectomy, partial laryngectomy, total laryngectomy with voice prosthesis, and salvage laryngectomy, conducted at a single tertiary care institute in India, were reviewed.

METHOD

A retrospective analysis of hospital records was performed for 192 glottic cancer patients who were surgically treated between 2003 and 2007.

RESULTS

Patients with tumour stages 1 or 2 glottic cancer treated with laser cordectomy had a local control rate of 85 per cent and five-year survival rate of 98.6 per cent. The findings suggest that the number of partial laryngectomies performed for stage 3 tumours is declining. Patients with a tumour stage 3 lesion with a fixed hemilarynx or a tumour stage 4 lesion, treated with total laryngectomy, were found to have a five-year survival rate of 61.6 per cent. Nodal status was significantly associated with five-year survival rate.

CONCLUSION

Surgery offers a viable five-year survival rate in glottic cancer patients.

Cancers of upper gingivobuccal sulcus, hard palate and maxilla: A tertiary care centre study in North India

Introduction:

Oral cancer is the sixth most common malignancy in the world, and the third most common in southeast Asia. Cancers of the upper gingivo-buccal complex are uncommon and reported infrequently. In this article, we have assessed the clinicopathological features of such cancers and their optimal management.

Materials and Methods:

We studied 64 patients with cancer of the upper gingivobuccal sulcus (GBS), hard palate, and maxilla seen between February 2009 and 2013 over a span of 4 years.

Results:

Of the 64 patients studied, 45 were male. The mean age at presentation was 50.59 years (24-80 years). Of the 64, 48 patients (75%) had a history of substance abuse in the form of tobacco chewing, smoking or alcohol. On presentation, 48 of the 64 patients (75%) had T4 disease, eight had T3, six had T2 lesion, one had T1 lesion, and 1 patient had a neck recurrence with distant metastatic disease (Tx). Out of the 64 patients, 31 had clinically palpable neck disease and two patients had distant metastatic disease. Of the 64 patients, 58 had squamous cell carcinoma, two had adenoid cystic carcinoma of the hard palate and one patient each had melanoma, sarcoma, neuroendocrine tumor, and mucoepidermoid carcinoma. Following imaging, 18 patients (28.13%) underwent upfront surgery and six following neoadjuvant chemotherapy. 14 of the 24 patients operated had simultaneous neck dissection. 2 patients with distant metastasis and 1 with cavernous sinus thrombosis received palliative chemotherapy. Out of the 64 patients, the other 24 who were inoperable were referred to radiotherapy.

Conclusion:

Upper GBS, hard palate and maxilla cancers are uncommon and are diagnosed at an advanced stage due to delay in presentation and ignorance of our population. Surgery offers the best form of treatment. NACT may be tried to downstage the disease in selected patients with borderline operable disease. However, generous margins should be taken post chemotherapy with concomitant neck dissection. Adjuvant radiotherapy is recommended in selected patients after surgery.

Depleting IFIT2 mediates atypical PKC signaling to enhance the migration and metastatic activity of oral squamous cell carcinoma cells

Interferon-induced protein with tetratricopeptide repeats 2 (IFIT2) is one of the most highly responsive interferon-stimulated genes, but its biological functions are poorly understood. In this study, we aimed to explore the underlying mechanisms by which depleting IFIT2 induces the migration of oral squamous cell carcinoma (OSCC) cells. Stable IFIT2-depleted cells underwent epithelial-mesenchymal transition (EMT) and exhibited enhanced cell motility and invasiveness compared with control cells. Furthermore, our results indicated that atypical protein kinase C (aPKC) was activated in IFIT2-depleted cells. Inhibition of aPKC using a specific myristoylated PKCζ pseudosubstrate or aPKC-targeting small interfering RNA (siRNA) abolished IFIT2 depletion-induced EMT, migration and invasion, indicating that the activation of aPKC has an essential role in regulating the cellular responses induced by IFIT2 depletion. Following tail-vein injection, IFIT2-depleted OSCC cells colonized not only the lungs but also the heart, head and neck, retroperitoneal, and peritoneal cavities; whereas control cells predominantly localized in the lungs. IFIT2 mRNA and protein expression was positively associated with E-cadherin expression in OSCC patient specimens. The loss of E-cadherin and IFIT2 expression was observed at the invasive front of OSCC tumors, suggesting that the loss of IFIT2 may induce EMT and lead to the metastasis of OSCCs. OSCC patients possessing reduced IFIT2-expression levels (IFIT2 <50%) exhibited greater rates of distant metastasis and poor prognoses compared with OSCC patients who expressed greater levels of IFIT2 (IFIT2 ≥50%). These results demonstrate that IFIT2 depletion activates the aPKC pathway and consequently induces EMT, cell migration and invasion. Most importantly, depleting IFIT2 may participate in OSCC tumor progression, particularly during metastasis. Taken together, our study demonstrates that IFIT2, a protein responsible for interferon stimulation, may prevent OSCC metastasis and serve as a valuable prognostic marker.

Texture analysis of CT images in the characterization of oral cancers involving buccal mucosa

OBJECTIVE

The aim of this study was to investigate the usefulness of texture analysis in the characterization of oral cancers involving the buccal mucosa and to assess its effectiveness in differentiating between the various grades of the tumour.

METHODS

Contrast enhanced CT examination was carried out in 21 patients with carcinoma of the buccal mucosa who had consented to retrospective analysis during a research study that was approved by the institutional review board. Two regions of interest (ROIs) were created, one at the site of the lesion and the other at the contralateral normal side. Texture analysis measures of fractal dimension (FD), lacunarity and grey level co-occurrence matrix (GLCM) were computed for each ROI. The numeric data from the two ROIs were compared and were correlated with the tumour grade as confirmed by biopsy.

RESULTS

The difference between the mean FD and GLCM parameters of the lesion vs the normal ROI were statistically significant (p < 0.05); no significant difference was observed between the three grades of tumour for any of the parameters (p > 0.05).

CONCLUSION

Texture analysis on CT images is a potential method in the characterization of oral cancers involving the buccal mucosa and deserves further investigation as a predictor of tumour aggression.

Comprehensive review of small bowel metastasis from head and neck squamous cell carcinoma

Secondary tumours of small intestine account for 10% of all small bowel cancers. The most common sites of primary tumour metastasizing to small bowel are uterus, cervix, colon, lung, breast and melanoma. The majority of these metastatic tumours come from adenocarcinoma primaries; squamous cell carcinoma constitutes a very small proportion of all metastatic small intestinal lesions. Metastasis to small bowel by head and neck squamous cell carcinoma is extremely rare and carries an unfavourable prognosis. Owing to the limited number of published studies, its characteristic features, clinical presentation and outcomes are poorly described. This work aims at specifying these characteristics by reviewing, compiling, analysing and reporting all published cases in the published literature on small bowel metastasis secondary to head and neck squamous cell carcinoma. To the best of our knowledge, this is the first comprehensive review article on the small intestinal metastasis from head and neck squamous cell carcinoma.

Distant metastases of a squamous cell carcinoma of the tongue in peripheral skeletal muscles and adjacent soft tissues

A 66-year-old female patient was admitted to our department with a large tumor of the tongue measuring 10 cm in diameter. The tumor occupied nearly the entire oral cavity and showed exophytic and ulcerative areas. Histological analysis revealed a low grade squamous cell carcinoma (SCC) of the tongue. Bilateral enlarged cervical lymphatic masses were also present. The extent of the tumor infiltration was assessed by fluoro-2-deoxy-glucose-positron emission tomography (PET) scans showing an elevated activity of the tracer corresponding to the assumed cervical metastases. Additionally, pulmonary metastases were identified. Contrast enhanced computed tomography (CT) scans showed metastases in the soft tissues of the abdomen, legs and arms. Foci of distant metastases were found in the left upper anterior thoracal wall, near the intraabdominal portion of the aorta, near the right iliac crest and in both the right vastus medialis- and adductor magnus muscles. The final diagnosis was a T4N3M1(G3)(C3) SCC of the tongue with multiple distant thoracal, abdominal and intramuscular metastases. The survival expectancy was five weeks, and the patient finally deceased by cardiopulmonary complications.

Outcome of patients with head and neck cancers: 10-year experience of a otorhinolaryngology--head and neck unit in a tertiary hospital of a developing country

Being a rapidly developing country, a study was needed to see how we faired in treating head and neck cancer patients compared with international standards. Although being a retrospective study, this research shows that there is still a lot to be done in our developing nation in educating the general public about head and neck cancers as most of them presented in the later stages to us. There also needs to be a proper review about the treatment modality offered to patient as our survival results are far behind in certain categories of cancers compared with the developed nations.

Squamous cell carcinoma of the superior gingival–buccal complex

Squamous cell carcinoma of the superior gingival-buccal complex are rare and few English-language data have been published on their biological behaviour. Reported in this paper are the clinical behaviour and treatment outcomes of squamous cell carcinoma of the upper gingival-buccal complex. We reviewed the charts of 110 patients with squamous cell carcinoma restricted to the upper gingiva, superior gingival-buccal sulcus and adjoining buccal mucosa, seen between 1997 and 2001. Separate outcome analyses were carried out among 86 patients who had undergone surgery, and 24 patients treated by radiotherapy or chemo-radiation. Disease-free survival at 2 and 5 years was 48.9% and 36%, respectively, and was independent of epicentre of disease. Five-year, disease-free survival was 48.8% and 0% for surgical treatment and non-surgical treatment groups. T stage (p=0.024) and extra-capsular spread of disease (p=0.036) were independent predictors of disease-free survival on multivariate analysis. Adequate surgical resection and adjuvant treatment, in the first instance, offers the best chance of disease control.

Increased survivin expression in high-grade oral squamous cell carcinoma: a study in Indian tobacco chewers

BACKGROUND

Oral cancer is one of the five leading sites of cancer in the Indian population. In the present study we analyzed the expression of apoptosis regulating genes, viz. survivin, Bcl-2, Bax and p53 in precancerous and cancerous lesions of the buccal mucosa of Indian tobacco chewers.

METHOD

Paraffin-embedded tissue samples from 38 patients with primary oral squamous cell carcinoma (OSCC) and 17 patients with leukoplakia were used. The expression of survivin, Bcl-2, Bax, and p53 was evaluated using immunohistochemical staining method.

RESULTS

Thirty-six percent OSCC were found to be positive for nuclear p53 staining while none of the precancerous lesions showed p53 positivity. Survivin, Bcl-2 and Bax expression was found to increase with increased grade of malignancy. Increase in survivin expression was statistically most significant (P < 0.001).

CONCLUSION

Increased expression of anti-apoptotic survivin in high-grade tumors suggests that survivin is likely to contribute significantly to apoptosis resistance in response to therapy.

Selective neck dissection (I–III) for node negative and node positive necks

Selective neck dissection (I-III) for oral cancers offers similar regional control rates with less morbidity as compared with modified radical neck dissection. Charts of 414 patients with oral cancer, who underwent selective neck dissection (I-III) during 1994-2001, were analysed retrospectively. Seventy nine percent of the patients had a primary tumour in the gingivo-buccal complex. Cancer of tongue showed a trend towards higher regional failure (12.3%) as compared to gingivo-buccal cancers (6.5%). Primary tumour was staged as T1-8%, T2-47%, T3-19% and T4-26%. Sixty five percent of the patients were clinically node negative. Isolated neck failure was observed in 4.8% of patients at 2 years and in 5.8% at 5 years. De-differentiation of primary tumour and perineural spread were associated with regional failures. Eighty three percent of the neck recurrences were in the ipsilateral neck and only 16% of these were at levels IV or V. In all, 30% of all regional failures were outside the field of dissection.

Gemcitabine in the treatment of advanced head and neck cancer

AIMS

Several new chemotherapy agents show varying degrees of activity in head and neck cancer. One of them is gemcitabine, which is a new nucleoside analogue with an innovative cytostatic mode of action. Gemcitabine has demonstrated a broad spectrum anti-tumoural effect and a favourable toxicity profile. These attributes prompted us to introduce gemcitabine into the treatment of head-and-neck tumours.

MATERIALS AND METHODS

Ten heavily pre-treated patients with recurrent and incurable squamous-cell carcinoma of the head and neck (SCCHN) were treated with Gem. The initial cycle consisted of six administrations of the drug (1250 mg/m2 once weekly intravenously over 30 min) followed by a week without cytotoxic treatment. All following cycles were composed of two infusions once weekly (d1, 8), followed by a week of rest.

RESULTS

Toxic effects, length of survival and tumour response was assessable in eight patients owing to one suicide and loss of one patient for follow-up. One complete remission, two partial remissions and three 'no change' situations (stable disease) were observed, yielding a response rate of 37.5%. Median survival was 8 months (range 3-12). The incidence of haematological toxicity was low, with grade 3-4 neutropenia in less than 10%. Flu-like symptoms were reported by one-third of patients.

CONCLUSIONS

In this small phase-II study, gemcitabine demonstrated a high anti-tumoural activity in SCCHN, with a favourable toxicity profile. Gemcitabine seems to be a promising new drug without severe burden even for patients who are refractory to other cytostatic drugs. Within recent years, the activity and tolerability of gemcitabine was documented in several phase I and phase II trials, especially in combination with cisplatin, and paclitaxel resp, carboplatin/paclitaxel, cisplatin/ifosfamide, and 5-fluorouracil/paclitaxel. The results of these trials will be outlined in the discussion.

Trends of oral and oropharyngeal cancer survival over five decades in 3267 patients treated in a single institution

The objective of this study was to analyze the influence of changes in the treatment on the prognosis of patients treated over 44 years in a single institution. The 5-decade trends in treatment approach and 5-year survival of 3267 patients treated between 1953 and 1997 were analyzed. An increase was observed in primary surgical treatment and its association with radiotherapy. In the 1950s, 29.1% of the patients were treated by surgery, 54.5% by radiotherapy and 16.4% by combined treatment; in the 1990s, these proportions were 39.7, 9.7 and 50.6%, respectively (P<0.001). There was a significant increase in the 5-year survival rates from 28.7% for patients treated in the 1950s to 43.2% in the 1990s (P<0.001). The changes in treatment approach for oral and oropharyngeal cancer over the last 5 decades, with an increase of surgical treatment and its combination with radiotherapy significantly improved the survival rates.

Loss of expression ofZAC/LOT1 in squamous cell carcinomas of head and neck

BACKGROUND

ZAC/Lot1 is a previously identified candidate tumor suppressor gene. The gene maps to the human chromosome 6q24-q25, a region frequently deleted in squamous cell carcinomas of the head and neck and other solid tumors.

METHODS

We have used a model of head and neck squamous cell carcinoma (HNSCC) and cell lines to analyze the role of the candidate tumor suppressor gene ZAC/Lot1 in oral carcinogenesis. We analyzed the expression in 11 cell lines, and we performed loss of heterozygosity (LOH)- and sequence analyses in 51 primary tumors.

RESULTS

Three (27.3%) of 11 cell lines showed a distinctly reduced expression of ZAC/Lot1 compared with expression levels of the gene in the normal oral mucosa. In addition, we analyzed 51 primary squamous cell carcinomas of the head and neck for LOH with seven microsatellite markers flanking ZAC/Lot1. We detected an average LOH rate of 31.4% in the region of interest. Sequence analysis revealed no mutations for the ZAC/Lot1 coding exons, including the exon/intron boundaries.

CONCLUSIONS

These data could suggest a minimal role for ZAC/Lot1 in a subgroup of HNSCC tumors.

Influence of time delay and clinical upstaging in the prognosis of head and neck cancer

The delayed time period between the first diagnosis of a head and neck cancer and its treatment can affect not only the clinical staging of the disease, but also its prognosis. The time period for clinical upstaging is studied in a retrospective cohort series. A retrospective case/control series was established to assess the prognosis of head and neck cancer patients due to a delay in treatment. In the first part of the study we included 69 patients who had confirmed clinical upstage before starting the oncologic treatment (cases). The survival of this series was compared to a historical control group of 138 patients matched by tumour site and stage, having received treatment within a short period after their first medical evaluation (controls). We observed that the natural evolution of a head and neck cancer was progressively faster, from an initial clinical stage to an advanced clinical stage until it becomes untreatable. It was observed that the delay in beginning oncologic treatment influenced the prognosis of the patients (P=0.030), especially in clinical stage IV patients (P=0.001) and oral cavity cancer patients (P=0.007).

The impact of molecular genetics on oral health paradigms

As a result of our increased understanding of the human genome, and the functional interrelationships of gene products with each other and with the environment, it is becoming increasingly evident that many human diseases are influenced by heritable alterations in the structure or function of genes. Significant advances in research methods and newly emerging partnerships between private and public sector interests are creating new possibilities for utilization of genetic information for the diagnosis and treatment of human diseases. The availability and application of genetic information to the understanding of normal and abnormal human growth and development are fundamentally changing the way we approach the study of human diseases. As a result, the issues and principles of medical genetics are coming to bear across all disciplines of health care. In this review, we discuss some of the potential applications of human molecular genetics for the diagnosis and treatment of oral diseases. This discussion is presented in the context of the ongoing technological advances and conceptual changes that are occurring in the field of medical genetics. To realize the promise of this new molecular genetics, we must be prepared to foresee the possibilities and to incorporate these newly emergent technologies into the evolving discipline of dentistry. By using examples of human conditions, we illustrate the broad application of this emerging technology to the study of simple as well as complex genetic diseases. Throughout this paper, we will use the following terminology: Penetrance--In a population, defined as the proportion of individuals possessing a disease-causing genotype who express the disease phenotype. When this proportion is less than 100%, the disease is said to have reduced or incomplete penetrance. Polymerase chain reaction (PCR)--A technique for amplifying a large number of copies of a specific DNA sequence flanked by two oligonucleotide primers. The DNA is alternately heated and cooled in the presence of DNA polymerase and free nucleotides, so that the specified DNA segment is denatured, hybridized with primers, and extended by DNA polymerase. MIM--Mendelian Inheritance in Man catalogue number from V. McKusick's Mendelian Inheritance in man (OMIM, 1998).

Protocols for the examination of tumors of diverse sites: introduction. Cancer committee of the College of American Pathologists

This issue of the Archives includes previously unpublished protocols for the examination of specimens removed from patients with cancer of diverse sites. We provide a historical context for the development of these protocols and describe the process of development and approval. General information about the structure and content of the protocols is also provided. Cancer protocol development is an important step in the process of standardized cancer reporting. The value of such standardized reporting is discussed.

Replication-competent herpes simplex virus vector G207 and cisplatin combination therapy for head and neck squamous cell carcinoma

Replication-competent virus vectors are attractive therapeutic agents for cancer. G207, a second-generation, multimutated herpes simplex virus type 1 (HSV-1), is one such vector that is safe in primates and efficacious against human tumors in athymic mice. Squamous cell carcinoma is the most frequently encountered malignancy of the head and neck, and the chemotherapeutic agent cisplatin is a standard treatment for recurrent head and neck cancer. In this study we examine the therapeutic potential of G207, alone and in combination with cisplatin, against squamous cell carcinoma. Human squamous cell carcinoma cell lines are sensitive to G207 replication and cytotoxicity in vitro at a multiplicity of infection of 0.01, including cisplatin sensitive (UMSCC-22A), moderately sensitive (UMSCC-38), and weakly sensitive (SQ20B) cell lines. Cisplatin did not inhibit the cytopathic effect of G207. G207 inhibited the growth of established subcutaneous head and neck tumors in athymic mice. The therapeutic effects of cisplatin and G207 in vivo were independent. However, in cisplatin-sensitive tumors (UMSCC-38), combination therapy resulted in 100% cures in contrast to 42% with G207 or 14% with cisplatin alone. We conclude that G207 should be considered for the treatment of head and neck cancer and that combination with chemotherapeutic agents may improve efficacy.

Protocols for the examination of tumors of diverse sites: introduction. Cancer Committee, College of American Pathologists

This issue of the ARCHIVES includes previously unpublished protocols for the examination of specimens removed from patients with cancer of diverse sites. We provide a historical context for the development of these protocols and describe the process of development and approval. General information about the structure and content of the protocols is also provided. Cancer protocol development is an important step in the process of standardized cancer reporting. The value of such standardized reporting is discussed.