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Tian Q, Jiang L, Dai D, Liu L, Shi X, Guo Y, Wu D, Yang J, Xu J, Cai Z, Ye Z, Xi Y, Zheng Z, Li H, Shui Y, Liu Y, Shang J, Wei S, Wei Q. Impact of Postoperative Radiotherapy on the Prognosis of Early-Stage (pT1-2N0M0) Oral Tongue Squamous Cell Carcinoma. J Clin Oncol 2024:JCO2301106. [PMID: 38560819 DOI: 10.1200/jco.23.01106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 12/01/2023] [Accepted: 02/08/2024] [Indexed: 04/04/2024] Open
Abstract
PURPOSE To identify subgroups of patients with early-stage (pT1-2N0M0) oral tongue squamous cell carcinoma (OTSCC) who may benefit from postoperative radiotherapy (PORT). PATIENTS AND METHODS This retrospective cohort study included 528 patients diagnosed between October 2009 and December 2021. Clinicopathological characteristics and treatments with or without PORT were analyzed for their impact on outcomes. RESULTS Among 528 patients who underwent radical surgery (median age, 62 years [IQR, 52-69]), 145 (27.5%) also underwent PORT. Multivariate analyses revealed that PORT was associated with improved survival outcomes, whereas moderate-to-poor differentiation, perineural infiltration (PNI), lymphovascular invasion (LVI), and increasing depth of invasion (DOI) were associated with poorer survival outcomes. For patients with moderate-to-poor differentiation, the surgery + PORT group showed improved outcomes compared with the surgery-alone group. After propensity score matching, the results were as follows: overall survival (OS), 97% versus 69%, P = .003; disease-free survival (DFS), 88% versus 50%, P = .001. After excluding cases with PNI/LVI, the differences persisted: OS, 97% versus 82%, P = .040; DFS, 87% versus 64%, P = .012. Similar survival benefits were observed in 104 patients with PNI and/or LVI (OS, 81% v 58%; P = .022; DFS, 76% v 47%; P = .002). In subgroups with DOI >5 mm or close margins, PORT contributed to improved DFS (80% v 64%; P = .006; 92% v 66%; P = .049) but did not significantly affect OS. CONCLUSION Patients with moderately-to-poorly differentiated pT1-2N0M0 OTSCC benefited from PORT. Our study provided evidence that patients with PNI and/or LVI who underwent PORT had improved survival. PORT also offered DFS benefit among patients with DOI >5 mm.
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Affiliation(s)
- Qiaoying Tian
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
- Cancer Center of Zhejiang University, Hangzhou, China
| | - Lin Jiang
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Surgical Oncology, Zhejiang Cancer Hospital, Hangzhou, China
- Key Laboratory of Head and Neck Cancer Translational Research of Zhejiang Province, Hangzhou, China
| | - Dongjun Dai
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Cancer Center of Zhejiang University, Hangzhou, China
| | - Lihong Liu
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Cancer Center of Zhejiang University, Hangzhou, China
| | - Xiaomeng Shi
- Department of Reproductive Endocrinology, The Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yinglu Guo
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Cancer Center of Zhejiang University, Hangzhou, China
| | - Dang Wu
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
- Cancer Center of Zhejiang University, Hangzhou, China
| | - Jia Yang
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
- Cancer Center of Zhejiang University, Hangzhou, China
| | - Jing Xu
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
- Cancer Center of Zhejiang University, Hangzhou, China
| | - Zhuoying Cai
- Department of Oral and Maxillofacial Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhimin Ye
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Yun Xi
- Department of Pathology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Zengguang Zheng
- Department of Pathology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Huimin Li
- Department of Pathology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Yongjie Shui
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
- Cancer Center of Zhejiang University, Hangzhou, China
| | - Yanming Liu
- Department of Oral and Maxillofacial Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinbiao Shang
- Department of Surgical Oncology, Zhejiang Cancer Hospital, Hangzhou, China
- Key Laboratory of Head and Neck Cancer Translational Research of Zhejiang Province, Hangzhou, China
| | - Shumei Wei
- Department of Pathology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qichun Wei
- Department of Radiation Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Cancer, Hangzhou, China
- Cancer Center of Zhejiang University, Hangzhou, China
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Chang CC, Wu YT, Lu HH, Cheng YJ, Tsai MH. The role of postoperative radiotherapy or chemoradiation in pT1-2N1M0 oral squamous cell carcinoma. J Formos Med Assoc 2024:S0929-6646(24)00150-5. [PMID: 38514372 DOI: 10.1016/j.jfma.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 02/29/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Postoperative radiotherapy (PORT) and concurrent chemoradiation (CCRT) are indicated for patients with advanced oral cancer. However, the benefits for pT1-2N1 disease without adverse pathological features are controversial. METHODS This retrospective study using the Taiwan Cancer Registry database included patients with pT1-2N1 oral cancer from January 1, 2011, to December 31, 2017. Overall survival was analyzed in patients receiving surgery alone, PORT, or CCRT. RESULTS Among the 862 patients, the five-year overall survival rate in patients receiving surgery alone, PORT, and CCRT was 62.2%, 58.7%, and 71.1% (P = 0.03), respectively. CCRT was associated with longer survival than PORT (P = 0.008). Survival in patients with pT2 disease was significantly higher with CCRT than PORT (P = 0.001), but no difference was observed in pT1 disease. CONCLUSION CCRT demonstrated a favorable impact on survival outcomes in patients diagnosed with pT2N1 oral cancer when compared to PORT. However, no significant survival benefits were observed for patients with pT1 disease.
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Affiliation(s)
- Chan-Chi Chang
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yin-Ting Wu
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsi-Huei Lu
- Division of Nuclear Medicine, Department of Medical Imaging, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yung-Jen Cheng
- Department of Radiation Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Mu-Hung Tsai
- Department of Radiation Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan.
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3
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Singh M, Thankappan K, Balasubramanian D, Pillai V, Shetty V, Rangappa V, Chandrasekhar NH, Kekatpure V, Kuriakose MA, Krishnamurthy A, Mitra A, Pattatheyil A, Jain P, Iyer S, Iyer NG, Subramaniam N. Contrasting clinical outcomes and socio-economic impact of young versus elderly-onset oral squamous cell carcinoma, a novel health economic analysis. Cancer Med 2024; 13:e6747. [PMID: 38225902 PMCID: PMC10905235 DOI: 10.1002/cam4.6747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 11/01/2023] [Accepted: 11/15/2023] [Indexed: 01/17/2024] Open
Abstract
OBJECTIVES The incidence of young-onset oral squamous cell carcinoma (OSCC) is growing, even among non-smokers/drinkers. The effects of adverse histopathological features on long-term oncologic outcomes between the young and old are controversial and confounded by significant heterogeneity. Few studies have evaluated the socio-economic impact of premature mortality from OSCC. Our study seeks to quantify these differences and their economic impact on society. MATERIALS AND METHODS Four hundred and seventy-eight young (<45 years) and 1660 old patients (≥45 years) with OSCC were studied. Logistic regression determined predictors of recurrence and death. Survival analysis was calculated via the Kaplan-Meier method. A separate health economic analysis was conducted for India and Singapore. Years of Potential Productive Life Lost (YPPLL) were estimated with the Human Capital Approach, and premature mortality cost was derived using population-level data. RESULTS Adverse histopathological features were seen more frequently in young OSCC: PNI (42.9% vs. 35%, p = 0.002), LVI (22.4% vs. 17.3%, p = 0.013) and ENE (36% vs. 24.5%, p < 0.001). Although 5-year OS/DSS were similar, the young cohort had received more intensive adjuvant therapy (CCRT 26.9% vs. 16.6%, p < 0.001). Among Singaporean males, the premature mortality cost per death was US $396,528, and per YPPLL was US $45,486. This was US $397,402 and US $38,458 for females. Among Indian males, the premature mortality cost per death was US $30,641, and per YPPLL was US $595. This was US $ 21,038 and US $305 for females. CONCLUSION Young-onset OSCC is an aggressive disease, mitigated by the ability to receive intensive adjuvant treatment. From our loss of productivity analysis, the socio-economic costs from premature mortality are substantial. Early cancer screening and educational outreach campaigns should be tailored to this cohort. Alongside, more funding should be diverted to genetic research, developing novel biomarkers and improving the efficacy of adjuvant treatment in OSCC.
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Affiliation(s)
- Manraj Singh
- Department of Head and Neck SurgerySingapore General Hospital and National Cancer CentreSingaporeSingapore
| | | | - Deepak Balasubramanian
- Department of Head and Neck Surgical OncologyAmrita Institute of Medical SciencesKochiIndia
| | - Vijay Pillai
- Department of Head and Neck Surgical OncologyMazumdar Shaw Medical Centre, Narayana HealthBangaloreIndia
| | - Vivek Shetty
- Department of Head and Neck Surgical OncologyMazumdar Shaw Medical Centre, Narayana HealthBangaloreIndia
| | - Vidyabhushan Rangappa
- Department of Head and Neck Surgical OncologyMazumdar Shaw Medical Centre, Narayana HealthBangaloreIndia
| | - Naveen Hedne Chandrasekhar
- Department of Head and Neck Surgical OncologyMazumdar Shaw Medical Centre, Narayana HealthBangaloreIndia
- Present address:
Department of Head and Neck Surgical OncologyApollo Proton Cancer CentreChennaiIndia
| | - Vikram Kekatpure
- Department of Head and Neck Surgical OncologyMazumdar Shaw Medical Centre, Narayana HealthBangaloreIndia
- Present address:
Department of Head and Neck Surgical OncologyCytecare HospitalBangaloreIndia
| | - Moni Abraham Kuriakose
- Department of Head and Neck Surgical OncologyMazumdar Shaw Medical Centre, Narayana HealthBangaloreIndia
| | | | - Arun Mitra
- Department of Surgical OncologyCancer Institute (WIA)ChennaiIndia
| | - Arun Pattatheyil
- Department of Head and Neck Surgical OncologyTata Medical CentreKolkataIndia
| | - Prateek Jain
- Department of Head and Neck Surgical OncologyTata Medical CentreKolkataIndia
| | - Subramania Iyer
- Department of Head and Neck Surgical OncologyAmrita Institute of Medical SciencesKochiIndia
| | - N. Gopalakrishna Iyer
- Department of Head and Neck SurgerySingapore General Hospital and National Cancer CentreSingaporeSingapore
| | - Narayana Subramaniam
- Department of Head and Neck Surgical OncologyMazumdar Shaw Medical Centre, Narayana HealthBangaloreIndia
- Present address:
Department of Head and Neck Surgical OncologySri Shankara Cancer Hospital and Research CentreBangaloreIndia
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4
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Need for adjuvant radiotherapy in oral cancer: depth of invasion rather than tumor diameter. Eur Arch Otorhinolaryngol 2023; 280:339-346. [PMID: 35913631 DOI: 10.1007/s00405-022-07561-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/17/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE The 8th edition of the TNM Cancer Staging Manual incorporates depth of invasion (DOI) into the pathologic tumor classification for oral squamous cell carcinoma (OSSC). While deep invading tumors with small tumor diameters (TD) have been categorized as early stage tumors in the 7th edition, they are now upstaged, potentially influencing the decision to initiate adjuvant radiotherapy (RT). METHODS OSCC patients surgically treated with curative intent between 2010 and 2019 were consecutively included. Tumors were staged based on TD only (according to the 7th edition TNM Cancer Staging Manual), then restaged based solely on DOI. RESULTS Of the 133 included patients, 58 patients (43.6%) had a different pT-stage when using DOI instead of TD for staging (upstaging in 23.3%). Overall survival (OS) was significantly worse in patients who were upstaged with DOI. In addition, stratification by adjuvant RT showed significant worse OS in upstaged patients without receiving adjuvant RT. CONCLUSIONS DOI seems to be an import indicator for adjuvant RT in OSCC-patients.
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5
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Tu IWH, Shannon NB, Thankappan K, Balasubramanian D, Pillai V, Shetty V, Rangappa V, Chandrasekhar NH, Kekatpure V, Kuriakose MA, Krishnamurthy A, Mitra A, Pattatheyil A, Jain P, Iyer S, Subramaniam N, Iyer NG. Risk Stratification in Oral Cancer: A Novel Approach. Front Oncol 2022; 12:836803. [PMID: 35875164 PMCID: PMC9301677 DOI: 10.3389/fonc.2022.836803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/09/2022] [Indexed: 12/14/2022] Open
Abstract
BackgroundOral squamous cell carcinoma (OSCC) is a common head and neck cancer with high morbidity and mortality. Currently, treatment decisions are guided by TNM staging, which omits important negative prognosticators such as lymphovascular invasion, perineural invasion (PNI), and histologic differentiation. We proposed nomogram models based on adverse pathological features to identify candidates suitable for treatment escalation within each risk group according to the National Comprehensive Cancer Network (NCCN) guidelines.MethodsAnonymized clinicopathologic data of OSCC patients from 5 tertiary healthcare institutions in Asia were divided into 3 risk groups according to the NCCN guidelines. Within each risk group, nomograms were built to predict overall survival based on histologic differentiation, histologic margin involvement, depth of invasion (DOI), extranodal extension, PNI, lymphovascular, and bone invasion. Nomograms were internally validated with precision–recall analysis and the Kaplan–Meier survival analysis.ResultsLow-risk patients with positive pathological nodal involvement and/or positive PNI should be considered for adjuvant radiotherapy. Intermediate-risk patients with gross bone invasion may benefit from concurrent chemotherapy. High-risk patients with positive margins, high DOI, and a high composite score of histologic differentiation, PNI, and the American Joint Committee on Cancer (AJCC) 8th edition T staging should be considered for treatment escalation to experimental therapies in clinical trials.ConclusionNomograms built based on prognostic adverse pathological features can be used within each NCCN risk group to fine-tune treatment decisions for OSCC patients.
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Affiliation(s)
- Irene Wen-Hui Tu
- Department of Head and Neck Surgery Singapore General Hospital and National Cancer Centre Singapore and Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Nicholas Brian Shannon
- Department of Head and Neck Surgery Singapore General Hospital and National Cancer Centre Singapore and Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Krishnakumar Thankappan
- Department of Head and Neck Surgical Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Deepak Balasubramanian
- Department of Head and Neck Surgical Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Vijay Pillai
- Department of Head and Neck Surgical Oncology, Mazumdar Shaw Medical Centre, Narayana Health, Bangalore, India
| | - Vivek Shetty
- Department of Head and Neck Surgical Oncology, Mazumdar Shaw Medical Centre, Narayana Health, Bangalore, India
| | - Vidyabhushan Rangappa
- Department of Head and Neck Surgical Oncology, Mazumdar Shaw Medical Centre, Narayana Health, Bangalore, India
| | - Naveen Hedne Chandrasekhar
- Department of Head and Neck Surgical Oncology, Mazumdar Shaw Medical Centre, Narayana Health, Bangalore, India
| | - Vikram Kekatpure
- Department of Head and Neck Surgical Oncology, Mazumdar Shaw Medical Centre, Narayana Health, Bangalore, India
| | - Moni Abraham Kuriakose
- Department of Head and Neck Surgical Oncology, Mazumdar Shaw Medical Centre, Narayana Health, Bangalore, India
| | | | - Arun Mitra
- Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India
| | - Arun Pattatheyil
- Department of Head and Neck Surgical Oncology, Tata Medical Centre, Kolkata, India
| | - Prateek Jain
- Department of Head and Neck Surgical Oncology, Tata Medical Centre, Kolkata, India
| | - Subramania Iyer
- Department of Head and Neck Surgical Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Narayana Subramaniam
- Department of Head and Neck Surgical Oncology, Mazumdar Shaw Medical Centre, Narayana Health, Bangalore, India
- *Correspondence: N. Gopalakrishna Iyer, ; Narayana Subramaniam,
| | - N. Gopalakrishna Iyer
- Department of Head and Neck Surgery Singapore General Hospital and National Cancer Centre Singapore and Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore
- *Correspondence: N. Gopalakrishna Iyer, ; Narayana Subramaniam,
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Muller S, Tilakaratne WM. Update from the 5th Edition of the World Health Organization Classification of Head and Neck Tumors: Tumours of the Oral Cavity and Mobile Tongue. Head Neck Pathol 2022; 16:54-62. [PMID: 35312982 PMCID: PMC9018914 DOI: 10.1007/s12105-021-01402-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/07/2021] [Indexed: 12/22/2022]
Abstract
The fifth chapter of the upcoming fifth edition of the 2022 World Health Organization Classification of Tumours of the Head and Neck titled Tumours of the oral cavity and mobile tongue, has had some modifications from the 2017 fourth edition. A new section "Non-neoplastic Lesions", introduces two new entries: necrotizing sialometaplasia and melanoacanthoma. The combined Oral potentially malignant disorders and Oral epithelial dysplasia section in the 2015 WHO has now been separated and submucous fibrosis and HPV-associated dysplasia are also discussed in separate sections. Carcinoma cuniculatum and verrucous carcinoma are described in dedicated sections, reflecting that the oral cavity is the most common location in the head and neck for both these entities which have distinct clinical and histologic features from conventional squamous cell carcinoma. This review summarizes the changes in Chapter 5 with special reference to new additions, deletions, and sections that reflect current clinical, histological, and molecular advances.
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Affiliation(s)
- Susan Muller
- Atlanta Oral Pathology, Emory at Decatur Hospital, Emory University School of Medicine, Decatur, GA, USA.
| | - Wanninayake M Tilakaratne
- Department of Oral Pathology, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpur, Malaysia
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7
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Singh M, Thankappan K, Balasubramanian D, Pillai V, Shetty V, Rangappa V, Chandrasekhar NH, Kekatpure V, Kuriakose MA, Krishnamurthy A, Mitra A, Pattatheyil A, Jain P, Iyer S, Iyer NG, Subramaniam N. Incorporation of adverse features in advanced oral cancer improves precision in staging and patient prognostication. Head Neck 2022; 44:964-974. [DOI: 10.1002/hed.26990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/05/2021] [Accepted: 01/14/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Manraj Singh
- Department of Head and Neck Surgery Singapore General Hospital and National Cancer Centre Singapore Singapore
| | - Krishnakumar Thankappan
- Department of Head and Neck Surgical Oncology Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham Kochi India
| | - Deepak Balasubramanian
- Department of Head and Neck Surgical Oncology Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham Kochi India
| | - Vijay Pillai
- Department of Head and Neck Surgical Oncology Mazumdar Shaw Medical Centre, Narayana Health Bangalore India
| | - Vivek Shetty
- Department of Head and Neck Surgical Oncology Mazumdar Shaw Medical Centre, Narayana Health Bangalore India
| | - Vidyabhushan Rangappa
- Department of Head and Neck Surgical Oncology Mazumdar Shaw Medical Centre, Narayana Health Bangalore India
| | - Naveen Hedne Chandrasekhar
- Department of Head and Neck Surgical Oncology Mazumdar Shaw Medical Centre, Narayana Health Bangalore India
| | - Vikram Kekatpure
- Department of Head and Neck Surgical Oncology Mazumdar Shaw Medical Centre, Narayana Health Bangalore India
| | - Moni Abraham Kuriakose
- Department of Head and Neck Surgical Oncology Mazumdar Shaw Medical Centre, Narayana Health Bangalore India
| | | | - Arun Mitra
- Department of Surgical Oncology Cancer Institute (WIA) Chennai India
| | - Arun Pattatheyil
- Department of Head and Neck Surgical Oncology Tata Medical Centre Kolkata India
| | - Prateek Jain
- Department of Head and Neck Surgical Oncology Tata Medical Centre Kolkata India
| | - Subramania Iyer
- Department of Head and Neck Surgical Oncology Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham Kochi India
| | | | - Narayana Subramaniam
- Department of Head and Neck Surgical Oncology Mazumdar Shaw Medical Centre, Narayana Health Bangalore India
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Jie W, Bai J, Yan J, Chi Y, Li BB. Multi-Site Tumour Sampling Improves the Detection of Intra-Tumour Heterogeneity in Oral and Oropharyngeal Squamous Cell Carcinoma. Front Med (Lausanne) 2021; 8:670305. [PMID: 34041255 PMCID: PMC8141800 DOI: 10.3389/fmed.2021.670305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/08/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Oral squamous cell carcinoma (OSCC) and oropharyngeal squamous cell carcinoma (OPSCC) are very common in head and neck malignancy. Intratumour heterogeneity (ITH) may hamper their responses to treatment. Hence, novel tumour sampling methods that reflect ITH are required. In this study, we investigated the clinical significance of multi-site tumour sampling (MSTS) to detect ITH in OSCC and OPSCC. Methods: One hundred eighty-two paired specimens were sampled by routine sampling (RS) or MSTS, respectively. Histologically, tumour grade, peri-tumoural vascular and lymphatic growth, perineural permeation, tumour necrosis, and muscle invasion were assessed. Immunohistochemically, the positive and average detection rates of P53(mutant), ki67 and CyclinD1 were detected. The exon 9 and exon 20 mutations of PIK3CA gene and the methylation status of the CDKN2A promoter were analysed. Results: Microscopically, the detection rate of perineural permeation, the detection density of peri-tumoural vascular and lymphatic growth, necrosis and muscle invasion in MSTS were significantly more frequent than those in RP (P < 0.05, P < 0.05, P < 0.01, P < 0.01). MSTS resulted in a higher detection rate of P53 (mutant), ki67, and CyclinD1 expression than did RS, but the difference was not significant. MSTS's detection rates in PIK3CA gene mutation and gene methylation sequencing in CDKN2A gene promoter region were both higher than RP (P < 0.05, P < 0.01). To be emphasised, the hotspot mutation H1047Rwas detected in one MSTS specimen (case 24M5) but in no RS specimens. Conclusions: This study verified that MSTS's advantage in the reflection of morphological and molecular characteristics of OSCC and OPSCC. MSTS was more representative than RP. Therefore, MSTS can compensate the RP limitations in ITH detection especially in large tumours.
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Affiliation(s)
- Weiping Jie
- Department of Oral Pathology, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing, China.,Research Unit of Precision Pathologic Diagnosis in Tumours of the Oral and Maxillofacial Regions, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiaying Bai
- Department of Oral Pathology, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing, China.,Research Unit of Precision Pathologic Diagnosis in Tumours of the Oral and Maxillofacial Regions, Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Yan
- Department of Oral Pathology, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing, China.,Research Unit of Precision Pathologic Diagnosis in Tumours of the Oral and Maxillofacial Regions, Chinese Academy of Medical Sciences, Beijing, China
| | - Yanting Chi
- Department of Oral Pathology, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing, China.,Research Unit of Precision Pathologic Diagnosis in Tumours of the Oral and Maxillofacial Regions, Chinese Academy of Medical Sciences, Beijing, China
| | - Bin-Bin Li
- Department of Oral Pathology, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing, China.,Research Unit of Precision Pathologic Diagnosis in Tumours of the Oral and Maxillofacial Regions, Chinese Academy of Medical Sciences, Beijing, China
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Margalit DN, Sacco AG, Cooper JS, Ridge JA, Bakst RL, Beadle BM, Beitler JJ, Chang SS, Chen AM, Galloway TJ, Koyfman SA, Mita C, Robbins JR, Tsai CJ, Truong MT, Yom SS, Siddiqui F. Systematic review of postoperative therapy for resected squamous cell carcinoma of the head and neck: Executive summary of the American Radium Society appropriate use criteria. Head Neck 2021; 43:367-391. [PMID: 33098180 PMCID: PMC7756212 DOI: 10.1002/hed.26490] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The aims of this systematic review are to (a) evaluate the current literature on the impact of postoperative therapy for resected squamous cell carcinoma of the head and neck (SCCHN) on oncologic and non-oncologic outcomes and (b) identify the optimal evidence-based postoperative therapy recommendations for commonly encountered clinical scenarios. METHODS An analysis of the medical literature from peer-reviewed journals was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. Prospective studies and methodology-based systematic reviews and meta-analyses of postoperative therapy for SCCHN were identified by searching Medline (OVID) and EMBASE (Elsevier) using controlled vocabulary terms (ie, National Library of Medicine Medical Subject Headings [MeSH], EMTREE). Study screening and selection was performed with Covidence software and full-text review. The RAND/UCLA appropriateness method was used by the expert panel to rate the appropriate use of postoperative therapy, and the modified Delphi method was used to come to consensus. RESULTS A total of 5660 studies were identified and screened using the title and abstract, leading to 201 studies assessed for relevance using full-text review. After limitation to the eligibility criteria, 101 studies from 1977 to 2020 were identified, including 77 with oncologic endpoints and 24 with function and quality of life endpoints. All studies reported staging prior to the implementation of American Joint Committee on Cancer (AJCC-8). CONCLUSIONS Prospective clinical studies and systematic reviews identified through the PRISMA systematic review provided good evidence for consensus statements regarding the appropriate use of postoperative therapy for resected SCCHN. Further research is needed in domains where consensus by the expert panel could not be achieved for the appropriateness of specific postoperative therapeutic interventions.
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Affiliation(s)
- Danielle N. Margalit
- Dana‐Farber/Brigham & Women's Cancer Center, Harvard Medical SchoolBostonMassachusettsUSA
| | | | | | | | | | - Beth M. Beadle
- Stanford University School of MedicineStanfordCaliforniaUSA
| | | | | | | | | | | | - Carol Mita
- Countway Library, Harvard Medical SchoolBostonMassachusettsUSA
| | | | | | - Minh T. Truong
- Boston University School of MedicineBostonMassachusettsUSA
| | - Sue S. Yom
- University of CaliforniaSan FranciscoCaliforniaUSA
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10
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Parikh AS, Fuller JC, Lehmann AE, Goyal N, Gray ST, Lin DT. Prognostic Impact of Adverse Pathologic Features in Sinonasal Squamous Cell Carcinoma. J Neurol Surg B Skull Base 2020; 82:e114-e119. [PMID: 34306926 DOI: 10.1055/s-0040-1710516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/17/2020] [Indexed: 10/24/2022] Open
Abstract
Objective This study aimed to describe the impact of adverse clinical and pathologic features in sinonasal squamous cell carcinoma (SCC). Design This study is designed with retrospective chart review. Setting The present study is conducted at a tertiary care institution. Participants All patients treated surgically for sinonasal SCC at our tertiary care institution between January 2006 and December 2013. Main Outcome Measures Overall survival (OS) and disease free survival (DFS) are the final measurement of this study. Results Forty-eight patients were identified. Mean age at surgery was 65.8 years, and mean follow-up time was 40.7 months. Eighteen patients (38%) had T1-T3 disease, while 30 patients (63%) had T4 disease. Seven patients (8.3%) had nodal disease at presentation. At 2, 5, and 10 years, OS was 71, 54, and 48%, respectively, while DFS was 64, 51, and 45%, respectively. Twelve patients (25%) experienced local recurrences with mean time to recurrence of 15.3 months. Twenty-five patients (52%) had positive margins, 24 (50%) had high-grade tumors, 18 (38%) had perineural invasion (PNI), and 15 (31%) had lymphovascular invasion (LVI). In the univariate analysis, T4 disease (risk ratio [RR] = 2.7) and high grade (RR = 2.4) had a significant association with DFS. In the multivariate analysis, high grade (RR = 4.0 and 4.5) and LVI (RR = 4.1 and 4.7) had a significant association with OS and DFS. Conclusion Our single-institution experience of 48 patients suggests that high grade and LVI are independently associated with survival outcomes in sinonasal SCC, while PNI and microscopically positive margins do not have a significant impact.
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Affiliation(s)
- Anuraag S Parikh
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States.,Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, United States
| | - Jennifer C Fuller
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States.,Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, United States
| | - Ashton E Lehmann
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States.,Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, United States
| | - Neerav Goyal
- Department of Otolaryngology-Head and Neck Surgery, Penn State University, Hershey, Pennsylvania, United States
| | - Stacey T Gray
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States.,Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, United States
| | - Derrick T Lin
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States.,Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, United States
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11
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Mäkitie A, Kamali A, Mroueh R, Lindford A, Koivunen P, Autio T, Lassus P, Halle M, Bäck L, Palmgren B, Hammarstedt-Nordenvall L. A descriptive study highlighting the differences in the treatment protocol for oral tongue cancer in Sweden and Finland. Acta Otolaryngol 2020; 140:188-194. [PMID: 31852347 DOI: 10.1080/00016489.2019.1699663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background and aims: Stage II cancer of the tongue is mostly managed surgically both locally and regionally. However, indications for postoperative radiotherapy and reconstructive options vary between centers. This paper aims to describe differences in treatment in a geographically homogenous cohort.Methods: A retrospective comparison was made between two cohorts of clinical T2N0 tongue cancer from Finland and Sweden. The Finnish cohort included 75 patients and the Swedish 54. All patients had curative intent of treatment and no previous head and neck cancer. Data analyzed consisted of pathological stage, size and thickness of tumor, frequency of reconstruction, radiotherapy delivered, and survival.Results: The Finnish cohort included a higher proportion of patients managed with reconstructive surgery (67%) than the Swedish cohort (0%), p < .00001. More patients were treated with postoperative radiotherapy (84%) in the Swedish cohort than in the Finnish (54%), p < .0002. The Finnish cohort had a higher level of survival and included more frequent downstaging (cTNM to pTNM).Conclusions and significance: Our data indicate a major difference in the management of T2N0 oral tongue cancer. The optimal cut-off size and growth pattern of the tumor warranting reconstruction should be further evaluated in a prospective manner considering both survival and quality of life.
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Affiliation(s)
- Antti Mäkitie
- Department of Otorhinolaryngology – Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Alexander Kamali
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rayan Mroueh
- Department of Otorhinolaryngology – Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andrew Lindford
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Petri Koivunen
- Department of Otorhinolaryngology – Head and Neck Surgery, Oulu University Hospital, Oulu, Finland
| | - Timo Autio
- Department of Otorhinolaryngology – Head and Neck Surgery, Oulu University Hospital, Oulu, Finland
| | - Patrik Lassus
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Martin Halle
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Leif Bäck
- Department of Otorhinolaryngology – Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Björn Palmgren
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lalle Hammarstedt-Nordenvall
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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12
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Ivaldi E, Di Mario D, Paderno A, Piazza C, Bossi P, Iacovelli NA, Incandela F, Locati L, Fallai C, Orlandi E. Postoperative radiotherapy (PORT) for early oral cavity cancer (pT1-2,N0-1): A review. Crit Rev Oncol Hematol 2019; 143:67-75. [DOI: 10.1016/j.critrevonc.2019.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 06/20/2019] [Accepted: 08/12/2019] [Indexed: 11/26/2022] Open
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13
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Hasmat S, Ebrahimi A, Gao K, Low THH, Palme C, Gupta R, Clark J. Multifocal perineural invasion is a better prognosticator than depth of invasion in oral squamous cell carcinoma. Head Neck 2019; 41:3992-3999. [PMID: 31487105 DOI: 10.1002/hed.25940] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/24/2019] [Accepted: 08/15/2019] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Prognostic significance of perineural invasion (PNI) in oral squamous cell carcinoma (OSCC) characterized as unifocal and multifocal was compared to depth of invasion (DOI) and extranodal extension (ENE). MATERIALS AND METHODS Univariable and multivariable analyses of 861 consecutive patients with OSCC undergoing treatment between 1995 and 2018 were performed, with local failure (LF) and disease-specific mortality (DSS) as the primary endpoints. RESULTS After adjusting for other adverse histopathological factors and adjuvant therapy, multifocal PNI was associated with a greater risk of LF (P = .01) and DSS (P = 0.02) compared to DOI. The effect of multifocal PNI was comparable to the effect of nodal metastases without ENE (P = 0.02). LF and DSS were not improved by the administration of adjuvant radiotherapy within unifocal or multifocal PNI groups. CONCLUSION Multifocal PNI is associated with a greater risk of death in OSCC than DOI. Its effect is comparable to that of nodal metastases (without ENE).
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Affiliation(s)
- Shaheen Hasmat
- Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Ardalan Ebrahimi
- Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Medical School College of Health and Medicine, Australian National University, Canberra, Australia
| | - Kan Gao
- Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Tsu-Hui Hubert Low
- Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | | | - Ruta Gupta
- Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Central Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Jonathan Clark
- Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
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14
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Chang WC, Chang CF, Li YH, Yang CY, Su RY, Lin CK, Chen YW. A histopathological evaluation and potential prognostic implications of oral squamous cell carcinoma with adverse features. Oral Oncol 2019; 95:65-73. [PMID: 31345396 DOI: 10.1016/j.oraloncology.2019.06.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/16/2019] [Accepted: 06/07/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVES This study aimed to evaluate the adverse clinicopathologic features of oral squamous cell carcinoma (OSCC), including margin status, depth of invasion, lymphovascular invasion, perineural invasion, and extranodal extension that significantly affect survival outcomes. MATERIALS AND METHODS This retrospective cross-sectional study included 341 patients with OSCC who underwent therapeutic surgical treatment in Taiwan. The Kaplan-Meier method was used to estimate survival outcomes. A multivariable Cox regression model was used to evaluate the associations of various clinicopathologic features with 5-year overall survival (OS) outcomes in patients with pN0 and pN+ tumors. RESULTS Overall, the patients had 5-year OS and progression-free survival rates of 60.0 and 47.9%, respectively. In the pN0 group, the multivariate analysis identified a positive margin (odds ratio [OR] = 16.3, 95% confidence interval [95% CI]: 3.7-72.3; P = 0.001), depth of invasion >5 mm (OR = 2.1, 95% CI: 1.2-3.7; P = 0.012), presence of lymphovascular space invasion (OR = 5.4, 95% CI: 1.3-22.0; P = 0.018), and presence of perineural invasion (OR = 4.3, 95% CI: 1.7-11.1; P = 0.002) as independent and significant prognosticators of OS. In the pN+ group, only the presence of extranodal extension independently predicted OS (OR = 1.7, 95% CI: 1.1-2.7; P = 0.0026). CONCLUSIONS When determining survival prognosis for patients with a pN0 status, we recommended including all adverse features. In contrast, extranodal extension was the most important prognostic factor for patients with a pN+ status.
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Affiliation(s)
- Wei-Chin Chang
- Department of Oral and Maxillofacial Surgery, Tri-Service General Hospital, Taipei City, Taiwan, ROC; School of Dentistry, National Defense Medical Center, Taipei City, Taiwan, ROC
| | - Ching-Fen Chang
- Department of Internal Medicine, China Medical University Hospital, Taichung City, Taiwan, ROC
| | - Yu-Hsuan Li
- Department of Oral and Maxillofacial Surgery, Tri-Service General Hospital, Taipei City, Taiwan, ROC; School of Dentistry, National Defense Medical Center, Taipei City, Taiwan, ROC
| | - Cheng-Yu Yang
- School of Dentistry, National Defense Medical Center, Taipei City, Taiwan, ROC
| | - Ruei-Yu Su
- Department of Pathology, Division of Clinical Pathology, Tri-Service General Hospital, Taipei City, Taiwan, ROC; Department of Pathology and Laboratory Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan, ROC; National Defense Medical Center, Taipei City, Taiwan, ROC
| | - Chih-Kung Lin
- Department of Pathology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei City, Taiwan, ROC
| | - Yuan-Wu Chen
- Department of Oral and Maxillofacial Surgery, Tri-Service General Hospital, Taipei City, Taiwan, ROC; School of Dentistry, National Defense Medical Center, Taipei City, Taiwan, ROC.
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