Outcome of salvage procedures for recurrent oral and oropharyngeal cancer

A systematic literature review of the human papillomavirus prevalence in locally and regionally advanced and recurrent/metastatic head and neck cancers through the last decade: The "ALARM" study

AIMS

The aim of this systematic literature review was to provide updated information on human papillomavirus (HPV) prevalence in locally and regionally advanced (LA) and recurrent/metastatic (RM) head and neck cancer (HNC) worldwide.

METHODS

Electronic searches were conducted on clinicaltrials.gov, MEDLINE/PubMed, Embase, and ASCO/ESMO journals of congresses for interventional studies (IS; Phase I-III trials) as well as MEDLINE and Embase for non-interventional studies (NIS) of LA/RM HNC published between January 01, 2010 and December 31, 2020. Criteria for study selection included: availability of HPV prevalence data for LA/RM HNC patients, patient enrollment from January 01, 2010 onward, and oropharyngeal cancer (OPC) included among HNC types. HPV prevalence per study was calculated as proportion of HPV+ over total number of enrolled patients. For overall HPV prevalence across studies, mean of reported HPV prevalence rates across studies and pooled estimate (sum of all HPV+ patients over sum of all patients enrolled) were assessed.

RESULTS

Eighty-one studies (62 IS; 19 NIS) were included, representing 9607 LA/RM HNC cases, with an overall mean (pooled) HPV prevalence of 32.6% (25.1%). HPV prevalence was 44.7% (44.0%) in LA and 24.3% (18.6%) in RM. Among 2714 LA/RM OPC patients from 52 studies with available data, mean (pooled) value was 55.8% (50.7%). The majority of data were derived from Northern America and Europe, with overall HPV prevalence of 46.0% (42.1%) and 24.7% (25.3%) across studies conducted exclusively in these geographic regions, respectively (Northern Europe: 31.9% [63.1%]). A "p16-based" assay was the most frequently reported HPV detection methodology (58.0%).

CONCLUSION

Over the last decade, at least one quarter of LA/RM HNC and half of OPC cases studied in IS and NIS were HPV+. This alarming burden is consistent with a potential implication of HPV in the pathogenesis of at least a subgroup of HNC, underscoring the relevance of HPV testing and prophylaxis to HNC prevention and management.

Oncological results of salvage treatment in patients with oropharynx carcinoma treated with radiotherapy

OBJECTIVE

To evaluate the possibilities of salvage after local recurrence in patients with oropharyngeal carcinomas treated with radiotherapy, and to analyse the prognostic factors related to the final control of the disease.

METHODS

Retrospective study of 596 patients with oropharyngeal carcinoma treated with radiotherapy during the period 1991-2018.

RESULTS

One hundred and eighty-one patients (30.4%) had a local recurrence. Of the patients with a local recurrence, 51 (28.2%) were treated with salvage surgery. Variables that were associated with the patient not receiving salvage surgery were age greater than 75 years, tumour location in the posterior hypopharyngeal wall, an initial tumour extent cT4, and a recurrence-free interval of less than 6 months. Five-year specific survival of patients treated with salvage surgery was 19.1% (95% CI: 7.3%-30.9%). Variables that were related to specific survival were extent of recurrence and status of resection margins. Final tumour control was not achieved in any of the patients with extensive recurrence (rpT3-4, n = 25) or positive resection margins (n = 22).

CONCLUSION

Patients with oropharyngeal carcinomas treated with radiotherapy with local tumour recurrence have a limited prognosis. Most patients (71.8%) were not considered candidates for salvage surgery. The 5-year specific survival of patients treated with salvage surgery was 19.1%.

The beavertail modified radial forearm free flap: Retrospective review of a versatile technique to increase flap bulk in the head and neck

OBJECTIVE

Utilization of free tissue transfers in head and neck reconstruction has greatly increased due to their dependability and reliability. Anterolateral thigh (ALT) and rectus abdominus (RA) free flaps may provide too much soft tissue bulk, especially in patients with a large body habitus. A radial forearm free flap (RFFF) may be modified with a "beaver tail" (BT), which provides a flap whose bulk may be tailored to a defect. The purpose of this paper is to describe the technique, how it can be used for a variety of defects and the outcomes of these reconstructions.

METHODS

A retrospective review of prospectively collected data was performed at single tertiary care center between 2012 and 2022. BT-RFFF was designed by leaving a fibroadipose tail vascularized to branches of the radial artery or separated from the vascular pedicle and left attached to the proximal portion of the skin paddle. Functional outcomes, tracheostomy dependence, and gastrostomy tube (G-tube) dependence as well as complications were determined.

RESULTS

Fifty-eight consecutive patients undergoing BTRFFF were included. Defects reconstructed included: oral tongue and/or floor of mouth 32 (55%), oropharynx 10 (17%), parotid 6 (10%), orbit 6 (10%), lateral temporal bone 3 (5%), and mentum 1 (2%). Indications for BTRFF were: need for bulk when the ALT and RA were too thick (53%) and need for a separate subcutaneous flap for contouring or deep defect lining (47%). Complications directly related to beavertail included a widened forearm scar (100%), wrist contracture (2%) partial flap loss (2%), and flap loss requiring a revision flap (3%). Ninety-three percent of patients with oral/oropharyngeal defects and 12-month follow-up tolerated oral intake without aspiration and 76% were tube-independent. Ninety-three percent were tracheostomy-free at last follow-up.

CONCLUSION

The BTRFF is a useful tool for reconstructing complex 3D defects requiring bulk where an ALT or rectus would otherwise provide too much bulk.

Functional and quality-of-life outcomes following salvage surgery for recurrent squamous cell carcinoma of the head and neck: a systematic review and meta-analysis

BACKGROUND

Recurrent head and neck squamous cell carcinomas (HNSCC) are frequently managed with salvage surgery, but the impact these operations have on function and quality-of-life (QoL) is understudied. This review aimed to provide a quantitative and qualitative assessment of the functional and QoL effects of salvage surgical procedures.

METHODS

Systematic review and meta-analysis were conducted of studies reporting QoL and function following salvage HNSCC resections.

RESULTS

The search identified 415 articles and 34 were selected for inclusion. Pooled random effects analysis revealed long-term feeding and tracheostomy tube rates of 18% and 7%. Pooled long-term feeding tube rates in open oral and oropharyngeal, transoral robotic, total and partial laryngectomy surgeries were 41%, 25%, 11% and 4%. Eight studies used validated QoL questionnaires.

CONCLUSIONS

Functional and QoL outcomes from salvage surgery are acceptable, but appear to be worse following open procedures. Prospective studies measuring changes over time are needed to assess these procedures impact on patient well-being.

Outcomes After Oral Cavity and Oropharyngeal Salvage Surgery

OBJECTIVES

Investigate outcomes following oral cavity and oropharyngeal salvage surgery.

METHODS

Adult patients who underwent salvage surgery for recurrent squamous cell carcinoma of the oral cavity and oropharynx from 1996 to 2018 were analyzed using multivariable Cox proportional hazards regression. Disease-free survival (DFS), overall survival (OS), associated factors, and basic quality measures were analyzed.

RESULTS

One hundred and eight patients (72% oral cavity, 28% oropharynx) were followed for a median of 17.9 months. Median DFS and OS were 9.9 and 21 months, respectively. Surgery with adjuvant chemoradiotherapy compared to surgery alone (hazard ratio [HR] = 0.15, 95% confidence interval [CI]: 0.03-0.78) and negative margins (HR = 0.36, 95% CI: 0.14-0.90) were associated with better DFS, while lymphovascular space invasion (LVSI) (HR = 2.66, 95% CI: 1.14-6.19) and higher stage (III vs. I-II, HR = 3.94, 95% CI: 1.22-12.71) were associated with worse DFS. Higher stage was associated with worse OS (HR = 3.79, 95% CI: 1.09-13.19). Patients were hospitalized for a median of 8 days with 24% readmitted within 30 days. A total of 72% and 38% of patients, respectively, underwent placement of a feeding tube or tracheostomy.

CONCLUSIONS

After oral cavity and oropharyngeal salvage surgery, adjuvant chemoradiotherapy, negative margins, negative LVSI, and lower stage were associated with a lower risk of recurrence. Only lower-stage disease was associated with improved survival. The majority of patients had feeding tubes, half underwent free tissue transfer, a third required tracheostomy, and a quarter was readmitted.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Salvage surgery for recurrent carcinoma of the oral cavity: assessment of prognostic factors

Salvage surgery is the most acceptable therapeutic option for disease control of loco-regional recurrences in oral cancers. Prognostic factors need to be assessed to select patients for salvage surgery who would benefit the most. This was a single-centre retrospective observational study conducted between 2015 and 2018. A total of 168 patients with recurrent oral cavity carcinoma who underwent salvage surgery were included for analysis. The primary endpoints of the study were to evaluate overall survival (rOS) after salvage surgery and prognostic factors affecting survival. In this study, the median rOS was 18 months and the median disease-free survival (rDFS) was 14 months. Advanced stage (hazard ratio (HR) 2.387, 95% confidence interval (CI) 1.496-3.808; P = 0.001) and multimodality treatment (HR 1.642, 95% CI 1.139-2.367; P = 0.008) in the initial disease, as well as nodal spread (HR 3.794, 95% CI 1.580-9.111; P = 0.008) and perineural invasion (HR 2.167, 95% CI 1.358-3.455; P = 0.001) in the recurrent disease, were found to adversely affect survival after salvage surgery. With thorough assessment of the prognostic factors and appropriate patient selection, survival may be favourable after salvage surgery for recurrent oral cavity carcinoma.

Clinical outcomes and prognostic factor analysis after salvage surgery for recurrent squamous cell carcinoma of the oral cavity

The purpose of this study was to analyze the oncological outcomes and predictive factors for successful curative salvage surgery after recurrent oral cavity squamous cell carcinoma. A retrospective study was conducted involving 73 patients who received surgery-based salvage treatment. The pattern of failure for primary treatment was local failure in 29 patients, regional failure in 29 patients, and loco-regional failure in 15 patients. The 5-year overall, loco-regional failure-free, and disease-free survival rates were 54.8%, 58.9% and 49.3%, respectively. Patients with an advanced initial N stage, previous treatment with combined modality therapy, loco-regional recurrence, advanced recurrent T stage, a disease-free survival of less than 8 months prior to salvage, and recurrence in a previously treated field had a significantly worse prognosis. Given the potential surgical morbidity, salvage surgery should be undertaken after careful consultation with patients who have factors for a poor prognosis.