Follow-up program in head and neck cancer

Treatment Complications of Head and Neck Cancers and Rehabilitation Measures: A Narrative Review

Head and neck cancers (HNCs) are malignant tumors mainly from squamous cells in the head and neck tissues. Treatment involves a multidisciplinary approach with surgery, radiotherapy, and chemotherapy. However, the long-term prognosis for patients with advanced-stage tumors is guarded, with a median survival time of approximately 24 months. HNC patients have very high rates of depression and anxiety and the highest suicide rate among all cancers due to the intense and challenging nature of the treatment, underscoring the importance of our collective efforts. Rehabilitation success depends on various factors, including tumor, patient, and treatment-related factors. Patients may require post-treatment oral rehabilitation measures, including implants, obturators, and flexible dentures. These measures are crucial, but they often need to be more utilized. Patients may face challenges in maintaining oral hygiene and managing mucositis. Additionally, it is essential to address other intricacies such as trismus, xerostomia, gustatory dysfunctions, neuropathy, speech impairments, and psychological disturbances. Unfortunately, there is little literature on post-treatment rehabilitative measures. Despite its crucial role in improving patients' quality of life, rehabilitation often receives inadequate attention compared to treatment. Our narrative review, which covers various factors that affect rehabilitation, including oral rehabilitation measures and post-treatment complications, is anticipated to deliver practical insights to professionals and inspire positive changes in their regular practice.

Oral Cavity Squamous Cell Carcinoma: Review of Pathology, Diagnosis, and Management

Squamous cell carcinoma of the oral cavity presents a significant global health burden, primarily due to risk factors such as tobacco smoking, smokeless tobacco use, heavy alcohol consumption, and betel quid chewing. Common clinical manifestations of oral cavity cancer include visible lesions and sores, often accompanied by pain in advanced stages. Diagnosis relies on a comprehensive assessment involving detailed history, physical examination, and biopsy. Ancillary imaging studies and functional evaluations aid in accurate staging and facilitate treatment planning. Prognostic information is obtained from histopathological factors, such as tumor grade, depth of invasion, lymphovascular invasion, and perineural invasion. Notably, lymph node metastasis, found in approximately half of the patients, carries significant prognostic implications. Effective management necessitates a multidisciplinary approach to optimize patient outcomes. Surgical resection is the backbone of treatment, aimed at complete tumor removal while preserving functional outcomes. Adjuvant therapies, including radiation and chemotherapy, are tailored according to pathological factors. Further work in risk stratification and treatment is necessary to optimize outcomes in squamous cell carcinoma of the oral cavity.

[Value of PET imaging in head and neck cancer]

The combination of positron-emission tomography (PET) with cross-sectional imaging in particular is becoming increasingly important in the diagnosis of head and neck tumors because, in addition to pure anatomy, the metabolic activity of tissue can be visualized and assessed. The combination of PET and computed tomography (CT) is already an established procedure in head and neck tumor patients in some indications, e.g., for primary tumor detection in cancer of unknown primary (CUP) syndrome or also after completed primary radio(chemo)therapy for evaluation of response, especially also with regard to nodal status. In some cases, salvage neck dissection can thus be avoided in the case of PET-negative findings. In the context of primary diagnosis, PET/CT imaging can be used primarily to evaluate distant metastasis. According to current guidelines, PET-based imaging is not (yet) of value in determining the local extent at initial diagnosis. A challenge is the still limited reimbursement by health insurance companies, which currently allow only certain indications, and the still lack of nationwide coverage.

Dietary intake effects on severity of cancer treatment-induced mucositis: A cross-sectional study

Background and Aims

Oral mucositis is one of the most serious complications due to chemotherapy and radiotherapy in head and neck cancer treatment. Oral mucositis causes a wide range of clinical signs and symptoms, such as ulcers, pain, and dysphagia. Additionally, because of speech limitations, patients' self-esteem will decrease, ultimately causing reduced quality of life. The primary objective of this study was to investigate the role of diet in the onset and progress of mucositis induced by chemotherapy and radiation therapy in patients with cancers.

Methods

In this study, 121 patients with a mean age of 51.43 ± 13.08 years were selected randomly and referred to the cancer institute, where they underwent their first phase of chemotherapy. In this step, patients were examined and their severity of oral mucositis was graded according to the World Health Organization criteria. They completed a 3-day allergen food recall and dietary recommendations were met. After completing the forms, four questionnaires were filled out for each patient, the patient's nutrition was analyzed using the N4 software, and the amount of macro- and micronutrients was measured.

Results

Micronutrients such as aspartic acid, glycine, serine, proline, alanine, arginine, glutamic acid, and vitamin B12 and macronutrients such as rose water, sausage, beverages, coffee, and lamb meat were examined, and a significant difference was observed between groups (grade 1 and 2 mucositis) (p < 0.005). In patients with grade 2 mucositis, a lower level of vitamin B12 was reported (p < 0.005). There is a negative correlation between amounts of macro- and micronutrients and grades of oral mucositis.

Conclusion

It can be concluded that diet plays a considerable role in the severity of oral mucositis caused by cancer treatment.

[Value of PET imaging in head and neck cancer]

The combination of positron-emission tomography (PET) with cross-sectional imaging in particular is becoming increasingly important in the diagnosis of head and neck tumors because, in addition to pure anatomy, the metabolic activity of tissue can be visualized and assessed. The combination of PET and computed tomography (CT) is already an established procedure in head and neck tumor patients in some indications, e.g., for primary tumor detection in cancer of unknown primary (CUP) syndrome or also after completed primary radio(chemo)therapy for evaluation of response, especially also with regard to nodal status. In some cases, salvage neck dissection can thus be avoided in the case of PET-negative findings. In the context of primary diagnosis, PET/CT imaging can be used primarily to evaluate distant metastasis. According to current guidelines, PET-based imaging is not (yet) of value in determining the local extent at initial diagnosis. A challenge is the still limited reimbursement by health insurance companies, which currently allow only certain indications, and the still lack of nationwide coverage.

Social, Ethical and Treatment Related Problems Faced by Healthcare Workers in the Care of Head and Neck Cancer Patients: A Narrative Review from the Bioethics Consortium from India

Head and neck cancer (HNC) presents a variety of ethical difficulties for an oncologist involved in screening, diagnosis, treatment, and rehabilitation that are challenging to address, especially for those professionals/people who are not trained in medical ethics. The bioethics department has spent the last ten years compiling information and rating the seriousness of numerous niche ethical concerns and their effects on healthcare professionals practising in India. Based on these findings, the current analysis makes an effort to outline the different challenges faced by oncologists when screening, diagnosing, treating, and rehabilitating people affected with HNC, particularly in a traditional nation like India. According to the authors, this is the first overview to address these issues from an Indian viewpoint, and it represents a small effort to document a crucial but unaddressed component of cancer treatment. It is hoped that these endeavours would aid in educating upcoming healthcare professionals on how to effectively handle the difficulties.

Surveillance of head neck cancer: Case for personalized and standardized surveillance

Although surgery, radiotherapy, chemotherapy, or combined treatment often elicits an initial satisfactory response, relapses are frequently observed within two years. Current surveillance methods, including clinical exams and imaging evaluations, have not unambiguously demonstrated a survival benefit, most probably due to a lack of sensitivity in detecting very early recurrence. Current guidelines advise post-treatment surveillance of head and neck cancer (HNC) patients should involve scheduled appointments with a variety of practitioners. The benefits of prolonged routine follow-up on survival have not been proven. Increasing numbers of HNC survivors raise the burden to provide efficient and effective care.

DKK1 affects survival of patients with head and neck squamous cell carcinoma by inducing resistance to radiotherapy and immunotherapy

BACKGROUND

Immune checkpoint inhibitors (ICIs) have been approved to treat various types of tumors, including head and neck squamous cell carcinoma (HNSC). However, most HNSC patients do not respond to ICIs. Radioimmunotherapy has been proposed to enhance the immune response rate in HNSC. Dickkopf-1 (DKK1), a secreted protein, plays important roles in the Wnt signaling pathways. Herein, we aimed to explore the effect of DKK1 on radioimmunotherapy in HNSC.

METHODS

We collected the gene expression profile and clinical information of HNSC patients from TCGA and GEO databases. The immune cell infiltration and immune score were assessed using R package CIBERSORT and ESTIMATE. The level of related pathways and biological processes were analyzed by GSEA. The signature scores of gene sets of interest were calculated by GSVA. We also performed cell viability and apoptosis assay, and clonogenic assay to investigate the radiation sensitivity of HSC-3 cells and CNE-2 cells after silencing DKK1 by siRNA.

RESULTS

We found DKK1 was significantly higher expressed in HNSC, and closely correlated with patients' survival time, especially the patients who received radiotherapy. DKK1-knockdown HSC-3 cells or CNE-2 cells showed a decrease in cell viability and colony formation, and an increase in apoptotic rate after radiation. DKK1^high tumors showed a more immunosuppressive microenvironment with lower infiltration of T cells and higher infiltration of marrow-derived suppressor cells (MDSCs).

CONCLUSION

Our data show that DKK1 can affect both radiotherapy and immunotherapy in HNSC, suggesting that DKK1 can be a potential target for radioimmunology in HNSC.

Expression of OLR1 gene on tumor-associated macrophages of head and neck squamous cell carcinoma, and its correlation with clinical outcome

Head and neck squamous cell carcinoma (HNSCC) is one of the most heavily immune infiltrated human tumors, having distinct immune subtypes associated with different molecular characteristics and clinical outcomes. The tumor microenvironment (TME) of HNSCC which was dominated by tumor-associated macrophages (TAMs) had a relatively inferior prognosis. High levels of oxidized low-density lipoprotein receptor 1 (OLR1) expression are associated with more aggressive and metastatic characteristics in multiple cancers. However, the link between the OLR1 expression and immunosuppression of TME, and the molecular mechanisms which govern intratumoral TAMs behavior are unclear. Here, we performed the transcriptional analysis based on a single-cell RNA-sequencing (scRNA-seq) dataset of HNSCC, and found that the OLR1 expression was specifically enriched on the TAMs. Evaluation of protein expression within histologic sections of primary HNSCC patient samples showed a co-expression pattern of OLR1 and CD68 on macrophages. A total of 498 tumor samples of HNSCC patients from The Cancer Genome Atlas (TCGA) database were also analyzed. Remarkably, OLR1 expression was dramatically higher in HNSCC tissues than that in adjacent normal tissues, and the patients with high levels of OLR1 expression had significantly unfavorable overall survival (Hazard Ratio = 1.724, log-rank P-value = 0.0066) when compared to patients harboring low expression levels of OLR1. In summary, we reported that the specific expression of OLR1 on the TAMs was significantly correlated with poor survival outcomes, revealing that OLR1 could serve as a potential prognosis marker and promising target for immunotherapy in HNSCC.

The Failure Patterns of Nasopharygeal Carcinoma After Intensity-Modulated Radiotherapy and Implications for Surveillance

Objective

To investigate the treatment outcomes, failure patterns and surveillance strategy in patients with nasopharyngeal carcinoma (NPC) after intensity-modulated radiotherapy (IMRT).

Methods

A cohort of patients with NPC who had received the full course of IMRT between 2008 and 2012 were retrospectively analyzed. The failure patterns, time to recurrence, and detection methods were recorded. The survival was calculated using the Kaplan–Meier method. Multivariate proportional hazard regression models were used to test the prognostic factors.

Results

In total, 2607 patients with NPC treated with IMRT were recruited. After the median follow-up of 112 months, 402 (15.4%) patients experienced distant metastasis, 225 (8.6%) patients had local recurrence, and 77 (3.0%) patients had regional recurrences. The 10-year overall survival (OS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) rates were 74.5%, 90.1%, and 79.3%, respectively. The factors of male sex, age >50 years, lactate dehydrogenase >245 IU/L, advanced T classification, and advanced N classification were associated with poor OS. The N disease classification was the most important factor in predicting distant metastasis, and advanced T disease classification for high risk of local recurrence. For patients with T1 disease, the incidence of local recurrence was less than 2%, and the incidence of distant metastasis was less than 5% for patients with N0 disease. About 83% of the recurrence occurred in the first 5 years, and 20% of the recurrences showed no symptoms.

Conclusion

High rate of local-regional control can be achieved for patients with NPC after IMRT, while distant metastasis remains as the major cause of failures. Patients with advanced N classification has high risk to develop distant metastasis, and most occurred within 5 years. Developing rational and individualized surveillance strategies based on the high risk factors of recurrence is helpful to balance the survival benefit and medical cost.

Predicting local persistence/recurrence after radiation therapy for head and neck cancer from PET/CT using a multi-objective, multi-classifier radiomics model

Objectives

Accurate identifying head and neck squamous cell cancer (HNSCC) patients at high risk of local persistence/recurrence (P/R) is of importance for personalized patient management. Here we developed a multi-objective, multi-classifier radiomics model for early HNSCC local P/R prediction based on post-treatment PET/CT scans and clinical data.

Materials and methods

We retrospectively identified 328 individuals (69 patients have local P/R) with HNSCC treated with definitive radiation therapy at our institution. The median follow-up from treatment completion to the first surveillance PET/CT imaging was 114 days (range: 82-159 days). Post-treatment PET/CT scans were reviewed and contoured for all patients. For each imaging modality, we extracted 257 radiomic features to build a multi-objective radiomics model with sensitivity, specificity, and feature sparsity as objectives for model training. Multiple representative classifiers were combined to construct the predictive model. The output probabilities of models built with features from various modalities were fused together to make the final prediction.

Results

We built and evaluated three single-modality models and two multi-modality models. The combination of PET, CT, and clinical data in the multi-objective, multi-classifier radiomics model trended towards the best prediction performance, with a sensitivity of 93%, specificity of 83%, accuracy of 85%, and AUC of 0.94.

Conclusion

Our study demonstrates the feasibility of employing a multi-objective, multi-classifier radiomics model with PET/CT radiomic features and clinical data to predict outcomes for patients with HNSCC after radiation therapy. The proposed prediction model shows the potential to detect cancer local P/R early after radiation therapy.

Relationship between Salivary Amylase and Xerostomia in Intensity-Modulated Radiation Therapy for Head and Neck Cancer: A Prospective Pilot Study

Purpose. A single-institution prospective pilot study was conducted to the assess correlation between salivary amylase and xerostomia in patients with head and neck squamous cell carcinoma (HNSCC) treated with intensity-modulated radiotherapy (IMRT). Methods and materials. Serum saliva amylase, clinician-reported xerostomia (using Common Terminology Criteria for Adverse Events), and patient-reported xerostomia (using 8-item self-reported xerostomia-specific questionnaire) were prospectively collected at baseline, during treatment and thereafter. Correlations between variables were assessed by correlation matrices. Results. Twelve patients with locally advanced HNSCC formed the cohort. Eighty-three percent were male, 75% were smokers, 100% had clinical positive lymph nodes at diagnosis, and 42% received induction chemotherapy. All patients received IMRT with concurrent cisplatin-based chemotherapy. No grade ≥4 xerostomia was observed. Severe (G3) acute and late xerostomia occurred in five cases (41.7%) and two cases (16.7%), respectively. Patient-reported xerostomia scores were highly correlated with the clinician-reported scores (ρ = 0.73). A significant correlation was recorded between the concentration of amylase and the acute (ρ = −0.70) and late (ρ = −0.80) xerostomia. Conclusion. Preliminary results are encouraging. Prospective clinical trials are needed to define the value of salivary amylase in the management of HNSCC tumors.

Effects of USP7 on radiation sensitivity through p53 pathway in laryngeal squamous cell carcinoma

The relationship between ubiquitin specific protease 7 (USP7) and radio-sensitivity in laryngeal squamous cell carcinoma (LSCC) has not been reported yet. Using gene chip and Label-Free mass spectrometry, we found that USP7 was significantly increased both in radioresistant LSCC patients and LSCC cells receiving irradiation. Since p53 is the most important downstream gene of USP7 and is frequently mutated in LSCC, we investigated the effects of USP7 on radioresistance of LSCC cells with or without p53 mutation. We found that knockdown of USP7 increased the radio-sensitivity in p53-mutated LSCC cells, while inhibiting the radio-sensitivity in p53-wild type cells. Knockdown of USP7 significantly inhibited the expression of the p53 and p53 pathway. Overexpressing endogenous p53 by CRISPR/dCas9 could reverse the effects of USP7 on radiosensitivity both in vitro and in vivo. Our results demonstrated the irradiation-induced USP7 led to radioresistance in p53-mutated LSCC cells but radio-sensitivity in p53-wild type cells. Therefore, the clinical application of USP7 inhibitors may improve the effects of radiotherapy in LSCC with p53 mutations and reduce the side effects on surrounding normal tissues without p53 mutation.

Assessment of conditions leading to lost-to-follow-up of head and neck cancer patients

PURPOSE

Head and neck cancer patients require close clinical follow up to monitor and address sequelae of treatment and for adequate cancer surveillance. The goal of this study is to determine barriers and risk factors for head and neck cancer patients who are lost-to-follow-up.

MATERIALS AND METHODS

A chart review of the Head and Neck Cancer Registry was performed to identify patients who were lost-to-follow-up (LTF). LTF was defined as missing two consecutive appointments as recommended by their oncologic surgeon. Those identified as LTF were contacted via email and phone to complete a 16-question survey addressing possible barriers to follow up.

RESULTS

Of the 353 patients reviewed, 53 met the criteria for LTF (15%). Forty-eight participants were contacted, and 23 surveys were completed (48%). Of the 23 patients that responded, 22% reported difficulty scheduling an appointment, 30% had transportation barriers, 22% had personal or work obligations that prevented follow up, 17% did not follow up because they "felt better," and 39% were following up with an otolaryngologist or oncologist closer to home. Only three participants (13%) were aware of the recommended 5-year surveillance period.

CONCLUSION

Head and neck cancer patients have a variety of reasons they are lost to follow-up. Understanding these barriers is critical to creating a patient-centered model that balances both clinical surveillance needs and reasonable expectations for patients. Improvements can be made to educate patients on the recommended length of follow-up and its importance.

Symptom-based remote assessment in post-treatment head and neck cancer surveillance: A prospective national study

OBJECTIVES

To report the incidence of locoregional recurrence in head and neck cancer (HNC) patients under surveillance following treatment undergoing symptom-based remote assessment.

DESIGN

A 16-week multicentre prospective cohort study.

SETTING

UK ENT departments.

PARTICIPANTS

HNC patients under surveillance following treatment undergoing symptom-based telephone assessment.

MAIN OUTCOME MEASURES

Incidence of locoregional recurrent HNC after minimum 6-month follow-up.

RESULTS

Data for 1078 cases were submitted by 16 centres, with follow-up data completed in 98.9% (n = 1066). Following telephone consultation, 83.7% of referrals had their face-to-face appointments deferred (n = 897/1072). New symptoms were reported by 11.6% (n = 124/1072) at telephone assessment; 72.6% (n = 90/124) of this group were called for urgent assessments, of whom 48.9% (n = 44/90) came directly for imaging without preceding clinical review. The sensitivity and specificity for new symptoms as an indicator of cancer recurrence were 35.3% and 89.4%, respectively, with a negative predictive value of 99.7% (p = .002). Locoregional cancer identification rates after a minimum of 6 months of further monitoring, when correlated with time since treatment, were 6.0% (n = 14/233) <1 year; 2.1% (n = 16/747) between 1 and 5 years; and 4.3% (n = 4/92) for those >5 years since treatment.

CONCLUSIONS

Telephone assessment, using patient-reported symptoms, to identify recurrent locoregional HNC was widely adopted during the initial peak of the COVID-19 pandemic in the United Kingdom. The majority of patients had no face-to-face reviews or investigations. New symptoms were significantly associated with the identification of locoregional recurrent cancers with a high specificity, but a low sensitivity may limit symptom assessment being used as the sole surveillance method.

The Role of Salvage in the Management of Patients with Sinonasal Squamous Cell Carcinoma

Objectives: This paper presents and discusses the rate and outcome of salvage according to various factors for patients with sinonasal squamous cell carcinoma (SNSCC). Methods: Data of 79 patients treated radically due to SNSCC between 2000 and 2016 in the National Cancer Research Institute, Gliwice branch, were analyzed. Surgery was the primary treatment in 63 (79%) of patients. The ratio, type, and effectiveness of salvage was assessed and correlated with prognostic factors. Probabilities of overall survival (OS), local control (LC), nodal control (NC), and locoregional control (LRC) were assessed and compared between the groups. Results: The 5-year LC, NC, and LRC survival rates were 62%, 75%, and 53%, respectively. The 5-year OS rate was 51%. In 34 (43%) patients, treatment failure was reported, and salvage was performed in 17 (50%) of them. It was shown that patients after any salvage had significantly longer 2- and 3-year OS rates when compared to patients with no salvage: 52% vs. 7% and 38% vs. 0%, respectively (p = 0.004). Two- and three-year OS rates for patients after effective and ineffective salvage were 83% vs. 33% and 83% vs. 11%, respectively (p = 0.02). For patients with effective salvage, OS did not differ significantly when compared to the OS of primarily cured patients (p = 0.6). Conclusions: For SNSCC patients after treatment failure, salvage is possible in half of the cases and can improve their overall survival even if not finally successful. Moreover, effective salvage can compensate for the failure and give the same ultimate OS as in primarily cured patients.

Intra-arterial chemoradiotherapy for locally advanced buccal mucosal cancer in an elderly patient with multiple comorbidities: A case report

BACKGROUND

The management of locally advanced oral cavity squamous cell carcinoma (LA-OCScc) in elderly patients with multiple comorbidities is difficult.

CASE

We report the case of an elderly patient with buccal mucosal squamous cell carcinoma as well as chronic renal dysfunction, hepatic cirrhosis, rheumatoid arthritis, and metachronous diffuse large B-cell lymphoma. We performed radiation therapy (a total dose of 70 Gy in 35 fractions) and six cycles of intra-arterial chemotherapy with 40 mg/m² cisplatin per week. After treatment, the tumor completely disappeared, and there was no recurrence or deterioration of comorbidities during the 12-month follow-up period.

CONCLUSION

Intra-arterial chemoradiotherapy may be a good treatment option for LA-OCScc in elderly patients with multiple comorbidities.

Oral Health Management and Rehabilitation for Patients with Oral Cancer: A Narrative Review

Surgery is the current first choice for oral cancer treatment. Intensity-modulated radiation therapy, molecular targeted drugs, and immune checkpoint inhibitors are still used as adjuvant therapy for advanced cancer. In addition, postoperative rehabilitation and multidisciplinary treatment have also been developed in recent years. Multidisciplinary team approaches and supportive care in oral cancer treatment reportedly shorten the time to treatment and improve outcomes. Although there is enough evidence confirming the role of oral and maxillofacial surgeons, dentists, and dental hygienists in supportive care in oral cancer treatment, there are very few systematic studies. In particular, oral health management is a concept that encompasses oral function management, oral hygiene management, and oral care during oral cancer treatment. We provide a narrative review focusing on oral health management from a multidisciplinary and supportive care perspective, applicable in oral cancer treatment.

Metabolism-Related Bioinformatics Analysis Reveals That HPRT1 Facilitates the Progression of Oral Squamous Cell Carcinoma In Vitro

Objectives

Many studies have shown that dysregulation of metabolism contributes to oncogenesis. However, the exact roles of metabolism-related genes (MRGs) in oral squamous cell carcinoma (OSCC) remain unclear. Thus, we aimed to identify a prognostic signature related to MRGs in OSCC.

Methods

The gene sequencing data of OSCC samples and the MRG set were downloaded from The Cancer Genome Atlas (TCGA) and the Molecular Signatures Database (MSigDB). The Wilcoxon rank-sum test was used to identify differentially expressed MRGs. Then, a prognostic signature was established by multivariate Cox regression analysis. Finally, prognosis-related MRGs were selected and further validated in OSCC tissues and cell lines.

Results

A prognostic signature that included 8 MRGs was constructed. Multiple survival analysis revealed that only HPRT1 might be an independent biomarker and indicator of poor overall survival in OSCC patients. The expression of HPRT1 was then found to be upregulated in OSCC tissues and cell lines, and suppression of HPRT1 gene expression by siRNA inhibited the proliferation, migration, and invasion of OSCC cells in vitro.

Conclusions

MRGs play an important role in the development of OSCC. Furthermore, HPRT1 might be an independent biomarker of OSCC and enhance OSCC proliferation, migration, and invasion in vitro; these results emphasize the potential utility of HPRT1 in OSCC therapy.

A Novel Overall Survival Nomogram Prediction of Secondary Primary Malignancies after Hypopharyngeal Cancer: A Population-Based Study

Objectives

We aimed to construct a nomogram for predicting the overall survival (OS) of patients with secondary primary malignancies (SPMs) after hypopharyngeal cancer (HPC).

Methods

613 HPC patients were included in the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2018, which were divided into training and validation cohorts. The least absolute shrinkage and selection operation (LASSO) and stepwise Cox regression were used to determine the variables by which a nomogram model was established.

Results

After the LASSO and stepwise Cox regression analysis, the age, year of diagnosis, sites of SPMs, SEER stage of SPMs, surgery for SPMs, and radiotherapy for SPMs were included for model establishment. The ROC curve showed good discrimination for the 3- and 5-year AUC values in the training (0.774 and 0.779, respectively) and validation (0.758 and 0.763, respectively) cohorts. The calibration curve indicated good prognostic accuracy, especially in the 5-year survival prediction for this model. The DCA also demonstrated clinical efficacy over a wide range of threshold probabilities. Lastly, the risk group classified by the individual nomogram values showed significantly different survival outcomes in both training and validation cohorts.

Conclusions

We constructed a nomogram to predict the OS of SPMs after HPC with good clinical values.

Retrospective analysis of adjuvant radiotherapy in oral cavity or oropharyngeal cancer: Feasibility of omitting lower-neck irradiation

Objectives

Adjuvant radiotherapy is the standard of care in locally advanced head and neck cancers. The radiation field is correlated with the surgical field in the adjuvant radiotherapy setting; therefore, tailoring the irradiation field is reasonable.

Materials and methods

We retrospectively analyzed patients with oral cavity and oropharyngeal cancers included in the cancer registry between 2015 and 2019 in the study hospital. Patients who underwent whole-neck irradiation (WNI) were compared with those who underwent lower-neck–sparing (LNS) irradiation.

Results

A total of 167 patients with oral cavity and oropharyngeal cancers were included in the study. Cancer recurrence was recorded in 33% of the patients. The rate of recurrence of oral cavity and oropharyngeal cancer at neck level IV was 8%. The 2-year incidence of level IV recurrence was lower in the WNI group than in the LNS group (2% vs. 10%; p = 0.04). The 2-year disease-free survival rates were 75% and 63% in the WNI and LNS groups, respectively (p = 0.08).

Conclusion

The rate of level IV recurrence was higher in the LNS group than in the WNI group. Trends of improvement in disease-free survival with lower-neck irradiation suggested that it is premature to consider LNS irradiation as daily practice in patients with oral cavity and oropharyngeal cancer.

Context-Aware Saliency Guided Radiomics: Application to Prediction of Outcome and HPV-Status from Multi-Center PET/CT Images of Head and Neck Cancer

Simple Summary

This study investigated the ability of context-aware saliency-guided PET/CT radiomics in the prediction of outcome and HPV status for head and neck cancer. In total, 806 HNC patients (training vs. validation vs. external testing: 500 vs. 97 vs. 209) from 9 centers were collected from The Cancer Imaging Archive (TCIA). Saliency-guided radiomics showed enhanced performance for both outcome and HPV-status predictions relative to conventional radiomics. The radiomics-predicted HPV status also showed complementary prognostic value. This multi-center study highlights the feasibility of saliency-guided PET/CT radiomics in outcome predictions of head and neck cancer, confirming that certain regions are more relevant to tumor aggressiveness and prognosis.

Abstract

Purpose: This multi-center study aims to investigate the prognostic value of context-aware saliency-guided radiomics in ¹⁸F-FDG PET/CT images of head and neck cancer (HNC). Methods: 806 HNC patients (training vs. validation vs. external testing: 500 vs. 97 vs. 209) from 9 centers were collected from The Cancer Imaging Archive (TCIA). There were 100/384 and 60/123 oropharyngeal carcinoma (OPC) patients with human papillomavirus (HPV) status in training and testing cohorts, respectively. Six types of images were used for radiomics feature extraction and further model construction, namely (i) the original image (Origin), (ii) a context-aware saliency map (SalMap), (iii, iv) high- or low-saliency regions in the original image (highSal or lowSal), (v) a saliency-weighted image (SalxImg), and finally, (vi) a fused PET-CT image (FusedImg). Four outcomes were evaluated, i.e., recurrence-free survival (RFS), metastasis-free survival (MFS), overall survival (OS), and disease-free survival (DFS), respectively. Multivariate Cox analysis and logistic regression were adopted to construct radiomics scores for the prediction of outcome (Rad_Ocm) and HPV-status (Rad_HPV), respectively. Besides, the prognostic value of their integration (Rad_Ocm_HPV) was also investigated. Results: In the external testing cohort, compared with the Origin model, SalMap and SalxImg achieved the highest C-indices for RFS (0.621 vs. 0.559) and MFS (0.785 vs. 0.739) predictions, respectively, while FusedImg performed the best for both OS (0.685 vs. 0.659) and DFS (0.641 vs. 0.582) predictions. In the OPC HPV testing cohort, FusedImg showed higher AUC for HPV-status prediction compared with the Origin model (0.653 vs. 0.484). In the OPC testing cohort, compared with Rad_Ocm or Rad_HPV alone, Rad_Ocm_HPV performed the best for OS and DFS predictions with C-indices of 0.702 (p = 0.002) and 0.684 (p = 0.006), respectively. Conclusion: Saliency-guided radiomics showed enhanced performance for both outcome and HPV-status predictions relative to conventional radiomics. The radiomics-predicted HPV status also showed complementary prognostic value.

Proliferation and Apoptosis Pathways and Factors in Oral Squamous Cell Carcinoma

Oral cancer is the most common form of head and neck squamous cell carcinoma (HNSCC) and most frequently presents as oral squamous cell carcinoma (OSCC), which is associated with an alarmingly high mortality rate. Internationally, a plethora of research to further our understanding of the molecular pathways related to oral cancer is performed. This research is of value for early diagnosis, prognosis, and the investigation of new drugs that can ameliorate the harmful effects of oral cancer and provide optimal patient outcomes with minimal long-term complications. Two pathways on which the progression of OSCC depends on are those of proliferation and apoptosis, which overlap at many junctions. Herein, we aim to review these pathways and factors related to OSCC progression. Publicly available search engines, PubMed and Google Scholar, were used with the following keywords to identify relevant literature: oral cancer, proliferation, proliferation factors, genes, mutations, and tumor suppressor. We anticipate that the use of information provided through this review will further progress translational cancer research work in the field of oral cancer.

Cost-effectiveness of pembrolizumab for the first-line treatment of recurrent or metastatic head and neck squamous cell carcinoma in the United States

AIMS

Pembrolizumab, as monotherapy in first-line recurrent or metastatic (R/M) head and neck squamous cell carcinoma (HNSCC) with a combined positive score (CPS) ≥1 and in combination with platinum and 5-fluorouracil (5-FU) in the overall R/M HNSCC population, received US FDA approval based on the KEYNOTE-048 trial. Using public drug prices, from a US payer perspective, we evaluated the cost-effectiveness of each pembrolizumab regimen vs. cetuximab + platinum+5-FU (EXTREME regimen, trial comparator), cisplatin + docetaxel + cetuximab (TPEx regimen), cisplatin + paclitaxel, and platinum+5-FU.

METHODS

A three-state partitioned-survival model was used to project costs and outcomes over 20 years with 3% annual discounting. Progression-free and overall survival were modeled using long-term extrapolation of KEYNOTE-048 data and, for alternative comparators, data from a network meta-analysis was used. Time-on-treatment was derived from KEYNOTE-048 or approximated using network meta-analysis progression-free survival estimates. Costs included first-line and subsequent treatments, disease management, adverse events, and terminal care costs. Utilities were derived from the KEYNOTE-048 Euro-QoL five-dimension data and using a US algorithm.

RESULTS

In the CPS ≥1 R/M HNSCC population, pembrolizumab monotherapy was dominant vs. EXTREME and TPEx regimens, and cost-effective (at $100,000/QALY threshold) vs. platinum+5-FU ($86,827/QALY) and cisplatin + paclitaxel ($81,473/QALY). Pembrolizumab combination therapy in the overall R/M HNSCC population was dominant vs. TPEx regimen, and cost-effective vs. EXTREME regimen ($1769/QALY), platinum+5-FU ($81,989/QALY), and cisplatin + paclitaxel ($89,505/QALY). Sensitivity analyses showed a high cost-effectiveness probability for pembrolizumab at the $100,000/QALY threshold.

CONCLUSIONS

First-line pembrolizumab monotherapy in patients with CPS ≥1, and pembrolizumab combination therapy in the overall R/M HNSCC population is cost-effective from the perspective of the US payers.

Precision Postoperative Radiotherapy in Sinonasal Carcinomas after Endonasal Endoscopic Surgery

Simple Summary

Sinonasal cancers are rare and heterogeneous tumors, mainly carcinomas, with essentially local evolution and a severe vital and functional prognosis. These tumors are more and more being treated in first intent by a mini-morbid endoscopic approach rather than open surgery as the cornerstone of curative treatment. Adjuvant radiotherapy remains necessary owing to non-optimal local control. This article describes the requirements of radiotherapy to ensure adequate delays, the potential of postoperative radiotherapy to increase local and distant disease control and to decrease morbidity further after mini morbid surgery and dose painting techniques, and reviews the criteria that lead to the choice of one technique over another.

Abstract

Radiotherapy plays an important role in the treatment of sinonasal cancer, mainly in the adjuvant setting after surgical resection. Many technological approaches have been described, including intensity-modulated radiotherapy, concomitant chemoradiotherapy, charged particle therapy or combined approaches. The choice is based on general criteria related to the oncological results and morbidity of each technique and their availability, as well as specific criteria related to the tumor (tumor extensions, pathology and quality of margins). The aims of this review are: (i) to provide an overview of the radiotherapy techniques available for the management of sinonasal malignant tumors and (ii) to describe the constraints and opportunities of radiotherapy owing to the recent developments of endonasal endoscopic surgery. The indication and morbidity of the different techniques will be discussed based on a critical literature review.

Retrospective study of the clinicopathological characteristics and prognosis of elderly patients with oropharyngeal squamous cell carcinoma

Objective

Oropharyngeal squamous cell carcinoma (OPSCC) is a malignant tumor that occurs at the tongue base, soft palate, palatine tonsil, and pharyngeal wall. Few studies of OPSCC have been performed in elderly patients.

Methods

Patients with human papilloma virus (HPV)-related OPSCC were extracted from the Head and Neck with HPV Status Database of the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2016. We identified 355 patients with HPV-positive status, and we retrospectively evaluated elderly (≥65 years) and younger (30–64 years) patient groups to compare the differences.

Results

Of the 355 patients who were diagnosed with HPV-related OPSCC, 113 constituted the elderly group. Comparing the elderly group with the younger group, the 3-year HPV-positive overall survival (OS) rates were 62.4% and 70.2%, respectively, and the 5-year OS rates were 50.4% and 59.2%, respectively. Cox regression analysis demonstrated that tumor (T) stage and chemotherapy were prognostic factors for OS.

Conclusion

Elderly patients with OPSCC had different clinicopathological characteristics. T stage and chemotherapy should be priorities when evaluating the OS of elderly patients with OPSCC.

Early glottic cancer recurrence: A critical review on its current management

INTRODUCTION

Recurrent early glottic cancer (rEGC) poses several issues in terms of timely diagnosis, correct re-staging, and treatment. We want to critically review the latest evidence about rEGC considering its epidemiology, biology, diagnostic challenges, and treatment strategies.

METHODS

A systematic search of the literature using PubMed from 1990 to October 31, 2020 was performed.

RESULTS

There are many different treatment options available (open surgery, transoral mini-invasive surgery, radiotherapy), and many factors related to the patient's status and previous treatments must be considered when planning the best management strategy for rEGC. While its overall prognosis remains satisfactory, it is of the utmost importance to appreciate all the clinical implications derived from the choice of the initial therapeutic modality, and from a correct primary and recurrent staging.

CONCLUSION

The balance between oncological and voice and swallowing functions represents the fundamental principle underlying rEGC management. Future studies should focus on molecular profiling of rEGC, and on the results of the emerging radiation delivery techniques and mini-invasive procedures.

A New Medical Record Proposal to the Prognostic Risk Assessment for MRONJ in Oncologic Patients: "Sapienza Head and Neck Unit" Proposal

Medication-related osteonecrosis of the jaw (MRONJ) is an adverse event associated with antiresorptive and antiangiogenic drugs. The use of these drugs in the treatment of cancer patients with bone metastasis is necessary and standardized in the literature. A multidisciplinary approach for the patient’s management is strongly recommended. Therefore, it should be necessary to integrate the path of these subjects with a dedicated dental screening in order to first assess the individual risk of developing a MRONJ, and then to plan dental treatments and oral hygiene sessions, and finally to schedule a follow-up to intercept and treat early osteonecrosis. The aim of this manuscript is to propose a new simple medical report to evaluate patients affected by metastatic bone cancer in order to reduce the risk of developing MRONJ.

Primary squamous cell carcinoma of major salivary gland: "Sapienza Head and Neck Unit" clinical recommendations

Primary squamous cell carcinoma of salivary gland (SCG) is an extremely rare type of malignant salivary gland tumor, which in turn results in scarcity of data available regarding both its treatment and associated genetic alterations. A retrospective analysis of 12 patients with primary SCG was conducted, along with analysis of the association between treatment, clinical/pathological characteristics, and outcomes. Most patients (8) were staged IVa, with the majority of them (10) having G3 fast growing cancer. Local and systemic recurrence were reported in only three out of nine parotid cases (0 out of 2 submandibular SCGs). In two out of eight patients local relapse occurred after integrated treatment, while recurrence occurred in two out of three patients undergoing exclusive surgery. Five patients eventually died. Treatment of resectable disease must be aggressive and multimodal, with achievement of loco-regional control in order to reduce rate of recurrence and improve outcomes. Metastatic disease would require a therapeutic strategy tailored to the molecular profile in order to improve the currently disappointing results.

Photo-Biomodulation as a Prevention Modality of Oral Mucositis in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

The aim of the study was to observe the effectiveness of a photo-biomodulation (PBM) protocol for the prevention of oral mucositis (OM) in patients undergoing allogeneic hematopoietic stem cell transplantation (aHSCT). A case-control study was conducted on 40 patients undergoing aHSCT. The patients were divided into two groups; the preventive group (PG) included 20 patients (7 females and 13 males) who were subjected to intra-oral PBM for five sessions a week, starting one day before the conditioning regimen and continuing until the 10th day after transplantation (D+10). In each session, ten points on the at-risk mucosal surfaces were irradiated using a double diode laser that emits two wavelengths simultaneously at 650 nm and at 904–910 nm with the following parameters at each point: energy of 4 J, and power of 88.9 mW. The control group (CG) included 20 patients (10 females and 10 males) who were not subjected to laser therapy and were selected retrospectively to compare the obtained results. For all patients, OM was assessed by the World Health Organization (WHO) grading scale. Eight patients in the PG did not experience OM during their hospitalization period (with grade 0). Severe OM was observed in 40% of the patients in the PG, while in the CG, severe OM was shown in 85% of the patients. The mean duration of OM in the PG was significantly lower than that of CG (4.7 days in the PG and 15 days in the CG) (p < 0.001). The study demonstrated that the preventive PBM protocol reduced the severity and duration of OM in patients undergoing aHSCT.

Induction chemotherapy in nonlaryngeal human papilloma virus-negative high-risk head and neck cancer: a real-world experience

The role of induction chemotherapy in the multidisciplinary treatment of locally advanced, nonlaryngeal high-risk human papilloma virus (HPV)-negative head and neck squamous cells carcinoma (HNSCC) is uncertain in terms of overall survival (OS). The primary objective of this study was to identify possible predictive factors of survival and outcome in patients with HNSCC who were treated with induction chemotherapy. Fifty-nine patients with stage IVa/b HPV-negative non-laryngeal HNSCC (mostly originating from the oral cavity) who underwent induction chemotherapy at Policlinico Umberto I were reviewed. Treatment outcomes in term of objective response rate (ORR), progression-free survival (PFS), OS and toxicities were analyzed. A significant association between nodal status, ORR, ongoing smoking use, toxicities and OS was demonstrated. ORR (obtained in 61% of patients) was associated with a reduction in mortality of 80% (P< 0.0001). Early discontinuation after just one cycle of induction chemotherapy was associated to a significantly shorter OS. In oral cavity radical surgery with negative margins was obtained in 15/16 patients. In 42% of patients G3-G4 toxicity occurred. Toxicity requiring hospitalization occurred in 42% and 21% of patients with oropharyngeal and oral cavity carcinoma, respectively. Five patients died of treatment-related causes. No treatment-related mortality occurred in oral cavity patients. G5 toxicities were different according to the sub-sites of disease (P = 0.05). Induction chemotherapy in non-laryngeal high-risk HNSCC is an active strategy, most importantly in oral cavity cancer, even though burdened with a high (G ≥ 3) toxicity and early discontinuation rate. These data will however need to be confirmed in further and larger studies.

Post-Treatment Head and Neck Cancer Care: National Audit and Analysis of Current Practice in the United Kingdom

OBJECTIVES

We aimed to audit current United Kingdom (UK) practice of Head and Neck Cancer (HNC) post-treatment surveillance against national guidelines, and determine the outcomes of these practices in detecting recurrence.

DESIGN

National cross-sectional study of current HNC surveillance practice.

SETTING

UK HNC outpatient departments.

PARTICIPANTS

HNC patients reviewed for post-treatment surveillance.

MAIN OUTCOME MEASURES

Compliance with UK multidisciplinary guidelines, and rates of cancer recurrence detection by time, clinic type and symptoms.

RESULTS

Data were analysed from 5,123 consultations across 89 UK centres. 30% of consultations were in dedicated multidisciplinary clinics, with input from Allied Health Professionals (AHPs) available on the day in 23% of all consultations. Recurrence was suspected in 344 consultations and investigated with MRI in 29.6% (n=102) and PET-CT in 14.2% (n=49). Patient education regarding recurrence symptoms, and smoking and alcohol advice, was provided in 20.4%, 6.2%, and 5.3% of cases, respectively. Rates of recurrence detected were 35% in expedited appointments and 5.2% in planned follow-ups (p=0.0001). Of the expedited appointments, 63% were initiated by patients and 37% by clinicians. Recurrence was higher in those with new symptoms (7.1% versus 2.2%). The strongest predictors of recurrence were dyspnoea (positive predictive value (PPV)=16.2%), neck pain (PPV=10.4%) and mouth/throat pain (PPV=9.2%).

CONCLUSIONS

Dedicated multidisciplinary clinics comprise a minority of consultations for HNC surveillance in the UK, with low availability of AHPs. PET-CT and MRI were underutilised for the investigation of suspected recurrence. There may be scope for greater emphasis on patient education and consequent patient-initiated symptom driven follow-up.

Does Medication-Related Osteonecrosis of the Jaw Influence the Quality of Life of Cancer Patients?

The aim of this study is to observe the influence of Medication-Related Osteonecrosis of the Jaw (MRONJ) on the physical and mental conditions of cancer patients using a Quality of Life (QoL) questionnaire during regular dental practice measures. Twenty cancer patients (8 males and 12 females) with established MRONJ were enrolled in the “MoMax” (Oral Medicine and Maxillofacial) project of the Department of Oral Sciences and Maxillofacial Surgery at “Sapienza” University of Rome, and were included in the study. The 12-item Short Form Survey was used to evaluate the QoL. Statistical analysis revealed a significant difference for Mental Component Summary (MCS) scores based on age (p = 0.018). The regression analysis revealed that the Physical Component Summary (PCS) scores were negatively influenced by the anti-resorptive medication duration (p = 0.031 and β = −1.137). No significant differences were observed with the other variables considered. The QoL of cancer patients is generally deteriorated and MRONJ may cause a further negative impact. This study highlights the possible need to include psychosocial and physical evaluations in the management process of MRONJ in cancer patients.

Impact of clinical complete response on treatment outcomes in patients with locally advanced HPV-negative oropharyngeal squamous cell carcinoma

OBJECTIVE

To evaluate treatment outcomes after definitive chemoradiotherapy (CRT) for human papilloma virus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC).

MATERIALS AND METHODS

We analyzed data concerning HPV-negative OPSCC patients treated with curative intent. All patients received concomitant high-dose cisplatin-based chemotherapy. Two different RT techniques were used: (1) sequential boost IMRT (S-IMRT) to a total dose of 70 Gy (2 Gy/fraction); (2) simultaneously integrated boost (SIB-IMRT) to a total dose of 67.5 Gy (2.25 Gy/fraction). Survival outcomes were estimated.

RESULTS

In total, 69 HPV-negative OPSCC patients were included (n = 40 S-IMRT; n = 29 SIB-IMRT). The median follow-up time was 40 months. The 3-year overall survival, disease-free survival, distant metastasis-free survival and locoregional-free survival were 67.1%, 63.3%, 64.5% and 66.0%, respectively. Alcohol abuse and advanced stage disease at presentation were the main risk factors for worse survival outcomes. Complete clinical response (cCR) at 3 months after CRT improved overall survival (86.3% versus 42.5%, p < 0.01). The cCR events were greater but not statistically significant in SIB-IMRT group compared to S-IMRT patients (69% versus 47.5%, p = 0.09).

CONCLUSIONS

The positive impact of cCR at 3 months on survival needs to be confirmed in randomized clinical trials, as well as its close correlation with SIB-IMRT technique. A proper stratification of HPV-negative OPSCC patients should be paramount to tailor treatment strategy in the near future.

The Prognostic Value of Adding Narrow-Band Imaging in Transoral Laser Microsurgery for Early Glottic Cancer: A Review

BACKGROUND AND OBJECTIVES

Transoral laser microsurgery (TLM) is a universally recognized safe and minimally invasive approach for early glottic cancer. Narrow band imaging (NBI) is an optical technique working with a filtered light that reveals superficial mucosal abnormalities through the neoangiogenic pattern. The aim of this systematic review is to demonstrate the role of intraoperative NBI during TLM for early glottic cancer to better evaluate tumor extension and for more precise margin resection.

STUDY DESIGN/MATERIALS AND METHODS

A systematic review of the literature following the PRISMA guidelines was performed. A literature search was performed using the following keywords: TLM, NBI, and early glottic cancer. Two independent authors evaluated the extracted data. Data regarding status of surgical margins after TLM, local recurrence, recurrence-free survival, and need of additional samples following NBI were collected.

RESULTS

Five articles met inclusion criteria with a total of 577 patients undergoing TLM with intraoperative NBI. A significant reduction of positive superficial margins was found in patients treated with (52%) and without (28.6%) intraoperative use of NBI (P < 0.05) CONCLUSIONS: Routine use of intraoperative NBI increases the accuracy of neoplastic superficial spreading evaluation and accuracy of mass resection during TLM for early glottic cancer. The significant reduction of superficial positive margins dramatically decreases the number of patients at risk and improves clinical outcomes. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Frequency and predictors of detecting early locoregional recurrence/disease progression of oral squamous cell carcinoma with high-risk factors on imaging tests before postoperative adjuvant radiotherapy

BACKGROUND

To clarify the frequency and predictors of detecting early locoregional recurrence/disease progression (LR/DP) during the interval between surgery and postoperative adjuvant radiotherapy with/without chemotherapy in patients with oral squamous cell carcinoma.

METHODS

Data on 65 patients who had undergone the initial radical surgery for previously untreated oral squamous cell carcinoma which were scheduled to receive adjuvant radiotherapy with/without chemotherapy were reviewed.

RESULTS

Of the 65 patients, 63 (97%) were margin-positive/close and/or extracapsular extension-positive (hereinafter, high-risk factors). Eighteen (28%) patients had abnormal findings suggestive of LR/DP on postoperative imaging. Fifteen (23%) patients were diagnosed with LR/DP and treatment policy was changed. Univariate and multivariate analyses revealed higher frequencies of abnormal findings suggestive of LR/DP (univariate/multivariate analysis, p = 0.020/0.036), diagnosing of LR/DP, and changing the treatment policy (univariate/multivariate analysis, p = 0.042/0.046), among the patients who underwent postoperative diagnostic imaging tests or radiotherapy-planning contrast-enhanced (CE) CT without diagnostic imaging tests as compared with those who underwent radiotherapy-planning non-CECT without such tests.

CONCLUSION

The frequency of detecting of early LR/DP before postoperative adjuvant treatment in oral squamous cell carcinoma patients with high-risk factors was high. Furthermore, postoperative diagnostic imaging tests and radiotherapy-planning CECT may be useful to detect early LR/DP in oral squamous cell carcinoma patients before postoperative adjuvant therapy.

[Management and complications of tumor resections of the midface]

Only about 8% of head and neck tumors affect the midface. This anatomical area is characterized by an enormous number of functionally important structures, and it is frequently only possible to achieve small resection margin distances. To avoid complications and unfavorable results, a dedicated preparation of both patient and surgeon is warranted. This review aims to provide encouragement for the postgraduate training of interested ENT specialists. Following the clinical course and based on recent literature, strategies to avoid complications of tumor surgery to the midface are given.

Analysis of Process-Related Quality Metrics and Survival of Patients with Oral Cavity Squamous Cell Carcinoma

Objective

To analyze the association of prior reported key quality metrics—neck dissection ≥18 nodes, radiation oncology referral for stage III/IV disease, unplanned surgery ≤14 days, and unplanned readmission ≤30 days—with disease-free survival (DFS) and overall survival (OS) in oral cavity cancer (OCC).

Study Design

A retrospective chart review.

Setting

A tertiary care center from 1995 to 2016.

Subjects and Methods

Data from patients with OCC who underwent primary surgery were studied. The association of quality metrics and pathology with DFS/OS was determined by Cox proportional hazards regression analysis.

Results

A total of 514 patients were included, and 398 (77.4%) underwent elective neck dissection. Key metrics were not associated with DFS on analysis, but higher pathologic stage and extracapsular extension (ECE) were. When stratified by stage, unplanned readmission within 30 days was associated with decreased survival on multivariate analysis (HR = 0.40; 95% CI, 0.20-0.85; P = .02) for patients with clinical stage III or IV disease. ECE was associated with decreased survival among these patients as well. Neck dissection with ≤18 nodes (HR = 0.62; 95% CI, 0.44-0.86; P = .004) and unplanned surgery within 14 days (HR = 0.56; 95% CI, 0.32-0.96; P = .03) were associated with decreased survival on univariate analysis but not on multivariate analysis. ECE and higher-stage disease were associated with decreased OS on multivariate analysis.

Conclusion

In this study, aggressive pathology, rather than adherence to key quality metrics, was associated with lower DFS and OS among patients with OCC. More studies are needed to elucidate the association of quality metrics with survival.

Multidisciplinary team in head and neck cancer: a management model

Nowadays, the multidisciplinary team (MDT) is an essential component for oncologic disease management. Its benefit is also extensively recognized in head and neck cancer (HNC) community, due to tumor rarity and complex treatment. A well-defined MDT management serves as a stable point to define the better strategy and offers a chance to optimize HNC clinical outcomes and patient's quality of life. We explored both mandatory and additional requirements for establishing a high-quality MDT. Then we proposed an example of HNC MDT organization. The aim is to contribute to the best way to systematize HNC care.

Management of salivary gland malignant tumor: the Policlinico Umberto I, "Sapienza" University of Rome Head and Neck Unit clinical recommendations

Salivary gland malignant tumor (SGMT) is a malignant disease requiring multidisciplinary approach. The rare incidence and the consequent lack of robust evidence-based medicine has called for a comprehensive update to draw recommendations for clinical practice. This paper is a summary of the XXX Head and Neck Unit guidelines regarding the management of SGMT. Recommendations include the indications for exclusive and adjuvant therapy, as well as metastatic management, for both major and minor SGMT.