Surgical treatment of early oral carcinoma-results of a prospective controlled multicenter study

Recurrence in Oral Squamous Cell Carcinoma Associated with Wide Field of Cancerization: Analysis of 93 Cases

Background

The late presentation of oral squamous cell carcinoma (OSCC) patients in the Sudan, with advanced stages and wide field of cancerization, have a negative impact on both the morbidity and the mortality of these patients. The present study aimed to investigate the clinicopathological behavior of OSCC and predictors of development of recurrence in these patients.

Methods

This a prospective longitudinal study of 93 OSCC patients surgically treated at Khartoum Teaching Dental Hospital. Tumor's associated field of cancerization was identified. The patients were followed clinically on regular basis, for a year, for the development of recurrence.

Results

Out of the 93 patients, 57 (61.3%) were males and 36 (38.7%) were females. 82% of the patients presented with stage IV tumors, and 58 (62.4%) of the cases had nodal metastasis. Twenty-eight (30%) patients developed recurrence. Of them 17 (18.3%) had regional recurrence, eight (8.6%) had local recurrence and three (3.2%) had locoregional recurrence. Multivariate cox regression analysis showed that Toombak dipping (P.value = 0.001), tumor staging (P.value = 0.039) and presence of mucosal filed changes (P.value = 0.001) were independent predictors for local recurrence and positive pathological lymph nodes (P.value = 0.00) and extranodal extension (P.value = 0.040) were independent predictors for regional recurrence.

Conclusion

The present study showed that OSCC patients in the Sudan present with advanced lesions, mostly associated with wide field of cancerization particularly Toombak dippers. Overall recurrences were identified in 30% of the cases, regional recurrence was the commonest type followed by local recurrence.

Spatial and Transcriptomic Analysis of Perineural Invasion in Oral Cancer

PURPOSE

Perineural invasion (PNI), a common occurrence in oral squamous cell carcinomas, is associated with poor survival. Consequently, these tumors are treated aggressively. However, diagnostic criteria of PNI vary and its role as an independent predictor of prognosis has not been established. To address these knowledge gaps, we investigated spatial and transcriptomic profiles of PNI-positive and PNI-negative nerves.

EXPERIMENTAL DESIGN

Tissue sections from 142 patients were stained with S100 and cytokeratin antibodies. Nerves were identified in two distinct areas: tumor bulk and margin. Nerve diameter and nerve-to-tumor distance were assessed; survival analyses were performed. Spatial transcriptomic analysis of nerves at varying distances from tumor was performed with NanoString GeoMx Digital Spatial Profiler Transcriptomic Atlas.

RESULTS

PNI is an independent predictor of poor prognosis among patients with metastasis-free lymph nodes. Patients with close nerve-tumor distance have poor outcomes even if diagnosed as PNI negative using current criteria. Patients with large nerve(s) in the tumor bulk survive poorly, suggesting that even PNI-negative nerves facilitate tumor progression. Diagnostic criteria were supported by spatial transcriptomic analyses of >18,000 genes; nerves in proximity to cancer exhibit stress and growth response changes that diminish with increasing nerve-tumor distance. These findings were validated in vitro and in human tissue.

CONCLUSIONS

This is the first study in human cancer with high-throughput gene expression analysis in nerves with striking correlations between transcriptomic profile and clinical outcomes. Our work illuminates nerve-cancer interactions suggesting that cancer-induced injury modulates neuritogenesis, and supports reclassification of PNI based on nerve-tumor distance rather than current subjective criteria.

Postoperative radiotherapy to the neck for pN1 status HNSCC patients after neck dissection

The significance of postoperative radiotherapy (PORT) to the neck for pN1 status head and neck squamous cell carcinomas (HNSCC) after neck dissection is unclear. A total of 208 patients with pN1 status HNSCC treated from January 1, 2001, to December 31, 2014, were enrolled in the current study. The 5-year regional recurrence-free survival (RRFS), overall survival (OS) and distant metastasis-free survival (DMFS) were compared between patients with or without PORT to the dissected neck. Moreover, the stratified Cox proportional hazards models were used to assess the association between PORT to the neck and survival before and after propensity score matching. Seventy-nine patients received PORT to the neck, while 129 did not. All patients were followed for over 5 years, with a median follow-up duration of 64.6 months. The PORT group did not show better survival results than the group without PORT to the neck in RRFS, OS or DMFS. Moreover, no evidence showed that PORT to the neck was independently associated with 5-year survival. PORT to the neck for pN1 status HNSCC after neck dissection did not lead to better survival. However, it is necessary to conduct prospective randomized clinical trials to confirm these results.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Targeted Photodynamic Therapy of Human Head and Neck Squamous Cell Carcinoma with Anti-epidermal Growth Factor Receptor Antibody Cetuximab and Photosensitizer IR700DX in the Mouse Skin-fold Window Chamber Model

Targeted photodynamic therapy (PDT) in head/neck cancer patients with a conjugate of the anti-epidermal growth factor receptor (EGFR) antibody, Cetuximab and a phthalocyanine photosensitizer IR700DX is under way, but the exact mechanisms of action are still not fully understood. In this study, the EGFR-overexpressing human head/neck OSC-19-luc2-cGFP tumor with transfected GFP gene was used in a skin-fold window chamber model in BALB/c nude mice. The uptake and localization of the conjugate in the tumor and its surrounding normal tissues were studied by an intravital confocal laser scanning microscopy with image analyses. The tumor was also irradiated with 690 nm laser light 24 h after conjugate administration. The vascular and tumor responses were examined by morphological evaluation and immunohistochemistry (IHC). The amount of conjugate in the tumor peaked at 24-48 h after injection. Image analyses of colocalization correlation parameters demonstrated a high fraction of the conjugate IR700DX colocalized in the GFP-expressing tumor cells. PDT-treated tumors showed extensive necrotic/apoptotic destruction with little vascular damage, while IHC showed no HIF-1α expression and decreased EGFR and Ki67 expression with activated caspase-3 overexpression, indicating a direct killing of tumor cells through both necrotic and apoptotic cell death.

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to “surgical management of oral cancer” published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient’s treatment goals.

Marginal or segmental mandibulectomy: treatment modality selection for oral cancer: a systematic review and meta-analysis

Surgery is the most well established mode of initial definitive treatment for the majority of oral cancers. The most important decision in terms of tumour ablation in oral cancers when the jaws are potentially involved is the management of the mandible. The aim of this study was to explore the differences in survival rate and disease control between patients undergoing marginal mandibulectomy and patients undergoing segmental mandibulectomy using a systematic review and meta-analysis approach. A total of 15 cohort studies, including 1672 participants, were identified. Meta-analysis provided weak evidence in favour of segmental mandibulectomy for local control. Segmental mandibulectomy gave 73% better disease-free survival than marginal mandibulectomy when the marrow was invaded (P=0.04). The overall survival rate was evaluated, and no statistically significant difference was found between the two different mandibulectomy approaches, although the results showed a trend in favour of segmental mandibulectomy which could increase the overall survival by 23%. Based on these findings regarding the survival rate and efficacy of disease control, this study indicates that a marginal mandibulectomy may be recommended for cases with no invasion or superficial invasion of the mandibular cortex, and a segmental mandibulectomy may be a more reasonable choice for patients with extensive mandibular cortex invasion or medullary invasion.

Lymph node management in the treatment of oral cancer: Analysis of a standardized approach

INTRODUCTION

A supraomohyoid neck dissection (SOHND) is part of the surgical management of patients with oral cancer, even in the absence of clinical or radiographic evidence of neck disease. We have investigated a standardized approach to the management of cervical lymph nodes, in patients with a primary oral cancer. A modified surgical technique has been presented and a clinical algorithm has been described and evaluated.

MATERIALS AND METHODS

SOHND was performed either uni- or bi-laterally. In cases of positive nodes in levels II or III, the dissection was extended in terms of a modified radical neck dissection (MRND) and a SOHND was performed contralaterally.

RESULTS

112 patients were included. 42% had lymph node metastases in any level. Overall, lymph node metastases were found in 2.8% of all examined nodes. Most metastases (34.6%) occurred in level Ib. 12.6% were located in level IIb. No metastases could be detected in levels IV and V. No statistically significant difference could be shown with regard to T-stage, location, or co-factors as gender and age.

DISCUSSION

SOHND is the gold-standard in patients with no preoperative evidence of lymph node metastases. The presented algorithm is able to facilitate dissection and histological analysis and might improve the surgical care in current treatment concepts. The extension to an MRND facilitates the identification of patients in need of adjuvant therapy.

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.

[Squamous cell carcinoma as the most common oral carcinoma. Diagnosis and therapy]

BACKGROUND

About 5 % of all malignant tumors affect oral cavity. With a share of 95% squamous cell carcinoma is the most common type of the malignant tumors of oral mucosa.

CASE REPORT

In our case the patient developed a squamous cell carcinoma of buccal mucosa about 2 years after excision of verrucous leukoplakia with epithelial dysplasia at the same location. Although chronic alcohol abuse, tobacco use and infection with HPV 16 are the most important risk factors for development of squamous cell carcinoma of the oral cavity, our patient had none of these risk factors. We treated the patient in accordance with current guidelines by complete excision of the tumor as well as an elective neck dissection of the ipsilateral side. Untill the present time the patient is free of recurrence.

CONCLUSIONS

Although rare, squamous cell carcinoma of oral mucosa may also occur in patients that have no risk factors for it. Therefore, every dental and medical examination in each patient should include an inspection of the entire oral mucosa.

Radiation therapy with concurrent retrograde superselective intra-arterial chemotherapy for gingival carcinoma

PURPOSE

The aim of this study was to review the efficacy and toxicity of radiation therapy with concurrent retrograde superselective intra-arterial chemotherapy in the treatment of gingival carcinoma.

METHODS AND MATERIALS

In all, 34 patients (21 men and 13 women) with squamous cell carcinoma of the gingiva underwent radiation therapy with concurrent retrograde superselective intra-arterial chemotherapy. Treatment consisted of daily external irradiation and concurrent retrograde superselective intra-arterial infusion with cisplatin and docetaxel. A median total dose of 60 Gy in 30 fractions was delivered to tumors.

RESULTS

Of the 34 patients, 29 (85 %) achieved a complete response (CR) and 5 had residual tumors. Of the 29 patients with a CR, 2 had local recurrences and 1 had distant metastasis 1-15 months after treatment. Twenty-six of the 36 patients had survived at a median follow-up time of 36 months (range 12-79 months); 4 died of cancer and 4 died of non-cancer-related causes. At both 3 and 5 years after treatment, the overall survival rates were 79 % and the cause-specific survival rates were 85 %. Osteoradionecrosis of the mandibular bone only developed in 1 patient after treatment.

CONCLUSION

Radiation therapy with concurrent retrograde superselective intra-arterial chemotherapy was effective and safe in the treatment of gingival carcinoma. This treatment may be a promising curative and organ-preserving treatment option for gingival carcinoma.

mTHPC-mediated photodynamic therapy of early stage oral squamous cell carcinoma: a comparison to surgical treatment

BACKGROUND

mTHPC-mediated photodynamic therapy (PDT) is used for treatment of early head and neck squamous cell carcinoma. This study is a retrospective comparison of PDT with transoral surgery in the treatment of early primary squamous cell carcinoma of the oral cavity/oropharynx.

METHODS

PDT data were retrieved from four study databases; surgical results were retrieved from our institutional database. To select similar primary tumors, infiltration depth was restricted to 5 mm for the surgery group. A total of 126 T1 and 30 T2 tumors were included in the PDT group, and 58 T1 and 33 T2 tumors were included in the surgically treated group.

RESULTS

Complete response rates with PDT and surgery were 86 and 76% for T1, respectively, and for T2 63 and 78%. Lower local disease-free survival for PDT compared to surgery was found. However, when comparing the need for local retreatment, no significant difference for T1 tumors was found, while for T2 tumors surgery resulted in significantly less need for local retreatment. No significant differences in overall survival between surgery and PDT were observed.

CONCLUSIONS

PDT for T1 tumors results in a similar need for retreatment compared to surgery, while for T2 tumors PDT performs worse. Local disease-free survival for surgery is better than for PDT. This may be influenced by the benefit surgery has of having histology available. This allows an early decision on reintervention, while for PDT one has to follow a wait-and-see policy. Future prospective studies should compare efficacy as well as morbidity.

Role of surgery in the management of head and neck cancer: a contemporary view of the data in the era of organ preservation

OBJECTIVE

Review of the literature on the role of surgery in the management of head and neck cancer in the era of organ preservation.

METHOD

Literature search based on the essential practice guidelines set out by the US National Comprehensive Cancer Network.

RESULTS

Despite the increasing popularity of non-surgical treatment options, the surgeon remains a key figure in the multidisciplinary head and neck cancer team, along with the radiation oncologist, the medical oncologist and the speech and swallowing therapist. Even when organ preservation is successful, early and late toxicity may cause serious complications, including laryngeal dysfunction with a 'frozen larynx'. When organ preservation fails, salvage surgery is often associated with increased complications and reduced survival.

CONCLUSION

There is a definite need to apply more rigorous standards to the use of organ preservation strategies, and to re-evaluate the role of surgery in head and neck cancer treatment.

The diagnosis and treatment of oral cavity cancer

BACKGROUND

About 10,000 persons are diagnosed as having carcinoma of the oral cavity or the throat in Germany every year. Squamous-cell carcinoma accounts for 95% of cases.

METHODS

We systematically reviewed the pertinent literature on predefined key questions about these tumors (which were agreed upon by a consensus of the investigators), concerning imaging, the removal of cervical lymph nodes, and resection of the primary tumor.

RESULTS

246 clinical trials were selected for review on the basis of 3014 abstracts. There was only one randomized, controlled trial (evidence level 1-); the remaining trials reached evidence levels 2++ to 3. Patients with mucosal changes of an unclear nature persisting for more than two weeks should be examined by a specialist without delay. The diagnosis is made by computed tomography or magnetic resonance imaging along with biopsy and a standardized histopathological examination. Occult metastases are present in 20% to 40% of cases. Advanced disease (stages T3 and T4) should be treated by surgery followed by radiotherapy, with or without chemotherapy. 20% of the patients overall go on to have a recurrence, usually within 2 to 3 years of the initial treatment. The 5-year survival rate is somewhat above 50%. Depending on the radicality of surgery and radiotherapy, there may be functional deficits, osteoradionecrosis, and xerostomia. The rate of loss of implants in irradiated bone is about 10% in 3 years.

CONCLUSION

The interdisciplinary planning and implementation of treatment, based on the patient's individual constellation of findings and personal wishes, are prerequisites for therapeutic success. Reconstructive measures, particularly microsurgical ones, have proven their usefulness and are an established component of surgical treatment.

mTHPC mediated photodynamic therapy (PDT) of squamous cell carcinoma in the head and neck: a systematic review

OBJECTIVE

Photodynamic therapy (PDT) is used in curative and palliative treatment of head and neck squamous cell carcinoma (HNSCC). To evaluate available evidence on the use of mTHPC (Foscan®) mediated PDT, we conducted a review of the literature.

MATERIALS AND METHODS

A systematic review was performed by searching seven bibliographic databases on database specific mesh terms and free text words in the categories; "head and neck neoplasms", "Photodynamic Therapy" and "Foscan". Papers identified were assessed on several criteria by two independent reviewers.

RESULTS

The search identified 566 unique papers. Twelve studies were included for our review. Six studies reported PDT with curative intent and six studies reported PDT with palliative intent, of which three studies used interstitial PDT. The studies did not compare PDT to other treatments and none exceeded level 3 using the Oxford levels of evidence. Pooling of data (n=301) was possible for four of the six studies with curative intent. T1 tumors showed higher complete response rates compared to T2 (86% vs 63%). PDT with palliative intent was predominantly used in patients unsuitable for further conventional treatment. After PDT, substantial tumor response and increase in quality of life was observed. Complications of PDT were mostly related to non-compliance to light restriction guidelines.

CONCLUSION

The studies on mTHPC mediated PDT for HNSCC are not sufficient for adequate assessment of the efficacy for curative intent. To assess efficacy of PDT with curative intent, high quality comparative, randomized studies are needed. Palliative treatment with PDT seems to increase the quality of life in otherwise untreatable patients.

Long-term experience in sentinel node biopsy for early oral and oropharyngeal squamous cell carcinoma

OBJECTIVE

Long-term results of sentinel node biopsy (SNB) in early (T1/T2) oral and oropharyngeal squamous cell carcinoma (OSCC) in a single-institution experience.

METHODS

Prospective consecutive cohort analysis of 79 patients (67% male, median age 60 years, age range 34-87 years) included between 2000 and 2006. Lymphatic mapping consisted of preoperative lymphoscintigraphy, single photon emission computed tomography (SPECT/CT), and intraoperative use of a handheld gamma probe. Endpoints of the study were neck control rate, overall (OS), disease-specific (DSS), and disease-free survival (DFS).

RESULTS

Twenty-nine of 79 patients (37%) had positive sentinel nodes (SN). Six of 29 (21%) patients showed isolated tumor cells, 14/29 (48%) micrometastases, and 9/29 (31%) macrometastases. OS, DFS, and DSS at 5 years for the entire cohort were 80, 85, and 87%, for SN-negative patients were 88, 96, and 96%, and for SN-positive patients were 74, 73, and 77%, respectively. Only the difference in DSS achieved statistical significance. The neck control rate after 5 years was 96% in SN-negative and 74% in SN-positive patients. This difference was statistically significant.

CONCLUSIONS

SNB is a safe and accurate staging modality to select patients with clinically stage I/II OSCC with occult lymph node disease for elective neck dissection (END). The promising reported short-term results have been sustained by long-term follow-up. Patients with negative SN and no END achieve an excellent neck control rate which compares favorably with reports on primary END. The neck control rate in SN-negative patients is superior to that in SN-positive patients, which is reflected in superior DSS.

Indications for radiotherapy after neck dissection

Up-front surgery and postoperative radiotherapy constitute a well-recognized treatment concept for locally or regionally advanced squamous cell carcinoma of the head and neck. This "treatment package" is further intensified with the concomitant application of chemotherapy during irradiation when high-risk features (ie, microscopically involved resection margins, extracapsular extension of the tumor from neck nodes, the presence of soft tissue deposits) are found on histopathologic examination of a resected specimen. With regard to neck disease, however, the demarcation line between low- and higher-risk clinical situations, which would differ with respect to the need for postoperative radiotherapy, is not clear. In an attempt to define the low-risk characteristics of disease in the neck that do not require adjuvant irradiation, we reviewed the available literature reports for any direct or indirect evidence on the value of postoperative radiotherapy in various clinical scenarios. The number of positive lymph nodes found in a dissected tissue specimen that should be used as a "cut-off" point for introduction of postoperative radiotherapy was evaluated in the context of both primary tumor characteristics and type of neck dissection.

Photodynamic therapy of early stage oral cavity and oropharynx neoplasms: an outcome analysis of 170 patients

The indications of photodynamic therapy (PDT) of oral cavity and oropharynx neoplasms are not well defined. The main reason is that the success rates are not well established. The current paper analyzes our institutional experience of early stage oral cavity and oropharynx neoplasms (Tis-T2) to identify the success rates for each subgroup according to T stage, primary or non-primary treatment and subsites. In total, 170 patients with 226 lesions are treated with PDT. From these lesions, 95 are primary neoplasms, 131 were non-primaries (recurrences and multiple primaries). The overall response rate is 90.7% with a complete response rate of 70.8%. Subgroup analysis identified oral tongue, floor of mouth sites with more favorable outcome. PDT has more favorable results with certain subsites and with previously untreated lesions. However, PDT can find its place for treating lesions in previously treated areas with acceptable results.

Metastatic neck disease beyond the limits of a neck dissection: attention to the 'para-hyoid' area in T1/2 oral tongue cancer

OBJECTIVE

We evaluated patients with small oral tongue cancer suffering from recurrence, which develops in the intervening area between the primary site and the neck. Lesions in the area around the cornu of the hyoid bone ('para-hyoid' area) often involve the hypoglossal nerve and the root of the lingual artery, resulting in treatment failure and death.

METHODS

A 10-year retrospective chart review was conducted of 248 oral tongue cancer patients with small primary tumors (T1/2). No patients who underwent postoperative radiotherapy (PORT) were included.

RESULTS

After excluding those who had local failure or developed new primary lesions, 6.3% of the patients were noted to have a para-hyoid lesion. A similar incidence was observed between the patients with and without previous neck dissection, 6.9% and 5.7%, respectively. All but one patient died due to uncontrolled neck disease.

CONCLUSIONS

Recurrent para-hyoid lesions could occur, irrespective of a previous neck dissection. In other words, the para-hyoid area is beyond the limits of a neck dissection. Once a para-hyoid lesion becomes clinically evident, it seems difficult to salvage. Therefore, a careful inspection of the area should be included intraoperatively in any type of neck dissection (i.e. elective or therapeutic) for patients with oral tongue cancer. This may be the key to improving the regional control rate of patients with small oral tongue cancer. We believe that some patients will benefit from more aggressive treatment of the neck, although PORT seems unnecessary for the majority of the patients with limited neck disease.

Management of the N0 neck in oral squamous cell carcinoma

Oral squamous cell carcinoma (SCC) has an unpredictable capacity to metastasize to the neck, an event that dramatically worsens prognosis. Metastasis occurs even in earlier stages when no neck lymph node involvement is clinically detectable (N0). Management of the N0 neck, namely when and how to electively treat, has been debated extensively. This article presents the controversies surrounding management of the N0 neck, and the benefits and pitfalls of different approaches used in evaluation and treatment. As current methods of assessing the risk for occult metastasis are insufficiently accurate and prone to underestimation of actual risk, and because selective neck dissection (SND) is an effective treatment and has minimal long-term detriment to quality of life, the authors believe that all patients who have oral SCC, excluding lip SCC, should be prescribed elective treatment of the neck lymphatics. However, this opinion remains controversial. Because of the morbidity of radiation therapy and because treatment of the primary tumor is surgical, elective neck dissection is the preferred treatment. In deciding the extent of the neck dissection, several retrospective studies and one randomized clinical trial have shown SND of levels I through III to be highly efficacious.

Surgery alone for squamous cell carcinoma of the oral cavity: survival rates, recurrence patterns, and salvage treatment

CONCLUSION

Surgery alone may be a reliable and feasible treatment of choice in selected patients with squamous cell carcinoma (SCC) of the oral cavity, given the proper indications.

OBJECTIVE

To evaluate the results of treatment of oral cavity SCC patients with surgery alone in a single institution.

PATIENTS AND METHODS

Between 1992 and 2004, 76 patients with previously untreated SCC of the oral cavity who had surgery alone without any other adjuvant treatment modalities were included in our study.

RESULTS

The 5-year overall rate, disease-specific survival rates, and locoregional control rate of all 76 patients were 69%, 83%, and 73%, respectively. A total of 16 patients (21%) presented with recurrences (8 with regional recurrences, 5 with local, 2 with locoregional, and 1 with distant metastasis). Four (6%) of the patients with primary T1 or T2 stage and one (50%) of those with T4 stage had recurrence at the primary site. The regional recurrence rate of patients with < or = N1 and > or = N2b was 10% (6 of 59) and 67% (2 of 3), respectively. Three of four patients who had recurrence at the primary site and attempted salvage treatment have been cured. However, only one of five patients with nodal recurrence and salvage treatment has recovered.

Squamous cell carcinoma of the oral tongue: a 25-year, single institution experience

Aim:

To report the characteristics, prognostic factors and treatment outcomes of 102 patients with squamous cell carcinoma of the oral tongue treated and followed up at a single institution over a 25-year period.

Patients and methods:

This retrospective study was carried out by auditing the medical records of 102 patients diagnosed with squamous cell carcinoma of the oral tongue and treated at our institution between 1982 and 2007. Patient follow up ranged from nine to 310 months (median 35 months). Fifty per cent of the patients were treated with surgery followed by a combination of chemotherapy and radiotherapy (43.1 per cent received concurrent chemoradiation and 6.9 per cent received sequential chemotherapy and radiotherapy), whereas 29.4 per cent received surgery followed by adjuvant radiotherapy alone. The remaining patients (20.6 per cent) did not undergo surgery and were treated with definitive radiotherapy with or without chemotherapy.

Results:

There were 48 men and 54 women. The age at presentation was 19–85 years (median 57 years). The peak incidence was observed between 60 and 70 years. Resection margins were clear in 75 per cent of patients and involved in 25 per cent. Stage I disease was found in 11.8 per cent of patients, stage II in 34.3 per cent, stage III in 22.5 per cent and stage IV in 31.4 per cent. The five-year disease-free survival and overall survival were 65.7 and 72.5 per cent, respectively. Thirty-five patients suffered recurrence after treatment, 74.0 per cent of them at the site of initial cervical nodal involvement. Univariate analysis for overall survival revealed the following as prognostic factors: treatment schedule (surgical vs non-surgical; p < 0.001); age (<60 years vs ≥60 years; p = 0.038); extent of cervical lymph node involvement (p = 0.015); primary tumour stage (p < 0.001); node stage (p = 0.034); and disease stage (p = 0.013). However, on multivariate analysis, only non-surgical treatment (p = 0.001) and advanced disease stage (p = 0.05) were found to have a negative influence on survival.

Conclusions:

Our limited data suggest that, in Iran, squamous cell carcinoma of the oral tongue tends to present at a locally advanced stage, with a high frequency of locoregional failure and a poor outcome. Combined modality therapy should be considered for the majority of patients with squamous cell carcinoma of the tongue.

[Prognostic value of infiltration of squamous cell carcinoma of the floor of the mouth]

OBJECTIVE

The aim of this preliminary retrospective study was to evaluate the prognostic value of tumor thickness in squamous cell carcinoma of the floor of the mouth.

MATERIALS AND METHODS

A total of 61 patients with previously untreated T1N0, T2N0 or T3N0 squamous cell carcinoma of the floor of the mouth were included in this preliminary study. An optical micrometer was used to determine the maximum of tumor thickness. We studied the relation between the overall survival at two and five years and tumor thickness.

RESULTS

The cohort comprised 52 male and nine female patients. The mean and the median thickness were 7.2 and 6mm, respectively. Overall survival was 79.5 and 36.7% at two and five years, respectively. There was no significant association between thickness and overall survival (p=0.71) and between thickness and disease-free survival (p=0.63).

CONCLUSION

The prognostic value of tumor thickness was not demonstrated in this preliminary study. We are currently conducting a study involving a larger patient population in our unit and we believe that tumor thickness should be considered in the management plan for patients with oral carcinoma.

Selective neck dissection for treating node-positive necks in cases of squamous cell carcinoma of the upper aerodigestive tract

CONTEXT AND OBJECTIVE

Modified radical neck dissection (MRND) is the classical treatment for neck metastases of squamous cell carcinoma (SCC) of the upper aerodigestive tract. However, it may still be accompanied by significant sequelae. One alternative for this treatment would be selective neck dissection (SND), which has a lower incidence of sequelae. The aim of this study was to define which neck metastasis cases would really be suitable candidates for SND.

DESIGN AND SETTING

Retrospective clinical-surgical trial at the Division of Head and Neck Surgery, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP).

METHODS

We retrospectively studied 67 patients with SCC of the upper aerodigestive tract, divided into two groups: 1) 47 patients treated by means of SND (node-negative or node-positive), 2) 20 patients treated by means of MRND (all node-positive).

RESULTS

Our results demonstrated that there was no difference between the patients treated with SND or MRND in relation to disease evolution, and that the main prognostic factor was lymph node involvement. We observed that patients with pharyngeal SCC and older patients presented worse evolution and would probably not be suitable candidates for SND.

CONCLUSIONS

SND may be a good option for treating node-positive necks in selected cases.

Efficacy of neck treatment in patients with head and neck squamous cell carcinoma

BACKGROUND

Treatment of head and neck squamous cell carcinoma (HNSCC) addresses the primary tumor and the lymphatic drainage. Modalities for the neck are neck dissection and/or radiation therapy. In most cases, the neck is treated by the modality that seems more appropriate for the primary. The aim of this study was to analyze the results of the neck treatments either by neck dissection alone, by radiation therapy alone or by neck dissection followed by radiation therapy.

METHODS

This was a retrospective chart analysis of 699 patients treated for a previously untreated HNSCC. The primary endpoint was recurrence at the treated neck.

RESULTS

Two hundred eighty-one (40%) patients underwent primary neck irradiation, 219 (31%) neck dissection alone, and 199 (29%) neck dissection followed by adjuvant irradiation. The 5-year regional control rates after neck dissection alone were 83% for pN0, 75% for pN1, 60% for pN2a, 59% for pN2b, and 50% for pN2c; after radiation alone, 89% for cN0, 87% for cN1, 40% for cN2a, 60% for cN2b, and 48% for cN2c; and after neck dissection with adjuvant radiation, 86% for pN0, 96% for pN1, 100% for pN2a, 88% for pN2b, and 88% for pN2c.

CONCLUSIONS

Radiation or neck dissection alone are efficient to control early neck disease. For advanced N2/3 neck disease, neck dissection followed by adjuvant radiation is highly efficient, whereas primary radiation results in a high number of regional failures. The literature suggests planned neck dissection to improve regional control for these patients.

Oral tongue carcinoma and its treatment in Finland

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

Management of the clinically negative neck in early squamous cell carcinoma of the oral cavity

The management of the clinically negative neck in early squamous cell carcinoma of the oral cavity is controversial. This article presents the arguments in favor and against the various options for management of these patients.

Estimation of an optimal external beam radiotherapy utilization rate for head and neck carcinoma

BACKGROUND

Radiotherapy is used commonly in the treatment of patients with head and neck carcinoma. The benchmark radiotherapy utilization rates for head and neck carcinoma largely are unknown. The objective of the current study was to determine the optimal radiotherapy utilization rate for patients with head and neck carcinoma and to compare this optimal rate with actual utilization rates where actual utilization data were available.

METHODS

An optimal radiotherapy utilization tree was constructed that depicted all patients with head and neck carcinoma in whom radiotherapy was indicated according to evidence-based treatment guidelines. The proportions of patients with clinical attributes that indicated possible benefit from radiotherapy were obtained from epidemiological data and were inserted into the utilization tree. The optimal proportion of patients with carcinoma of the head and neck who should receive radiotherapy was calculated by merging the evidence-based recommendations with the epidemiological data in the tree. Optimal rates of radiotherapy utilization were compared with actual rates obtained from population-based studies.

RESULTS

Radiotherapy was indicated at some point during their illness in 74% of all patients with head and neck carcinoma. By subsite, the optimal radiotherapy utilization rates were oral cavity, 74%; lip, 20%; larynx, 100%; oropharynx, 100%; salivary gland, 87%; hypopharynx, 100%; nasopharynx, 100%; paranasal sinuses, 100%; and unknown squamous cell carcinoma of the head and neck, 90%. All treatment recommendations were based on Level III or IV evidence. Assessment of actual radiotherapy utilization rates indicated an increased use of radiotherapy over time for head and neck carcinoma. However, there also were some decreases in the use of radiotherapy for some carcinoma subsites over the past 20 years, despite the lower actual rates compared with the optimal rates. The reasons for these reductions in use were not identified.

CONCLUSIONS

The actual radiotherapy utilization rate for patients with head and neck carcinoma corresponded reasonably closely to the optimal rate for some populations but also identified some shortfalls for other patient groups. The results of this study provide a way of assessing shortfalls in radiotherapy.

mTHPC-mediated photodynamic therapy for early oral squamous cell carcinoma

Surgery and radiotherapy are standard treatments for early oral squamous cell carcinoma, both resulting in good tumour control. However, neither of these modalities is without consequent functional or cosmetic impairment, and there are patients in whom both are contraindicated. Furthermore, there is a significant risk of metachronous tumours developing in the oral cavity, and salvage or retreatment with either surgery or radiotherapy poses difficulties. Photodynamic therapy (PDT) offers the potential for improved functional and cosmetic outcomes, while achieving comparable tumour control. We conducted an open-label, multicentre study to assess the efficacy and safety of meta-tetrahydroxyphenylchlorin (mTHPC) in patients with early oral cancer. One hundred twenty-one patients received intravenously administered mTHPC, followed 96 hr later by illumination of the tumour surface with 652 nm laser light. Of these patients, 114 were protocol compliant. A complete tumour response was achieved in 85% of protocol-compliant patients (97 of 114 patients). A complete response was maintained in 85% of responders at 1 year and in 77% at 2 years. One- and 2-year actuarial survival rates were 89% and 75%, respectively. In the opinion of the investigators, tumour clearance was accompanied by excellent cosmetic and functional results, without impact on the patients' performance status. Mild-to-moderate pain at the treatment site, a recognised side effect of PDT in the oral cavity, was reported by 82% of patients but was manageable with appropriate analgesia. Mild-to-moderate skin photosensitivity reactions were reported for 13% of patients. mTHPC offers an effective alternative treatment for early oral squamous cell carcinoma. It is associated with excellent functional and cosmetic results and can be used in conjunction with other standard therapies.

Current treatment options in squamous cell carcinoma of the oral cavity

Oral cavity SCC remains a significant health problem and requires a multidisciplinary approach. Treatment with surgery alone or in combination with adjuvant radiotherapy for more advanced lesions is the standard of care. Major advances have been made in surgical approaches,reconstructive options, and the rehabilitation of patients who have oral cavity SCC. These advances have significantly improved disease-specific outcome and quality of life. The future may lie in the development of treatment regimes that combine early detection with organ preservation and result in improved cure rates and quality of life.

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

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

CT determination of lymphocytic infiltration around head and neck squamous cell carcinomas may be a predictor of lymph node metastases

The histological detection of a peritumoral lymphocytic infiltration (PLI) and a sharp tumor border in patients with squamous cell carcinoma (SCC) of the larynx, pharynx or oral cavity is inversely correlated with the development of cervical lymph node metastases and is therefore a favorable prognostic factor. However, preoperative biopsies are often too small for an evaluation of these tumor features. Here, we examined retrospectively whether elevation of peritumoral density values as determined by contrast-enhanced computed tomography (CT) correlates with PLI and the presence of cervical lymph node metastases. A total of 40 patients with primarily resected SCC were studied (pT1=8, pT2=13, pT3=9, pT4=10); 25 patients were pN-positive. All tumors were histologically analyzed regarding PLI (present or not) and the tumor border (sharp or infiltrating). Based on standardized CT examinations (90 ml contrast agent at 1.5 ml/s), repeated region-of-interest (ROI)-based peritumoral density measurements were obtained. Correlations between CT density, PLI, tumor border and metastatic involvement of regional lymph nodes were statistically evaluated. CT densities were significantly higher (P<0.001) in patients with PLI and sharp tumor borders than in patients without PLI and patients with infiltrating tumor borders. Moreover, the presence of PLI, sharp tumor borders and elevated peritumoral CT densities were each correlated with the absence of lymph node metastases (P<0.001). An elevation of peritumoral CT densities is linked to PLI and sharp tumor borders on histology and a lower risk to develop lymph node metastases. For a patient-adapted therapy, these relations have to be prospectively evaluated regarding their prognostic relevance.

Tumor thickness influences prognosis of T1 and T2 oral cavity cancer?but what thickness?

BACKGROUND

Previous studies have demonstrated that tumor thickness might influence prognosis in oral cancer, but the significant point at which outcome changes has varied from 1.5 mm to 6 mm. The clinical relevance of thickness remains unclear, and a reproducible prognostic "breakpoint" needs to be defined.

METHODS

Tumor thickness was measured in 145 oral cavity squamous cancers, clinically staged T1 (n = 62) or T2 (n = 83). Clinical and pathologic data were collected prospectively between 1988 and 2000, but thickness was measured on paraffin sections for this study. Minimum follow-up was 2 years, and thickness was correlated with local control, cervical node involvement, and survival. Patients with clinically positive nodes (n = 21) were not excluded. Overall, 55 patients had pathologic node involvement at some time in their disease.

RESULTS

Median tumor thickness was 6.2 mm, and there was little variation between sites: tongue, 6.4 mm; floor of mouth, 6.6 mm; and other sites, 5.7 mm. Median thickness for T1 tumors was 4.3 mm, significantly less than the T2 group, 8 mm (p <.01). Median thickness also varied significantly for tumors with associated nodal disease (8.5 mm) and without nodal disease (5.8 mm) (p <.01). Prognosis changed significantly at a cutoff of 4 mm with local control, nodal disease, and survival rates of 91%, 8%, and 100%, respectively, for tumors <4 mm compared with 84%, 48%, and 74% for those 4 mm or more thick (p <.01). Subgrouping greater than and less than 3 mm and 5 mm also showed a difference but with poorer discrimination. Thickness and pathologic nodal involvement were highly significant independent prognostic factors.

CONCLUSIONS

Tumor thickness is a highly significant, objectively measurable prognostic factor in early stage oral cancers. There is a need to standardize techniques of measurement to allow a multi-institutional study to be carried out. This will facilitate the development of strategies aimed at improving the outcome of higher risk patients.

Neck node metastasis after successful brachytherapy for early stage tongue carcinoma

BACKGROUND AND PURPOSE

The accuracy of factors for predicting lymph node metastasis in patients with early-stage (stage I and II) mobile tongue carcinoma and prognostic factors associated with the clinical and pathological findings of lymph node metastasis were examined.

MATERIAL AND METHODS

Between 1971 and 1998, 616 patients with early stage mobile tongue carcinoma were treated by brachytherapy with or without external irradiation. Neck lymph node metastasis occurred in a total of 237 cases, and 191 of them were not associated with primary failure. Neck dissection was performed in 169 of these 191 cases, and 16 cases were treated by radiotherapy. A pathological analysis was possible in 159 of the 169 neck dissection cases.

RESULTS

There were 88 tongue cancer recurrences, and the incidence of neck metastasis was 38% (191/528) in the cases of primary controlled early tongue carcinoma, and 25% (38/151) and 41% (153/377), in stage-I and -II carcinoma, respectively. Neck metastasis was diagnosed within 12 months in 80% of cases, and within 24 months in 95%. Macroscopic appearance, tumor thickness and tumor length were identified as significant risk factors by a univariate analysis, but macroscopic appearance was the only significant risk factor identified by a multivariate analysis (P<0.001). The incidence of cervical lymph node metastasis was 62% among the invasive/ulcerative type tongue carcinomas, and was lower among the superficial type and exophytic/nodular type (20 and 35%, respectively). Regional and/or distant failure occurred in 75 of the 169 neck dissection cases (44%). The incidence of regional/distant failure was extremely high (49/68=72%) in the extra-nodal invasion group, and extra-nodal invasion was found even in small metastatic node less than 1 cm in length (20%).

CONCLUSIONS

The macroscopic appearance of the primary tongue carcinoma has a major impact on the incidence of lymph node metastasis in patients with early tongue cancer, and extra-nodal invasion was the dominant risk factor for regional and distant failure. Treatment policy for clinically negative neck metastasis in early tongue cancer patients should be determined after considering the possibility of neck metastases and the morbidity associated with elective neck dissection.

Oral mucosal dysplastic lesions and early squamous cell carcinomas: underdiagnosis from incisional biopsy

OBJECTIVES

To evaluate the degree and causes of underdiagnosis of incisional biopsy in oral potentially malignant lesions (PML).

DESIGN

Cross-sectional retrospective study.

MATERIALS AND METHODS

All pathology slides (incisional biopsy and resection specimen) from 46 patients with oral PML were reviewed and scored blind. The provisional diagnosis was considered in order to provide underdiagnosis or overdiagnosis according to whether this score was lower or higher than the final diagnosis.

MAIN OUTCOME MEASURES

Concordance between the scores for provisional and final diagnoses was compared for reviewed and unreviewed assessments.

RESULTS

Upon review, underdiagnosis significantly decreased from 23.9% to 4.4% (P=0.016, chi-square with the Yates' correction). As the underdiagnosis ratio was not significantly influenced by intra- or inter-observer variability, it is likely to be related to pathologists' interpretation difficulties when examining incisional biopsy specimens.

CONCLUSIONS

The good quality of incisional biopsy samples was demonstrated, but clinicians should be conscious of the possible underdiagnosis by incisional biopsy when planning therapy in suspected early oral squamous cell carcinoma lesions.