Salvage treatment for recurrent squamous cell carcinoma of the oral cavity

Retrograde intra-arterial chemotherapy and daily concurrent proton beam therapy for recurrent oral cavity squamous cell carcinoma: Analysis of therapeutic results in 46 cases

BACKGROUND

The purpose of this study was to evaluate the efficacy and toxicities of proton beam therapy combined with intra-arterial infusion chemotherapy via superficial temporal and occipital arteries for recurrent oral cavity squamous cell carcinoma (SCC).

METHODS

Between October 2009 and June 2013, 46 patients with recurrent oral cavity SCC were treated by proton beam therapy combined with intra-arterial infusion chemotherapy of cisplatin (CDDP) and docetaxel. Treatment consisted of proton beam therapy (28.6-74.8 GyE in 13-34 fractions) and intra-arterial infusion chemotherapy (CDDP, 30-50 mg/body/week; docetaxel, 5-25 mg/body/week).

RESULTS

One-year and 2-year overall survival (OS) rates were 65% and 46%, respectively. One-year and 2-year local control rates were 81% and 70%, respectively.

CONCLUSION

These findings suggest that proton beam therapy combined with intra-arterial infusion chemotherapy could be applied effectively and safely for patients with recurrent oral cavity SCC. © 2016 Wiley Periodicals, Inc. Head Neck 38:1145-1151, 2016.

Retrospective study on factors affecting the prognosis in oral cancer patients who underwent surgical treatment only

Background

This study was performed to evaluate their 5-year survival rates and identify the factors affecting the prognosis of oral cancer patients who had undergone surgical treatment only.

Methods

Among 130 patients who were diagnosed with malignant tumor of oral, maxillofacial, and surgical treated in the Department of Oral and Maxillofacial Surgery at Chonnam National University Hospital within a period from January 2000 to December 2010, for 11 years, 84 patients were investigated who were followed up for more than 5 years after radical surgery; oral cancer is primary and received only surgical treatment. The survival rate according to gender, age, type and site of cancer, TNM stage, cervical lymph node metastasis and its stage, recurrence or metastasis, time of recurrence and metastasis, and differentiation were investigated and analyzed.

Results

Overall, 5-year survival rate in patients who received only surgical treatment was 81.2 %, and disease-specific 5-year survival rate was 83.1 %. The disease-specific 5-year survival rate based on TNM stage, metastasis of cervical lymph node, N stage, and presence of recurrence/metastasis was a significant difference (p < 0.05). The disease-specific 5-year survival rate based on sex, age, type of tumor, primary site, and differentiation was not a significant difference (p > 0.05).

Conclusions

These results suggest that good survival rate can be obtained with surgical treatment only, and stage of oral cancer, cervical lymph node metastasis and stage, recurrence or metastasis, time of recurrence, and metastasis have a significant effect on survival rate in oral cancer patients.

Postoperative PET/CT and target delineation before adjuvant radiotherapy in patients with oral cavity squamous cell carcinoma

BACKGROUND

The purpose of this study was for us to present our evaluation of the effectiveness of positron emission tomography (PET)/CT imaging in postoperative patients with oral cavity squamous cell carcinoma (SCC) before initiating adjuvant radiation therapy.

METHODS

Treatment planning PET/CT scans were obtained in 44 patients with oral cavity SCC receiving adjuvant radiation. We identified target areas harboring macroscopic disease requiring higher radiation doses or additional surgery.

RESULTS

Fourteen PET/CT scans were abnormal. Thirteen patients underwent surgery and/or biopsy, increased radiation dose, and/or addition of chemotherapy. Eleven patients received higher radiation doses. Patients undergoing imaging >8 weeks were more likely to have abnormal results (p = .01). One-year distant metastases-free survival was significantly worse in patients with positive PET/CT scans (61.5% vs 92.7%; p = .01). The estimated positive predictive value (PPV) was 38% for postoperative PET/CT scanning.

CONCLUSION

We demonstrated that 32% of patients have abnormal PET/CT scans resulting in management changes. Patients may benefit from postoperative PET/CT imaging to optimize adjuvant radiation treatment planning. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1285-E1293, 2016.

Autofluorescence imaging in recurrent oral squamous cell carcinoma

The survival of patients with oral cancer is decreased by locoregional recurrence after an initial multimodal treatment. In order to identify lesions in the oral cavity for a possible recurrence, clinical evaluation as well as MRI or CT scanning is advised. The evaluation of mucosa lesions is hampered by changes related to radio- and chemotherapy as well as reconstruction with tissue flaps. Several techniques for easier identification of tissue abnormalities in the oral cavity have been advocated as adjuncts in order to facilitate identification. Especially methods using altered tissue fluorescence have gained much interest during the last decade. The aim of our prospective study was to evaluate fluorescence properties of undiagnosed mucosa lesions with the VELscope device in patients with multimodal treated oral cancer prior to histological confirmation. In total, 41 patients with a history of oral squamous cell carcinomas (OSCC) (19 females and 22 males) with undiagnosed mucosa lesions where included in the study. After clinical evaluation, examination and documentation using the VELscope® device were performed. Then, an incisional biopsy was performed. An autofluorescence loss indicating a malignant or dysplastic mucosa condition could be detected in six patients (14.6 %); however, only one OSCC and one SIN revealed a complete autofluorescence loss. In four patients, OSCC was present in lesions with retained autofluorescence. Sensitivity and specificity for the VELscope® examination to identify malignant oral lesions by autofluorescence were 33.3 and 88.6 %, respectively. The positive and negative predictive values were 33.3 and 88.6 %, respectively. No statistical correlation between gender and lesion appearance versus autofluorescence loss could be detected. In contrast to mucosa lesions in patients with no prior treatment, the autofluorescence evaluation with the VELscope reveals no additional information in our analysis. Accordingly, invasive biopsies as gold standard are still needed to get sufficient evidence regarding potential malignancy in patients after multimodal treatment for oral cancer.

Molecular events in relapsed oral squamous cell carcinoma: Recurrence vs. secondary primary tumor

Relapses have a great impact on both the morbidity and mortality rates of oral squamous cell carcinoma (OSCC) patients. Current classification criteria are imprecise and need improvements. Recent advances in understanding of OSCC relapses on a molecular level provide new possibilities to better classify true recurrences and second primary tumors. This review discusses the limitations of the current OSCC relapse classification method and presents possible alternatives to improve this classification based on molecular techniques. Moreover, these molecular techniques add to the further understanding of these lesions and may provide tools for clinical management.

The advantages and drawbacks of routine magnetic resonance imaging for long-term post-treatment locoregional surveillance of oral cavity squamous cell carcinoma

PURPOSE

Assess the clinical utility and accuracy of routine surveillance head and neck magnetic resonance imaging (HN-MRI) for the detection of locoregional recurrence in patients with a history of oral cavity squamous cell carcinoma (OCSCC) without concurrent suspicious symptoms or signs 6 months or more after treatment.

MATERIALS AND METHODS

For OCSCC patients who underwent routine (defined as: without concurrent suspicious symptoms or signs) surveillance HN-MRI at 6 months or more after treatment completion, we retrospectively determined the detection rate of locoregional disease and false positive rate.

RESULTS

Out of an original cohort of 533 OCSCC patients, 46 patients, who were disease-free 6 months after treatment, had undergone 108 routine HN-MRIs from 6 to 48 months after surgery without the presence of concurrent suspicious symptoms or signs and had 6 months of subsequent follow up. 1 out of 46 (2.2%) had a true positive regional recurrence. 10 out of 46 (21.7%) patients experienced a false positive locoregional finding.

CONCLUSIONS

Routine HN-MRI for locoregional surveillance of OCSCC, when used in patients without concurrent suspicious symptoms or exam findings over 6 months since treatment, may be unnecessary and costly given the very low rate of recurrence and high false positive rate. Our study supports the National Comprehensive Cancer Network guideline of limiting imaging after 6 months of primary treatment completion to patients with suspicious clinical findings. Nonetheless, managing physicians should continue to be empowered to use surveillance imaging based on risk profiles and unique circumstances for each patient.

Factors predicting outcome after salvage treatment for stage IV oral squamous cell carcinoma: Evidence of the potential importance of the cyclooxygenase-2-prostaglandin E2 pathway

BACKGROUND

We determined the clinicopathological factors that predicted outcome after salvage treatment for stage IV oral squamous cell carcinoma (OSCC). Additionally, the prognostic significance of the cyclooxygenase-2 (COX-2)/microsomal prostaglandin-E synthase-1 (mPGES-1) pathway was evaluated.

METHODS

Thirty-one patients who underwent salvage surgery were included. COX-2 and mPGES-1 levels were quantified by real time polymerase chain reaction (PCR).

RESULTS

The 2-year disease-free and overall survival rates were 46% and 53%, respectively. Adequacy of initial treatment, tobacco smoking, and the presence of pathological risk factors were predictive of mortality. In patients who had not received chemotherapy before salvage surgery, high levels of intratumoral COX-2 and mPGES-1 were associated with poor prognosis. By contrast, high intratumoral COX-2 and mPGES-1 after chemotherapy were associated with improved outcomes.

CONCLUSION

Clinicopathological factors may inform treatment decisions in patients with stage IV OSCC. Expression patterns of COX-2 and mPGES-1 correlated with outcome and warrant further investigation. © 2014 Wiley Periodicals, Inc. Head Neck 37: 1142-1149, 2015.

Irradiation for locoregionally recurrent, never-irradiated oral cavity cancers

BACKGROUND

The purpose of this study was to report the clinical outcomes and related prognostic factors of patients who underwent radiotherapy (RT) for the treatment of recurrent, never-irradiated oral cavity cancer (recurrent OCC).

METHODS

The records of consecutive patients with nonmetastatic recurrent OCC who presented to and were treated with RT at our institution between 1989 and 2011 were reviewed. The Kaplan-Meier method was used to calculate overall survival (OS). The cumulative incidences of disease-specific death, local failure, regional failure, and distant metastasis were calculated with death as a competing risk.

RESULTS

One hundred twenty-three patients were identified. Median follow-up for living patients was 54 months and 16 months for all patients. Ninety-one patients had salvage surgery followed by adjuvant RT. Definitive RT was utilized in the remaining 32 patients. The 5-year OS was 40%. The 5-year cumulative incidence of disease-specific death, local failure, regional failure, and distant metastasis was 55%, 34%, 22%, and 20%, respectively. Recurrent T classification and lack of salvage surgery were independently associated with worse disease-specific death and decreased OS, respectively. Subset analysis of patients who underwent salvage surgery demonstrated that age, recurrent T classification, and perineural invasion (PNI) were independently associated with decreased OS; recurrent T classification and thicker tumors were independently associated with worse disease-specific death; and positive/close margins and primary T classification were independently associated with increased local failure.

CONCLUSION

In this group of patients with recurrent OCC, clinical outcomes were similar or improved when compared with other recurrent OCC-specific reports. In the salvage surgery subset, tumor thickness and PNI are recurrent pathologic features associated with outcomes that were only previously demonstrated in studies of primary disease. Because of the relatively worse outcomes in patients receiving definitive or adjuvant RT for recurrent OCC, we advocate for the appropriate use of postoperative RT in the initial management of oral cavity cancers.

Success of salvage treatment: a critical appraisal of salvage rates for different subsites of HNSCC

OBJECTIVE

Despite advances in interdisciplinary treatment protocols, the chance of cure for recurrent head and neck squamous cell carcinoma (HNSCC) following failed primary therapy is poor and often entails a high morbidity. Recurrence rates vary widely in the literature depending on tumor localization, primary tumor stage, and treatment modality, and only a minority of patients can be salvaged.

STUDY DESIGN

Historical cohort study.

SETTING

This study valuates the outcomes of patients treated for recurrent squamous cell carcinoma of the larynx, pharynx, and oral cavity in the largest tertiary referral center of Switzerland to find predictors for survival in salvage surgery with curative intent.

SUBJECTS AND METHODS

Included were 176 consecutive patients with recurrent disease after primary curative treatment of HNSCC, in locations mentioned previously. Kaplan-Meier survival analyses with log-rank testing were performed depending on T and N stage, gender, treatment, and location of first relapse to evaluate the impact on overall survival, disease specific survival, and recurrence free survival.

RESULTS

Overall successful salvage rates were 49.2% for laryngeal recurrence, 35.1% for oral cavity, 32.7% for oropharyngeal, and a mere 17.4% for hypopharyngeal recurrences. Predictive factors for better outcome were location of recurrence, female gender, lymph node status, and extent of salvage treatment.

CONCLUSION

In case of recurrent disease, laryngeal cancers showed the best salvage rates, whereas in hypopharyngeal relapses, very few patients could be successfully salvaged. Patients therefore should be carefully selected and counseled for salvage treatment according to patient motivation, age, type of previous treatment, surgical resectability, and exclusion of distant recurrence.

Transoral laser microsurgery for oral squamous cell carcinoma: oncologic outcomes and prognostic factors

BACKGROUND

Modest survival rates are published for treatment of oral squamous cell carcinoma (OSCC) using conventional approaches. Few cohort studies are available for transoral resection of OSCC.

METHODS

Analysis for recurrence, survival, and prognosis of patients with OSCC treated with transoral laser microsurgery (TLM) ± neck dissection was obtained from a prospective database.

RESULTS

Ninety-five patients (71 patients had stages T1-T2 and 24 had stages T3-T4 disease) with minimum follow-up of 24 months met criteria and demonstrated negative margins in 95%. Five-year local control (LC) and disease-specific survival (DSS) were 78% and 76%, respectively. Surgical salvage achieved an absolute final locoregional control of 92%. Immune compromise and final margins were prognostic for LC, whereas T classification, N classification, TNM stage, comorbidity, and perineural invasion were also significant for DSS.

CONCLUSION

We document a large series of patients with OSCC treated with TLM, incorporating T1 to T4 primaries. A significant proportion of stage III/IV cases demonstrates feasibility of TLM in higher stages, with final margin positivity of 5%, LC greater than 90%, and comparable survival outcomes.

Predictors of locoregional recurrence in T1-2N0 tongue cancer patients

Locoregional recurrence of oral tongue squamous cell carcinoma (OTSCC) has been considered a poor prognostic entity in terms of survival rate. The purpose of this study was to evaluate the incidence of locoregional recurrence and to identify significant risk factors for locoregional recurrence in early-stage OTSCC. We retrospectively reviewed the records of 58 patients who underwent radical surgery for T1-2N0 OTSCC. The local recurrence and regional recurrence rates were 10.3 % (6/58 patients) and 15.5 % (9/58 patients) in this study, respectively. The survival rate of patients with local recurrence was 66.7 %, which was significantly lower than that (96.2 %) of patients without local recurrence, whereas the survival rates of patients with or without regional recurrence were not significantly difference. Pattern of invasion (POI), neoadjuvant chemotherapy (NAC) and the status of the surgical margin were identified as factors influencing local recurrence. In particular, the status of the deep surgical margin was a high potential independent risk factor. The deep surgical margin was resected closely in many NAC-treated cases, suggesting that NAC may lead to local recurrence and a poor outcome. No efficacy of NAC was observed, suggesting that the standard treatment for early OTSCC is surgery alone.

Efficacy and safety of photodynamic therapy with temoporfin in curative treatment of recurrent carcinoma of the oral cavity and oropharynx

Therapeutic options for recurrent carcinoma of the upper aérodigestive tract (UADT) are limited. The prognosis of these tumours remains poor with significant rate of recurrence and a lower median survival time. Photodynamic therapy (PDT) is a relatively new therapeutic alternative which combines the use of a photosensitising agent and light to induce a cytotoxic effect on the tissues. This is a retrospective single-centre study carried out in patients with a recurrence of an oral cavity or oropharyngeal carcinoma or a second appearance of tumour in a previously irradiated area. There were no metastases in lymph nodes or other organs. Laser treatment was carried out 96 h after temoporfin (Foscan(®)) injection. In our series we had 14 cases with a complete response, 1 partial response. Overall survival at 1 year was 72 % and 36 % at 5 years. Disease-specific survival at 1 year was 82 % and 45 % at 5 years. Recurrence-free survival at 1 year was 52 % and 34 % at 5 years. Side effects mainly described are pain in the area of illumination, well controlled. PDT with Foscan(®) gives useful results in terms of survival and improvement in quality of life with few adverse events or severe complications. The fact that it has low toxicity and that treatment sessions can be repeated mean it should be considered in the therapeutic armamentarium for recurrent carcinoma of the UADT.

Follow up after IMRT in oral cavity cancer: update

PURPOSE

Except for early stages (T1/2 N0), the prognosis for patients with oral cavity cancer (OCC) is known to be worse than for those with pharyngeal carcinoma. While definitive intensity modulated radiation therapy (IMRT)-chemotherapy affords loco-regional control rates (LRC) of approximately 80% in advanced pharyngeal cancer, corresponding rates are reported to be much lower for OCC. The aim of this work was to evaluate loco-regional disease control and overall survival (OAS) in a relatively large OCC patient cohort treated in the IMRT era.

METHODS AND MATERIALS

Between October 2002 and June 2011, 160 OCC patients were treated with curative intention IMRT at our department. 122 patients (76%) were referred with primary disease and 38 patients (24%) with a recurrent OCC at least 3 months after surgery alone. Definitive IMRT was performed in 44/160 patients (28%), whilst 116 patients underwent previous surgery. Simultaneous systemic therapy was administered in 72%.

RESULTS

Patients with postoperative IMRT (+/-systemic therapy) with R0-1 status (n = 99) reached significantly higher LRC/OAS rates than patients following IMRT for macroscopic disease (n = 61), with 84%/80% versus 38%/33% at 3 years, respectively (p < 0.0001). This was found in patients treated for initial, as well as recurrent, disease. Less than 2% persisting grade 3/4 late effects were observed.

CONCLUSIONS

IMRT for R0-1 situations translated into a highly significant superior LRC and OAS compared to the IMRT cohort treated for macroscopic disease. Treatment was well tolerated.

¹⁸F-FDG PET/CT and MRI in the follow-up of head and neck squamous cell carcinoma

We evaluated the diagnostic performance of (18)F-FDG PET/CT and MRI for the assessment of head and neck squamous cell carcinoma (HNSCC) relapse. Since early treatment might prevent inoperable relapse, we also evaluated THE performance of early unenhanced (18)F-FDG PET/CT in residual tumor detection. The study was prospectively performed on 32 patients who underwent (18)F-FDG PET/CT and MRI before treatment and at 4 and 12 months after treatment. (18)F-FDG PET/CT was also performed 2 weeks after the end of radiotherapy. Histopathology or a minimum of 18 months follow-up were used as gold standard. Before treatment (18)F-FDG PET/CT and MRI detected all primary tumors except for two limited vocal fold lesions (sensitivity 94%). MRI was more sensitive than (18)F-FDG PET/CT for the detection of local extension sites (sensitivity 75 vs 58%), but at the cost of a higher rate of false positive results (positive predictive value 74 vs 86%). For relapse detection at 4 months, sensitivity was significantly higher for (18)F-FDG PET/CT (92%) than for MRI (70%), but the diagnostic performances were not significantly different at 12 months. For the detection of residual malignant tissue 2 weeks post-radiotherapy, sensitivity and specificity of (18)F-FDG PET/CT were respectively 86 and 85% (SUV cut-off value 5.8). (18)F-FDG PET/CT is effective in the differentiation between residual tumor and radiation-induced changes, as early as 2 weeks after treatment of a primary HNSCC. For follow-up, performance of (18)F-FDG PET/CT and MRI are similar except for a higher sensitivity of (18)F-FDG PET/CT at 4 months.

The treatment of oral cancer: an overview for dental professionals

Oral cancer is a serious life-threatening disease. Dental professionals may be the first individuals to identify/suspect these lesions before referring to oral and maxillofacial surgeons and oral medicine specialists. Because the general dentist will likely follow on with the patient's future oral health, it is important that he or she has a basic understanding of the various treatments involved in treating oral malignancies and their respective outcomes. The four main modalities discussed in this review include surgery alone, radiotherapy alone, surgery with radiotherapy, and chemotherapy with or without surgery and radiotherapy. Chemotherapy has become an area of great interest with the introduction of new 'targeted therapies' demonstrating promising results in conjunction with surgery. Despite these results, the toxicities associated with chemotherapy regimens are frequent and can be severe, and therefore may not be suitable for all patients. Treatment modalities have improved significantly over the decades with overall decreases in recurrence rates, improved disease-free and overall survival, and an improved quality of life. Prognosis, however, is still ultimately dependent on the clinical stage of the tumour at the initial diagnosis with respect to size, depth, extent, and metastasis as recurrence rates and survival rates plummet with disease progression.

Minimizing complications in salvage head and neck oncological surgery following radiotherapy and chemo-radiotherapy

PURPOSE OF REVIEW

The term salvage surgery denotes oncological surgery after failed radiotherapy or chemoradiotherapy (CRT). Salvage surgery is a high-risk endeavour as it carries a significant risk of complications. The purpose of this review is to assess the ways in which complications from salvage surgery can be prevented and minimized. This is a complex subject and complications are often multifactorial and interrelated. There are many aspects that can be discussed; however, to address each of them individually would be impossible and beyond the scope of this article. We will, therefore, focus this review on the most relevant aspects to current practice for head and neck surgeons.

RECENT FINDINGS

Salvage surgery after failure of radiotherapy and CRT remains controversial and many aspects still lack evidence. Many patients with recurrent cancer are not suitable for salvage surgery due to severe co-morbidities or disease progression. Salvage surgery is best carried out in tertiary centres by experienced multidisciplinary teams. Preoperative assessment and evaluation is critical to success and to minimize complications. Surgical principles include single incisions, delicate tissue handling, use of frozen sections, adopting a critical approach to neck dissections and the use of flaps, secondary surgical voice restoration for laryngectomies and appropriate postoperative care.

SUMMARY

This review emphasizes the importance of a multidisciplinary approach by experienced teams, the centralization of resources and teams, a structured and thorough patient assessment, surgical planning and a systematic attention to detail when addressing patients undergoing salvage surgery.

Predictors for tumor recurrence after primary definitive surgery for oral cancer

PURPOSE

The purpose of this study was to identify significant predictors for oral squamous cell carcinoma recurrence.

PATIENTS AND METHODS

This Ambispective cohort study was performed in consecutive metastasis-free patients treated for oral squamous cell carcinoma with curative intent from 1998 through 2003. Variables included gender, age, tumor site, macroscopic pattern of the lesion, coexisting disorders (diabetes, hepatic and heart disorders, other tumors/diseases), degree of differentiation, and pathologic TNM stage. Tumor recurrence was considered the dependent variable (outcome). The distribution of recurrences was assessed with χ(2) test. Survival times were estimated by Kaplan-Meier curves and differences were examined with log-rank test. Multiple Cox regression study was also performed. The significance level chosen for all tests was P < .05.

RESULTS

One hundred eighteen patients entered the study. Tumor recurrence was 44.9% during the follow-up period (10% local, 29.7% regional, and 5% distant). The mean period that had elapsed before recurrence was 15 months (1.5 to 81.8), with most recurrences (66%) during the first year after treatment (84.9% before 2 years). Multivariate Cox regression analysis indicated the presence of a coexisting disorder (P = .022) as the most relevant prognostic factor for relapse, because patients with associated diseases had a 2.43-fold risk of recurrence. Tumor stage (P = .037), degree of differentiation (P = .042), and macroscopic pattern of the lesion (P = .022) were also identified as prognostic factors for relapse.

CONCLUSIONS

The risk profile for oral cancer recurrence includes patients younger than 60 years with coexisting diseases whose primary tumor occurred as an ulcerated lesion, and diagnosed at an advanced stage with a poorly differentiated tumor.

Temoporfin-mediated photodynamic therapy in patients with advanced, incurable head and neck cancer: A multicenter study

BACKGROUND

The aim of this study was to confirm the efficacy of temoporfin (Foscan)-mediated photodynamic therapy (PDT) in patients with end-stage head and neck squamous cell carcinoma (HNSCC).

METHODS

Thirty-nine patients with recurring HNSCC lesions ≤10 mm in depth were injected with temoporfin, followed by illumination of the tumor surface.

RESULTS

Of 39 treated patients, 19 achieved complete response, 2 partial response, 5 stable disease, 5 had progressive disease, and 8 patients were nonevaluable. Thus, in the per-protocol analysis, the response rate was 68%. Of the treated patients 54% had a response. Median survival was significantly longer for responders (37 months) than for nonresponders (7.4 months). Nine patients were alive at 3.7 to 6.5 years (median, 4.8 years) post-treatment, 7 free of disease. No major toxicities were observed.

CONCLUSIONS

Patients with advanced HNSCC with lesions ≤10 mm in depth, who have exhausted other treatment options, can achieve significant local control and survival benefit from temoporfin-mediated PDT.

Analysis of differentially expressed proteins in oral squamous cell carcinoma by MALDI-TOF MS

PURPOSE

To explore the presence of differentially expressed proteins in OSCC for discrimination of tumour and normal mucosa to establish potential biomarkers and therapeutic targets.

EXPERIMENTAL DESIGN

Paired protein samples of 12 individuals (tongue cancer and non-cancerous mucosa) were separated by two-dimensional polyacrylamid gel electrophoresis. The protein patterns were compared pairwise and protein spots were quantified. We identified about 70 regulated proteins which we subsequently identified by MALDI-TOF mass spectrometry.

RESULTS

Cancerous and non-cancerous tissues could be most precisely distinguished by a panel of proteins. They include the heat shock proteins (hsp)70 and 90, keratins (ck) 5, 6, 13, 14, 16, 17 and 19, beta globin, alpha-2-actin, stratifin, tropomyosin, calreticulin precursor, beta-2-tubulin, galectin7, thioredoxin, involucrin, adenylyl-cyclase-associated protein, disulfide isomerase-associated protein, thyrosine 3-monooxygenase, MYL2 and the s100 calcium binding protein. MYL3, cardiac muscle alpha actin 1 proprotein and transferrin were under-represented in OSCC. Six biomarkers, ck6 und ck13, beta globin, alpha-2-actin, hsp70 and hsp90 discriminated best between cancerous and non-cancerous oral tissues. All over-expressed proteins were analysed by STRING-analysis to highlight experimentally determined and computationally predicted interactions between the proteins. Especially involucrin, hsp70, calreticulin precursor, stratifin, (ck) 5, 6, 14, 19, tyrosine 3-monooxygenase, beta-2-tubulin and disulfide isomerase associated protein showed multiple relations.

CONCLUSION

We identified six proteins which are differentially expressed in most OSCC compared to healthy tissues. Of those, by string analysis, multiple interaction partners are assumed for hsp70. This protein is supposed to be the most promising candidate as marker molecule and target for OSCC therapy.

Salvage treatment for recurrent oropharyngeal squamous cell carcinoma

BACKGROUND

This study evaluates the oncological outcome of patients with recurrent oropharyngeal squamous cell carcinoma (OPSCC) after primary radiation therapy +/- chemotherapy, primary surgical therapy, and surgical therapy followed by radiation therapy +/- chemotherapy.

METHODS

A total of 156 patients (36%) of a cohort of 427 treated for OPSCC between 1990 and 2006 developed recurrent disease. Fifty-one patients (12%) qualified for salvage treatment. Study endpoints were 5-year overall survival (OS) and disease-specific survival (DSS).

RESULTS

The 5-year OS and DSS rates after salvage treatment were 29% and 40%; after initial primary radiation therapy, 25% and 40%; after initial surgery followed by radiation therapy, 40% and 40%; and after initial surgery alone, 20% and 40%.

CONCLUSIONS

Patients with an advanced OPSCC have a considerable risk for recurrence. Despite poor ultimate outcome, salvage treatment should be attempted in patients with resectable disease, good performance status, and absence of distant metastases.

Factors predictive of successful outcome following salvage treatment of isolated neck recurrences

Objective: The aim of this study was to evaluate the outcome and predictive factors for salvage treatment of isolated neck recurrence after primary curative surgery for head and neck squamous cell carcinoma (HNSCC).

Study Design: Case series with chart review.

Setting: Head and neck cancer clinic in a tertiary care university hospital.

Subjects and Methods: A retrospective study was conducted with 236 patients who developed a recurrence after primary curative surgery with or without radiotherapy for HNSCC.

Results: Isolated neck recurrence developed in 61 (26%) patients. Salvage treatment was offered to 49 patients, and the overall salvage rate was 33 percent (20 of 61). The salvage rate for the surgical salvage group was 46 percent (16 of 35) and 28 percent (4 of 14) for the nonsurgical salvage group (chemoradiation) ( P = 0.14 ). The three-year overall survival rate was 36 percent for patients with surgical salvage and 12 percent for patients with nonsurgical salvage ( P = 0.101). There were no survivors of the supportive care group (0 of 12). Univariate analysis of individuals with isolated neck recurrence showed that patients who had previous treatment with surgery alone, a disease-free time longer than one year, previous pathologic N- status, recurrence in the undissected neck, or recurrent N1 had significantly improved salvage time ( P < 0.05). However, in multivariate analysis, the factors previous treatment with surgery alone and recurrent N1 submitted to the salvage treatment were independent predictors of a successful salvage of isolated neck recurrence.

Conclusion: Our results suggest that the ideal candidates for salvage neck treatment include those patients with recurrent N1 disease and those whose previous treatment was surgery only.

Reirradiation after salvage surgery and microvascular free flap reconstruction for recurrent head and neck carcinoma

OBJECTIVE

To evaluate the outcome and complications of reirradiation of recurrent head and neck cancer after salvage surgery and microvascular reconstruction.

STUDY DESIGN

Retrospective.

SUBJECTS AND METHODS

Twelve patients underwent salvage surgery with microvascular reconstruction for recurrent or second primary head and neck cancer in a previously irradiated field. Median prior radiation therapy dose was 63.0 Gy. Patients then underwent postoperative reirradiation, and received a median total cumulative radiation dose of 115.0 Gy.

RESULTS

Three (25%) patients experienced acute complications (<3 months) during reirradiation. Four (33%) patients developed grade 3 or 4 late reirradiation complications (>3 months). There were no incidences of free flap failure, brain necrosis, spinal cord injury, or carotid rupture. The incidence of soft tissue necrosis and osteoradionecrosis was 8%. Six (50%) patients are alive without evidence of recurrent disease a median of 40 months after reirradiation.

CONCLUSION

Microvascular free flaps allow for maximal resection and reliable reconstruction of previously irradiated cancers before high dose reirradiation and may reduce the incidence of severe late complications and treatment related mortality.

Outcome in recurrent head neck cancer treated with salvage-IMRT

BACKGROUND

Recurrent head neck cancer (rHNC) is a known unfavourable prognostic condition.The purpose of this work was to analyse our rHNC subgroup treated with salvage-intensity modulated radiation therapy (IMRT) for curable recurrence after initial surgery alone.

PATIENTS

Between 4/2003-9/2008, 44 patients with squamous cell rHNC were referred for IMRT, mean/median 33/21 (3-144) months after initial surgery. None had prior head neck radiation. 41% underwent definitive, 59% postoperative IMRT (66-72.6 Gy). 70% had simultaneous chemotherapy.

METHODS

Retrospective analysis of the outcome following salvage IMRT in rHNC patients was performed.

RESULTS

After mean/median 25/21 months (3-67), 22/44 (50%) patients were alive with no disease; 4 (9%) were alive with disease. 18 patients (41%) died of disease. Kaplan Meier 2-year disease specific survival (DSS), disease free survival (DFS), local and nodal control rates of the cohort were 59/49/56 and 68%, respectively.Known risk factors (advanced initial pTN, marginal initial resection, multiple recurrences) showed no significant outcome differences. Risk factors and the presence of macroscopic recurrence gross tumor volume (rGTV) in oral cavity patients vs others resulted in statistically significantly lower DSS (30 vs 70% at 2 years, p = 0.03). With respect to the assessed unfavourable outcome following salvage treatment, numbers needed to treat to avoid one recurrence with initial postoperative IMRT have, in addition, been calculated.

CONCLUSION

A low salvage rate of only approximately 50% at 2 years was found. Calculated numbers of patients needed to treat with postoperative radiation after initial surgery, in order to avoid recurrence and tumor-specific death, suggest a rather generous use of adjuvant irradiation, usually with simultaneous chemotherapy.

Avaliação de fatores demográficos e estadiamento clínico nos pacientes submetidos a resgate cirúrgico por carcinomas epidermóides de orofaringe

O tratamento clássico do carcinoma epidermóide das vias aéreas digestivas superiores (VADS) é a cirurgia, associada ou não à radioterapia pós-operatória. As recidivas loco-regionais constituem a principal falha no tratamento inicial e o diagnóstico precoce favorece a indicação de cirurgia de resgate. OBJETIVO: Análise descritiva dos dados demográficos e de estadiamento no resgate cirúrgico dos tumores de orofaringe. CASUÍSTICO E MÉTODOS: Estudo retrospectivo de 78 pacientes, submetidos à cirurgia em todos os casos e a radioterapia complementar em 37 destes. RESULTADOS: Predomínio do gênero masculino em 70 casos, com idade média de 54,2 anos e etnia branca em 54 pacientes. O pacientes foram estadiados em T3 e T4 em 38 casos. Dos 78 pacientes, 40 eram pescoço N0. Trinta e cinco pacientes desenvolveram recidiva loco-regional e à distância. Das recidivas loco-regionais, 17 deles foram submetidos ao resgate cirúrgico, sendo que 12 pacientes foram reestadiados na recidiva em T1; 2 em T2 e quanto ao N, 2 eram N2a e 2 eram N2b. A idade média dos pacientes submetidos ao resgate foi de 52,8 anos, com predomínio na etnia branca e gênero masculino. CONCLUSÃO: O resgate predominou em estádios I e II com controle da doença em 58,8%.

Assessment of demographics factors and clinical staging in patients submitted to salvage surgery for oropharyngeal squamous cell carcinoma

The usual management of upper aero digestive tract squamous cell carcinoma is surgery associated or not to post surgical radiotherapy. Loco-regional relapses constitute the main failure of the initial treatment and early diagnosis justifies the indication of salvage surgery.

Aim

Descriptive analysis of demographic data and staging for salvage surgery of oropharynx tumors.

Material and methods

We studied retrospectively 78 patients submitted to surgery in all cases; however, just 37 patients received post surgical radiotherapy.

Results

There was a predominance of males in 70 cases, with mean age of 54.2 years, and 54 patients were Caucasian. The patients were classified as T3 and T4 in 38 cases and 40 patients were classified as N0 neck. 35 patients developed loco-regional distant relapses. 17 patients were submitted to salvage surgery and 12 patients were reclassified as T1; 2 patients T2 and in relation to the clinical stage N, 2 patients were N2a and 2 patients N2b. The average age of the patients submitted to salvage surgery was 52.8 years, with predominance of male Caucasians.

Conclusion

Clinical stage I and II were accorded salvage surgery.

Angiopoietin-1 and -2 expression in recurrent squamous cell carcinoma of the oral cavity

BACKGROUND AND OBJECTIVES

Our objective was to evaluate the clinical significance of angiopoietin-1 (Ang-1) and Ang-2 expression in recurrent but operable squamous cell carcinoma of the oral cavity (OCSCC).

PATIENTS AND METHODS

Formalin-fixed, paraffin-embedded tissues from 40 patients who underwent surgical intervention for local or local-regional recurrent OCSCC between 1995 and 2005 were immunohistochemically analyzed for Ang-1 and Ang-2 expression.

RESULTS

The recurrent TNM staging classified 5 patients as stage I, 4 as stage II, 2 as stage III, and 29 as stage IV. The actuarial 3-year disease-free survival rate was 43.1% with a mean follow-up of 18.4 months (ranged 1-70 months). High expression of Ang-1 was significantly correlated with positive nodal stage (P = 0.041). Patients with more advanced recurrent stage of the tumors (P = 0.0036) and high expression of Ang-2 (P = 0.045) showed lower actuarial 3-year disease-free survival. However, Cox's regression analysis revealed that only recurrent tumor (rT) stage was an independent prognostic factor for survival (P = 0.019, 95% CI = 1.473-82.017, relative risk = 10.992).

CONCLUSIONS

Recurrent OCSCC with high Ang-1 or Ang-2 expression in the tumor bed exhibits aggressive tumor behavior. However, the salvage outcome depends on the rT stage.

Combined VSV oncolytic virus and chemotherapy for squamous cell carcinoma

OBJECTIVES

Vesicular stomatitis virus (VSV) is a negative-strand ribonucleic acid (RNA) virus that replicates specifically in tumor cells and has oncolytic effects in a variety of malignant tumors. We previously demonstrated recombinant VSV vectors incorporating viral fusion protein (rVSV-F) and interleukin 12 (rVSV-IL12) to have significant antitumor effects against squamous cell carcinoma (SCC) in a murine model. Here we evaluate the potential to combine a potent chemotherapeutic agent for SCC (cisplatin) with rVSV-F and rVSV-IL12 to improve efficacy.

STUDY DESIGN

In vitro, three SCC cell lines were tested using rVSV-F and rVSV-IL12 with cisplatin, monitoring viral replication and cell survival. In an orthotopic floor of mouth murine SCC model, intratumoral injections of virus combined with systemic cisplatin were tested for tumor control and animal survival.

RESULTS

In vitro, virus and cisplatin combination demonstrated rapid replication and enhanced tumor cell kill. Human keratinocytes were unaffected by virus and cisplatin. In vivo, combined rVSV-F with cisplatin reduced tumor burden and improved survival (P = .2 for both), while rVSV-IL12 monotherapy had better tumor control (P = .06) and survival (P = .024) than combination therapy.

CONCLUSIONS

Addition of cisplatin did not affect the ability of either virus to replicate in or kill murine SCC cells in vitro. In vivo, combination therapy enhancedrVSV-F antitumor activity, but diminished rVSV-IL12 antitumor activity. Combination therapy may provide useful treatment for SCC with the development of more efficient viral vectors in combination with different chemotherapy agents or immunostimulatory agents.

Salvage Reconstruction of Extensive Recurrent Oral Cancer Defects With the Pectoralis Major Myocutaneous Flap

PURPOSE

This study aimed to evaluate the usefulness of the pectoralis major myocutaneous flap for reconstruction of oral and facial defects after excision of recurrent oral cancer and the results of salvage surgery.

PATIENTS AND METHODS

Twenty-four patients with recurrent squamous cell carcinoma of the oral cavity underwent salvage surgical treatment. Pectoralis major flaps were used for reconstruction of the extensive defects caused by excision of the tumors. The complications of the flap and the prognosis of the patients were analyzed with a follow-up from 5 to 65 months (mean = 18.5 months).

RESULTS

Fourteen flaps were used for mucosal lining of the mouth, and 10 flaps were used for reconstruction of the cutaneous defects. The overall success rate of the flap was 70.8%. Flap-related complications developed in 13 patients (54.2%). Major complications occurred in 7 patients (29.2%), and minor complications occurred in 6 (25.0%). Three patients (12.5%) had complications unrelated to the flap. The reconstruction of the base of the tongue, the floor of the mouth, and the oropharynx emerged as a significant risk factor for flap necrosis on binary logistic regression analysis (P < .05). The overall 1-, 3-, and 5-year overall survival rate was 72.8%, 30.9%, and 20.6%, respectively.

CONCLUSION

The pectoralis major myocutaneous flap is a reliable choice for reconstruction of extensive soft tissue defects caused by excision of recurrent oral cancer. The major complications correlate with the site of reconstruction. Many patients benefit from salvage surgery, and some of them can survive 2 to 4 years postoperatively.

Global proteomic analysis distinguishes biologic differences in head and neck squamous carcinoma

The goal of this study was to establish a method for detecting biologically significant differences in protein expression of head and neck squamous cell carcinoma (HNSCC) obtained from the same samples utilized in gene expression analyses. Proteins from two head and neck tumor cell lines, SCC-25 and FaDu, were isolated from the denatured protein solution remaining from the TRIzol extraction procedure used for isolation of total RNA for microarray analysis. Peptides resulting from chemical and enzymatic digestion of the proteins were first separated by strong cation-exchange chromatography, followed by liquid chromatography-mass spectrometry (LC-MS) analysis on a QqTOF mass spectrometer. Stable isotope-labeled synthetic peptides were added to each ion-exchange fraction as internal standards, for reversed-phase HPLC retention time alignment. Protein extraction and digestion were repeated three times for each cell line and each extract was analyzed three times by LC-MS. To discriminate between technical vs biological variation, the ion-exchange fraction, retention time, normalized mass and signal intensity of these nine data sets were constructed into numerical arrays for statistical analysis. Of the approximately 50,000 signals, 90 peptide ions were found to discriminate the two cell lines with high stringency. Of those, six peptides were derived from vimentin and four peptides were derived from annexin II; both expressed more in SCC-25. Follow-up analysis of some of these signals by LC-MS/MS and RNA expression profiling revealed both concordance and discordance of RNA and protein expression. This study demonstrates that this procedure is highly reliable for identifying peptides that distinguish biological variability among samples, indicating that this method can be applied to study clinical samples, to identify potential prognostic biomarkers for HNSCC.

Salvage surgery with free flap reconstruction: factors affecting outcome after treatment of recurrent head and neck squamous carcinoma

OBJECTIVE

To determine factors predicting the outcome after salvage surgery with microvascular flap reconstruction for recurrent squamous cell cancer (SCC) of the head and neck.

STUDY DESIGN

This is a retrospective analysis of patients treated at an academic medical center.

METHODS

One hundred six patients underwent salvage surgery and microvascular flap reconstruction after prior unsuccessful cancer treatment using surgery, radiation, or chemotherapy. All patients had a follow-up interval after salvage surgery of at least 24 months unless cancer rerecurrence occurred within 24 months after salvage surgery. Factors including age, sex, comorbidity level, tobacco use, alcohol use, disease-free interval since prior therapy, prior radiation, prior chemotherapy, prior surgery, recurrent tumor T class, recurrent tumor N class, recurrent cancer stage, and tumor location were examined to determine their association with cancer rerecurrence after salvage surgery. Successful treatment was defined as patients who remained free from cancer rerecurrence for a minimum 2 year period after salvage surgery.

RESULTS

Advanced recurrent T class (P = .02) was significantly associated with cancer recurrence. Recurrent cancer stage and patient smoking status approached statistical significance (P = .06).

CONCLUSION

Patients with recurrent T1 and T2 class are the best candidates for salvage surgery and microvascular flap reconstruction for treatment of recurrent SCC of the head and neck. Patients with T3 and T4 class recurrent cancers and patients who continue to smoke after initial diagnosis and treatment of head and neck SCC are poor candidates to undergo salvage surgery.