Recurrence and salvage treatment of squamous cell carcinoma of the oral cavity

Patterns of failure after salvage head and neck surgery

BACKGROUND

Advancements in immunotherapy for recurrent head and neck cancer have necessitated a better understanding of salvage surgical outcomes. This study aimed to determine patterns of failure following salvage head and neck surgery.

METHODS

A retrospective cohort study was conducted of 280 patients who underwent salvage surgery for recurrent mucosal squamous cell carcinoma from 1997 to 2018. Cumulative incidence was calculated using the nonparametric Aalen-Johansen estimator. Time to recurrence (TTR) and overall survival (OS) were estimated using the Kaplan-Meier method and multivariable Cox proportional hazard models were used to evaluate associated factors.

RESULTS

The 2 and 5-year cumulative incidence rates of second recurrence were 48.3 % (95 % CI 42.4-54.3) and 54.9 % (95 % CI 48.9-60.8), respectively. At 5 years, second locoregional recurrence was twice as common as distant recurrence (41.5 % [95 % CI 35.6-47.4] vs. 21.7 % [95 % CI 16.8-26.6]). The median TTR was 21.1 months (95 % CI 4.4-34.8), which varied by site (38.2 larynx/hypopharynx, 13.9 oral cavity, 8.3 sinonasal, and 7.8 oropharynx, P=.0001). The median OS was 32.1 months (95 % CI 24.1-47.6) and was worse for patients who were Black (hazard ratio [HR] 2.15, 95 % CI 1.19-3.9), current smokers (HR 2.73, 95 % CI 1.53-4.88), former smokers (HR 2.00, 95 % CI 1.19-3.35), ≥ 60 years of age (HR 1.41, 95 % CI 1.01-1.97), or received multimodal primary therapy (HR 1.98, 95 % CI 1.26-3.13).

CONCLUSION

Rates of recurrence and mortality after salvage surgery were poor but worse for patients who were Black, older, smoked, had initial multimodal therapy, or had sinonasal or oropharyngeal cancers.

Induction chemotherapy with paclitaxel, carboplatin, and cetuximab (PCE) followed by chemoradiotherapy for unresectable locoregional recurrence after curative surgery in patients with squamous cell carcinoma of the head and neck

Background

The significance of induction chemotherapy (IC) in the treatment of squamous cell carcinoma of the head and neck (SCCHN) with unresectable locoregional recurrence after curative surgery has not been clarified. The aim of this study was to evaluate the efficacy of IC followed by chemoradiotherapy (CRT) in these patients.

Methods

Among patients with unresectable locoregional recurrent SCCHN who had not undergone prior irradiation and were eligible for cisplatin, we conducted a retrospective analysis of patients who received CRT following IC with paclitaxel, carboplatin, or cetuximab (IC-PCE group) and those who received CRT without prior IC (CRT group) between June 2013 and August 2021.

Result

Forty-two patients were included. The CRT group and IC-PCE group consisted of 15 and 27 patients, respectively. Primary site was the oral cavity (n=25), oropharynx (n=3), hypopharynx (n=13) and larynx (n=1). Objective response rate (ORR) with IC-PCE was 55.6%; 24 patients (88.9%) subsequently received CRT. ORR after completion of CRT was significantly better in the IC-PCE group (95.8% in the IC-PCE group vs. 66.7% in the CRT group, p=0.024). Progression-free survival (PFS) of the total population on median follow-up of 2.4 years (range: 0.8-7.3) tended to be better in the IC-PCE group (2-year PFS: 55.6% in the IC-PCE group vs. 33.3% in the CRT group, log-rank p=0.176), especially in oral cancer (2-year PFS: 37.5% in the IC-PCE group vs. 0% in the CRT group, log-rank p=0.015).

Conclusion

Therapeutic strategies including IC-PCE in patients with unresectable locoregional recurrent SCCHN after curative surgery may contribute to improved prognosis, especially in oral cancer.

Recurrence of oral squamous cell carcinoma in surgically treated patients at Khartoum Teaching Dental Hospital retrospective cross-sectional study

BACKGROUND

In terms of survival rate, recurrent oral squamous cell carcinoma (OSCC) after primary surgery is considered as a poor prognostic indicator.

OBJECTIVE

This study aims to determine the incidence of OSCC recurrence among patients treated at Khartoum Teaching Dental Hospital (KTDH) and possible risk factors associated with it.

METHODS

Records of 303 patients with a history of radical surgery were retrieved from the hospital's archives, and the histopathological records were retrieved from the archival specimens of Professor Ahmed Suleiman Oral Pathology Laboratory, Faculty of Dentistry, and University of Khartoum.

RESULTS

Advanced stages of OSCC (III, IV) were associated with higher recurrence rates, and the poorly differentiated OSCC was the commonest recurrent type.

CONCLUSION

The condition of the surgical margin is a significant predictor of OSCC recurrence and tumor stage. The tumor site, the type of surgical resection, and the tumor differentiation were also identified as significant factors influencing the recurrence of OSCC.

Long-term outcomes of patients with oral cavity cancer receiving postoperative radiotherapy after salvage neck dissection for cervical lymph node recurrence

BACKGROUNDS

We aimed to clarify the outcomes of postoperative radiotherapy (PORT) after salvage neck dissection for cervical lymph node (LN) recurrence in oral cavity cancer.

METHODS

We retrospectively evaluated overall survival (OS), recurrence-free survival (RFS), recurrence patterns, and adverse events of 51 patients with high-risk features receiving PORT after salvage neck dissection between 2009 and 2019.

RESULTS

After a median follow-up of 7.4 years from PORT initiation, the 7-year OS and RFS rates were 66.3% (95% CI: 54.0-81.3) and 54.6% (95% CI: 42.1-70.9), respectively. Age <70 years and isolated LN recurrence were significantly associated with longer OS and RFS. Among the 22 patients who experienced recurrence, 14 experienced recurrence within the radiation field. PORT-related grade 3 acute mucositis (35%) and late adverse events (osteoradionecrosis [4%] and laryngeal stenosis [2%]) were observed.

CONCLUSIONS

PORT after salvage neck dissection for cervical LN recurrence achieved good survival with acceptable toxicity.

Dual Sec62/Ki67 immunocytochemistry of liquid-based cytological preparations represents a highly valid biomarker for non-invasive detection of head and neck squamous cell carcinomas

BACKGROUND

Head and neck squamous cell carcinomas (HNSCC) are frequently diagnosed in advanced stages, which limits therapeutic options and results in persistently poor patient outcomes. The aim of this study was to use liquid-based swab cytology (LBC) in combination with dual immunocytochemical detection of migration and proliferation markers Sec62 and Ki67 in order to allow non-invasive early detection of HNSCC as well as to analyse the diagnostic validity of this method for predicting the malignancy of suspicious oral lesions.

METHODS

104 HNSCC patients and 28 control patients, including healthy patients (n = 17), papilloma (n = 1) and leukoplakia patients (n = 10), were included in this study. For all patients, an LBC swab followed by simultaneous immunocytochemical detection of Sec62 and Ki67 was performed. Immunocytochemical as well as cytopathological results were correlated with histological diagnoses and clinical findings.

RESULTS

All HNSCC patients (100%) showed dual Sec62/Ki67 positivity, and all control patients except for the papilloma patient were negative for Sec62/Ki67 (96.4%), resulting in a 100% sensitivity and 96.4% specificity of Sec62/Ki67 dual stain for non-invasive detection of HNSCC. The positive predictive value was 99% and the negative predictive value was 100%. Sec62 expression levels showed a positive correlation with tumour de-differentiation (p = 0.0489).

CONCLUSION

Simultaneous immunocytochemical detection of Sec62/Ki67 using LBC represents a promising non-invasive and easy-to-apply tool for the early detection of HNSCC in routine clinical practice. This novel technique can help to avoid incisional biopsies and reduce the frequency with which general anaesthesia is used in diagnostic procedures in patients with suspicious oral lesions.

EGFR-targeted fluorescence molecular imaging for intraoperative margin assessment in oral cancer patients: a phase II trial

Inadequate surgical margins occur frequently in oral squamous cell carcinoma surgery. Fluorescence molecular imaging (FMI) has been explored for intraoperative margin assessment, but data are limited to phase-I studies. In this single-arm phase-II study (NCT03134846), our primary endpoints were to determine the sensitivity, specificity and positive predictive value of cetuximab-800CW for tumor-positive margins detection. Secondary endpoints were safety, close margin detection rate and intrinsic cetuximab-800CW fluorescence. In 65 patients with 66 tumors, cetuximab-800CW was well-tolerated. Fluorescent spots identified in the surgical margin with signal-to-background ratios (SBR) of ≥2 identify tumor-positive margins with 100% sensitivity, 85.9% specificity, 58.3% positive predictive value, and 100% negative predictive value. An SBR of ≥1.5 identifies close margins with 70.3% sensitivity, 76.1% specificity, 60.5% positive predictive value, and 83.1% negative predictive value. Performing frozen section analysis aimed at the fluorescent spots with an SBR of ≥1.5 enables safe, intraoperative adjustment of surgical margins.

Post-operative PET/CT improves the detection of early recurrence of squamous cell carcinomas of the oral cavity

BACKGROUND

We evaluate the impact of post-operative 18-fluorodeoxyglucose positron emission tomography with computed tomography (PET/CT) for radiation planning on the detection of early recurrence (ER) and treatment outcomes in oral squamous cell carcinoma (OSCC).

METHODS

We retrospectively reviewed the records of patients treated with post-operative radiation between 2005 and 2019 for OSCC at our institution. Extracapsular extension and positive surgical margins were classified as high risk features; pT3-4, node positivity, lymphovascular invasion, perineural invasion, tumor thickness >5 mm, and close surgical margins were considered intermediate risk features. Patients with ER were identified. Inverse probability of treatment weighting (IPTW) was used to adjust for imbalances between baseline characteristics.

RESULTS

391 patients with OSCC were treated with post-operative radiation. 237 (60.6%) patients underwent post-operative PET/CT planning vs. 154 (39.4%) who were planned with CT only. Patients screened with post-operative PET/CT were more likely to be diagnosed with ER than those planned with CT only (16.5 vs. 3.3%, p < 0.0001). Among patients with ER, those with intermediate features were more likely than those high risk features to undergo major treatment intensification, including re-operation, the addition of chemotherapy, or intensification of radiation by ≥ 10 Gy (91% vs. 9%, p < 0.0001). Post-operative PET/CT was associated with improved disease-free and overall survival for patients with intermediate risk features (IPTW log-rank p = 0.026 and p = 0.047, respectively) but not high risk features (IPTW log-rank p = 0.44 and p = 0.96).

CONCLUSIONS

Use of post-operative PET/CT is associated with increased detection of early recurrence. Among patients with intermediate risk features, this may translate to improved disease-free survival.

Early relapse is an adverse prognostic factor for survival outcomes in patients with oral cavity squamous cell carcinoma: results from a nationwide registry study

BACKGROUND

The prognostic significance of the relapse interval in patients with resected oral cavity squamous cell carcinoma (OCSCC) is a matter of ongoing debate. In this large-scale, registry-based, nationwide study, we examined whether the time interval between surgery and the first disease relapse may affect survival outcomes in Taiwanese patients with OCSCC.

METHODS

Data made available by the Taiwan Health Promotion Administration as of 2004 were obtained. The study cohort consisted of patients who were included in the registry between 2011 and 2017. Disease staging was performed according to the American Joint Committee on Cancer (AJCC) Staging Manual, Eight Edition. We retrospectively reviewed the clinical records of 13,789 patients with OCSCC who received surgical treatment. A total of 2327 (16.9%) patients experienced a first disease relapse. The optimal cutoff value for the relapse interval was 330 days when both 5-year disease-specific survival (DSS) and overall survival (OS) (≤ 330/>330 days, n = 1630/697) were taken into account. In addition, we undertook a propensity score (PS)-matched analysis of patients (n = 654 each) with early (≤ 330 days) versus late (> 330 days) relapse.

RESULTS

The median follow-up time in the entire study cohort was 702 days (433 and 2001 days in the early and late relapse groups, respectively). Compared with patients who experienced late relapse, those with early relapse showed a higher prevalence of the following adverse prognostic factors: pT4, pN3, pStage IV, poor differentiation, depth of invasion ≥ 10 mm, and extra-nodal extension. Multivariable analysis revealed that early relapse was an independent adverse prognostic factor for both 5-year DSS and OS (average hazard ratios [AHRs]: 3.24 and 3.91, respectively). In the PS-matched cohort, patients who experienced early relapse showed less favorable 5-year DSS: 58% versus 30%, p < 0.0001 (AHR: 3.10 [2.69 - 3.57]) and OS: 49% versus 22%, p < 0.0001 (AHR: 3.32 [2.89 - 3.81]).

CONCLUSION

After adjustment for potential confounders and PS matching, early relapse was an adverse prognostic factor for survival outcomes in patients with OCSCC. Our findings may have significant implications for risk stratification.

Identification and validation of neurotrophic factor-related genes signature in HNSCC to predict survival and immune landscapes

Background: Head and neck squamous cell carcinoma (HNSCC) is the seventh most common type of cancer worldwide. Its highly aggressive and heterogeneous nature and complex tumor microenvironment result in variable prognosis and immunotherapeutic outcomes for patients with HNSCC. Neurotrophic factor-related genes (NFRGs) play an essential role in the development of malignancies but have rarely been studied in HNSCC. The aim of this study was to develop a reliable prognostic model based on NFRGs for assessing the prognosis and immunotherapy of HNSCC patients and to provide guidance for clinical diagnosis and treatment. Methods: Based on the TCGA-HNSC cohort in the Cancer Genome Atlas (TCGA) database, expression profiles of NFRGs were obtained from 502 HNSCC samples and 44 normal samples, and the expression and prognosis of 2601 NFRGs were analyzed. TGCA-HNSC samples were randomly divided into training and test sets (7:3). GEO database of 97 tumor samples was used as the external validation set. One-way Cox regression analysis and Lasso Cox regression analysis were used to screen for differentially expressed genes significantly associated with prognosis. Based on 18 NFRGs, lasso and multivariate Cox proportional risk regression were used to construct a prognostic risk scoring system. ssGSEA was applied to analyze the immune status of patients in high- and low-risk groups. Results: The 18 NFRGs were considered to be closely associated with HNSCC prognosis and were good predictors of HNSCC. The multifactorial analysis found that the NFRGs signature was an independent prognostic factor for HNSCC, and patients in the low-risk group had higher overall survival (OS) than those in the high-risk group. The nomogram prediction map constructed from clinical characteristics and risk scores had good prognostic power. Patients in the low-risk group had higher levels of immune infiltration and expression of immune checkpoints and were more likely to benefit from immunotherapy. Conclusion: The NFRGs risk score model can well predict the prognosis of HNSCC patients. A nomogram based on this model can help clinicians classify HNSCC patients prognostically and identify specific subgroups of patients who may have better outcomes with immunotherapy and chemotherapy, and carry out personalized treatment for HNSCC patients.

Outcomes for recurrent oral cavity squamous cell carcinoma

OBJECTIVES

We sought to determine overall survival (OS), prognostic factors, cost, and functional outcomes after surgery for locally recurrent oral cavity squamous cell carcinoma (OCSCC).

MATERIALS AND METHODS

We retrospectively reviewed 399 cases of locally recurrent OCSCC from 1997 to 2011, of which 259 patients were treated with salvage surgery. Survival and prognostic factors were evaluated using univariable and multivariable Cox regression, the Kaplan-Meier method, and the log-rank test.

RESULTS

The 5-year OS for patients undergoing surgical salvage, nonsurgical therapy, or supportive care was 44.2%, 1.5%, and 0%, respectively. For patients who underwent surgical salvage, 133 (51%) patients experienced a second recurrence at a median of 17 months. Factors associated with OS included disease-free interval ≤ 6 months (P =.0001), recurrent stage III-IV disease (P <.0001), and prior radiation (P =.0001). Patients with both advanced stage and prior radiation had a 23% 5-year OS, compared with 70% for those with neither risk (P <.001). Functionally, 85% of patients had > 80% speech intelligibility and 81% were able to eat by mouth following salvage surgery. Of the patients who required tracheostomy, 78% were decannulated. The adjusted median hospital and professional charges for patients were $129,696 (range $9,238-$956,818).

CONCLUSIONS

Patients with recurrent OCSCC who underwent salvage surgery have favorable functional outcomes with half of alive at 5 years but poorer OS for advanced disease, disease-free interval ≤ 6 months, and prior radiation. Additionally, treatment is associated with high cost, and about half of patients ultimately develop another recurrence.

Neoadjuvant immunoradiotherapy in patients with locally advanced oral cavity squamous cell carcinoma: a retrospective study

BACKGROUND

Although anti-programmed death receptor-1 (PD-1) agents have been evaluated in the neoadjuvant setting for the treatment of locally advanced head and neck cancer, including oral cavity squamous cell carcinoma (OCSCC), the overall response rate is modest. The aim of the present study was to evaluate the efficacy and safety of neoadjuvant nivolumab in combination with stereotactic body radiotherapy (SBRT) for the treatment of locally advanced OCSCC.

METHODS

OCSCC patients who underwent surgical resection within 6 months of treatment with nivolumab plus SBRT from December 2018 to February 2021 were analyzed retrospectively.

RESULTS

All 30 eligible patients enrolled in this study well tolerated the neoadjuvant treatment with no serious adverse events (AEs). Of them, 27 patients (90.0%) achieved R0 resection, and 5 patients (16.7%) experienced procedure-associated complications. The complete response (CR), partial response (PR) and stable disease (SD) were 10.0%, 46.7% and 43.3% respectively. The major pathological response (MPR), complete pathological response (pCR) and clinical to pathological downstaging rate were 60.0%, 33.3% and 83.3% respectively. During the median follow-up period of 13.5 months, 26 patients (86.7%) who underwent surgical resection remained alive. The disease-free survival (DFS) and overall survival (OS) at 24 months were 70.4% and 76.4% respectively.

CONCLUSIONS

Neoadjuvant nivolumab plus SBRT is safe and efficacious, and could be used as a potential neoadjuvant option for the treatment of patients with locally advanced OCSCC.

Development and Validation of an Oral Cavity Cancer Outcomes Prediction Score Incorporating Patient-Derived Xenograft Engraftment

IMPORTANCE

Patient-derived xenografts (PDXs) offer the opportunity to identify patients with oral cavity squamous cell carcinoma (OSCC) who are at risk for recurrence and optimize clinical decision-making.

OBJECTIVE

To develop and validate a prediction score for locoregional failure (LRF) and distant metastases (DM) in OSCC that incorporates PDX engraftment in addition to known clinicopathological risk factors.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, PDX models were generated from patients with OSCC treated with curative intent at Princess Margaret Cancer Centre (Toronto, Canada) between 2006 and 2018. The cohort included 288 patients (aged ≥18 years) with a new diagnosis of nonmetastatic (M0) OSCC whose tumor samples were available for engraftment under the skin of xenograft mice. Patients were scored as a nonengrafter if PDX formation did not occur within 6 months. Data analysis was performed between August 2006 and May 2018.

INTERVENTIONS

All patients received up-front curative-intent surgery followed by either observation or postoperative radiation with or without concurrent chemotherapy based on institutional guidelines.

MAIN OUTCOMES AND MEASURES

Main outcomes were LRF, DM, and overall survival (OS). Multivariable analysis (MVA) was used to identify predictors of LRF and DM. Factors retained in the final MVA were used to construct a prediction score and classify patients into risk groups.

RESULTS

Overall, 288 patients (mean [SD] age at diagnosis, 63.3 [12.3] years; 112 [39%] women and 176 [61%] men) with OSCC were analyzed. The MVA identified pT3-4, pathologic extranodal extension, and engraftment as predictors of LRF and DM. Patients whose tumors engrafted (n = 198) were more likely to develop LRF (hazard ratio [HR], 1.98; 95% CI, 1.24-3.18) and DM (HR, 2.64; 95% CI, 1.21-5.75) compared with nonengrafters. A prediction score based on the aforementioned variables identified patients at high risk and low risk for LRF (43.5% vs 26.5%), DM (38.2% vs 8.4%), and inferior OS (34% vs 66%) at 5 years. Additionally, rapid engraftment was shown to be similarly prognostic, with rapid engrafters demonstrating higher rates of relapse and poor OS.

CONCLUSIONS

In this cohort study, a prediction score using OSCC PDX engraftment, in conjunction with pT3-4 and pathologic extranodal extension, was associated with improved prognostic utility of existing clinical models and predicted patients at risk for LRF, DM, and poor survival.

Salvage Surgery in Recurrent Oral Squamous Cell Carcinoma

More than half of patients with oral cancer recur even after multimodality treatment and recurrent oral cancers carry a poorer prognosis when compared to other sites of head and neck. The best survival outcome in a recurrent setting is achieved by salvage surgery; however, objective criteria to select an ideal candidate for salvage surgery is difficult to frame, as the outcome depends on various treatment-, tumor-, and patient-related factors. The following is summarizes various tumor- and treatment-related factors that guide our decision-making to optimize oncologic and functional outcomes in surgical salvage for recurrent oral cancers. Short disease-free interval, advanced tumor stage (recurrent and primary), extracapsular spread and positive tumor margins in a recurrent tumor, regional recurrence, and multimodality treatment of primary tumor all portend worse outcomes after surgical salvage. Quality of life after surgical intervention has shown improvement over 1 year with a drastic drop in pain scores. Various trials are underway evaluating the combination of immunotherapy and surgical salvage in recurrent head and neck tumors, including oral cavity, which may widen our indications for salvage surgery with improved survival and preserved organ function.

Prognostic factors in salvage surgery for recurrent head and neck cancer: A systematic review and meta-analysis

INTRODUCTION

Although salvage surgery (SS) is considered the best curative choice in recurrent head and neck cancer, the identification of patients who can benefit the most from this treatment is challenging.

METHODS

We systematically reviewed the prognostic role of pre- and post-surgery factors in patients undergoing SS for recurrent head and neck cancer (oral cavity, oropharynx, hypopharynx, and larynx).

RESULTS

Twenty-five studies met the inclusion criteria out of 1280 screened citations. Pre-surgery factors significantly associated with worse overall survival were age>60 years, advanced initial stage, early recurrence, and regional recurrence; no heterogeneity between study emerged. Among post- surgery factors, worse survival emerged for positive surgical margins, extracapsular extension and perineural invasion.

CONCLUSION

The identification of pre-surgery factors associated with poor outcomes may help the selection of the best candidate to SS; alternative treatments should be considered for high-risk patients. Post-surgery predictors of worse prognosis may guide clinicians in tailoring patients' surveillance.

Neoadjuvant presurgical PD-1 inhibition in oral cavity squamous cell carcinoma

Oral cavity squamous cell carcinoma (OCSCC) is a prevalent surgically treated subset of head and neck cancer with frequent recurrence and poor survival. Immunotherapy has demonstrated efficacy in recurrent/metastatic head and neck cancer. However, whether antitumor responses could be fostered by neoadjuvant presurgical immunotherapy remains unclear. Using a Simon's two-stage design, we present results of a single-arm phase-II trial where 12 patients with stage II-IVA OCSCC received 3 to 4 biweekly doses of 3 mg/kg nivolumab followed by definitive surgical resection with curative intent. Presurgical nivolumab therapy in this cohort shows an overall response rate of 33% (n = 4 patients; 95% CI: 12%-53%). With a median follow up of 2.23 years, 10 out of 12 treated patients remain alive. Neoadjuvant nivolumab is safe, well-tolerated, and is not associated with delays in definitive surgical treatment in this study. This work demonstrates feasibility and safety for incorporation of nivolumab in the neoadjuvant setting for OCSCC (ClinicalTrials.gov: NCT03021993).

Outcomes of salvage treatment in patients with recurrent oral squamous cell carcinoma

BACKGROUND

The survival outcomes of different salvage treatments for patients with recurrent oral cancer remain unclear.

METHODS

A total of 556 patients with recurrent oral cancer between 2010 and 2015 were reviewed. Clinical/pathological risk factors and different salvage treatments were analyzed.

RESULTS

The 2-year disease-free survival rates after recurrence in patients not receiving salvage operation (305 patients), receiving salvage operation with (121 patients), and without (130 patients) major pathological risk factors (margin or extranodal extension) were 5.3%, 32.4%, and 77.2%, respectively (p < 0.001). The 2-year overall survival rates were 20.3%, 58.4%, and 89.2%, respectively (p < 0.001). A late-onset recurrence, salvage radiation, and salvage operation were independent factors for good disease-free and overall survival. Salvage radiation showed survival benefits among patients not indicated for salvage operations.

CONCLUSIONS

Salvage operation was the first choice for recurrent oral cancer. Patients who received the salvage operation without major risk factors had the best survival.

Assessment of tumor depth in oral tongue squamous cell carcinoma with multiparametric MRI: correlation with pathology

OBJECTIVES

To compare the correlation of depth of invasion (DOI) measured on multiple magnetic resonance imaging (MRI) sequences and pathological DOI, in order to determine the optimal MRI sequence for measurement.

METHODS

A total of 122 oral tongue squamous cell carcinoma (OTSCC) patients were retrospectively analyzed, who had received preoperative MRI and surgical resection. DOIs measured on fat-suppressed T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), dynamic enhanced-T1 high-resolution insotropic volume examination (e-THRIVE), and contrast-enhanced fat-suppressed T1WI (CE-T1WI) were respectively compared to those measured in pathologic specimens. The cutoff value of the best correlated MRI sequence was determined, and the T staging accuracy of MRI-derived DOI was evaluated.

RESULTS

DOI derived from e-THRIVE showed the best correlation (r = 0.936, p < 0.001) with pathological DOI. The area under the curve values of MRI-derived DOI distinguishing T1 stage from T2 stage and distinguishing T2 stage from T3 stage were 0.969 and 0.974, respectively. The T staging criteria of MRI-derived DOI were 6.2 mm and 11.4 mm, with a staging accuracy of 86.9% compared to pathological DOI criteria of 5 mm and 10 mm.

CONCLUSION

E-THRIVE was the optimal MR sequence to measure the MR-derived DOI, and DOI derived from e-THRIVE could serve as a potential cut-off value as a clinical T staging indicator of OTSCC.

KEY POINTS

• Multiparametric MRI helps radiologists to assess the neoplasm invasion in patients with oral tongue squamous cell carcinoma. • Retrospective study indicated that measurement was most accurate on enhanced-T1 high-resolution insotropic volume examination dynamic contrast enhancement images. • T staging of oral tongue squamous cell carcinoma was accurate according to the dynamic contrast enhancement MRI-derived depth of invasion.

Preoperative Immunotherapy in the Multidisciplinary Management of Oral Cavity Cancer

Despite advances in multimodal treatment for oral cavity squamous cell carcinoma, recurrence rates remain high, providing an opportunity for new therapeutic modalities that may improve oncologic outcomes. Much recent attention has been paid to the molecular interactions between the tumor cells with the adjacent peritumoral microenvironment, in which immunosuppressive molecular changes create a landscape that promotes tumor progression. The rationale for the introduction of immunotherapy is to reverse the balance of these immune interactions in a way that utilizes the host immune system to attack tumor cells. In the preoperative setting, immunotherapy has the advantage of priming the unresected tumor and the associated native immune infiltration, supercharging the adaptive anti-tumor immune response. It also provides the basis for scientific discovery where the molecular profile of responders can be interrogated to elucidate prognostic markers to aid in future patient selection. Preoperative immunotherapy is not without limitations. The risk of surgical delay due to immune adverse events must be carefully discussed by members of a multidisciplinary treatment team and patient selection will be critical. One day, the discovery of predictive biomarkers may allow for algorithms where pre-surgical immunotherapy decreases the size of surgical defect and impacts the intensity of adjuvant therapy leading to improved patient survival and decreased morbidity. With further study, immunotherapy could become a key component of future treatment algorithm.

Prognostic value of tumor mutational burden in patients with oral cavity squamous cell carcinoma treated with upfront surgery

Background

Oral cavity is the most prevalent site of head and neck squamous cell carcinomas (HNSCCs). Most often diagnosed at a locally advanced stage, treatment is multimodal with surgery as the cornerstone. The aim of this study was to explore the molecular landscape of a homogenous cohort of oral cavity squamous cell carcinomas (OCSCCs), and to assess the prognostic value of tumor mutational burden (TMB), along with classical molecular and clinical parameters.

Patients and methods

One hundred and fifty-one consecutive patients with OCSCC treated with upfront surgery at the Institut Curie were analyzed. Sequencing of tumor DNA from frozen specimens was carried out using an in-house targeted next-generation sequencing panel (571 genes). The impact of molecular alterations and TMB on disease-free survival (DFS) and overall survival (OS) was evaluated in univariate and multivariate analyses.

Results

Pathological tumor stage, extranodal spread, vascular emboli, and perineural invasion were associated with both DFS and OS. TP53 was the most mutated gene (71%). Other frequent molecular alterations included the TERT promoter (50%), CDKN2A (25%), FAT1 (17%), PIK3CA (14%), and NOTCH1 (15%) genes. Transforming growth factor-β pathway alterations (4%) were associated with poor OS (P = 0.01) and DFS (P = 0.02) in univariate and multivariate analyses. High TMB was associated with prolonged OS (P = 0.01 and P = 0.02, in the highest 10% and 20% TMB values, respectively), but not with DFS. Correlation of TMB with OS remained significant in multivariate analysis (P = 0.01 and P = 0.005 in the highest 10% and 20% TMB values, respectively). Pathological tumor stage combined with high TMB was associated with good prognosis.

Conclusion

Our results suggest that a high TMB is associated with a favorable prognosis in patients with OCSCC treated with upfront surgery.

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High TMB is associated with a favorable prognosis in patients with OCSCC treated with upfront surgery

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Pathological tumor stage combined with high TMB is associated with good prognosis

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TP53 was the most mutated gene (71%). Other frequent molecular alterations included the TERT promoter (50%)

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TGFβ pathway alterations were associated with poor outcomes, although it was only observed in 4% of the patients

Serum beta-2 microglobulin analysis in patients with oral squamous cell carcinoma

AIM

This study aims to compare the level of serum beta-2 microglobulin (β2-M) in normal healthy individuals and patient with squamous cell carcinoma (SCC).

METHODOLOGY

This study has been conducted in patients attending the Department of Oral and Maxillofacial Surgery, Yenepoya Dental College, Deralakatte, Mangalore. Sample comprises of 25 cases of clinically and histologically diagnosed oral cancer and 25 normal healthy individuals as control group. The serum was analyzed for β2-M by enzyme-linked immunosorbent assay.

RESULTS

It was observed that there was a significant increase in serum β2-M levels in oral SCC patients as compared to controls. Circulating levels in serum β2-M were also elevated significantly among different clinical stages with progressive rise from stage I to stage IV of the disease.

CONCLUSION

The evaluation of these markers would be useful in assessing malignant change, increasing accuracy of clinical diagnosis and also in assessing the spread and invasiveness of the cancer of the oral cavity.

Magnetic resonance imaging differentiates locoregional flaps from free flaps after reconstructive surgical treatment of tongue cancer

OBJECTIVE

The aim of this study was to compare magnetic resonance imaging (MRI) features of reconstruction with locoregional flaps (LRFs) with free flaps (FFs) after surgical treatment for tongue cancer.

STUDY DESIGN

In total, 115 cases of postoperative tongue carcinoma (67 cases of LRF surgery and 48 cases of FF surgery) were retrospectively reviewed. All patients had undergone nonenhanced and contrast-enhanced MRI at 0-4, 5-12, and 13-48 months after surgery. Signal intensity, margins, maximal size, contrast enhancement, change in the hyoglossus and mylohyoid muscles, recurrence, lymph node metastasis, and complications were evaluated.

RESULTS

Significant differences were found between LRF and FF for signal intensity (P < .001) in all 3 periods, with LRF mostly isointense with muscle on T1-weighted images (T1WIs) and FF producing mixed hyperintensity with muscular striations in all cases in T1WIs and T2-weighted images (T2 WIs). Margin definition was similar between groups in the early period, but sharp margins were more common in FF after 4 months (P ≤ .018). LRF was significantly smaller than FF in all periods (P ≤ .017). Both mylohyoid and hyoglossus enlargements were common in the early period in both groups, but all cases became atrophic later.

CONCLUSIONS

MRI can differentiate LRFs from FFs in a variety of parameters after flap reconstructive surgery for tongue cancer.

Patterns of growth of lingual carcinoma on magnetic resonance imaging and correlations with clinicopathologic outcomes

OBJECTIVE

The aim of this study was to identify patterns of tumor growth as revealed on magnetic resonance imaging (MRI) and to evaluate the correlation of these patterns with histopathologic features and rates of recurrence, disease-free survival (DFS), and overall survival (OS).

STUDY DESIGN

In a retrospective analysis of patients with tongue carcinoma, tumor advancing margins, patterns of tumor enhancement, and enhancement beyond tumor margins were studied on MRI. Histopathologic findings included differentiation, margin status, perineural invasion (PNI), and lymphovascular invasion (LVI). MRI and histopathologic features were correlated with outcomes.

RESULTS

Ill-defined tumor margins and enhancement beyond tumor margins were associated with recurrences (P ≤ .001) regardless of perineural invasion or LVI. DFS and OS were adversely affected by ill-defined tumor margins (P ≤ .010). DFS was also affected by enhancement beyond the tumor margins (P < .001). A heterogeneous pattern of enhancement showed a trend toward a decrease in DFS and OS (P = .088 and .092, respectively). Advancing tumor margins on MRI were independent predictors of overall survival. MRI characteristics exhibited significant associations with histopathologic margins, PNI, and LVI.

CONCLUSIONS

Ill-defined advancing tumor margins, a heterogeneous pattern of enhancement, and enhancement beyond the tumor margins on MRI adversely affect outcomes and prognosis in tongue carcinoma.

ICG-induced NIR fluorescence mapping in patients with head & neck tumors after the previous radiotherapy

BACKGROUND

The distinction between tumor and healthy tissues is complicated in the areas previously subjected to radiation therapy (RT). This is related to the fact that tissues can undergo delayed and irreversible deterioration such as inflammation, vascular alteration and fibrosis. The trials related to the fluorescence -guided surgery (FSG) in Head and Neck Squamous Cell Carcinoma (HNSCC) patients, previously subjected to RT, have not yet been reported. The present study addresses for the first time the possibilities of tumor near-infrared (NIR) imaging using Indocynaine Green (ICG) in irradiated areas.

METHODS

Four patients with histologically confirmed HNSCC were included in this study. All included patients were previously treated with RT with at least 50 Gy. RT-radiation fields from original treatment fully encompassed the second tumor or recurrence. ICG was injected via cephalic vein 45 min before the images were captured using a NIR camera system Artemis. The images were also captured before ICG injection serving as background signal. The fluorescence intensity measurements were carried out using specially designed software.

RESULTS

ICG fluorescence clearly demonstrated a significant difference in fluorescence intensity between healthy and tumor tissues in 2 of 4 patients. Histology post-resection analysis confirmed a complete tumor resection with safe surgical margins. No difference between tumor and surrounding healthy tissue was detected in patients with an epidermoid carcinoma developed from sclerohypertrophic lichen.

CONCLUSIONS

In our pilot study, we clearly established the feasibility of using NIR FGS with ICG to delineate tumor and healthy tissues in irradiated areas in infiltrating lichen-free tumors.

Oral squamous cell carcinoma: epidemiological study and risk factor assessment based on a 39-year series

Oral squamous cell carcinoma (OSCC) remains a challenge for head and neck surgeons, with low 5-year survival rates despite improvements in diagnostic techniques and therapies. This retrospective observational study was performed to evaluate the epidemiology and risk factors in a cohort of 666 patients with invasive OSCC over a 39-year period. Risk factors assessed were age, sex, toxic habits, premalignant lesions, tumour location and size, and neck involvement, and pathological factors such as surgical margins, tumour thickness, perineural invasion, and bone invasion. These factors were analysed over time, and their influence on recurrence and survival rates examined. Results were compared with those of current epidemiological studies in the literature. This series showed a tendency to diagnosis at older ages (P<0.001) and decreased differences in sex distribution (P<0.001) over time. Regarding risk factors, tobacco and alcohol drinking increased significantly in females, but remained stable in males. Forty percent of the patients developed recurrences during follow-up; the relapse rate did not improve over time (45.6% in the 1980s to 36.1% in 2010-2017). The 5-year survival rate also remained stable over time, ranging from 62.7% (1980s) to 71.7% (2010-2017). This epidemiological study analysed trends across four decades in a stable cohort, with results that may be extrapolated to the populations of European countries. The results confirmed that recurrence rates and survival rates have not improved over time, despite better surgical treatments and new therapies. Further studies are needed to improve knowledge about genetics and tumour behaviour in oral cancer.

The role of MRI-derived depth of invasion in staging oral tongue squamous cell carcinoma: inter-reader and radiological-pathological agreement

Background

The 8th edition of tumor, node, metastasis (TNM) classification incorporates depth of invasion evaluation in the staging of oral cavity squamous cell carcinoma, since it is a predictor of nodal metastasis and an independent prognostic factor. Although the histopathological definition of depth of invasion is clear, an accurate method for its radiological assessment has not yet been validated.

Purpose

To investigate the role of MRI-derived depth of invasion evaluation in staging oral tongue squamous cell carcinoma and to assess the inter-reader agreement and the radiological–pathological correlation.

Material and Methods

We retrospectively reviewed 43 patients with oral tongue squamous cell carcinoma who underwent preoperative MRI. The MRI-derived depth of invasion was measured by two radiologists, each with a different degree of experience in head and neck imaging. The pathological depth of invasion was recorded from histopathological reports. The inter-reader and the radiological–histopathological correlations for the depth of invasion were evaluated with Bland–Altman plots, the intraclass correlation coefficients (ICC), and the paired samples test; agreements for T staging were assessed using the Kappa coefficient.

Results

Inter-reader reliability was excellent for the MRI-derived depth of invasion (ICC = 0.91), very good between MRI-derived depth of invasion and pathological depth of invasion (ICC = 0.89 for the experienced reader, 0.86 for the inexperienced reader). Both readers reached a good agreement regarding T staging (kappa value = 0.70). Furthermore, the agreement between radiological and pathological T staging was good (kappa value = 0.74 for the experienced reader, 0.60 for the inexperienced reader).

Conclusion

MRI-derived depth of invasion should be measured in the pretreatment assessment of oral tongue squamous cell carcinoma as it has an excellent inter-reader reliability and nearly excellent radiological–pathological correlation.

Outcomes and Predictive Value of Post-adjuvant Therapy PET/CT for Locally Advanced Oral Squamous Cell Carcinoma

OBJECTIVES/HYPOTHESIS

For locally advanced oral squamous cell carcinoma (OSCC) treated by surgery and adjuvant therapy, consensus has yet to be reached on whether the optimal time to initiate surveillance positron emission tomography/computed tomography (PET/CT) scan is before or after adjuvant therapy. In this study, we characterize the utility of PET/CT scans obtained 3 months after adjuvant therapy.

STUDY DESIGN

PET/CT scans were obtained for 220 patients with stage III, IVA, or IVB OSCC who underwent resection followed by adjuvant radiotherapy or chemoradiotherapy.

METHODS

Using the Neck Imaging Reporting and Data System, PET/CT scans were dichotomized as suspicious (primary or neck category ≥3, or distant lesion present) versus nonsuspicious. We then computed differences in locoregional progression, distant progression, and overall survival; positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity; and success rate of salvage.

RESULTS

Sixty-seven patients (30%) had suspicious PET/CT scans, which were significantly associated with local failure (hazard ratio [HR] 14.0, 95% confidence interval [CI] 7.3-26.6), distant failure (HR 18.4, 95% CI 9.6-35.3), and poorer overall survival (HR 9.5, 95% CI 5.0-17.9). Overall PPV, locoregional PPV, NPV, sensitivity, and specificity were 85%, 79%, 73%, 58%, and 92%, respectively. Among those with biopsy-confirmed progression, 37 patients (65%) underwent salvage therapy; four (11%) were without evidence of disease at last follow-up.

CONCLUSIONS

For locally advanced OSCC, PET/CT scan 3 months after adjuvant therapy is strongly predictive of disease recurrence and survival, demonstrating improved performance over postoperative imaging in previous studies. Following a suspicious post-adjuvant therapy PET/CT scan, cure of locoregional recurrence is possible but unlikely.

LEVEL OF EVIDENCE

4 Laryngoscope, 2020.

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

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

Immune Evasion by Head and Neck Cancer: Foundations for Combination Therapy

Head and neck cancer is disfiguring and deadly, and contemporary treatment has fallen short in terms of morbidity and mortality. The rich immune infiltrate within these tumors designates them as prime candidates for immunotherapy and success with these drugs has been documented for recurrent and metastatic head and neck cancer. Still, single-agent immunotherapy has generated either only transient responses or durable response in only a minority subset of patients. Mapping the immune escape mechanisms enacted by head and neck cancer within the tumor microenvironment allows for rational design of strategies to overcome this tolerance. We outline the immune pathway derangements within the head and neck cancer microenvironment and discuss combination treatment strategies to overcome the limitations of immunologic monotherapy.

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

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

Predictors of Early Recurrence Prior to Planned Postoperative Radiation Therapy for Oral Cavity Squamous Cell Carcinoma and Outcomes Following Salvage Intensified Radiation Therapy

PURPOSE

To determine predictors and outcomes for oral squamous cell carcinoma (OSCC) patients who had early recurrence before commencement of postoperative radiation therapy (PORT).

METHODS

Retrospective review was performed for patients with OSCC treated with PORT between 2003 and 2015 after curative-intent surgery. Early recurrence was defined as tumor recurrence after surgical resection and before initiating planned PORT. Patients were classified into the following groups: (1) adjuvant PORT group (no early recurrence), (2) salvage PORT group (locoregional early recurrence), and (3) palliative PORT group (locoregional and distant early recurrence). For the whole cohort, multivariable analysis (MVA) was applied to identify predictors of early recurrence. In the salvage group, the post-PORT recurrence-free rate was estimated, and MVA was used to identify predictors of recurrence-free rate, disease-free survival, and overall survival (OS).

RESULTS

Six hundred and one patients were identified, of whom 513 (85%) were treated with adjuvant PORT. Eighty-eight patients (15%) had early recurrence (28 of 88; 32% were biopsy proven) before PORT (70 in the salvage group and 18 in the palliative group). On MVA, oral tongue subsite, microscopic positive resection margin, pT3-4, and pN2-3 were associated with the development of early recurrence (P < .05 for all). The 3-year OS rates for patients with OSCC treated with adjuvant and salvage PORT were 71% (95% confidence interval [CI], 67%-75%) and 41% (95% CI, 30%-56%), respectively (P < .001; median follow-up was 3.4 and 2.9 years, respectively). After salvage PORT, the 3-year recurrence-free rate was 36% (95% CI, 23%-47%). On MVA, extranodal extension and volume of early recurrent gross disease were associated with poor recurrence-free rate, disease-free survival, and OS (P < .05 for all).

CONCLUSION

Early recurrences are not uncommon in patients with high-risk features, Further study is required to improve prediction and outcomes of this very high-risk group.

The Current Role of Salvage Surgery in Recurrent Head and Neck Squamous Cell Carcinoma

Chemoradiotherapy has emerged as a gold standard in advanced squamous cell carcinoma of the head and neck (SCCHN). Because 50% of advanced stage patients relapse after nonsurgical primary treatment, the role of salvage surgery (SS) is critical because surgery is generally regarded as the best treatment option in patients with recurrent resectable SCCHN. Surgeons are increasingly confronted with considering operation among patients with significant effects of failed non-surgical primary treatment. Wide local excision to achieve clear margins must be balanced with the morbidity of the procedure, the functional consequences of organ mutilation, and the likelihood of success. Accurate selection of patients suitable for surgery is a major issue. It is essential to establish objective criteria based on functional and oncologic outcomes to select the best candidates for SS. The authors propose first to understand preoperative prognostic factors influencing survival. Predictive modeling based on preoperative information is now available to better select patients having a good chance to be successfully treated with surgery. Patients with a high comorbidity index, advanced oropharyngeal or hypopharyngeal primary tumors, and both local and regional recurrence have a very limited likelihood of success with salvage surgery and should be strongly considered for other treatments. Following SS, identifying patients with postoperative prognostic factors predicting high risk of recurrence is essential because those patients could benefit of adjuvant treatment or be included in clinical trials. Finally, defining HPV tumor status is needed in future studies including recurrent oropharyngeal SCC patients.

Assessment of tumor margins in head and neck cancer using a 3D-navigation system based on PET/CT image-fusion - A pilot study

OBJECTIVES

Determination of tumor margins in patients with squamous cell carcinoma of the head and neck (SCCHN) is mostly based on preoperative magnetic resonance imaging (MRI) or computed tomography scans (CT). Local recurrence of disease is often correlated with the presence of positive resection margins after surgical treatment. Positron emission tomography/computed tomography (PET/CT) imaging plays a crucial role in the assessment of patients with SCCHN. The purpose of this study was to determine whether PET/CT could predict tumor extension.

METHODS

In 12 patients who underwent surgical treatment of primary SCCHN (Stage III-IV) F18-FDG PET/CT image-fusion was performed on a 3D navigation-system based workstation. Image-guided needle biopsies were obtained from four different, color-coded metabolic areas within the tumor. The histopathological findings were correlated with findings on corresponding PET/CT scans.

RESULTS

81.3% of biopsies from the central area were positive. Specimens taken from the outer metabolic zone were positive in 66.7% of the patients. The highest incidence of positive biopsies was found in the zone adjacent to the outermost area. There was a statistically significant difference in positive tumor histopathology when comparing the various metabolic zones (p = 0.03).

CONCLUSION

Exact determination of tumor is an important research topic, although results remain controversial. The results of this study suggest that in some cases PET scans may overestimate tumor extension.

Estimating Survival After Salvage Surgery for Recurrent Oral Cavity Cancer

Importance

Locoregional recurrence of oral cavity squamous cell carcinoma (OCSCC) continues to be a life-threatening and difficult clinical situation. Salvage surgery can result in significant morbidities, and survival following recurrence is poor.

Objective

To outline prognostic factors influencing overall survival (OS) following salvage surgery for OCSCC to guide management of treatment for patients with locoregionally recurrent disease.

Design, Setting, and Participants

The medical records of 293 patients presenting to the London Health Sciences Center with locoregionally recurrent OCSCC between October 5, 1999, and May 2, 2011, were retrospectively reviewed. The primary outcome was OS from salvage treatment to last follow-up or death. Univariate analyses were carried out using the Cox proportional hazards regression model. A recursive partitioning analysis was used to create risk groups based on prognosis. Analysis was conducted from December 8, 2015, to February 26, 2016.

Results

Of the 293 patients evaluated, 59 (20%) had recurrence identified after their initial OCSCC treatment; 39 (66%) were men, and the mean (SD) age at diagnosis was 62.2 (11.8) years. Thirty-nine (66%) of these patients underwent salvage surgery for locoregional recurrence with curative intent. Five-year OS from the time of salvage surgery was 43%. Recursive partitioning analysis identified 3 risk groups: (1) high risk (patients who received adjuvant chemoradiotherapy or radiotherapy after initial surgery) with 5-year OS rate of 10% (hazard ratio [HR], 9.41; 95% CI, 2.68-33.04), (2) intermediate risk (previous surgery alone, age ≥62 years) with a 5-year OS rate of 39% (HR, 2.95; 95% CI, 0.86-10.09), and (3) low risk (previous surgery alone, age <62 years) with 5-year OS rate of 74%.

Conclusions and Relevance

This recursive partitioning analysis identified 3 prognostic groups in patients undergoing salvage surgery for recurrent OCSCC. The marked differences in survival between these groups should be taken into consideration when counselling and managing treatment for patients with locoregionally recurrent disease.

The effectiveness of elective neck dissection on early (stage I, II) squamous cell carcinoma of the oral tongue

Objectives

The purpose of this study was to evaluate and compare the treatment outcomes of partial glossectomy with or without elective neck dissection in patients with tongue squamous cell carcinoma (SCCa).

Materials and Methods

A total of 98 patients who were diagnosed with tongue SCCa and underwent partial glossectomy between 2005 and 2014 were evaluated. Only 14 patients received elective neck dissection, and 84 patients received only partial glossectomy.

Results

There were 56 men and 42 women with a mean age of 57 years and mean follow-up period of 33.7 months. There were 70 patients graded as T1 and 28 as T2. The total occult metastasis rate was 17.3%. The 5-year overall survival rate was 83.3% with elective neck dissection and 92.4% with observation. The 5-year disease-free survival rate was in 70.7% in the elective neck dissection group and 65.3% in the observation group.

Conclusion

We retrospectively reviewed the records of 98 patients with tongue SCCa. These patients were divided into two groups, those who underwent elective neck dissection and those who did not. There was no statistically significant difference between the groups undergoing partial glossectomy with or without elective neck dissection.

Salvage surgery in recurrent head and neck squamous cell carcinoma: Oncologic outcome and predictors of disease free survival

OBJECTIVE

Salvage surgery in recurrent SCCHN is associated with poor outcomes. This study aimed to better identify suitable surgical candidates and those at high risk of new recurrence.

MATERIALS AND METHODS

Single-center retrospective analysis of 109 patients undergoing salvage surgery for recurrent SCCHN. Univariate and multivariate analyses were used to identify prognostic factors affecting disease-free survival (DFS).

RESULTS

The following factors showed a significant impact on DFS: Disease-free interval >6months [HR 0.53; p=0.04], age>70years [HR 0.26; p=0.03], primary chemoradiotherapy [HR 2.39; p<0.01] compared to radiotherapy, oropharynx [HR 5.46; p<0.01] and hypopharynx [HR 3.92; p=<0.01] sites, compared to larynx, initial stage III [HR 7.10; p<0.01] and stage IV [HR 4.13; p<0.01], compared to stage I, locoregional recurrence [HR 4.57; p<0.01], compared to local recurrence. Univariate analysis also identified significant postoperative predictors of poor DFS including flap reconstruction [HR 3.44; p<0.01], postoperative complications [HR 2.09; p=0.01], positive margins [HR 3.64; p<0.01] and close margins [HR 3.83; p<0.01]. On multivariate analysis, oropharynx site [HR 3.98; p<0.01], initial stage III [HR 5.93; p<0.01] and locoregional recurrence [HR 2.93; p=0.04] were independent preoperative prognostic factors for DFS. Positive margins [HR 2.32; p=0.04], close margins [HR 2.94; p=0.02], extracapsular spread (ECS) [HR 4.04; p=0.03] and postoperative complications [HR 3.64; p<0.01] were independent postoperative prognostic factors.

CONCLUSIONS

Patients with advanced primary nonlaryngeal tumor and locoregional recurrence have limited success with salvage surgery. Because patients with positive margins and ECS are at high risk of relapse, adjuvant treatment should be discussed.

Follow-up of oral cancer patients: three uneventful years may be enough

OBJECTIVE

To explore the possibility of shortening the length of follow-up from 5 to 3 years in patients who have undergone curative treatment of an oral squamous cell carcinoma.

STUDY DESIGN

The medical records of 225 patients who had undergone initial curative treatment at the VU University Medical Center in Amsterdam, the Netherlands, between 2004 and 2009 were analyzed.

RESULTS

In 96 patients (42.7%) a secondary event occurred. Eighty-six percent of the secondary events were detected within 3 years. In the fourth and fifth years, 14% of the secondary events were found, consisting mainly of second primary tumors.

CONCLUSIONS

Most secondary events occurred within the first 3 years of follow-up. Therefore, the case can be made for an altered regimen of follow-up beyond 3 years based on certain risk factors unique to the patient as well as the patient's ability to adequately report symptoms that may be associated with recurrent disease.

Selection of Ideal Candidates for Surgical Salvage of Head and Neck Squamous Cell Carcinoma: Effect of the Charlson-Age Comorbidity Index and Oncologic Characteristics on 1-Year Survival and Hospital Course

IMPORTANCE

Salvage surgery for recurrent head and neck squamous cell carcinoma (HNSCC) carries substantial risks of morbidity and mortality. Risk factors for death within 1 year should be better defined.

OBJECTIVES

To report preoperative oncologic prognostic factors predictive of short-term (<1 year) survival after salvage surgery in patients with HNSCC, to assess whether preoperative age and comorbidity predicts 1-year mortality, and to report hospital courses after salvage surgery within 1 year.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective medical record review of 191 patients with recurrent HNSCC treated with salvage surgery from January 1, 2003, through December 31, 2013, at a tertiary academic center.

INTERVENTIONS

Surgical salvage of HNSCC (larynx, oral cavity, oropharynx, or hypopharynx) with curative intent.

MAIN OUTCOMES AND MEASURES

Primary outcome was survival 1 year after salvage surgery. Secondary outcomes were length of inpatient hospital stay, days of admissions, and skilled nursing facility disposition within 1 year stratified by survival status. Presalvage Charlson-Age Comorbidity Index (CACI) was calculated. Associations among CACI, oncologic risk factors, and risk of death within 1 year after salvage surgery are investigated using multivariable analysis.

RESULTS

Of 191 patients studied, 53 (27.7%) died within 1 year after salvage surgery. Patients who died within 1 year had more total inpatient admissions (P < .001), longer total length of stay (P < .001), and higher risk of discharge to a skilled nursing facility (P < .001) and spent 17.3% (interquartile range, 5.2-36.3) of their remaining days in the hospital. Independent risk factors for death within 1 year are CACI (relative risk [RR], 1.43; 95% CI, 1.16-1.76), primary T3 or T4 stage (RR, 2.34; 95% CI, 1.27-4.31), and disease-free interval of less than 6 months (RR, 5.61; 95% CI, 1.78-16.7).

CONCLUSIONS AND RELEVANCE

Medical comorbidity and age as measured by the CACI, primary T3 or T4 stage, and short disease-free interval must be considered in selecting patients ideal for surgical salvage surgery for recurrent HNSCC. Patients with these risk factors should be more strongly considered for palliative measures.

Molecular events in relapsed oral squamous cell carcinoma: Recurrence vs. secondary primary tumor

Relapses have a great impact on both the morbidity and mortality rates of oral squamous cell carcinoma (OSCC) patients. Current classification criteria are imprecise and need improvements. Recent advances in understanding of OSCC relapses on a molecular level provide new possibilities to better classify true recurrences and second primary tumors. This review discusses the limitations of the current OSCC relapse classification method and presents possible alternatives to improve this classification based on molecular techniques. Moreover, these molecular techniques add to the further understanding of these lesions and may provide tools for clinical management.

Irradiation for locoregionally recurrent, never-irradiated oral cavity cancers

BACKGROUND

The purpose of this study was to report the clinical outcomes and related prognostic factors of patients who underwent radiotherapy (RT) for the treatment of recurrent, never-irradiated oral cavity cancer (recurrent OCC).

METHODS

The records of consecutive patients with nonmetastatic recurrent OCC who presented to and were treated with RT at our institution between 1989 and 2011 were reviewed. The Kaplan-Meier method was used to calculate overall survival (OS). The cumulative incidences of disease-specific death, local failure, regional failure, and distant metastasis were calculated with death as a competing risk.

RESULTS

One hundred twenty-three patients were identified. Median follow-up for living patients was 54 months and 16 months for all patients. Ninety-one patients had salvage surgery followed by adjuvant RT. Definitive RT was utilized in the remaining 32 patients. The 5-year OS was 40%. The 5-year cumulative incidence of disease-specific death, local failure, regional failure, and distant metastasis was 55%, 34%, 22%, and 20%, respectively. Recurrent T classification and lack of salvage surgery were independently associated with worse disease-specific death and decreased OS, respectively. Subset analysis of patients who underwent salvage surgery demonstrated that age, recurrent T classification, and perineural invasion (PNI) were independently associated with decreased OS; recurrent T classification and thicker tumors were independently associated with worse disease-specific death; and positive/close margins and primary T classification were independently associated with increased local failure.

CONCLUSION

In this group of patients with recurrent OCC, clinical outcomes were similar or improved when compared with other recurrent OCC-specific reports. In the salvage surgery subset, tumor thickness and PNI are recurrent pathologic features associated with outcomes that were only previously demonstrated in studies of primary disease. Because of the relatively worse outcomes in patients receiving definitive or adjuvant RT for recurrent OCC, we advocate for the appropriate use of postoperative RT in the initial management of oral cavity cancers.

Multiple primary squamous cell carcinomas of the oral cavity

PURPOSE

There is a subset of patients who develop multiple primary squamous cell carcinomas (SCCs) of the oral cavity. The aim of this study was to better characterize this group of patients and determine whether there are any associated risk factors.

MATERIALS AND METHODS

This is a retrospective review of all patients treated for oral SCCs at the University of Maryland Department of Oral and Maxillofacial Surgery from November 1989 to February 2013. The inclusion criteria were patients who developed at least 3 primary oral cancers. Lesions were considered separate primaries if they involved different anatomic regions within the oral cavity and were more than 2 cm apart or if they occurred more than 5 years apart.

RESULTS

Of 1,478 patients treated during this time frame, 20 met the inclusion criteria. There were 14 women and 6 men (female-to-male ratio, 2.3:1). Nineteen were Caucasian and 1 was of Indian ethnicity. The average number of primaries per patient was 3.9 (range, 3 to 6 primaries). The mean age at first diagnosis was 63.3 years (44 to 86 yr). The mean interval between the different primaries was 32 months (0 to 228 months). The most common site involved was the gingiva (45% of cases), followed by the tongue, buccal mucosa, retromolar fossa, and soft or hard palate. The mean follow-up was 118 months (22 to 342 months). Eleven patients developed nodal disease. Of those 11 patients, 9 died of the disease (<20% survival). The average time to neck involvement was 66.4 months. The average time from last neck involvement to death was 11.5 months. More than half the patients were nonsmokers or had quit more than 10 years before the first diagnosis. All patients quit smoking during the course of their treatment yet continued to develop multiple primaries. Three patients had proliferative verrucous leukoplakia (PVL), and 4 patients had biopsy-proved lichen planus.

CONCLUSION

The incidence of multiple primary SCCs within the oral cavity appears to more commonly involve Caucasian women without risk factors, although lichen planus and PVL might play a role. The gingiva appears to be the most commonly involved primary site, and subsequent primaries tend to be restricted to the oral cavity. Close observation and early expectant treatment appear to improve prognosis and survival in these patients. Cervical nodal metastases adversely affected survival (P = .02) as did the development of more than 4 primary carcinomas (P = .04).

Health-related quality of life of patients treated with primary chemoradiotherapy for oral cavity squamous cell carcinoma: a comparison with surgery

Our aim was to document the health-related quality of life (QoL) of patients with squamous cell carcinoma (SCC) of the oral cavity who were treated with chemoradiotherapy, and to compare it with that of patients treated with conventional surgery with or without adjuvant treatment. All patients who presented with SCC of the oral cavity treated with chemoradiotherapy alone at the Royal Brisbane & Women's Hospital between 2000 and 2011 and who were alive without disease were included. Health-related QoL was assessed by the University of Washington QoL questionnaire version 4, and the European Organisation for the Research and Treatment of Cancer (EORTC) QoL questionnaires C30 and HN35. The questionnaires were sent to all survivors. Those who responded to chemoradiotherapy were matched with patients who were treated by conventional surgery with or without adjuvant treatment by age, sex, subsite of tumour, and TNM stage. Sixteen patients completed the questionnaires (8 in each group). There was no significant difference between the 2 groups in any of the domains of any of the questionnaires. The overall outcome scores for both treatments in all 3 groups were reasonably high, which suggests that both treatments provided acceptable health-related QoL. The surgical group recorded higher scores than the chemoradiotherapy alone group in all domains of the UW-QoL except shoulder and anxiety. They recorded lower scores in all scales and items of EORTC HN35. There was no significant difference in health-related QoL between the 2 groups. Conventional surgery with or without adjuvant treatment recorded higher scores in most QoL domains including chewing, swallowing, saliva, and speech, issues most important to patients with SCC of the oral cavity.

Transoral laser microsurgery for oral squamous cell carcinoma: oncologic outcomes and prognostic factors

BACKGROUND

Modest survival rates are published for treatment of oral squamous cell carcinoma (OSCC) using conventional approaches. Few cohort studies are available for transoral resection of OSCC.

METHODS

Analysis for recurrence, survival, and prognosis of patients with OSCC treated with transoral laser microsurgery (TLM) ± neck dissection was obtained from a prospective database.

RESULTS

Ninety-five patients (71 patients had stages T1-T2 and 24 had stages T3-T4 disease) with minimum follow-up of 24 months met criteria and demonstrated negative margins in 95%. Five-year local control (LC) and disease-specific survival (DSS) were 78% and 76%, respectively. Surgical salvage achieved an absolute final locoregional control of 92%. Immune compromise and final margins were prognostic for LC, whereas T classification, N classification, TNM stage, comorbidity, and perineural invasion were also significant for DSS.

CONCLUSION

We document a large series of patients with OSCC treated with TLM, incorporating T1 to T4 primaries. A significant proportion of stage III/IV cases demonstrates feasibility of TLM in higher stages, with final margin positivity of 5%, LC greater than 90%, and comparable survival outcomes.