Compartmental surgery for oral tongue and floor of the mouth cancer: Oncologic outcomes

MRI and frozen section evaluation of mylohyoid muscle in determining surgical approach for T2-T3 floor of the mouth cancer

PURPOSE

The choice of surgical approach for floor of the mouth (FOM) cancer, particularly for intermediate-stage tumors (cT2-cT3), remains controversial. This study aims to evaluate a method considering mylohyoid muscle (MM) invasion as a determinant for surgical approach selection, utilizing magnetic resonance imaging (MRI) preoperatively and frozen section (FS) analysis intraoperatively.

METHODS

This observational retrospective cohort study analyzed patients undergoing surgical resection of cT2 and cT3 FOM squamous cell carcinoma (SCC) between January 2013 and June 2023. MM infiltration assessed by preoperative MRI determined the surgical approach: clear infiltration led to compartmental surgery (CS), while doubtful or absent infiltration led to transoral surgery (TOS). Conversion from TOS to CS occurred intraoperatively based on macroscopic evidence or positive FS. Data collected included demographic, clinical, surgical, and pathological variables. Survival analysis was conducted using Kaplan-Meier method.

RESULTS

Among 44 patients included, majority had cT2 tumors (59.1%). MM resection was necessary in 22.7% of cases. Overall survival (OS) and progression-free survival (PFS) did not significantly differ between TOS and CS groups. Radiological depth of invasion (rDOI) < 10 mm is correlated with MM preservation in 89% of cases, while rDOI > 10 mm is correlated with MM resection only in 23.8% of cases. Pathological depth of invasion (pDOI) discrepancies were observed in the two groups: in CS group is shown a higher pDOI (> 10 mm) confirmation (90%). Surgical complications and functional outcomes differed between TOS and CS groups.

CONCLUSION

Considering MM invasion for surgical approach selection in cT2-cT3 FOM tumors appears oncologically safe, with better functional outcomes in muscle preservation. Preoperative MRI for MM assessment combined with intraoperative FS analysis provides reliable guidance for surgical decision-making.

Primary Management of Operable Locally Advanced Oral Cavity Squamous Cell Carcinoma: Current Concepts and Strategies

INTRODUCTION

Locally advanced oral cavity carcinoma (LAOCSCC) is primarily treated with surgery followed by radiotherapy with or without chemotherapy.

METHODS

A review of literature using PubMED was performed for studies reporting the management of LAOCSCC. Based on the reviewed literature and opinions of experts in the field, recommendations were made.

RESULTS

Studies have shown that outcomes following resection of T4a and infranotch (inferior to mandibular notch) T4b are comparable. We discuss the concept of compartmental resection of LAOCSCC and issues concerning the management of the neck. Further, patients who refuse or are unable to undergo surgery can be treated with chemoradiotherapy with uncertain outcomes. The role of neoadjuvant chemotherapy has shown promise for organ (mandibular) preservation in a select subset of patients.

CONCLUSION

The management strategy for LAOCSCC should be determined in a multidisciplinary setting with emphasis on tumor control, functional preservation, and quality of life of the patient.

Three-Dimensional-Printed Template-Guided Radioactive Seed Brachytherapy via a Submental Approach for Recurrent Base of Tongue and Floor of Mouth Cancer

Background

This study assessed clinical outcomes of three-dimensional-printed template (3DPT)-guided radioactive seed brachytherapy (RSBT) via a submental approach for recurrent base of tongue and floor of mouth cancer.

Methods

Thirty-one patients with recurrent lingual and floor of mouth squamous cell carcinoma after surgery and radiotherapy were treated with 3DPT-guided RSBT from 2015 to 2022. Seeds were implanted through a submental approach guided by 3DPTs. Local control (LC), overall survival (OS), disease control (DC) and quality of life (QOL) were evaluated.

Results

The median follow-up was 13.7 months. The 1-, 3- and 5-year LC rates were 66.1%, 66.1%, and 55.1% respectively. The 1-, 3- and 5-year OS rates were 63.4%, 33.4%, and 8.3%. The 1-, 3- and 5-year DC rates were 37.8%, 26.5%, and 21.2%. Univariate analysis showed tumor size significantly affected LC (P = 0.031). The presence of extraterritorial lesions affected DC and OS on multivariate analysis (P < 0.01). QOL improved significantly in domains of pain, swallowing, chewing, taste, and emotion after treatment compared to baseline. Four patients (13%) developed necrosis and osteoradionecrosis.

Conclusions

3DPT-guided submental RSBT provided favorable LC and QOL for recurrent tongue/floor of mouth cancer with minimal toxicity; moreover, severe toxicity should be noted.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Sternocleidomastoid flap for reconstruction of tongue small cell carcinoma: A case report

BACKGROUND

The management of tongue carcinoma is excision and radical neck dissection followed with reconstruction. This is a case report of a patient with tongue squamous cell carcinoma (SCC) who underwent the procedure with sternocleidomastoid (SCM) flap reconstruction.

CASE SUMMARY

A 52-year-old woman without smoking history complained tongue ulcer since 3 years ago. Based on the histopathological examination, the patient was diagnosed with T2N2M0 right tongue SCC and underwent wide excision of tumor; right mandibular; neck dissection and were reconstructed with SCM flap.

CONCLUSION

SCC of the tongue requires wide excision and dissection of the neck and mandible if infiltration into the surrounding lymph nodes has been found. The SCM flap reconstruction could be used post-surgery.

Compartmental tongue surgery for intermediate-advanced squamous cell carcinoma: A multicentric study

BACKGROUND

A multicentric study was conducted on technical reproducibility of compartmental tongue surgery (CTS) in advanced tongue cancers (OTSCC) and comparison to standard wide margin surgery (SWMS).

METHODS

We studied 551 patients with OTSCC treated by CTS and 50 by SWMS. Oncological outcomes were analyzed. A propensity score was performed to compare survival endpoints for the two cohorts.

RESULTS

In the CTS group, survival and prognosis were significantly associated with positive lymph-nodes, extranodal extension, depth of invasion and involvement of the soft tissue connecting the tongue primary tumor to neck lymph nodes (T-N tract), independently from the center performing the surgery. SWMS versus CTS showed a HR Cause-Specific Survival (CSS) of 3.24 (95% CI: 1.71-6.11; p < 0.001); HR Loco-Regional Recurrence Free Survival (LRRFS) of 2.54 (95% CI: 1.47-4.40; p < 0.001); HR Overall Survival (OS) of 0.11 (95% CI: 0.01-0.77; p = 0.03).

CONCLUSION

Performing the CTS could provide better CSS and LRRFS than SWMS regardless of the center performing the surgery, in advanced OTSSC.

Indications for sentinel lymph node biopsy in node-negative oral cancers

BACKGROUND

We aimed to define the indications for sentinel lymph node biopsy (SLNB), the third option for cervical treatment in oral cancer with negative cervical lymph nodes.

METHODS

The greatest depth of invasion (DOI) and long diameter (LD) of the primary site were used as exposures. SLN metastasis was considered the outcome.

RESULTS

In three trials conducted between 2009 and 2016, 158 patients were eligible and reassigned to this study group. The scatterplot based on the respective values of DOI and LD would eventually be divided into three sections. In cases of sections T1, T2, and T3, the proportions of SLN metastasis positivity were 21.3%, 35.3%, and 51.2%, respectively. In certain cases of T1 with 2 mm < DOI ≤ 5 mm and 8 mm < LD ≤ 20 mm, the proportion of SLN metastasis positivity was 40.9%.

CONCLUSIONS

SLNB-navigated or assisted neck dissection can be added as an effective procedure for N0 neck control.

Beyond the boundaries of compartmental hemiglossectomy: a proposal for an anatomically based classification of surgical approaches to advanced oral tongue squamous cell carcinoma

INTRODUCTION

In the last decade, compartmental surgery (CTS) has been the surgical approach of choice for advanced tumors of the tongue and oral floor.

METHODS

Advanced tumors (cT3-T4) oral tongue squamous cell carcinoma (OTSCC) may extend beyond the lingual septum and involve the contralateral hemitongue, developing along the intrinsic transverse muscle. The disease may then involve the genioglossus muscle and, more laterally, the hyoglossus muscle.

RESULTS

The surgical approach to the contralateral tongue must be guided by anatomic and anatomopathological principles to achieve a safe oncological resection based on the principles of CTS.

CONCLUSION

We propose a schematic classification of glossectomies that extend to the contralateral hemitongue based on the anatomy and pathways of tumor spread.

Comparison of transoral and combined approach for surgical treatment of moderately advanced tongue and floor of the mouth cancer

Introduction. Surgical approach for oral cancer treatment is one of the key factors that determines oncologic effectiveness, risk of postoperative complications, need for reconstructive methods etc. Currently, there exists lack of strict criteria for using one or another approaches based on the sound scientific evidence for a primary tumor of given depth of invasion.

Aim. The aim of the study is a retrospective comparative analysis of oncologic efficiency of transoral and combined approaches for surgical treatment of tongue and floor of the mouth moderately advanced carcinoma.

Materials and methods. 75 patients aged between 30 and 80 years with tongue and floor of the mouth squamous cell carcinoma with depth of invasion from 10 to 20 mm were included into the study. In 29 cases the tumor was resected transorally (Group 1), in 45 – via combined approach (Group 2). Group 2 patients had more advanced tumors both locally and regionally. 13 patients of Group 1 and 27 patients of Group 2 underwent adjuvant radiotherapy. The following parameters were used for comparative analysis: the rate of local and regional recurrence, locoregional control, the rate of distant metastasis and Kaplan–Meyer overall survival.

Results. Mean follow up was 33.77 ± 27.72 months (range 14–115 months). The rate of local and regional recurrence was higher in Group 2 (20 % vs 10.3 % and 22.2 % vs 17.2 % respectively). Locoregional control was better in Group 1 (72.4 % vs 62.2 %). The difference for neither of the above-mentioned parameters did not reach statistical significance. Median survival was statistically significantly better in Group 1: 66 ± 17.42 months vs 23 ± 3.85 months (p = 0.030). Poorer treatment results in Group 2 can be explained by a higher proportion of patients with more advanced tumors in this group.

Conclusion. The results of the present study do not allow to conclude that combined approach has oncologic advantage over less aggressive transoral approach for tumors with depth of invasion from 10 to 20 mm. It is questionable to recommend the combined approach as a universal one for lesions with such a stage of local invasiveness.

Salvage surgery for patients with residual/persistent diseases after improper or insufficient treatment of oral squamous cell carcinoma: can we rectify these mistakes?

BACKGROUND

Patterns of failure after treatment of oral and squamous cell carcinomas (OSCC) are diversified, with recurrences being one of the common causes. A special group of patients are sometimes encountered in the outpatient clinic for improper or insufficient initial treatment with reports of positive margins, implying residual/persistent diseases. The question of whether these patients can be surgically salvaged remain unanswered.

METHODS

A retrospective study was performed between January 2013 and December 2017 for patients with residual or rapid recurrent (within 3 months) OSCCs, who received salvage surgeries in our institution. The patients with residual/persistent OSCCs were those with microscopic or macroscopic positive surgical margins, while those with rapid recurrent OSCCs were those with close or negative margins, but unabated painful symptoms right after treatment. Both clinicopathological and prognostic variables were analyzed. The focus was also directed towards lessons for possible initial mistakes, resulting in these residual/persistent diseases.

RESULTS

Of 103 patients, 68 (66%) were men, with mean age of 56.3 years. The overall survival reached 60.2%. Regarding the primary OSCC status, most of our patients (n = 75, 72.8%) were diagnosed with ycT2-3 stages. Besides, most patients were found with macroscopic residual diseases (52.4%) before our salvage surgery. The sizes of the residual/persistent OSCCs were generally under 4 cm (87.3%) with minimally residual in 21 (20.4%). Among all the variables, primary T stage (p = 0.003), and residual lesion size (p < 0.001) were significantly associated with the prognosis in multivariate analysis. Though the causes for the initial surgical failure were multifactorial, most were stemmed from poor planning and unstandardized execution.

CONCLUSIONS

Cases with residual/persistent OSCCs were mostly due to mistakes which could have been avoided under well-round treatment plans and careful surgical practice. Salvage surgery for cases with smaller residual/persistent OSCCs is still feasible with acceptable outcomes.

The T-N tract involvement as a new prognostic factor for PORT in locally advanced oral cavity tumors

OBJECTIVE

The space comprised between tumor and neck lymph nodes (T-N tract) is one of the main routes of tumor spread in oral cavity tumors. Aim of the study was to investigate the impact of T-N tract involvement on the postoperative radiotherapy (PORT) outcomes.

MATERIALS AND METHODS

Patients (pts) treated between 2000 and 2016 with indication to PORT were retrospectively retrieved. Inclusion criteria were: (a) locally advanced tumors of the oral cavity, (b) who received with indication to PORT (c) with a minimum follow-up of six months.

RESULTS

One hundred and fifty-seven pts met the inclusion criteria (136 pts treated with PORT and 21 pts not treated with PORT). In the PORT cohort, the T-N tract involvement had no impact on both OS (p = .09) and LRFS (p = .2). Among the non-PORT cohort, both OS (p = .007) and LRFS (p = .017) were worse for pts with positive T-N tract compared to those with negative T-N tract. PORT improved both OS (p = .008) and LRFS (p = .003) in pts with positive T-N tract but not in those with negative T-N tract (p = .36 and p = .37, respectively).

CONCLUSIONS

Our results suggest that involvement of T-N tract should be considered as prognostic factors informing the indication to PORT.

High-risk early-stage oral tongue squamous cell carcinoma, when free margins are not enough: Critical review

Oral tongue squamous cell carcinoma (OTSCC) is a quite peculiar disease from an anatomical and biological standpoint. An increasing amount of literature highlights the existence of a small subset of T1-T2N0 OTSCC, properly resected on a margin-dependent basis, which conversely proved higher than expected rates of loco-regional/distant failure and disease-specific mortality. These specific high-risk tumors might not have a margin-dependent disease and could possibly benefit from a more aggressive upfront loco-regional treatment, especially addressing the so-called T-N tract. Widespread adoption of a histopathological risk model would allow early recognition of these high-risk diseases and, consequently, intensification of the traditional treatment strategies in that specific niche. We reviewed the available knowledge trying to shed light on the potential determinants of the dismal prognosis of these high-risk OTSCC, with special reference to the role of overlooked T-N tract involvement and possible alternatives in terms of elective neck management and risk stratification.

Step-by-Step Cadaver Dissection and Surgical Technique for Compartmental Tongue and Floor of Mouth Resection

Background

The aim of oral cancer surgery is tumor removal within clear margins of healthy tissue: the latter definition in the literature, however, may vary between 1 and 2 cm, and should be intended in the three dimensions, which further complicates its precise measurement. Moreover, the biological behavior of tongue and floor of mouth cancer can be unpredictable and often eludes the previously mentioned safe surgical margins concept due to the complexity of tongue anatomy, the intricated arrangements of its intrinsic and extrinsic muscle fibers, and the presence of rich neurovascular and lymphatic networks within it. These structures may act as specific pathways of loco-regional tumor spread, allowing the neoplasm to escape beyond its visible macroscopic boundaries. Based on this concept, in the past two decades, compartmental surgery (CS) for treatment of oral tongue and floor of mouth cancer was proposed as an alternative to more traditional transoral resections.

Methods

The authors performed three anatomical dissections on fresh-frozen cadaver heads that were injected with red and blue-stained silicon. All procedures were documented by photographs taken with a professional reflex digital camera.

Results

One of these step-by-step cadaver dissections is herein reported, detailing the pivotal points of CS with the aim to share this procedure at benefit of the youngest surgeons.

Conclusions

We herein present the CS step-by-step technique to highlight its potential in improving loco-regional control by checking all possible routes of tumor spread. Correct identification of the anatomical space between tumor and nodes (T-N tract), spatial relationships of extrinsic tongue muscles, as well as neurovascular bundles of the floor of mouth, are depicted to improve knowledge of this complex anatomical area.

Survival Outcomes in Oral Tongue Cancer: A Mono-Institutional Experience Focusing on Age

Objective

The prognostic role of age among patients affected by Oral Tongue Squamous Cell Carcinoma (OTSCC) is a topic of debate. Recent cohort studies have found that patients diagnosed at 40 years of age or younger have a better prognosis. The aim of this cohort study was to clarify whether age is an independent prognostic factor and discuss heterogeneity of outcomes by stage and treatments in different age groups.

Methods

We performed a study on 577 consecutive patients affected by primary tongue cancer and treated with surgery and adjuvant therapy according to stage, at European Institute of Oncology, IRCCS. Patients with age at diagnosis below 40 years totaled 109 (19%). Overall survival (OS), disease-free survival (DFS), tongue specific free survival (TSFS) and cause-specific survival (CSS) were compared by age groups. Multivariate Cox proportional hazards models were used to assess the independent role of age.

Results

The median follow-up time was 5.01 years (range 0–18.68) years with follow-up recorded up to February 2020. After adjustment for all the significant confounding and prognostic factors, age remained independently associated with OS and DSF (respectively, p = 0.002 and p = 0.02). In CSS and TSFS curves, the role of age seems less evident (respectively, p = 0.14 and p = 0.0.37). In the advanced stage sub-group (stages III–IV), age was significantly associated with OS and CSS with almost double increased risk of dying (OS) and dying from tongue cancer (CSS) in elderly compared to younger groups (OS: HR = 2.16 95%, CI: 1.33–3.51, p= 0.001; CSS: HR = 1.76 95%, CI: 1.03–3.01, p = 0.02, respectively). In our study, young patients were more likely to be treated with intensified therapies (glossectomies types III–V and adjuvant radio-chemotherapy). Age was found as a prognostic factor, independently of other significant factors and treatment. Also the T–N tract involved by disease and neutrophil-to-lymphocyte ratio ≥3 were independent prognostic factors.

Conclusions

Young age at diagnosis is associated with a better overall survival. Fewer younger people than older people died from tongue cancer in advanced stages.

Postoperative radiotherapy is associated with improved survival in pT1-2N1 oral and oropharyngeal cancer without adequate neck dissection

Background

To assess the benefit of postoperative radiotherapy in patients with pT1-2N1M0 oral and oropharyngeal cancer by the quality of neck dissection.

Methods

In the Surveillance, Epidemiology, and End Results database, pT1-2N1M0 oral and oropharyngeal cancer patients treated by primary tumor resection and neck dissection with or without radiotherapy were included between 2004 and 2015. Univariate and multivariate analysis were used to explore the effect of adjuvant radiotherapy on 5-year overall survival (OS) and disease-specific survival (DSS) among different quality of neck dissection.

Results

Of the 1765 patients identified, 1108 (62.8%) had oral cancer, 1141 (64.6%) were men, and 1067 (60.5%) underwent adjuvant radiotherapy. After adjusting for confounding factors, postoperative radiotherapy reduced the adjusted hazard ratio (aHR) of 5-year OS to 0.64 (95% confidence interval [CI] 0.49–0.84) in those with < 18 lymph nodes (LNs) removed, but not in those with 19–24 LNs removed (aHR 0.78; 95% CI 0.73–1.13), and in those with ≥ 25 LNs removed (aHR 0.96; 95% CI 0.75–1.24). For 5-year DSS, similar effect was observed. The adjusted hazard ratio was 0.66 (95% confidence interval, 0.45–0.97) in those with < 18 LNs. The protective effect was not seen in those with 18–24 LNs (aHR 1.07; 95% CI 0.59–1.96), and in those with ≥ 25 LNs (aHR 1.12; 95% CI 0.81–1.56). Sensitivity testing also showed a robust protective effect of postoperative radiotherapy in patients with < 18 LNs removed.

Conclusion

Radiotherapy was associated with improved survival in pT1-2N1M0 oral and oropharyngeal cancer patients without adequate neck dissection.

Genome-wide study of salivary miRNAs identifies miR-423-5p as promising diagnostic and prognostic biomarker in oral squamous cell carcinoma

Survival rates of oral squamous cell carcinoma (OSCC) remained substantially unchanged over the last decades; thus, additional prognostic tools are strongly needed. Salivary miRNAs have emerged as excellent non-invasive cancer biomarker candidates, but their association with OSCC prognosis has not been investigated yet. In this study, we analyzed global salivary miRNA expression in OSCC patients and healthy controls, with the aim to define its diagnostic and prognostic potential.

Methods: Saliva was collected from patients with newly diagnosed untreated primary OSCC and healthy controls. Global profiling of salivary miRNAs was carried out through a microarray approach, while signature validation was performed by quantitative real-time PCR (RT-qPCR). A stringent statistical approach for microarray and RT-qPCR data normalization was applied. The diagnostic performance of miRNAs and their correlation with OSCC prognosis were comprehensively analyzed.

Results: In total, 25 miRNAs emerged as differentially expressed between OSCC patients and healthy controls and, among them, seven were significantly associated with disease-free survival (DFS). miR-106b-5p, miR-423-5p and miR-193b-3p were expressed at high levels in saliva of OSCC patients and their combination displays the best diagnostic performance (ROC - AUC = 0.98). Moreover, high expression of miR-423-5p was an independent predictor of poor DFS, when included in multivariate survival analysis with the number of positive lymph nodes - the only significant clinical prognosticator. Finally, we observed a significant decrease in miR-423-5p expression in matched post-operative saliva samples, suggesting its potential cancer-specific origin.

Conclusion: Salivary miRNAs identified in our cohort of patients show to be accurate in OSCC detection and to effectively stratify patients according to their likelihood of relapse. These results, if validated in an independent set of patients, could be particularly promising for screening/follow-up of high-risk populations and useful for preoperative prognostic assessment.

Intraoral ultrasonography in the assessment of DOI in oral cavity squamous cell carcinoma: a comparison with magnetic resonance and histopathology

Objective

The first-line therapeutic approach for oral cavity squamous cell carcinoma (OCSCC) is complete surgical resection. Preoperative assessment of depth of invasion (cDOI) is crucial to plan the surgery. Magnetic resonance (MR) and intraoral ultrasonography (IOUS) have been shown to be useful tools for assessment of DOI. The present analysis investigates the accuracy of MR and IOUS in evaluating DOI in OCSCC compared to histological evaluation (pDOI).

Materials and methods

Forty-nine previously untreated patients with cT1-T3 OCSCC were reviewed. Nine patients were staged with MR alone, 10 with IOUS alone, and 30 with both MR and IOUS.

Results

Mean difference between cDOI_MR and pDOI values of 0.2 mm (95% CI − 1.0–1.3 mm) and between cDOI_IOUS and pDOI of 0.3 mm (95% CI − 1.0–1.6 mm). Spearman R between cDOI_MR and pDOI was R = 0.83 and between cDOI_IOUS and pDOI was R = 0.76. Both radiological techniques showed high performance for the correct identification, with the optimum cut-off of 5 mm, of patients with a pDOI ≥ 4 mm and amenable to a neck dissection, with an AUC of 0.92 and 0.82 for MR and IOUS, respectively.

Conclusion

Both examinations were valid approaches for preoperative determination of DOI in OCSCC, although with different cost-effectiveness profiles and indications.

Electronic supplementary material

The online version of this article (10.1007/s00405-020-06421-w) contains supplementary material, which is available to authorized users.

Histometabolic Tumor Imaging of Hypoxia in Oral Cancer: Clinicopathological Correlation for Prediction of an Aggressive Phenotype

Introduction

Fluorodeoxyglucose-positron emission tomography (FDG-PET) is a widely used imaging tool for oral squamous cell carcinoma (OSCC). Preliminary studies indicate that quantification of tumor metabolic uptake may correlate with tumor hypoxia and aggressive phenotypes.

Methods

Retrospective review of a consecutive cohort of OSCC (n = 98) with available pretherapeutic FDG-PET/CT, treated at the University Hospital Zurich. Clinico-pathologico-radiological correlation between maximum standard uptake value (SUV_max) of the primary tumor, immunohistochemical staining for hypoxia-related proteins glucose transporter 1 (GLUT1) and hypoxia-inducible factor 1-alpha (HIF1a), depth of invasion (DOI), lymph node metastasis, and outcome was examined.

Results

Positive staining for GLUT1 and HIF1a on immunohistopathological analysis correlated with increased SUV_max on pretherapeutic imaging and with increased DOI (Kruskal–Wallis, P = 0.037, and P = 0.008, respectively). SUV_max and DOI showed a strong positive correlation (Spearman Rho, correlation coefficient = 0.451, P = 0.0003). An increase in SUV_max predicted nodal metastasis (Kruskal–Wallis, P = 0.017) and poor local control (log rank, P = 0.047).

Conclusion

In OSCC, FDG-PET-derived metabolic tumor parameter SUV_max serves as a surrogate marker for hypoxia and can be used to predict tumor aggressiveness, with more invasive phenotypes and poorer local control.

Compartmental Surgery With Microvascular Free Flap Reconstruction in Patients With T1-T4 Squamous Cell Carcinoma of the Tongue: Analysis of Risk Factors, and Prognostic Value of the 8th Edition AJCC TNM Staging System

Compartmental surgery and primary reconstruction with microvascular free flaps represent the gold-standard in the treatment of oral tongue squamous cell carcinoma (OTSCC). However, there are still unclear clinical features that negatively affect the outcomes. This retrospective study included 80 consecutive patients with OTSCC who underwent compartmental surgery and primary reconstruction by free flap. The oncologic outcomes, the reliability of the 8th edition American Joint Committee on Cancer (AJCC) staging system and the prognostic factors were evaluated. Fifty-nine males and 21 females (mean age 57.8 years, range 27-81 years) were treated between November 2010 and March 2018 (one patient had two metachronous primaries). Seventy-one patients (88.75%, 52 males, 19 females, mean age of 57.9 years, range of 27-81 years) had no clinical history of previous head and neck radiotherapy and were considered as naive. Histology showed radical surgery on 80/81 lesions (98.8%), with excision margins >0.5 cm, while in 1 case (1.2%), a close posterior margin was found. According to the 8th AJCC classification, 37 patients (45.7%) were upstaged shifting from the clinical to the pathological stage, and 39 (48.1%) showed an upstaging while shifting from the 7th to the 8th AJCC staging system (no tumors were downstaged). Nodal involvement was confirmed in 33 patients (40.7%). Perineural and lymphovascular invasion were present in 9 (11.1%) and 11 (13.6%) cases, respectively. Twenty-two patients (27.1%) underwent adjuvant therapy. The 5-years disease-specific, overall, overall relapse-free, locoregional relapse-free and distant metastasis-free survival rates were 73.2, 66.8, 62.6, 67.4, and 86%, respectively. Patients with a lymph node ratio >0.09 experienced significantly worse outcomes. Univariate analysis showed that patients with previous radiotherapy, stage IV disease, nodal involvement, and lymphovascular invasion had significantly worse outcomes. Multivariate analysis focused naive patients and showed that lymphovascular invasion, advanced stage of disease, and node involvement resulted reliable prognostic factors, and patients with the same tumor stage and histological risk factors who did not undergo adjuvant therapy experienced significantly worse outcomes. In our series, surgery played a major role in the treatment of local extension; adjuvant therapy resulted strictly indicated in patients with advanced-stage disease associated with risk factors.

Surgical resection of oral cancer: en-bloc versus discontinuous approach

OBJECTIVES

In the past literature agreed on treating oral carcinomas, using an "en-bloc" resection (EBR) but recently minimally invasive transoral surgery has spread as the preferable treatment for selected cases. This latter technique, which is performed with a discontinuous resection (DR), allows for a satisfactory postoperative quality of life (QoL) maintaining good survival rates.

MATERIALS AND METHODS

In this study, we analyzed data about 147 surgically treated patients with oral cancer involving tongue and floor of the mouth. The sample was divided according to the surgical approach: EBR and DR group which were compared in terms of recurrence, overall survival, disease-free survival, and QoL.

RESULTS

In the DR group, survival analysis showed better results in term of survival, locoregional control, and postoperative anxiety, while the other QoL scores were similar in the two groups.

CONCLUSION

The more invasive approach does not correlate to a better outcome. In selected cases, DR is an oncologically safe technique; EBR is still a valid option to treat advanced oral cancers.

Compartmental Surgery for Oral Tongue Cancer: Objective and Subjective Functional Evaluation

OBJECTIVE

To assess functional outcomes in patients treated by compartmental tongue surgery (CTS) and reconstruction for advanced oral tongue/floor-of-mouth cancer.

STUDY DESIGN

Retrospective case series.

METHODS

A retrospective cohort of patients (n = 48) treated by CTS and free flap reconstruction was prospectively evaluated concerning postoperative functional outcomes at different time points (6 months and 1 year). Swallowing was studied by videonasal endoscopic evaluation (VEES) and videofluoroscopy (VFS), testing various food consistencies and grading the results with the Donzelli scale. Speech articulation, lingual strength, and endurance were studied by phone call and Iowa Oral Performance Instrument (IOPI). Subjective tests (EORTC H&N35 and UWQOL) were administered.

RESULTS

After 1 year, VEES showed a Donzelli scale of 67% level 1, 23% level 2, and 10% level 3. Vallecular pouch was present in 81% of patients. VFS showed levels 1, 2, and 3 in 42%, 25%, and 33%, respectively, with liquids (L); 48%, 19%, and 33%, with semi-liquids (SL); and 54%, 33%, and 13%, with semi-solids (SS). Vallecular pouch residue was present in 69% with L, 73% with SL, and 87% with SS. The mean number of words recognized at phone call was 56 of 75 (range, 27-74). IOPI showed a mean tongue strength of 19.2 kPa (range, 0-40), and a mean endurance of 16.2 seconds (range, 0-60).

CONCLUSION

CTS does not significantly affect speech. Sub-clinical food aspiration and vallecular pouch are present in a significant proportion of patients, especially when adjuvant treatments are administered. Residual tongue strength is not affected when proper reconstruction is performed.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E176-E183, 2021.

Magnetic Resonance vs. Intraoral Ultrasonography in the Preoperative Assessment of Oral Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

Background: Preoperative assessment is critical to decide the most adequate surgical strategy for oral squamous cell carcinoma (SCC). Magnetic resonance (MR) and intraoral ultrasonography (US) have been reported to be of great value for preoperative estimation of depth of invasion (DOI) and/or tumor thickness (TT). This review aims to analyze the accuracy of MR and intraoral US in determining DOI/TT in oral SCC, by assuming histological evaluation as the reference method.

Methods: The procedure was conducted following the modified 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We performed a systematic search of papers on PubMed, Scopus, Web of Science, and Cochrane Library databases until July 31st, 2019. For quantitative synthesis, we included nine studies (487 patients) focused on MR, and 12 (520 patients) focused on intraoral US. The Pearson correlation coefficient (r) between DOI/TT evaluated with MR or intraoral US was assumed as effect size. A meta-analysis (MA) for each study group (MR and US) was performed by using the random-effects models with the DerSimonian–Laird estimator and r-to-z transformation.

Results: In the MA for MR studies, a high heterogeneity was found (I² = 94.84%; Q = 154.915, P < 0.001). No significant risk of bias occurred by evaluating funnel plot asymmetry (P = 0.563). The pooled (overall) r of the MR studies was 0.87 (95% CI from 0.82 to 0.92), whereas the pooled r-to-z transformed was 1.44 (95% CI from 1.02 to 1.85). In the MA for US studies a high heterogeneity was found (I² = 93.56%; Q = 170.884, P < 0.001). However, no significant risk of bias occurred (P = 0.779). The pooled r of the US studies was 0.96 (95% CI from 0.94 to 0.97), whereas the pooled r-to-z transformed was 1.76 (95% CI from 1.39 to 2.13). These outputs were confirmed in additional MA performed by enrolling only MR (n = 8) and US (n = 11) studies that evaluated TT.

Conclusions: MR and intraoral US seem to be promising approaches for preoperative assessment of DOI/TT in oral SCC. Remarkably, a higher pooled r and r-to-z transformed were observed in the intraoral US studies, suggesting that this approach could be more closely related to histopathological findings.

The role of the T-N tract in advanced stage tongue cancer

BACKGROUND

We investigated the role of the soft tissue tract between the primary tumor and the neck lymph nodes, the "T-N tract," in patients with tongue squamous cell carcinoma at an advanced stage.

METHODS

We performed a compartmental tongue surgery in 233 patients. Cumulative incidence of relapses and overall survival curves were compared by T-N tract involvement. Multivariate Cox proportional hazards models were used to assess the independent role of T-N tract.

RESULTS

At 4 years of follow-up, patients with disease in the T-N tract experienced a significantly more distant recurrence (40%) than did patients without T-N tract involvement (22%; P = .02). Multivariate Cox models indicate a significant almost triple risk of distant metastases (hazard ratio [HR], 2.70; 95% CI, 1.01-7.19; P = .05) and double risk of death (HR, 2.09; 95%CI, 1.13-3.85; P = .02) in patients with "T-N tract involvement."

CONCLUSIONS

Our data show that the T-N tract plays an important role in prognosis and survival in patients with tongue cancer.