Is there a role of induction chemotherapy followed by resection in T4b oral cavity cancers?

Compartmental surgery for T4b oral squamous cell carcinoma involving the masticatory space

PURPOSE OF REVIEW

This review aims to describe the oncological outcomes of T4b oral squamous cell carcinomas (OSCC) with masticatory space involvement as well as the surgical approaches that are able to achieve compartmental 'en bloc' resection of these lesions.

RECENT FINDINGS

The masticatory space is subdivided into infra-notch and supra-notch spaces according to the axial plane passing through the mandibular notch between the coronoid process and the condyle neck. Compartmental resection for T4b OSCC with masticatory space invasion can be successfully achieved via purely external approaches or combining external and transnasal endoscopic routes. Infra-notch T4b OSCC showed survival outcomes comparable to T4a OSCC, thus prompting treatment with curative intent.

SUMMARY

Compartmental resection of the masticatory space is technically feasible with comprehensive control of tumour margins. Use of a transnasal endoscopic anterior route within a multiportal approach may provide better control of margins at the level of the pterygo-maxillary fissure. Equivalent survival outcomes between T4a and infra-notch T4b OSCC are reported. Thus, a downstaging of the latter to T4a is advisable and compartmental surgery of such advanced lesions could be considered as a first-line treatment option in selected patients.

Locally Advanced oral Squamous cell Carcinomas: Auditing and Outcome Appraisal

Introduction: Patients with OSCC in India (oral squamous cell carcinoma) presents at a later stage with approximately 28% presenting at stage III and 64% at stage IV disease. In this retrospective study we have reviewed the treatment modalities rendered and outcomes associated for the management of locally advanced oral squamous cell carcinoma in our Institute. We evaluated the survival data and the factors effecting survival. Methods: Kaplan Meir method was used to evaluate OS and DFS rate and log rank test was used to compare the survival amongst groups. Cox regression analysis (univariate and multivariate) was used to evaluate the hazard ratio to find out the possible factors influencing risk of death and disease. Results: The median OS and DFS in our study were 32 and 24 months respectively. On a subset analysis of only T4b patients who underwent either upfront surgery or induction chemotherapy followed by surgery there was no significant difference in OS and DFS. All patients with TURD had partial response after induction chemotherapy and were subjected to surgical resection followed by adjuvant therapy. Conclusion: Extracapsular spread, bone involvement, skin infiltration, treatments, surgical margins and Lymph node size are the prime predictors of survival.Upfront surgery remains the standard of care for resectable LAOSCC. Induction chemotherapy might improve the resectability in technically unresectable OSCC. There is no difference in survival between concurrent chemoradiation, sequential chemoradiation and radical radiotherapy in the management of unresectable disease.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04168-4.

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.

Impact of Positive-Margin Resection of External Auditory Canal Squamous Cell Carcinoma

BACKGROUND

Positive-margin resection of external auditory canal squamous cell carcinoma (EAC-SCC) is still a major cause of recurrence. The aim of this study is to examine the clinical impact of positive-margin resection of EAC-SCCs.

METHODS

We retrospectively reviewed 40 surgical cases with en bloc temporal bone resection of EAC-SCC at a tertiary referral center from October 2016 to March 2022.

RESULTS

Two-year disease-specific, overall, and disease-free survival rates for all 40 cases reviewed were 85.2%, 88.85%, and 76.96%, respectively. En bloc resection with a negative margin significantly improved patient prognosis (p < 0.001). Positive-margin resection was observed in 9/40 cases (22.5%). Insufficient assessment of preoperative images was the cause in two of these cases. Postoperative lymph node metastasis and distant metastasis were observed in cases in which vascular, lymphatic duct or perineural invasion was found on postoperative pathological examination. In addition, three cases in which no vascular, lymphatic duct, or perineural invasion was found exhibited local recurrence during the follow-up period. Of the nine positive-margin resection cases, only two showed no postoperative recurrence.

CONCLUSIONS

Once positive-margin resections are confirmed, cases might have a high risk of tumor recurrence, even with the addition of postoperative adjuvant chemoradiotherapy.

Neoadjuvant chemotherapy for locally advanced head and neck squamous cell carcinoma - Is it still relevant? A practice pattern survey among oncologists of India

Objectives

Concurrent chemotherapy is the recommended treatment for locally advanced head and neck (H&N) squamous cell carcinoma, and neoadjuvant chemotherapy (NACT) is debated with a few special indications. NACT for advanced head and neck cancer has been studied in clinical trials for more than 2 decades without clear demonstration of the benefit for loco regional tumor control or overall patient survival. Its benefit remains controversial in the absence of clear evidence to define its role. However, there is widespread use of NACT among oncologists. We conducted an online survey to find out the frequency, pattern, prevalence, and aims for use of NACT in locally advanced head and neck cancers among radiation, medical, and surgical oncologists.

Materials and Methods

Oncologists across India who expressed interest to participate in our survey were asked to complete a short online questionnaire designed to identify the current practice pattern of NACT in head and neck cancer. A mobile app-based questionnaire was sent to 200 oncologists across the country to assess the pattern of NACT use and to solicit their most frequent therapy approach for patients with locoregionally advanced head and neck cancer.

Results

One hundred and fifty (150) oncologists completed and returned the survey (75%), and 130 were finalized (94 radiation oncologists, 19 medical oncologists, and 17 surgical oncologists). The single most common treatment approach reported for patients with locoregionally advanced H&N cancer was that of sequential chemoradiation (61%), specifically NACT with the TPF regimen (78.5%), followed by radiation therapy. The primary objectives cited by respondents for the use of NACT included the desire to buy time for definitive treatment (20%) and to achieve R0 resection (19.2%). Use of NACT in most patients was more preferred by medical oncologists (21.1%) and radiation oncologists (19.1%) than surgical oncologists (11.8%). Thus, there is not much difference in perception in practice of NACT in radiation, medical, and surgical oncologists. A minimum of two cycles of NACT was preferred by more than half of the doctors (55.4%) with 59.6% radiation oncologists using it before further assessment.

Conclusion

Although level I evidence for inferior outcomes with NACT as compared to concurrent chemoradiation therapy is there, the use of NACT is quite common among various oncologists in the country because of reasons such as buying time for definitive treatment, achieving R0 resection, better outcome and survival, partial response, better tolerability, better distant control, LN size regression, down-staging of primary tumor, selection of chemosensitive patients, reducing the volume of the radiation field, and better tolerability of subsequent Chemoradiation (CTRT) intensity of subsequent chemoradiation therapy.

Surgical outcomes of T4b oral cancers: assessment of prognostic factors and a need to re-evaluate the current staging system

T4b oral cancer is a broad umbrella term for all advanced oral cancers, the prognosis of which varies drastically for disease of the same stage, according to the extent of the masticator space involvement. This was a retrospective observational study including all consecutive T4b oral squamous cell carcinoma patients treated surgically between January 2015 and January 2016 and followed up until January 2020. The disease was classified as upper disease or lower disease based on the anatomical location in relation to an imaginary plane passing through the base of the retromolar trigone. The prime objective was to evaluate overall survival and prognostic factors affecting overall survival. The projected 5-year overall and disease-free survival rates were 40.7% and 35.6%, respectively. The assessment of prognostic factors revealed that lower disease (lower anatomical subsites), bone invasion, and lymph nodal spread significantly affected survival. Patients with disease in an upper anatomical location without bone and nodal involvement can achieve fairly good survival (projected 5-year overall survival of 64.2%) when compared to the other subsets of patients. We propose a re-evaluation of the current staging system based on the prognostic features, so that all patients are not considered under a single stage, since their survival differs significantly.

Integrated proteomics and phosphoproteomics revealed druggable kinases in neoadjuvant chemotherapy resistant tongue cancer

Tongue squamous cell carcinoma is an aggressive oral cancer with a high incidence of metastasis and poor prognosis. Most of the oral cavity cancer patients present in clinics with locally advanced unresectable tumors. Neoadjuvant treatment is beneficial for these individuals as it reduces the tumor size aiding complete resection. However, patients develop therapy resistance to the drug regimen. In this study, we explored the differential expression of proteins and altered phosphorylation in the neoadjuvant chemotherapy resistant tongue cancer patients. We integrated the proteomic and phosphoproteomic profiles of resistant (n = 4) and sensitive cohorts (n = 4) and demonstrated the differential expression and phosphorylation of proteins in the primary tissue of the respective subject groups. We observed differential and extensive phosphorylation of keratins such as KRT10 and KRT1 between the two cohorts. Furthermore, our study revealed a kinase signature associated with neoadjuvant chemotherapy resistance. Kinases such as MAPK1, AKT1, and MAPK3 are predicted to regulate the resistance in non-responders. Pathway analysis showed enrichment of Rho GTPase signaling and hyperphosphosphorylation of proteins involved in cell motility, invasion, and drug resistance. Targeting the kinases could help with the clinical management of neoadjuvant chemotherapy-resistant tongue cancer.

Assessment of neoadjuvant chemotherapy with docetaxel, cisplatin, and fluorouracil in patients with oral cavity cancer

BACKGROUND

Chemotherapy with docetaxel, cisplatin, and fluorouracil (TPF) has been studied in patients with head and neck cancer. Its impact on patients with oral cavity cancer was not specified.

METHODS

We consecutively reviewed medical files of patients with untreated oral cavity cancer who received neoadjuvant TPF chemotherapy in our department from January 2017 to April 2020. Outcomes included the objective response to TPF chemotherapy, factors associated with the response, and progression and survival in different response groups.

RESULTS

A total of 167 patients were included, with half of stage IV disease. Complete or partial response was observed in 51 patients. A total of 91 patients had stable disease, and 25 patients had progressive disease. The response was not associated with age, sex, anatomic subsite, and the tumor's T stage. It was related with N stage (p < 0.001) and clinical stage (p = 0.004). Most patients with bulky nodes or nodes with obvious necrosis showed low response or even progressed after neoadjuvant TPF chemotherapy. The planned surgery was conducted in 159 patients. Disease relapse mostly occurred in 2 years after treatment. The 2-year overall survival and the progression-free survival were 89.0% and 85.2% for patients with complete or partial response, 62.4% and 55.6% for patients with stable disease, and 12.5% and 4.2% for patients with progressive disease, respectively.

CONCLUSIONS

The response of neoadjuvant TPF chemotherapy in patients with oral cavity cancer is related to disease stage, especially the nodal stage. Patients with complete or partial response developed less progression events and better survival.

Induction Chemotherapy in Squamous Cell Carcinoma of Tongue—Still a Slippery Role?

Background Tongue cancers are more common in the Indian subcontinent and a leading cause of morbidity and mortality among oral cavity cancers. Induction chemotherapy has been considered an intriguing and smart option for many reasons, but even after years of studies and debates, its role has not been fully established in the management of tongue cancers.

Materials and Methods In this study, we evaluated 17 patients with oral tongue carcinomas with locally advanced stage, enrolled into a protocol of three drug (docetaxel, cisplatin, 5-fluorouracil) induction chemotherapy for three cycles. After completion of the three cycles, patients were clinically and radiologically re-evaluated and surgery was done if locally operable.

Results At the completion of three cycles, five patients were partial responders, four patients were complete responders, and five patients had progressive disease after three cycles. Those patients with response underwent surgery. There were no significant morbid intraoperative or postoperative complications observed in seven out of nine patients. At the end of treatment completion, five out of nine patients had tumor residue/high-risk features and were planned for adjuvant radiotherapy.

Conclusion For locally advanced oral tongue carcinomas, the role of induction chemotherapy before surgery has been fruitful and its impact on function preservation with acceptable oncological clearance is an emerging alternative. Spacing chemotherapy and radiotherapy reduce the incidence of adverse effects of combined treatment.

Survival and clinicopathological characteristics of cT4b oral squamous cell carcinoma based on different treatment modalities: A single-center retrospective study

INTRODUCTION

Primary surgical treatment for oral squamous cell carcinoma (OSCC) is reserved for T1 to T4a tumors, but not for T4b tumors, according to the present National Comprehensive Cancer Network clinical practice guidelines. In this retrospective study, we aimed to determine the association between the clinicopathological characteristics and different treatment modalities for T4b OSCC based on whether patients received primary surgical treatment. Therefore, we conducted a survival analysis based on different treatment modalities.

METHODS

This retrospective cohort study enrolled 125 patients with clinical stage T4b OSCC who received treatment and were followed up at Changhua Christian Hospital between January 1, 2008 and December 31, 2018.

RESULTS

Overall, 81 patients received primary surgical treatment and 44 received primary nonsurgical treatment. Comparison of the clinicopathological characteristics between those who did and did not undergo surgery revealed no significant differences in age at tumor diagnosis, tumor location, clinical N stage, and involved tumor area based on computed tomography or magnetic resonance imaging, or stratified Charlson Comorbidity Index scores. In the survival analysis, Kaplan-Meier curves revealed that patients who received treatment modalities including surgery exhibited better survival than those who received treatment modalities that did not include surgery.

CONCLUSIONS

In the present study, patients with T4b OSCC treated with primary surgery had a better overall survival rate than those who received nonsurgical treatment. In the future, it will be necessary for clinicians worldwide to report the treatment outcomes of patients with T4b OSCC based on the common criteria.

Induction Chemotherapy for Advanced Oral Cavity Cancer

PURPOSE OF REVIEW

Head and neck cancer is a heterogeneous disease, comprising multiple subsites with diverse etiologic factors, pathology and molecular features, response to treatment, and prognosis. Systemic treatment is usually incorporated in the management of locally advanced head and neck squamous cell carcinoma, and the use of induction chemotherapy has theoretical benefits on reducing the risk of distant metastasis, provide an in vivo testing of response and tumor biology and the potential to allow a more personalized and less toxic local treatment after downstaging. The aim of this review is to access the role of induction chemotherapy in patients with locally advanced oral cavity cancer.

RECENT FINDINGS

Clinical trials analyzing this treatment strategy in patients with resectable disease, followed by surgery, and in unresectable disease, followed by (chemo)radiotherapy or surgery are discussed, pointing out strengths and limitations of this data and highlighting the standard treatment in each clinical scenario. Future perspectives, including the incorporation of checkpoint inhibitors and biomarkers for patient selection are discussed. Surgery followed by (chemo)radiation is the standard of care for resectable oral cavity cancer patients, and chemoradiation is the standard for those considered as unresectable. Future trials with the incorporation of immunotherapy and better patient selection based on clinical and molecular biomarkers can bring new hopes for better therapeutic results in these patients.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Chemoradiation in Unresectable Oral Cavity Cancer: A Myth or Reality!

Objective  Earlier studies have shown that chemoradiation (CTRT) has benefits in the head-and-neck cancer, but how far it is true for oral cavity subset that has not been exactly explored. Keeping the null hypothesis as CTRT has no benefit in oral cavity cancer, we studied the outcome of patients undergoing chemoradiation in unresectable oral cavity cancers. The aim of this study is to study whether overall survival (OS) increases with chemoradiation in unresectable oral cavity cancers.

Patients and Methods  Between December 2014 and February 2017, 23 patients aged 18 years and above were planned chemoradiation for unresectable oral cavity cancer and were included for this analysis.

Results  The median age of patients was 43 years and all patients were addicted to tobacco. In total, 12 of 23 (52%) completed CTRT. One patient (1/23) was alive at the time of final analysis with median OS of 5.83 (2.73–9.60) months. The median progression free survival and OS in patients who completed chemoradiation were 6.42 months (95% confidence interval [CI]: 3.67–10.53) and 8.9 months (95% CI: 4.4–23.07), respectively.

Conclusion  CTRT has a limited role in unresectable oral cancers.

Delay to surgery after neoadjuvant chemotherapy in head and neck squamous cell carcinoma affects oncologic outcomes

BACKGROUND

Neoadjuvant chemotherapy (NAC) is used in head and neck squamous cell carcinoma (HNSCC) for downstaging advanced disease and decreasing distant metastasis (DM). To the authors' knowledge, no study has specifically examined the impact of a delayed time to surgery (TTS) after NAC on oncologic outcomes. They thus aimed to identify a cutoff for TTS after NAC and its effect on survival indices.

METHODS

This was a retrospective review of all patients with HNSCC receiving NAC followed by surgery with curative intent between March 2016 and March 2019 at the MD Anderson Cancer Center. Receiver operating characteristic analysis was used to identify a cutoff for TTS, and this cutoff was used to analyze the overall survival (OS), locoregional recurrence rate, DM-free rate, and disease-free survival (DFS). A multivariate Cox regression analysis was performed.

RESULTS

One hundred one patients were analyzed with a median follow-up of 24.7 months. The 3-year OS and locoregional recurrence rates did not differ with a TTS ≥ 34 days. However, the 3-year DM-free rate was significantly worse (56% vs 90%; P = .001) in the group with a TTS ≥ 34 days, and the 3-year DFS was significantly lower (26% vs 64%; P = .006). In a multivariate analysis, a TTS ≥ 34 days (hazard ratio [HR], 4.92; 95% confidence interval [CI], 1.84-13.13) and extracapsular extension (HR, 3.01; 95% CI, 1.13-8.00) were significant independent predictors of a poorer DM-free rate. Weight loss > 10% (HR, 5.53; 95% CI, 1.02-30.24) was the only independent predictor for a TTS ≥ 34 days.

CONCLUSIONS

Emphasis should be placed on early definitive locoregional treatment after NAC, particularly in patients who do not respond to NAC. There is a need to validate these findings and establish new benchmarks for the interval between NAC and surgery.

Survival Impact of Surgical Resection in Locally Advanced T4b Oral Squamous Cell Carcinoma

OBJECTIVE/HYPOTHESIS

With non-surgical treatment, T4b oral squamous cell carcinoma (OSCC) have an unacceptably poor prognosis. A subset of patients if selected wisely for surgery, can have significantly improved survival. The present study aims to explore the feasibility of radical resection and neoadjuvant chemotherapy (NACT) in the T4b OSCC and their impact on survival, along with the factors affecting it.

STUDY DESIGN

This is a retrospective analysis of 302 consecutive patients with T4b OSCC presented at our institute between July 2015 and January 2016.

METHODS

Three different treatment protocols were decided depending on the extent of the disease-upfront resection, NACT (followed by surgery or chemo/radiation depending on the response), or upfront non-surgical treatment (chemotherapy and/or radiotherapy).

RESULTS

Upfront surgery was done in 67 (22.19%) patients and 155 (51.32%) patients received NACT. The rest of the patients received upfront non-surgical treatment. The overall response rate of NACT was 23.23% and the resectability rate was 36.13%. The median OS for the whole population was 12 months (30 months for the surgical group and 9 months for the non-surgical group). There was no survival difference between supra versus infra-notch tumors (P value = .552) or post-NACT versus upfront surgery (P value = .932). Nodal involvement was the most important poor prognostic factor affecting both DFS (P = .006) and OS (P = .002).

CONCLUSIONS

With proper patient selection after thorough clinico-radiological assessment, a subset of T4b OSCC can be operated with curative intention; either upfront or after downstaging with NACT, which ultimately translates into improved survival.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2266-E2274, 2021.

Locally Advanced Oral Cavity Cancers: What Is The Optimal Care?

Patients with oral cavity cancers often present late to seek medical care. Surgery is usually the preferred upfront treatment. However, surgical resection cannot be achieved in many cases with advanced disease without major impact on patient’s quality of life. On the other hand, radiotherapy (RT) and chemotherapy (CT) have not been employed routinely to replace surgery as curative treatment or to facilitate surgery as neoadjuvant therapy. The optimal care of these patients is challenging when surgical treatment is not feasible. In this review, we aimed to summarize the best available evidence-based treatment approaches for patients with locally advanced oral cavity cancer. Surgery followed by RT with or without CT is the standard of care for locally advanced oral cavity squamous cell carcinoma. In the case of unresectable disease, induction CT prior to surgery or chemoradiotherapy (CRT) can be attempted with curative intent. For inoperable patients or when surgery is expected to result in poor functional outcome, patients may be candidates for possibly curative CRT or palliative RT with a focus on quality of life.

Role of structures in the masticator space in selecting patients with resectable T4b oral cancer: findings from a survival analysis

Oral squamous cell cancers involving the masticatory space are staged as unresectable cancers and their treatment is difficult. Curative treatment with extensive surgery followed by adjuvant therapy is one of the treatment options. In this retrospective study, the survival of 123 patients (93 with T4a cancers, 30 with T4b cancers), treated during the period August 2009 to August 2015, was evaluated. The majority had bucco-alveolar cancers (62.6%), were male (61.8%), and were tobacco users (76.4%). The select group of T4b oral cancer patients were treated with surgery, which included infratemporal fossa clearance in all 30 patients, followed by adjuvant therapy. The masseter was the most commonly involved masticatory muscle, and 24 patients had fewer than three involved structures. Free margins were obtained in 90.2% of cases; 41.5% of cases were node-positive. One hundred and four patients (84.6%) completed adjuvant treatment. The median follow-up was 42 months. For node-negative patients with T4a and T4b cancers, the 5-year overall survival was 59% and 50.2%, respectively (P= 0.62), and 5-year disease-free survival was 64.6% and 53.5%, respectively (P= 0.01). In conclusion, the select group of patients with T4b oral cancers and less than three masticatory space structures involved had comparable outcomes to those with T4a cancers after treatment with surgery and adjuvant radiotherapy.

Compartmental Clearance of Infratemporal Fossa for T4b Carcinoma of Buccal Mucosa/Alveolus: Clinical Outcomes

T4 b carcinoma of oral cavity has poor outcomes. The aim for analysis is to evaluate the clinical outcomes with infratemporal fossa clearance for stage T4b carcinoma of oral cavity. Fifty four patients out of maintained data of 528 patients of oral cavity carcinoma were evaluated for current retrospective analysis. All had T4b disease on imaging and underwent bite composite resection with ITF clearance. The median age of the cohort was 52 years. At last follow-up, 28 patients were alive. Twenty two patients had loco-regional recurrence (ITF recurrence 7), and 16 patients had distant metastasis. At median follow-up of 29 months, 2-year loco-regional control, DFS and OS were 52%, 54% and 54%, respectively. Perineural invasion, pathological tumour stage, node positive and ITF tissue involvement were associated with poor oncological outcomes. ITF clearance is feasible in clinical practice and provides curative option for this group.

Dihydropyrimidine dehydrogenase mutation in neoadjuvant chemotherapy in head and neck cancers: Myth or reality?

PURPOSE

The docetaxel, 5-fluorouracil (5-FU), and cisplatin (TPF) regimen in India is associated with high percentages of Grade 3-4 toxicity. This analysis was planned to evaluate the incidence of dihydropyrimidine dehydrogenase (DPD) mutation in patients with severe gastrointestinal toxicity, to assess whether the mutation could be predicted by a set of clinical criteria and whether it has any impact on postneoadjuvant chemotherapy response.

METHODS

All consecutive patients who received TPF regimen in head and neck cancers between January 2015 and April 2015 were selected. Patients who had predefined set of toxicities in Cycle 1 were selected for DPD mutation testing. Depending on the results, C2 doses were modified. Postcompletion of two cycles, patients underwent radiological response assessment. Descriptive statistics has been performed. The normally distributed continuous variables were compared by unpaired Student's t-test, whereas variables which were not normally distributed by Wilcoxon sum rank test. For noncontinuous variables, comparison was performed by Fisher's exact test.

RESULTS

Out of 34 patients, who received TPF, 12 were selected for DPD testing, and 11 (32.4%, 95% confidence interval [95% CI]: 19.1-49.3%) had DPD mutation. The predictive accuracy of the criteria for the tested DPD mutations was 81.3% (95% CI: 62.1-100%). Of the 11 DPD mutation positive patients, except for one patient, all others received the second cycle of TPF. The dose adjustments done in 5-FU were 50% dose reduction in 9 patients and no dose reduction in one patient. The response rate in DPD mutated patients was 27.3% (3/11) and that in DPD nonmutated/nontested was 39.1% (9/23) (P = 0.70).

CONCLUSION

In this small study, it seems that the incidence of DPD mutation is more common in Indian then it's in the Caucasian population. Clinical toxicity criteria can accurately predict for DPD mutation. Postdose adjustments of 5-FU from C2 onward, TPF can safely be delivered in the majority of patients with DPD heterozygous mutations without decrement in efficacy.

Prognostic value of GLUT-1 expression in oral squamous cell carcinoma: A prisma-compliant meta-analysis

BACKGROUND

A variety of studies have evaluated the correlation between glucose transporter-1 (GLUT-1) expression and prognosis of oral squamous cell carcinoma (OSCC); however, the results were inconsistent and inconclusive. A meta-analysis was performed to assess the prognostic significance of GLUT-1 in OSCC.

METHODS

Electronic databases of PubMed, Embase, and Web of Science were searched for relevant studies. The last search was updated on July 2016. Odds ratio (OR) and 95% confidence interval (CI) were pooled to evaluate the relationship between GLUT-1 and clinical features and hazard ratio (HR) and 95% CI were combined to measure the effect of GLUT-1 on overall survival (OS). P value < 0.05 was considered as statistically significant.

RESULTS

A total of 13 studies with 1301 subjects were included for meta-analysis. The pooled data showed that high GLUT-1 expression was associated with advanced tumor stages (n = 7, OR = 2.99, 95% CI: 2.01-4.46, P < 0.001), higher tumor grade (n = 5, OR = 3.34, 95%CI: 1.12-9.94, P = 0.031), tumor size (n = 5, OR = 3.36, 95%CI: 2.04-5.51, P < 0.001), lymph node metastasis (n = 5, OR = 3.15, 95%CI: 1.89-5.25, P < 0.001), tobacco use (n = 3, OR = 2.18, 95%CI: 1.18-4.01, P = 0.013), and distant metastasis (n = 2, OR = 3.06, 95%CI: 1.19-7.9, P = 0.02). Furthermore, increased GLUT-1 expression was also correlated with shorter OS (n = 8, HR = 1.88, 95%CI: 1.51-2.33, P < 0.001). No significant publication bias was detected in this meta-analysis.

CONCLUSION

GLUT-1 overexpression was in connection with aggressive clinical features and worse OS in OSCC. However, further studies are still needed to verify whether GLUT-1 could serve as a prognostic biomarker for OSCC.

Neoadjuvant chemotherapy in oral cancers: Selecting the right patients

The standard of care treatment for oral squamous cell carcinoma (OSCC) at present, consist of surgical resection followed by adjuvant radiotherapy and chemotherapy as indicated. Despite recent advances the overall prognosis remains guarded. Role of neoadjuvant chemotherapy is being explored with premise of reducing extent of surgical resection, improving loco-regional control and decreasing distant metastasis, thereby improving treatment outcomes by decreasing mortality and morbidity. However, indications of neoadjuvant chemotherapy in oral cancers are not clearly defined. Majority of studies have failed to demonstrate a significant benefit of neoadjuvant chemotherapy in terms of loco regional control and overall survival in resectable OSCC. In a select subset of patients with locally very advanced and unresectable OSCC, neoadjuvant chemotherapy has been shown to cause tumor shrinkage and improve resectability. These hypothesis generating findings of reduction in distant metastasis, improved resectability and functional outcome, however need further validation. In summary, the role of neoadjuvant chemotherapy for OSCC remains investigational and has a limited role outside clinical trial.

Pre-treatment performance status and stage at diagnosis in patients with head and neck cancers

Performance status (PS) is a key factor in the selection of treatment in head and neck cancer patients (HNC). There is a probability in the development of an unfavorable PS with HNC advancing stages. This retrospective study was done on data of patients registered during the period from January 2010 to December 2012 at a cancer registry in the North Eastern India. PS was recorded according to the WHO scale. Multinomial logistic regression analysis was conducted to assess the probability of poor performance status with advancing stage. Out of 3,593 patients, there were 78.9% (2,836) males and 21.1% (757) females. Average PS0 was seen in 57.4% of all HNCs, less than 1% of all cases in HNCs with poor PS3-4 except in cases with thyroid, parotid and nose and PNS cancers, 0.7% stage IV (±M1) HNC with PS4, favorable PS0-1 was seen in 84% to 100% of cases, RR=57.1 (CI=21.2-154.1) in M1 for PS4 and with advancing stages the probability of worsening of PS0 to PS4 was 3 times (P=0.021, 95% CI= 1.187-8.474). In HNC, the majority of patients presents with a favorable PS0- 1 with different odds of worsening of PS with advancing stages and the presence of metastasis in stage IV is significantly associated with a poor PS.

E-cadherin expression and prognosis of oral cancer: a meta-analysis

This study aims to evaluate the association of E-cadherin expression with the prognosis of oral squamous cell carcinoma (OSCC). Literature retrieval, selection and assessment, data extraction, and meta-analyses were performed according to the Revman 5.0 guidelines. In the meta-analysis, we utilized either fixed effects or random effects model to pool the HR according to the test of heterogeneity. A total of nine eligible studies included 973 OSCC patients were analyzed. Of the patients, 76.3 % had low expression of E-cadherin according to the cutoff value defined by the authors. The pooled hazard ratio (HR) of low expression of E-cadherin for overall survival (OS) was 0.65 (95 % CI 0.52 to 0.80, P<0.001); in Asian population, the HR for overall survival of the patients with reduced expression of E-cadherin was 0.84 (95 % CI 0.75 to 0.95, P=0.006), and in non-Asian population, the HR for overall survival of the patients with reduced expression of E-cadherin was 0.54 (95 % CI 0.41 to 0.69, P<0.001). Patients with reduced expression of E-cadherin appear to have a poorer OS compared with those with normal or higher expression of E-cadherin.