Prognostic factors in mandibular gingival squamous cell carcinoma: A 10-year retrospective study

Clinicopathological analysis of 134 patients with squamous cell carcinoma of the mandibular gingiva

Objective

The accurate assessment of the involvement of mandibular gingival squamous cell carcinoma (SCC) is essential for determining the extent of resection and is also useful for predicting lymph node metastasis and prognosis. The purpose of this study was to investigate the factors for predicting the prognosis.

Study design

We reviewed 134 patients with mandibular gingival SCC treated between 2008 and 2017. The clinical findings, TN stage, relationship between radiographical type and histological pattern, and factors affecting the survival rate were investigated.

Results

The moth-eaten radiographic type was significantly associated with histologically infiltrative pattern. For all 134 cases, the 5-year OS was 89.5 %, and 5-year DSS was 93.9 %. The 5-year DSS was 95.0 % for cN0 and/or pN0 cases and 90.3 % for pN (+) cases, with a significant difference. The significant risk factors for lymph node metastasis were teeth extractions by previous physicians and moth-eaten radiographic type.

Conclusion

The risk factor for poor prognosis was lymph node metastasis. In addition, teeth extractions by previous physicians and moth-eaten radiographic type were the risk factors for lymph node metastasis. It is recommended that these cases be treated considering the possibility of cervical lymph node metastasis.

Reconstructive surgery and adjuvant radiotherapy for the multimodal approach in oral cancer: a single cancer centre experience

Introduction and importance

Ablative surgery for oral cancer, irrespective of the histological subtype, causes large tissue defects, functional and aesthetic damage. Microsurgical free flaps have been widely used in reconstruction after resection, with satisfactory success rates in conjunction with adjuvant radiotherapy (RT). This study aims to describe our clinical institutional experience based on the multimodal treatment performed in four cases diagnosed with oral squamous cell carcinoma with the use of different microvascular free flaps and RT.

Case series presentation

Four patients underwent reconstructive microsurgery after surgical resection of oral cancer, using three types of free flap: radial forearm fasciocutaneous, osteomyocutaneous fibular, and anterolateral thigh musculocutaneous flaps; RT was performed in Case 2 and Case 3. In the period of 3 years after microsurgical reconstruction and RT, flaps remain clinically stable without failure signs in full patients submitted to multimodal treatment.

Clinical discussion

After resection of oral carcinomas, extensive tissue defects can be successfully treated with reconstructive microsurgery using different types of microvascular free flaps. RT for locoregional control is a feasible option and did not seem to interfere with the survival of flaps.

Conclusion

An enhance long-term follow-up to assess overall and disease-free survival rates and quality of life must be carried out; however, cohort studies would be necessary for better understanding of the role of each treatment in the multimodal scheme.

Perineural Invasion Is a Significant Prognostic Factor in Oral Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

(1) Objectives: This systematic review and meta-analysis aimed to summarize current evidence regarding the prognostic role of perineural invasion (PNI) in patients with oral squamous cell carcinoma (OSCC). (2) Methods: We searched Cochrane Central, ProQuest, PubMed, Scopus, Science Direct, and Web of Science, using relevant keywords to identify eligible articles. Two independent reviewers conducted two-stage screening, data extraction, and quality assessment. The risk of bias was assessed using the Newcastle-Ottawa Scale (NOS) criteria. All analyses were performed using comprehensive meta-analysis (CMA; version 3.3.070) software. (3) Results: The study included 101 published articles encompassing 26,062 patients. The pooled analyses showed that PNI was associated with significantly worse overall survival (OS; HR = 1.45, 95% CI: 1.32-1.58; p < 0.001), worse disease-specific survival (DSS; HR = 1.87, 95% CI: 1.65-2.12; p < 0.001), and worse disease-free survival (DFS; HR = 1.87, 95% CI: 1.65-2.12; p < 0.001). Similarly, both local recurrence-free survival (LRFS) and regional recurrence-free survival (RRFS) were worse in patients with PNI (HR = 2.31, 95% CI: 1.72-3.10, p < 0.001; and HR = 2.04, 95% CI: 1.51-2.74, p < 0.001), respectively. The random-effect estimate of three studies demonstrated that the presence of PNI was associated with worse failure-free survival (FFS; HR = 2.59, 95% CI: 1.12-5.98, p < 0.001). (4) Conclusions: The current evidence suggests that PNI can be used as an independent predictor of the prognosis for patients with OSCC. The presence of PNI was associated with worse OS, DFS, DSS, FFS, and with recurrence. Asian patients and patients with extra-tumoral or peripheral PNI invasion were associated with worse prognosis.

[Clinical factors affecting the prognosis of lower gingival squamous cell carcinoma]

OBJECTIVE

To define the clinical factors that influence local recurrence and survival in patients with lower gingival squamous cell carcinoma (LGSCC) and determine whether bone invasion is an independent prognostic factor for them.

METHODS

A total of 104 patients with LGSCC hospitalized in Peking University Stomatology Hospital from June 2013 to December 2015 were enrolled in this retrospective study.All the patients were followed-up for more than 3 years.The degree of bone invasion was assessed using preoperative imaging data (CT and panoramic radiograph).The degree of bone invasion was divi-ded into four categories: no bone invasion, invasion of cortical bone, invasion of bone marrow cavity, and invasion of the mandibular canal.According to the central position of tumor, it was divided into two types: anterior mandibular invasion (anterior region of the mental foramen) and posterior mandibular invasion (posterior region of the mental foramen).

RESULTS

of different invasion depth groups were compared using Mann-Whitney U test.P value < 0.05 was considered to be statistically significant.Kaplan-Meier survival analysis method was used to draw survival curve, and COX regression was used to explore the risk ratio (HR) and 95% confidence interval (CI) of prognostic factors of LGSCC.

RESULTS

The follow-up results showed that the 1-, 3-, and 5-year survival rates of LGSCC in this group were 91%, 84%, 82%, respectively.32.7%(34/104) of patients had cervical lymph node metastasis.The cervical lymph node metastasis rate of the anterior segment of the mandible was 12.5%(2/16), and 36.4%(32/88) for the posterior segment of the mandible (P < 0.05).Univariate and multivariate COX analysis showed that the N stage and local recurrence were the prognostic factors of LGSCC patients (P < 0.05).

CONCLUSION

As the degree of mandibular invasion increases, the prognosis of patients with mandibular gum cancer becomes worse.N stage and local recurrence are prognostic risk factors for LGSCC.The incidence of cervical lymph node metastasis for LGSCC is related to the primary tumor location.It is concluded that tumors located at the posterior of the mandible might be more prone to cervical lymph node metastasis than the anterior of the mandible.Thus various levels of cervical lymph node dissection strategies should be adopted for different sites of LGSCC.

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

Introduction

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

Purpose

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

Methods

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

Results

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

Conclusions

PNI is a negative prognostic factor in oral cancer.

Use of anterior ramus bone graft for mandibular reconstruction in elderly patients

In this study, we investigated the feasibility of using a geometrically designed anterior ramus graft to reconstruct lateral mandibular defects. This was achieved by assessing the anatomical dimensions of the mandibular ramus on computed-tomographies. The design sequence and application of the graft was also demonstrated using one of our cases. The following dimensions were measured; a and b - horizontal length from mid-ramus to the posterior and anterior ramus border respectively, c - longest length of the graft, Mp - width at the centre of the ramus, h - vertical length of the angle at its cross-section, w - horizontal length of the angle at its cross-section, x - cross-sectional area along the mandible angle. A total of 80 mandibular rami were examined. The mean length of a, b, c were 17.3 ± 1.8 mm, 15.9 ± 1.2 mm, 54.6 ± 3.8 mm, respectively. The mean width of Mp was 9.8 ± 1.1 mm. The mean cross section area of Eo-Md (x) was 326.7 ± 67.8 mm². The average length of h and w were 26.5 ± 3.2 and 15.6 ± 2.1 mm, respectively. The use of virtual surgical planning (VSP) to geometrically design the graft was also described. Together with VSP, the anterior ramus bone graft will allow for reconstruction of the mandible with greater surgical efficiency, reduced complexity and without the need for extra-oral bone harvest. This may be an useful alternative in situations where simpler reconstructive procedures are preferred.

Managing misdiagnosed gingival squamous cell carcinoma (GSCC) with occult symptoms: A report of two cases

Introduction

importance: Gingival squamous cell carcinoma (GSCC) is a rare neoplasm. GSCC has nonspecific features which commonly misdiagnosed with a simple toothache.

Case presentation

These are two cases; the first one describes a 62-year-old female who presented with pain in her right posterior mandibular teeth, and she was misdiagnosed with periodontal disease, but later histopathological tests confirmed gingival squamous cell carcinoma (GSCC). Consequently, the patient underwent surgery, and the gingival tumor was totally resected. Afterward, the patient was receiving chemotherapy, and the radiotherapy was postponed until the chemotherapy completion.

The second case is of a 58-year-old female who presented with pain in her mandibular incisors, and she developed a dermal fistula on her chin and therefore underwent several gingival curettages. The following histopathologic tests confirmed GSCC so she underwent surgery, after the surgery it was planned to give her chemotherapy.

Clinical discussion

GSCC is a rare neoplasm with a 6% incidence of all oral malignancies. GSCC is a very challenging cancer for a physician or a pathologist to diagnose because GSCC usually mimics the characteristics of a large variety of diseases and abnormalities. Unlike oral neoplasms, GSCC has the least association with smoking. This may lead to make mistakes in the treatment or misdiagnose it until the late-stage of GSCC.

Conclusion

Despite the rare incidence of Gingival squamous cell carcinoma (GSCC), clinicians should consider GSCC while investigating any localized lesion with nonspecific oral symptoms.

•

GSCC usually presents with non-specific symptoms.

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Doctors should think of GSCC as a probable diagnosis of oral lesions with vague presentation.

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Suspicious oral lesions should be biopsied as soon as possible.

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The primary or metastatic malignancy must be surgically removed.

Research on neck dissection for oral squamous-cell carcinoma: a bibliometric analysis

Neck dissection for oral squamous-cell carcinoma (OSCC) is a clinically controversial issue and has therefore been the subject of abundant research. However, no one has performed a bibliometric study on this topic to date. The aim of this study was to assess the development of research on neck dissection for OSCC in terms of the historical evolution, current hotspots and future directions, particularly including research trends and frontiers from 2010 to 2019. Literature records related to research on neck dissection for OSCC were retrieved from the Web of Science Core Collection (WoSCC). CiteSpace was used as a tool to perform a bibliometric analysis of this topic. The survey included 2 096 papers. “Otorhinolaryngology” was the most popular research area. The most active institutions and countries were Memorial Sloan Kettering Cancer Center and the USA, respectively. Shah J.P. was the most cited author. Among the six identified “core journals”, Head & Neck ranked first. The top three trending keywords were ‘invasion’, ‘upper aerodigestive’ and ‘negative neck’. ‘D’Cruz AK (2015)’ was the most cited and the strongest burst reference in the last decade. The study evaluated the effect on survival of elective versus therapeutic neck dissection in patients with lateralized early-stage OSCC. The depth of invasion and the management of N0 OSCC were research frontiers in this field. The present study provides a comprehensive bibliometric analysis of research on neck dissection for OSCC, which will assist investigators in exploring potential research directions.

Implications of Tumor Size, Subsite, and Adjuvant Therapy on Outcomes in pT4aN0 Oral Cavity Carcinoma

Objective

To determine if tumor size, subsite, and adjuvant radiation therapy (AXRT) are associated with overall survival (OS) in patients with pT4aN0 oral cavity squamous cell carcinoma (OSCC) who underwent mandibulectomy with negative surgical margins (NSMs).

Study Design

Retrospective cohort study.

Setting

National Cancer Database (NCDB).

Subjects and Methods

Retrospective analysis of the NCDB that included patients diagnosed with pT4aN0 OSCC who underwent mandibulectomy with NSMs between 2004 and 2015. The association of age, Charlson-Deyo score (CDS), tumor size, subsite, and AXRT with OS was analyzed. The cases were divided into 3 subgroups based on maximal tumor dimension for subgroup analysis; tumors ≤2.0 cm, tumors 2.1 to 4.0 cm, and tumors >4.0 cm.

Results

For the entire cohort; age ( P < .001; hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.02-1.03), CDS ( P = .013; HR, 0.57; 95% CI, 0.37-0.89), tongue subsite ( P = .003; HR, 2.01; 95% CI, 1.27-3.40), floor of mouth subsite ( P = .001; HR, 1.76; 95% CI, 1.28-2.42), tumor size ( P < .001; HR, 0.57; 95% CI, 0.45-0.72), and AXRT ( P < .001; HR, 1.46; 95% CI, 1.24-1.72) were associated with OS on multivariate analysis. On subgroup analysis, AXRT not significantly associated with OS in patients with gingival, hard palate, retromolar trigone, and not specified tumors ≤2.0 cm ( P = .323; HR, 1.29; 95% CI, 0.78-2.15).

Conclusions

In patients with pT4aN0 OSCC who underwent mandibulectomy with NSMs, age, CDS, tongue subsite, floor of mouth subsite, tumor size, and AXRT are associated with OS. AXRT was not significantly associated with overall survival in patients with gingival, hard palate, retromolar trigone, and not specified tumors ≤2.0 cm.

A Review of Controversial Issues in the Management of Head and Neck Cancer: A Swiss Multidisciplinary and Multi-Institutional Patterns of Care Study-Part 1 (Head and Neck Surgery)

Background: The Head and Neck Cancer Working Group of Swiss Group for Clinical Cancer Research (SAKK) has investigated the level of consensus (LOC) and discrepancy in everyday practice of diagnosis and treatment in head and neck cancer.

Materials and Methods: An online survey was iteratively generated with 10 Swiss university and teaching hospitals. LOC below 50% was defined as no agreement, while higher LOC were arbitrarily categorized as low (51–74%), moderate (75–84%), and high (≥85%).

Results: Any LOC was achieved in 62% of topics (n = 60). High, moderate and low LOC were found in 18, 20, and 23%, respectively. Regarding Head and Neck Surgery, Radiation Oncology, Medical Oncology, and biomarkers, LOC was achieved in 50, 57, 83, and 43%, respectively.

Conclusions: Consensus on clinical topics is rather low for surgeons and radiation oncologists. The questions discussed might highlight discrepancies, stimulate standardization of practice, and prioritize topics for future clinical research.

Oncologic outcome of marginal mandibulectomy in squamous cell carcinoma of the lower gingiva

Background

There is a large amount of controversy about the best management of the mandible in oral squamous cell carcinoma (SCC), mainly owing to the inability to acquire accurate bone invasion status. Therefore, our goal was to analyse the oncologic safety in patients undergoing marginal mandibulectomy (MM) for cT1-2 N0 SCC of the lower gingiva.

Methods

Patients undergoing MM for untreated cT1-2 N0 SCC of the lower gingiva were retrospectively enrolled. The main endpoints of interest were locoregional control (LRC) and disease-specific survival (DSS).

Results

A total of 142 patients were included in the analysis, and a pathologic positive node was noted in 27 patients. Cortical invasion was reported in 23 patients, and medullary invasion was reported in 9 patients. The 5-year LRC and DSS rates were 85 and 88%, respectively. Patients with bone invasion had a significantly higher risk for recurrence than patients without bone invasion. However, the DSS was similar in patients with versus without bone invasion. Patients with a high neutrophil lymphocyte ratio had a higher risk for worse prognosis.

Conclusions

The oncologic outcome in patients undergoing MM for cT1-2 N0 SCC of the lower gingiva was favourable; bone invasion was not uncommon, but it significantly decreased the prognosis in patients undergoing MM.

Survival Outcomes in T4aN0M0 Mandibular Gingival Squamous Cell Carcinoma Treated with Surgery Alone

Objectives

To measure disease-free, disease-specific, and overall survival among patients with T4aN0M0 mandibular gingival squamous cell carcinoma who were treated with surgery alone.

Study Design

Case series with chart review.

Setting

Tertiary care center.

Subjects and Methods

A retrospective chart review was performed of all adult patients treated surgically with an oral cavity composite resection between January 2005 and March 2017. Among other data, patient preoperative characteristics were recorded (eg, age, sex, smoking history, alcohol use, and clinical stage); operative notes were reviewed to determine tumor subsite involvement, reconstruction method, and intraoperative surgical complications; and pathology reports were evaluated for various pathologic findings. Survival outcomes were determined with Kaplan-Meier analysis.

Results

The mean follow-up was 18.5 months (range, 0.1-100). The 1- and 5-year disease-free survival rates were 90.5% and 84.5%, respectively, while the 1- and 5-year disease-specific survival rates were 87.8% and 81.9%. The 1- and 5-year overall survival rates were 86.4% and 80.6%.

Conclusions

Patients with T4aN0M0 squamous cell carcinoma of the mandibular gingiva treated with surgery alone have a 5-year overall survival of 80.6%. Treatment with surgery alone obviates morbidities associated with adjuvant therapy while upholding survival outcomes.

Retrospective study of survival in human papillomavirus-negative oropharyngeal squamous cell carcinoma treated with primary surgery and associated prognostic factors

Background

Oropharyngeal squamous cell carcinoma (OPSCC) is an aggressive malignancy which has been investigated for decades and reported highly associated with the human papillomavirus (HPV) infection, yet there is no consensus reached on the optimal treatment paradigm. The relatively lower prevalence of HPV in China makes it important to evaluate the outcomes of HPV-negative OPSCC.

Purpose

Our study was carried out in an attempt to evaluate the outcomes of squamous cell carcinoma of the oropharynx treated with primary surgery and identify the associated prognostic factors.

Patients and methods

We retrospectively analyzed the outcomes of the primary surgically treated HPV-negative OPSCC cases at our institution between 2008 and 2013. Overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were determined by Kaplan-Meier analysis. Prognostic factors of outcomes were investigated by uni- and multivariate analyses.

Results

In this study, neck metastasis rate was 61.3%. Level II nodes were the most vulnerable. The 3-year disease-specific survival, overall survival, and disease-free survival rates were 76.7%, 75.6%, and 62.8%, respectively. Forearm free flaps were the most commonly utilized in the reconstructions. A multivariate analysis indicated that N stage and adjuvant radiotherapy were predictive factors for 3-year disease-specific survival.

Conclusion

The outcomes of the surgical treatment of oropharyngeal squamous cell carcinoma were acceptable, and N-stage, adjuvant radiotherapy were identified as prognostic factors.

Do we need a different staging system for tongue and gingivobuccal complex squamous cell cancers?

OBJECTIVES

To determine the need for a separate staging system for gingivobuccal complex squamous cell cancers (GBCSCC) based on 5-year overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) data from one institution.

PATIENTS AND METHODS

An Institutional Review Board (IRB)-approved retrospective analysis was performed on an oral cavity cancer patient database. Patients from 1985 to 2012 with primary surgical treatment for biopsy-proven squamous cell cancer (SCC) from either the oral tongue (TSCC Group) or gingivobuccal complex (GBCSCC Group), were selected as two separate subgroups. The clinicopathologic data were used to stage the patients based on the American Joint Committee on Cancer 7th edition. Survival outcomes including 5-year OS, RFS, and DSS were calculated and analyzed. A multivariate analysis was performed to identify if subsite was an independent predictor for the survival outcomes, adjusting for other variables. A p-value of less than .05 was considered statistically significant.

RESULTS

936 patients with TSCC and 486 patients with GBCSCC were considered eligible for the analysis. Patients with GBCSCC were more likely to be older (p < .001) and presented with more advanced disease (p < .001) compared to patients with TSCC. Unadjusted hazard ratio (HR) suggested GBCSCC had poor OS compared to TSCC. However, after adjusting for other variables, the adjusted HR was not significant (p = .593). There was no difference in 5-year DSS or RFS in either of the study groups.

CONCLUSION

With similar survival outcomes by stage, there is no justification for using a different staging system for GBCSCC.