The impact of surgical margin status and use of an interstitial implant on T1, T2 oral tongue cancers after surgery

Brachytherapy of the head and neck: An University of California Los Angeles guide to morbidity reduction

The head and neck (H&N) region is among the most intricate and functional part of our anatomy. Major functional nerves and blood vessels with importance that affect the entire body emanate from the base of skull. Brachytherapy plays an important role as a single modality therapy in early cancer of the lip and oral cavity and a supplemental role in the pharynx or in advanced or recurrent disease. Morbidity in the H&N is intensely personal and disabling. Its avoidance is critical in determining the success or failure of a treatment program, and it is essential to preservation of quality of life. This article summarizes the current literature regarding morbidity related to H&N brachytherapy to aid patients and physicians to achieve optimal outcomes.

[Brachytherapy for head and neck cancers]

The main indications of the brachytherapy of head and neck cancers are the limited tumours of the lip, the nose, the oral cavity and the oropharynx. Nasopharynx tumours are nowadays treated by intensity-modulated radiotherapy. This technique can be exclusive, associated with external radiotherapy or postoperative. It can also be a salvage treatment for the second primaries in previously irradiated areas. If the low dose rate brachytherapy rules remain the reference, the pulse dose rate technique allows the prescription of the dose rate and the optimisation of the dose distribution. Results of high dose rate brachytherapy are now published. This paper reports the recommendations of the Gec-ESTRO, published in 2017, and takes into account the data of the historical low dose rate series, and is upgraded with the pulsed-dose rate and high dose rate series.

A combined prognostic factor for improved risk stratification of patients with oral cancer

PURPOSE

We aimed to identify a combined prognostic factor for predicting better performance in risk stratification.

MATERIALS AND METHODS

We reviewed the clinical and pathological variables of 316 patients with oral squamous cell carcinoma (OSCC) who underwent surgery. To identify a combined predictor, principal component analysis (PCA) was performed.

RESULTS

Univariate analysis showed that the independent prognostic variables for overall survival (OS) were pathologic T stage (T1 vs T4, HR = 1.99, 95% CI: = 1.083-3.675, P = 0.026) and pathologic N stage (N0 vs N2, HR=1.90, 95% CI: = 1.17-3.08, P = 0.008). In the multivariate analysis, only pathologic T stage was significant (P = 0.006 and P = 0.007); however, the multivariate model was not significant (P = 0.191). The multivariate model became significant by including lymph node ratio (LNR) instead of pathologic N stage (P = 0.0025 in numeric LNR, P = 0.0007 in categorized LNR). Also, the performance of prediction model was improved by a combined prognostic factor (P = 0.0002).

CONCLUSIONS

The newly identified combined prognostic factor included resection margin, differentiation, and LNR, and they were insignificant factors independently except for LNR. This combined prognostic factor showed a good performance although it did not include molecular markers; therefore, it may be used conveniently for risk stratification of patients with OSCC by combining only clinical information.

Postoperative interstitial brachytherapy for resectable squamous cell carcinoma of the tongue

PURPOSE

To evaluate the efficiency and toxicity of postoperative brachytherapy (POBT) in the treatment of resectable mobile tongue squamous cell carcinoma.

PATIENTS AND METHODS

This was a retrospective single-center study of patients with SSC of the mobile tongue who were treated between August 1992 and June 2013 by glossectomy and neck dissection followed by (192)Ir interstitial brachytherapy of the tumor bed. Endpoints were local control, cancer-specific survival (CSS), overall survival (OS), and morbidity. Independent prognostic factors were analyzed in a Cox regression model.

RESULTS

A total of 112 patients were identified (median age, 55 years [range, 15-84]; 76% male). Patient and tumor characteristics were: T1T2N0 (85%), pN+ (13%), positive surgical margins (14%), negative margins <5 mm (29%), dysplasic margins (14%), lymphatic vessel invasion (5%), and perineural spread (5%). Median followup was 6.7 years (1.5 months to 17.7 years). Local control, CSS, and OS rates at 2 years were 79%, 81%, and 72%, respectively. The corresponding 5-year rates were 76%, 67%, and 56%, respectively. After POBT, 22% of patients presented grade ≥2 necrosis and 8% experienced chronic pain. Independent prognostic factors were positive surgical margins for poor local control and tumor recurrence and lymphatic vessel invasion for poor OS.

CONCLUSION

POBT provided good local control and better CSS and OS than reported for surgery alone. Morbidity was higher than that reported for brachytherapy alone but may be considered acceptable in a well-selected patient population at high risk of local recurrence.

Prognostic factors in squamous cell carcinoma of the oral cavity

Researchers have been looking for factors that can influence the prognosis of oral cancer, because its outcome is highly uncertain. Aim: To evaluate variables that can impact the survival rate of patients with squamous-cell carcinoma of the oral cavity. Material and Methods: Data analysis of 45 patients from January, 2001 to January, 2006. Survival rate curves have been estimated using the Kaplan-Meier method and they have been compared through the log-rank test and the Cox regression standard. Study design: Retrospective analysis. Results: Total five-year survival rate was of 39% fpr these patients. Only the neck metastases (p=0.017), postoperative radiotherapy (p=0.056) and diseased margin(p=0.004) variables had statistic relevance. Survival rate was lower in patients with neck metastases, margins involved and those who underwent postoperative radiotherapy, in other words, those with the most aggressive tumors. After adjustment, radiotherapy did not prove to be statistically relevant. It is likely that the survival rate of 39% was due to the high number of patients with metastasis (52%) and because the samples were mostly of tongue and mouth floor diseases (82%), which are the hardest to control. Conclusion: Neck metastases and diseased margins of oral cavity carcinomas are the prognostic factors that can most impact the survival rate.

Postoperative brachytherapy alone and combined postoperative radiotherapy and brachytherapy boost for squamous cell carcinoma of the oral cavity, with positive or close margins

BACKGROUND

Postoperative radiotherapy is necessary for squamous cell carcinoma (SCC) of the oral cavity with positive or close margins. The aim of the study is to define the indications of postoperative brachytherapy (BRT).

METHODS

From 1979 to 1993, 82 patients with positive or close margins had postoperative BRT (58 T1-2, 24 T3-4, 45 mobile tongue, 37 floor of mouth). Forty-six patients had combined radiotherapy (RT) with a mean dose of 48 Gy, and BRT boost with a mean dose of 24 Gy. Thirty-six patients had BRT alone with a mean dose of 60 Gy. BRT was performed with interstitial low dose rate Iridium 192.

RESULTS

Overall survival (OS), cause-specific survival (CSS), and local control (LC) at 5 years were, respectively, for T1-2/N0N- with BRT, 75%, 85%, and 88%,and with RT-BRT 70%, 92%, and 92%; for T1-2/N+ with RT-BRT, 44%, 67%, and 78%; for T3-4/N- with RT-BRT, 42%, 90%, and 80%; and for T3-4/N+ with RT-BRT, 22%, 43%, and 57%. Prognostic factors for OS, CSS, and LC were N+ (p </=.009), extracapsular spread (ECS+;p </=.000001), and T stage for LC only (p =.02). Prognostic factors for complications were a high number of wires with a cutoff at five wires (p =.008), a high dose rate with a cutoff at 0.57 Gy/hr (p =.01), and a high total dose (BRT + RT) with a cutoff at 71 Gy (p =.07).

CONCLUSIONS

BRT alone for SCC T1-2/N0N- is better than RT-BRT because, with equivalent results, it avoids the adverse events of postoperative RT (xerostomia) and permits the treatment of a second head and neck primary in nonirradiated tissue. The results for the T3-4/N- are acceptable with this approach (ie, RT-BRT) but may be improved for N+.

Analysis of treatment results for oral tongue cancer

OBJECTIVE

The study reports the results of treatment of oral tongue cancer with five different treatment modalities with long-term follow-up.

STUDY DESIGN

Retrospective study of 332 patients with oral tongue cancer treated in the Departments of Otolaryngology-Head and Neck Surgery and Radiation Therapy at Washington University School of Medicine (St. Louis, MO) from 1957 to 1996.

METHODS

Patients with biopsy-proven squamous cell carcinoma of the oral tongue who were previously untreated and were treated with curative intent by one of five modalities and who were eligible for 5-year follow-up were included. The treatment modalities included local resection alone, composite resection alone (with neck dissection), radiation therapy alone, local resection with radiation therapy, and composite resection with radiation therapy. Multiple diagnostic, treatment, and follow-up parameters were studied using standard statistical analysis to determine statistical significance.

RESULTS

The overall 5-year disease-specific survival rate (DSS) was 57% with death due to tumor in 43%. The 5-year cumulative disease-specific survival probability (CDSS) was 0.61 (Kaplan-Meier) with a mean of 17.5 years and a median of 30.1 years. The DSS by treatment modality included local resection (73%), composite resection (61%), radiation therapy (46%), local resection and radiation therapy (65%), and composite resection with radiation therapy (CR/RT) (44%). Overall, local resection had a significantly improved DSS and CR/RT had a decreased DSS that was related to the stage of disease being treated. In treating stage IV disease, CR/RT produced a more significantly improved CDSS than the other treatment modalities. Recurrence at the primary site was as common as recurrence in the neck. Eighty-nine percent of recurrences occurred within the first 60 months. Recurrence significantly decreased survival. DSS was significantly improved in patients with clear margins of resection. Metastasis to a distant site occurred in 9.6% of patients. Twenty-one percent of patients had second primary cancers, and 54% of these patients died of their second primary cancer.

CONCLUSIONS

Significant improvement in DSS was seen in patients with clear margins, early stage grouping and clinical (pretreatment) tumor stage, and negative nodes. Significant decrease in DSS was seen in patients with close or involved margins, advanced stage grouping and clinical (pretreatment) tumor staging, positive clinical (pretreatment) node staging, and tumor recurrence. Obtaining clear margins of resection is crucial because it significantly affects survival. A minimum of 5 years of close monitoring is recommended because of the high incidence of second primary cancers.

Discrepancies in frozen section mucosal margin tissue in laryngeal squamous cell carcinoma

BACKGROUND

Head and neck surgeons commonly request frozen sections. Practice patterns vary from laboratory to laboratory on how the tissue is used in performing the frozen section. Some pathologists wish to see all the material submitted by consuming it completely during frozen section, whereas others reserve some for permanent section. We wished to determine whether knowledge of margin status was initially inaccurate because of reserving tissue for permanent section.

METHODS

Sixty-five laryngectomies (total and partial) with margin assessment enhanced by frozen section evaluation were studied. Forty-five laryngectomy specimens, generating 249 frozen sections in which a permanent section was prepared from tissue remaining from frozen section examination, were studied.

RESULTS

Five of the 249 frozen sections contained a discrepancy between the frozen section and permanent section because of insufficient leveling of the frozen section block. These five discrepancies were called negative on frozen section, but permanent section revealed dysplasia (two cases of mild dysplasia, one case with moderate dysplasia, and one case with severe dysplasia) or carcinoma in situ (one case). Twenty laryngectomies in which the frozen section tissue was consumed at the time of frozen section generated 103 frozen sections. In eight of the frozen sections involving six cases, the diagnostic tissue was not present on one or two of the frozen section levels examined.

CONCLUSIONS

We conclude that in examining margins for laryngeal squamous cell carcinoma the frozen section tissue should be completely sampled by examining several levels at the time of frozen section. This requires consuming or exhausting the frozen section tissue rather than reserving any remaining frozen tissue for a paraffin-embedded permanent section.

Postoperative brachytherapy alone for T1-2 N0 squamous cell carcinomas of the oral tongue and floor of mouth with close or positive margins

PURPOSE

To evaluate the efficacy of postoperative brachytherapy alone (brachy) for Stage T1-2 squamous cell carcinomas (SCC) of the floor of mouth (FM) and the oral tongue (OT) with close or positive margins.

METHODS AND MATERIALS

Between 1979 and 1993, 36 patients with T1-2 N0 (24 T1, 12 T2) OT (19), and FOM (17) SCC with close or positive margins following surgery underwent postoperative brachy. Mean patient age was 56 years (range 37-81) and sex ratio was 3.5:1 male:female. Mean surgery to brachy interval was 36 days (range 16-68). The technique used was interstitial Iridium-192 ((192)Ir) brachytherapy with plastic tubes and manual afterloading. Mean total dose was 60 Gy (range 50-67.4) at a mean dose rate of 0.64 Gy/h (range 0.32-0.94). Mean patient follow-up was 80 months.

RESULTS

The 5-year actuarial overall and cause-specific survivals of the entire group were 75% and 85%, respectively. The local control was 88.5% at 2 years, with a plateau apparent after 23 months. Of the 4 local relapses, 2 were salvaged with surgery and external beam radiotherapy (EBR). No tumor or treatment factors, including tumor size, margin status, disease site, or radiation dose, were correlated with local control. The 2 head and neck second primaries underwent curative treatment on nonirradiated tissue. One patient developed a grade 3 sequelae (bone and soft tissue necrosis). Grade 2-3 chronic sequelae were seen in 7 of 17 and 3 of 19 FOM and OT tumors, respectively (p = 0.09).

CONCLUSION

Postoperative brachy is a promising approach in T1-2 N0 OT and FOM SCC with close or positive margins. This approach is associated with high rate of locoregional control and low risk of chronic sequelae, obviates major surgery, avoids potential sequelae of EBR (xerostomia, dysgueusia, fibrosis), and avoids treatment of second head and neck primary on nonirradiated tissues.

Surfing prognostic factors in head and neck cancer at the millennium

The ability to reliably predict cancer outcome could tailor therapy to the aggressiveness of the tumour to achieve the best results in terms of loco-regional control, overall survival and quality of life. Retrospective and prospective clinical trials involving large series of patients have validated some predictive clinical and pathological factors, whereas the utility of many other prognostic factors has not been established. This has led to some confusion in clinical practice. In order to clarify the significance, role and cost of these prognostic factors we carried out a Medline search of all papers published between 1993 and 1998 concerning the reliability and cost of markers with prognostic significance, in head and neck squamous cell carcinoma, and assessed the results according to a number of criteria relating to reliability and cost. Regarding reliability we classified prognostic factors into: (1) those with a proven significance based on the fact that they were unanimously reported as having an independent statistical correlation with outcome and prognosis; and (2) those for which results were not unanimous, and which significance is still controversial. Cost analysis showed a substantial difference between validated tests which are of low cost and experimental tests which are expensive. Based on these data regarding both the reliability and cost of each prognostic factor, we propose guidelines for their use in clinical practice in the year 2000.