Post-operative radiotherapy in carcinoma of buccal mucosa, a prospective randomized trial

Adjuvant therapy for intermediate risk factors in oral cancer: Can we reach a consensus?

Oral carcinoma is a common disease that poses challenges in treatment management, especially for advanced cases. Adjuvant therapies, such as radiation and chemoradiation therapy, are typically used for advanced oral cancer patients. However, there is uncertainty regarding the use of adjuvant therapy for early-stage patients with certain soft histological parameters. The UICC manual of clinical oncology suggests that adjuvant therapy for such parameters is desirable but not essential. These parameters include perineural invasion, lymphovascular invasion, single nodal positivity, and patterns of invasion, which complicate the decision-making process for including adjuvant therapy. This review aims to provide evidence-based literature for effectively managing this patient group and developing treatment protocols based on current evidence.

Oncologic Outcome in Advanced Oral Squamous Cell Carcinoma After Refusal of Recommended Adjuvant Therapy

Importance

Clinicians may be confronted with patients refusing recommended adjuvant therapy (AT) after the primary resection of an advanced oral squamous cell carcinoma (OSCC). However, for this tumor entity, data are lacking regarding the oncological outcomes and associated factors after refusal of AT.

Objective

To evaluate the difference in survival and disease recurrence for patients with and without recommended AT after resection of advanced OSCC.

Design, Setting, and Participants

In this single-center retrospective matched cohort study, patients with advanced OSCC who refused recommended AT between January 2010 and December 2021 were matched 1:1 according to Union for International Cancer Control tumor staging with patients who completed AT.

Exposures

Patients with advanced OSCC who refused or completed recommended AT between 2010 and 2021.

Main Outcomes and Measures

The primary outcome of this study was the comparison of overall survival (OS) and recurrence-free survival (RFS) between the 2 study groups.

Results

A total of 82 patients (mean [SD] age at time of surgery, 68.0 [11.3] years; 38 [46.3%] female, 44 [53.7%] male) with and without AT (41 per study group) were included in the analysis. Patients refusing AT developed more frequent disease recurrence than patients who completed AT (61.0% vs 26.8%; difference, 34.2%; odds ratio, 4.26; 95% CI, 1.68-10.84). In addition, patients who refused AT presented with lower 2-year OS (72.7% vs 88.6%; difference, 15.9%; 95% CI, 8.6%-40.6%) and much lower 2-year RFS (39.1% vs 74.2%; difference, 35.1%; 95% CI, 0.2%-70.5%). In the patient cohort who rejected AT, a worse OS was associated with female sex (48.6% vs 90.5%; difference, 41.9%; 95% CI, 0.6%-84.4%), pT1-2 category (57.1% vs 92.3%; difference, 35.2%; 95% CI, 3.3%-73.6%), and pN1 or higher category (61.2% vs 82.6%; difference, 21.4%; 95% CI, 14.1%-56.8%). Lower RFS was associated with female sex (37.9% vs 90.9%; difference, 53.0%; 95% CI, 8.0%-97.9%), advanced T category (pT3-4, 35.3% vs 80.0%; difference, 44.7%; 95% CI, 6.4%-95.3%), lymph node yield of 20 or greater (31.4% vs 80.6%; difference, 49.2%; 95% CI, 4.9%-93.4%), and lymph node ratio of less than 4.6% (36.6% vs 84.4%; difference, 47.8%; 95% CI, 1.8%-93.1%).

Conclusions and Relevance

In this cohort study of patients with advanced OSCC, refusal of AT was associated with worse oncological outcomes. The prevalence of disease recurrence during follow-up was 34% higher in patients who refused AT than in patients who completed AT. The results from this study may assist clinicians in guiding patients who are considering refusal of or withdrawal from AT.

Efficacy of adjuvant radiation in early-stage cancers of buccal mucosa: an institutional experience

PURPOSE

The purpose of this study is to determine if depth of infiltration is the only risk factor that will determine the outcomes in early-stage buccal mucosa patients or do the other minor risk factors have an impact too.

METHODS

It is a retrospective analysis of 226 patients with early-stage buccal mucosa cancer who were treated with curative intent from 2010 to 2020. These patients were grouped in two arms, surgery alone (n = 111) and surgery followed by adjuvant radiotherapy (n = 115). Patients were followed up and local and regional recurrences and distant metastasis were recorded.

RESULTS

Our results show that addition of radiation to the standard surgery arm improves overall survival and disease-free survival, though the improvement in overall survival was not statistically significant. This improvement was more pronounced in the depth of infiltration > 5 mm and in 5 mm or less depth of infiltration this benefit was not statistically significant. Other factors like perineural invasion, lymphovascular invasion, tumour size, node positive, margin positive were considered for univariate analysis. Although there was a trend towards improvement of OS and DFS, it was not statistically significant as far as these factors are concerned.

CONCLUSION

The role of adjuvant radiation in early-stage cancers of buccal mucosa is a crucial tool with definitive DFS benefit and requires more prospective trials to answer the OS benefit.

Management of Stage III Oral Cavity Squamous Cell Carcinoma in Light of the New Staging System: a Critical Review

PURPOSE OF REVIEW

Oral squamous cell carcinoma (OSCC) patients have a poor prognosis, especially in advanced stages. AJCC/UICC staging system 8th edition (TNM8) included depth of invasion (DOI) as part of T staging and stage III has become a heterogeneous group of lesions, composed of patients with larger DOI and/or width. Additionally, stage III includes N1, regardless of the primary tumor width or DOI. The real prognostic value of each of these characteristics and the need for adjuvant treatment for stage III patients is not well established.

RECENT FINDINGS

TNM8 stratified OSCC into prognostic groups based on overall survival. Extranodal extension, positive or close margins, pT3 or pT4 tumors, pN2 or pN3 nodal disease, nodal disease in levels IV or V, perineural invasion, vascular invasion, and lymphatic invasion are the main adverse features for OSCC, and adjuvant treatment is largely recommended for these patients. Stage III patients should be addressed with caution. So far, there is no significant evidence for recommending or excluding adjuvant treatment for stage III OSCC without adverse features. The authors largely recommend adjuvant radiotherapy for these cases, especially because pT3 without adverse features is rare. Further studies on this topic are necessary.

Biochemical analysis of saliva in head and neck cancer patients receiving definitive chemoradiotherapy

BACKGROUND

Radiation therapy leads to salivary gland damage that causes xerostomia, the standard radiation-induced complication during radiotherapy that affects the quality of life in head and neck cancer patients. This study was conducted at a tertiary cancer institute in Punjab state to analyze the influence of radiation therapy on various parameters and substances of saliva.

MATERIALS AND METHODS

Sixty head and neck cancer patients who underwent conventional radiotherapy on a Cobalt machine were included. Saliva was collected in both stimulated and unstimulated states. Stimulated whole saliva was collected by applying two to three drops of citric acid solution (2%) over the dorsum of the tongue bilaterally at 30-s intervals for 2 min. Biochemical changes in the whole saliva were evaluated by biochemical methods at baseline, completion of therapy, and 3 and 6 months post-radiotherapy completion.

RESULTS

The lowest concentration of proteins was seen after the therapy in unstimulated and stimulated saliva. Salivary protein levels showed a rising trend toward baseline in 3- and 6-month posttherapy samples. The peak value (0.4 mg/dl) was reached in the stimulated saliva after therapy. Salivary amylase did not show a consistent concentration graph. The salivary concentrations of sodium, potassium, and chloride showed peak values after radiotherapy. The lowest salivary pH was obtained at completion of therapy, both in unstimulated and stimulated saliva. After 3 months of chemoradiotherapy, the saliva reached a pH value of 8.3, whereas 6-month posttherapy sample showed a pH value of 8.4 in both unstimulated and stimulated saliva.

CONCLUSIONS

At the completion of chemoradiotherapy, the total salivary protein, albumin, and inorganic components (calcium, magnesium, phosphorus) showed a downward trend from the baseline values due to the damage caused to the acinar part of the salivary gland by radiotherapy. The rise in salivary electrolytes' concentrations is attributed to the fact that even though there is loss of absorptive property of the tubular portion of the salivary gland, it retains its secretory property. Saliva becomes thick, scarce, tenacious, and acidic during the period of chemoradiotherapy.

International assessment of interobserver reproducibility of flap delineation in head and neck carcinoma

Background: Several reports have suggested that radiotherapy after reconstructive surgery for head and neck cancer (HNC), could have deleterious effects on the flaps with respect to functional outcomes. To predict and prevent toxicities, flap delineation should be accurate and reproducible. The objective of the present study was to evaluate the interobserver variability of frequent types of flaps used in HNC, based on the recent GORTEC atlas.Materials and methods: Each member of an international working group (WG) consisting of 14 experts delineated the flaps on a CT set from six patients. Each patient had one of the five most commonly used flaps in HNC: a regional pedicled pectoralis major myocutaneous flap, a local pedicled rotational soft tissue facial artery musculo-mucosal (FAMM) (2 patients), a fasciocutaneous radial forearm free flap, a soft tissue anterolateral thigh (ALT) free flap, or a fibular free flap. The WG's contours were compared to a reference contour, validated by a surgeon and a radiologist specializing in HNC. Contours were considered as reproducible if the median Dice Similarity Coefficient (DSC) was > 0.7.Results: The median volumes of the six flaps delineated by the WG were close to the reference contour value, with approximately 50 cc for the pectoral, fibula, and ALT flaps, 20 cc for the radial forearm, and up to 10 cc for the FAMM. The volumetric ratio was thus close to the optimal value of 100% for all flaps. The median DSC obtained by the WG compared to the reference for the pectoralis flap, the FAMM, the radial forearm flap, ALT flap, and the fibular flap were 0.82, 0.40, 0.76, 0.81, and 0.76, respectively.Conclusions: This study showed that the delineation of four main flaps used for HNC was reproducible. The delineation of the FAMM, however, requires close cooperation between radiologist, surgeon and radiation oncologist because of the poor visibility of this flap on CT and its small size.

Postoperative Observation Versus Radiotherapy for Pathologic N1 Oral Cavity Squamous Cell Carcinoma

OBJECTIVES

To investigate the benefit of postoperative radiotherapy (PORT) for low-volume (pN1) nodal disease after resection of oral cavity squamous cell carcinoma.

MATERIALS AND METHODS

The National Cancer Database was queried for adults with nonmetastatic squamous cell carcinoma of the oral cavity treated by surgical resection with pathologic stage T1-2 N0-2 (American Joint Committee on Cancer 7th edition) and with the maximal exclusion of standard indications for PORT. Overall survival was compared within pN1 for observation versus PORT and then compared for pN1 versus pN0 and versus pN2 stratified by receipt of observation or PORT. Multivariable Cox regression was used to adjust for potential confounders between PORT and survival, including comorbidity and age.

RESULTS

Overall 5017 pN0, 530 pN1, and 253 pN2 patients were identified, of whom 9%, 35%, and 64% received PORT, respectively. Within the pN1 cohort, PORT was associated with improved survival versus observation (adjusted hazard ratio, 0.66; 95% confidence interval, 0.46-0.97; P=0.03). Among observed patients, the prognosis of pN1 was equivalent to pN2 and inferior to pN0; in contrast, among patients treated with PORT, the prognosis of pN1 was equivalent to pN0 and superior to pN2. Without PORT, pN1 remained an adverse risk factor relative to pN0 regardless of the depth of invasion, lymph node size, lymph node location, and extent of lymph node dissection.

CONCLUSIONS

PORT was associated with a survival benefit compared with observation. Notably, pN1 was an adverse risk factor relative to pN0 if, and only if, patients did not receive PORT, suggesting pN1 by itself may be an indication for PORT.

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

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.

Preservation of swallowing in resected oral cavity squamous cell carcinoma: examining radiation volume effects (PRESERVE): study protocol for a randomized phase II trial

BACKGROUND

Patients with resected oral cavity squamous cell carcinoma (OCSCC) are often treated with adjuvant radiation (RT) ± concomitant chemotherapy based on pathological findings. Standard RT volumes include all surgically dissected areas, including the tumour bed and dissected neck. RT has significant acute and long-term toxicities including odynophagia, dysphagia, dermatitis and fibrosis. The goal of this study is to assess the rate of regional failure with omission of radiation to the surgically dissected pathologically node negative (pN0) hemi-neck(s) compared to historical control, and to compare oncologic outcomes, toxicity, and quality of life (QoL) profiles between standard RT volumes and omission of RT to the pN0 neck.

METHODS

This is a multicentre phase II study randomizing 90 patients with T1-4 N0-2 OCSCC with at least one pN0 hemi-neck in a 1:2 ratio between standard RT volumes and omission of RT to the pN0 hemi-neck(s). Patients will be stratified based on overall nodal status (nodal involvement vs. no nodal involvement) and use of concurrent chemotherapy. The primary endpoint is regional failure in the pN0 hemi-neck(s); we hypothesize that a 2-year regional recurrence of 20% or less will be achieved. Secondary endpoints include overall and progression-free survival, local recurrence, rate of salvage therapy, toxicity and QoL.

DISCUSSION

This study will provide an assessment of omission of RT to the dissected pN0 hemi-neck(s) on oncologic outcomes, QoL and toxicity. Results will inform the design of future definitive phase III trials.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03997643 . Date of registration: June 25, 2019, Current version: 2.0 on July 11 2020.

Management of locally advanced oral cancers

Despite easy access to clinical examination majority of oral cancer patients ironically present with locally advanced disease, which is a heterogeneous group that includes all stage III/IV tumours in absence of distant metastasis. The AJCC TNM classification has included all tumours with depth of invasion >1 cm into locally advanced group irrespective of their surface dimensions. Surgery followed by adjuvant therapy provides best results and should be offered to all patients when operable. There have been a slew of recent publications popularising the concept of compartmental excision in variance to traditional resection with adequate margins. The role of chemotherapy has been explored in this group of patients for both organ preservation as well as to aid bioselection of suitable patients with borderline operable tumours for surgery.

The role of adjuvant (chemo-)radiotherapy in oral cancers in the contemporary era

Squamous cell carcinoma of oral cavity (OSCC) is predominantly managed with surgery. Post-operative radiotherapy (PORT) and chemoradiotherapy (POCRT) enhance disease control in OSCC patients with adverse anatomic and pathologic primary and nodal features. Knowledge about disease behavior, surgery and radiotherapy advances, and the emergence of new systemic agents prompt refinement of PORT volumes and POCRT regimens. Traditional and emerging prognostic models that include adverse histopathological features underpin such approaches. This review summarizes research over recent decades with emphasis on the 2015 to Feb 2019 period describing: (1) Indications for PORT and/or POCRT, addressing surgical "margin status" including the definition of a "clear" margin to permit withholding PORT/POCRT; these concepts include characterizing the specimen yielding these measurements, the optimal time point to assess these findings, and the putative value of a "revised margin" performed during the same operative procedure, (2) Emerging prognostic factors including nodal burden (total number of involved lymph nodes) and perineural invasion, (3) PORT volume design, dose/fractionation and optimal surgery-to-PORT interval, (4) Chemotherapy dose, schedule, and agents, and (5) On-going clinical trials involving systemic agents and combinations of chemotherapy with immunotherapy.

Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx: ASCO Clinical Practice Guideline

PURPOSE

The aim of the current work is to provide evidence-based recommendations to practicing physicians and others on the management of the neck in patients with squamous cell carcinoma of the oral cavity and oropharynx.

METHODS

ASCO convened an Expert Panel of medical oncology, surgery, radiation oncology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1990 through 2018. Outcomes of interest included survival, regional disease control, neck recurrence, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 124 relevant studies to inform the evidence base for this guideline. Six clinical scenarios were devised; three for oral cavity cancer and three for oropharynx cancer, and recommendations were generated for each one.

RECOMMENDATIONS

For oral cavity cancers, clinical scenarios focused on the indications for and the hallmarks of a high-quality neck dissection, indications for postoperative radiotherapy or chemoradiotherapy, and whether radiotherapy alone is sufficient elective treatment of an undissected neck compared with high-quality neck dissection. For oropharynx cancers, clinical scenarios focused on hallmarks of a high-quality neck dissection, factors that would favor operative versus nonoperative primary management, and clarifying criteria for an incomplete response to definitive chemoradiation for which salvage neck dissection would be recommended. Consensus was reached and recommendations were made for all six clinical scenarios. Additional information is available at www.asco.org/head-neck-cancer-guidelines .

Oral cancers: Current status

Oral cancer is a global disease. Despite a well elucidated tumour progression model, these cancers present late. Attempts at early detection by way of adjunctive diagnostic technologies and screening have not lived up to expectations in spite initial promise. Surgery is the mainstay of treatment. Treatment intensification by way of adjuvant radiation/chemo radiation is warranted for those with high risk features. Recent studies have explored intensification in those with intermediate risk factors in an attempt to improve outcomes. There has been generation of recent robust evidence that has influenced the need and extent of neck dissection. Neoadjuvant chemotherapy (NACT) may have a potential role in organ preservation and borderline resectable oral cancers. Recurrent tumours should be offered surgery whenever feasible while the addition of biological agents to chemotherapy gives best results in the palliative settings.

Personalizing Postoperative Treatment of Head and Neck Cancers

Head and neck cancer (HNC) treatment is a complex multidisciplinary undertaking. Although overtreatment can result in functional and cosmetic defects, undertreatment can result in cancer recurrence. Surgery and chemoradiotherapy are both accepted standards for the curative intent treatment of locally advanced mucosal squamous cell carcinoma of the head and neck, but are often prioritized differently depending on the site of tumor origin (e.g., oral cavity/sinonasal vs. oropharynx/larynx), tumor burden, tumor biology, quality-life considerations, and patient preference. Regardless of modalities chosen, failure to cure remains a considerable problem in locally advanced disease. For patients treated with primary surgery, high-risk pathologic features portend higher recurrence rates, and adjuvant therapy can reduce these rates and improve outcomes. This report details which tumor- and nodal-related factors are indications for adjuvant therapy, examines the impact of tumor HPV status on adjuvant treatment paradigms, and considers which systemic therapies should be used for which patients when trimodality therapy is indicated.

Comparisons of the clinical outcomes of different postoperative radiation strategies for treatment of head and neck squamous cell carcinoma

Purpose

We previously reported unfavorable locoregional control with limited field postoperative radiotherapy for head and neck squamous cell carcinoma patients and thus revised the strategy to cover the whole neck. Head and neck squamous cell carcinoma Patients' outcomes were retrospectively analyzed to compare the efficacy of two treatments.

Material and methods

Before 2010, the clinical target volume covered the tumor bed and/or involved the neck region. Since 2011, whole-neck irradiation was planned. Univariate analysis, multivariate analysis, and propensity score matching were performed. The study included 275 patients: 186 received limited field postoperative radiotherapy and 89 received whole-neck postoperative radiotherapy. The median follow-up time for the entire cohort was 40.8 months.

Results

In univariate analysis, the radiation strategy had no significant effect on overall survival and progression-free survival. In multivariate analysis, whole-neck postoperative radiotherapy was a favorable factor for overall survival, progression-free survival, and locoregional control. Propensity score matching resulted in a cohort comprising 118 well-matched patients evenly divided between the limited field postoperative radiotherapy and whole-neck postoperative radiotherapy groups. Whole-neck postoperative radiotherapy group achieved a significantly better 2-year overall survival (56.4% vs. 78.1%; P = 0.003), 2-year progression-free survival (34.7% vs. 59.8%; P = 0.009), and 2-year locoregional control (54.4% vs. 83.2%; P < 0.001). The limited field postoperative radiotherapy group developed significantly more locoregional recurrences both in-field (35.2% vs. 15.1%, P = 0.003) and out-of-field (25.0% vs. 0%, P < 0.001) in the matched-pair cohort.

Conclusion

Whole-neck postoperative radiotherapy is a more appropriate choice than limited field postoperative radiotherapy to improve overall survival, progression-free survival and locoregional control.

Postoperative radiotherapy for patients with oral squamous cell carcinoma with intermediate risk of recurrence: A case match study

BACKGROUND

The purpose of this study was to determine the effect of postoperative radiotherapy (PORT) on recurrence and survival in patients with oral squamous cell carcinoma (OSCC) of intermediate recurrence risk.

METHODS

Intermediate risk patients, defined as pT1, pT2, pN0, or pN1 with at least one adverse pathological feature (eg, lymphovascular/perineural invasion), were identified from the head and neck databases of the Liverpool Head and Neck Cancer Unit and the Sydney Head and Neck Cancer Institute. Patients who received surgery and PORT were case matched with patients treated by surgery alone based on pN, pT, margins, and pathological features.

RESULTS

Ninety patients were matched into 45 pairs. There was significant improvement (P = .039) in locoregional control with PORT (84%) compared with surgery alone (60%), which was concentrated in the pN1 subgroup (P = .036), but not the pN0 subgroup (P = .331).

CONCLUSION

PORT significantly improves locoregional control for intermediate risk OSCC.

A 10-year analysis of the oral squamous cell carcinoma profile in patients from public health centers in Uruguay

The aim of this study was to evaluate the demographic, clinical, and therapeutic characteristics and predictive factors of poor prognosis in patients with primary oral squamous cell carcinoma (OSCC) in Uruguay. Medical records of patients with the diagnosis of primary OSCC treated between 2000 and 2010 in Uruguayan public hospitals were selected. Data on demographic characteristics, risk factors, clinical features, treatment, and outcome were collected. Associations of independent variables with outcomes were assessed using Pearson chi-squared and Fisher's tests. Of 200 patients with OSCC, 79.4% were men (3.8:1 male:female ratio), with a mean age of 60.75 ± 11.26 years. Tobacco and alcohol consumption were reported by 85.3% and 63.5% of patients, respectively. The most commonly affected location was the tongue (42.5%), with lesions exhibiting ulcerous aspects in 87.9% of cases and pain at the time of diagnosis in 70.4% of cases. One hundred sixty-one (82.1%) patients had advanced-stage (III/IV) OSCC. Surgery was the most common treatment option, and the overall 5-year survival rate was 58.5%. Univariate analysis showed that the predictors of poor prognosis were clinical aspect, size, regional metastasis, clinical stage, and treatment. In Uruguay, OSCC is diagnosed late, which is associated with a low survival rate. Educational and preventive measures and investment to improve early diagnosis should be undertaken.

Sequential therapy of advanced buccal mucosa squamous cell carcinoma: three-year outcome

PURPOSE

Squamous cell carcinoma (SCC) of the buccal mucosa is aggressive and requires multimodal treatment. The objective of this study was to evaluate the outcome of sequential therapy (neoadjuvant therapy plus surgery plus radiotherapy) in advanced buccal SCC and explore the prognostic factors.

PATIENTS AND METHODS

In this retrospective cohort study, patients with advanced buccal cancer who received neoadjuvant chemotherapy (cisplatin, docetaxel, and 5-fluorouracil) followed by surgery and radiotherapy in the authors' department were reviewed. The outcomes of chemotherapy and surgery were analyzed. Overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. The prognostic values of age, gender, histologic grade, lymph node status, tumor stage, pathologic response, and adverse pathologic features were explored using the log-rank test and the Cox regression model.

RESULTS

From 2008 to 2011, data from 22 patients were analyzed. The overall response rate of chemotherapy was 72.7%. The pathologic complete or partial response rate was 40.9%. The median follow-up was 36 months. The 2-year DFS and OS rates were 63.3% and 67.2%, respectively. Male and younger patients showed an association with poor outcome. Multivariate analysis showed that gender was a predictive factor with respect to DFS and OS (P = .023 and .014, respectively).

CONCLUSION

Sequential therapy (neoadjuvant therapy plus surgery plus radiotherapy) tends to be effective for advanced buccal cancer. Female patients have better survival.

Oral cancer: Current role of radiotherapy and chemotherapy

The term oral cavity cancer (OSCC) constitutes cancers of the mucosal surfaces of the lips, floor of mouth, oral tongue, buccal mucosa, lower and upper gingiva, hard palate and retromolar trigone. Treatment approaches for OSCC include single management with surgery, radiotherapy [external beam radiotherapy (EBRT) and/or brachytherapy], as well as adjuvant systemic therapy (chemotherapy and/or target agents); various combinations of these modalities may also be used depending on the disease presentation and pathological findings. The selection of sole or combined modality is based on various considerations that include disease control probability, the anticipated functional and cosmetic outcomes, tumor resectability, patient general condition, and availability of resources and expertise. For resectable OSCC, the mainstay of treatment is surgery, though same practitioners may advocate for the use of radiotherapy alone in selected "early" disease presentations or combined with chemotherapy in more locally advanced stage disease. In general, the latter is more commonly reserved for cases where surgery may be problematic. Thus, primary radiotherapy ± chemotherapy is usually reserved for patients unable to tolerate or who are otherwise unsuited for surgery. On the other hand, brachytherapy may be considered as a sole modality for early small primary tumor. It also has a role as an adjuvant to surgery in the setting of inadequate pathologically assessed resection margins, as does postoperative external beam radiotherapy ± chemotherapy, which is usually reserved for those with unfavorable pathological features. Brachytherapy can also be especially useful in the re-irradiation setting for persistent or recurrent disease or for a second primary arising within a previous radiation field. Biological agents targeting the epithelial growth factor receptor (EGFR) have emerged as a potential modality in combination with radiotherapy or chemoradiotherapy and are currently under evaluation in clinical trials.

Interventions for the treatment of oral cavity and oropharyngeal cancer: radiotherapy

BACKGROUND

The management of advanced oral cavity and oropharyngeal cancers is problematic and has traditionally relied on surgery and radiotherapy, both of which are associated with substantial adverse effects. Radiotherapy has been in use since the 1950s and has traditionally been given as single daily doses. This method of dividing up the total dose, or fractionation, has been modified over the years and a variety of approaches have been developed with the aim of improving survival whilst maintaining acceptable toxicity.

OBJECTIVES

To determine which radiotherapy regimens for oral cavity and oropharyngeal cancers result in increased overall survival, disease free survival, progression free survival and locoregional control.

SEARCH STRATEGY

The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 28 July 2010), CENTRAL (The Cochrane Library 2010, Issue 3), MEDLINE via OVID (1950 to 28 July 2010) and EMBASE via OVID (1980 to 28 July 2010). There were no restrictions regarding language or date of publication.

SELECTION CRITERIA

Randomised controlled trials where more than 50% of participants had primary tumours of the oral cavity or oropharynx, and which compared two or more radiotherapy regimens, radiotherapy versus other treatment modality, or the addition of radiotherapy to other treatment modalities.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of risk of bias was undertaken independently by two or more authors. Study authors were contacted for additional information as required. Adverse events data were collected from published trials.

MAIN RESULTS

30 trials involving 6535 participants were included. Seventeen trials compared some form of altered fractionation (hyperfractionation/accelerated) radiotherapy with conventional radiotherapy; three trials compared different altered fractionation regimens; one trial compared timing of radiotherapy, five trials evaluated neutron therapy and four trials evaluated the addition of pre-operative radiotherapy. Pooling trials of any altered fractionation radiotherapy compared to a conventional schedule showed a statistically significant reduction in total mortality (hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.76 to 0.98). In addition, a statistically significant difference in favour of the altered fractionation was shown for the outcome of locoregional control (HR 0.79, 95% CI 0.70 to 0.89). No statistically significant difference was shown for disease free survival.No statistically significant difference was shown for any other comparison.

AUTHORS' CONCLUSIONS

Altered fractionation radiotherapy is associated with an improvement in overall survival and locoregional control in patients with oral cavity and oropharyngeal cancers. More accurate methods of reporting adverse events are needed in order to truly assess the clinical performance of different radiotherapy regimens.

Buccal mucosa carcinoma: surgical margin less than 3 mm, not 5 mm, predicts locoregional recurrence

Background

Most treatment failure of buccal mucosal cancer post surgery is locoregional recurrence. We tried to figure out how close the surgical margin being unsafe and needed further adjuvant treatment.

Methods

Between August 2000 and June 2008, a total of 110 patients with buccal mucosa carcinoma (25 with stage I, 31 with stage II, 11 with stage III, and 43 with Stage IV classified according to the American Joint Committee on Cancer 6^th edition) were treated with surgery alone (n = 32), surgery plus postoperative radiotherapy (n = 38) or surgery plus adjuvant concurrent chemoradiotherapy (n = 40).

Main outcome measures: The primary endpoint was locoregional disease control.

Results

The median follow-up time at analysis was 25 months (range, 4-104 months). The 3-year locoregional control rates were significantly different when a 3-mm surgical margin (≤3 versus >3 mm, 71% versus 95%, p = 0.04) but not a 5-mm margin (75% versus 92%, p = 0.22) was used as the cut-off level. We also found a quantitative correlation between surgical margin and locoregional failure (hazard ratio, 2.16; 95% confidence interval, 1.14 - 4.11; p = 0.019). Multivariate analysis identified pN classification and surgical margin as independent factors affecting disease-free survival and locoregional control.

Conclusions

Narrow surgical margin ≤3 mm, but not 5 mm, is associated with high risk for locoregional recurrence of buccal mucosa carcinoma. More aggressive treatment after surgery is suggested.

Postoperative Radiotherapy in Head and Neck Cancer

Though early stage head and neck cancers can be cured either by surgery or radiation, patients with locally advanced disease continues to pose a therapeutic challenge. Locoregional failure is the major cause of death in head and neck cancers. As the outcome of locally advanced head and neck cancer is less than promising, a combined modality approach is generally undertaken in this group of patients. The combination of surgery, radiation and more recently, chemotherapy and targeted therapy can improve outcomes in locally advanced head and neck cancer patients. This overview discusses the rationale and role of postoperative radiotherapy (PORT) in advanced head and neck cancers, the radiotherapy technique in brief and methods of enhancing the efficacy of postoperative RT by altering the fractionation schedules and adding chemotherapy and targeted therapy.

Management of gingivobuccal complex cancer

INTRODUCTION

Squamous cell carcinoma of the oral cavity ranks as the 12th most common cancer in the world and the 8th most frequent in males. It accounts for up to one-third of all tobacco-related cancers in India. Cancer of the gingivobuccal complex is especially common in Indians due to their tobacco habits. This review focuses on the management of lower gingivobuccal complex cancers.

PATIENTS AND METHODS

References for this review were identified by search of Medline and other bibliographic information available in the PubMed database. The search terms carcinoma oral cavity, and cancer oral cavity, buccal mucosa, gingiva, gingivobuccal complex, and alveolus cancer/carcinoma were used. References from relevant articles and abstracts from international conferences were also included. Only articles published in the English language were used.

RESULTS

Treatment of gingivobuccal complex cancer is primarily surgical. Radical neck dissection, or its modification, is the standard treatment for the node-positive neck. Supraomohyoid neck dissection is the accepted treatment for the node-negative neck. Radiotherapy is usually not the preferred modality of treatment for early gingivobuccal complex cancer. It is used either as postoperative adjuvant treatment or as definitive treatment for advanced cancer with or without chemotherapy. Chemotherapy has been used as neo-adjuvant, adjuvant or palliative treatment. Advanced cancers are common and continue to pose a challenge to the multidisciplinary team.

CONCLUSIONS

Gingivobuccal complex cancer remains a major public health problem despite being highly preventable and easily detectable. Advanced cancers constitute a major proportion of patients presenting for treatment. These patients are difficult to treat and have a poor outcome.

Squamous cell carcinoma of the gingivobuccal complex: predictors of locoregional failure in stage III-IV cancers

The purpose of our study was to analyze the indicators of loco-regional failure in a large cohort of patients with gingivobuccal complex tumors treated at a single institution. A retrospective review of 2275 patients diagnosed with tumors of the gingivobuccal complex was conducted from January 1997 to December 1999; 642 patients who fulfilled our inclusion criteria were analyzed. A univariate analysis, multivariate analysis, and disease-free survival are reported. During a median follow up of 2.51 years, there were 228 (35.5%) recurrences with a median post-recurrence survival of 2.7 months. The incidence of occult neck metastasis was 29%. The 2- and 5-year DFS rates were 63.8% and 53.3%, respectively. On multivariate analysis, tumor depth and metastatic lymphadenopathy were found to be independent prognostic factors for disease-free survival. Advanced gingivobuccal cancers fail loco-regionally. Cervical metastasis and tumor depth influence disease-free survival. Elective neck dissection due to a high incidence of occult neck disease is recommended.

Treatment outcome of combined modalities for buccal cancers: unilateral or bilateral neck radiation?

PURPOSE

To evaluate the outcome of treatment for buccal cancers and assess the impact of unilateral vs. bilateral adjuvant neck radiation.

METHODS AND MATERIALS

We retrospectively reviewed the course of 145 patients newly diagnosed with buccal squamous cell carcinoma without distant metastases who completed definitive treatment between January 1994 and December 2000. Of 145 patients, 112 (77%) had Stage III or IV disease. All underwent radical surgery with postoperative radiotherapy (median dose, 64 Gy), including unilateral neck treatment in most (n = 120, 82.8%). After 1997, cisplatin-based concomitant chemoradiotherapy was given for high-risk patients with more than two involved lymph nodes, extracapsular spread, and/or positive margins.

RESULTS

The 5-year disease-specific survival rate for Stages I-IV was 87%, 83%, 61%, and 60%, respectively (p = 0.01). The most significant prognostic factor was N stage, with the 5-year disease-specific survival rate for N0, N1, and N2 being 79%, 65%, and 54%, respectively (p = 0.001). For patients with more than two lymph nodes or positive extracapsular spread, cisplatin-based concomitant chemoradiotherapy improved locoregional control (p = 0.02). Locoregional control did not differ between patients undergoing unilateral or bilateral neck treatments (p = 0.95). Contralateral neck failure occurred in only 2.1%.

CONCLUSIONS

In patients with buccal carcinoma after radical resection, ipsilateral neck radiation is adequate. Bilateral prophylactic neck treatment does not confer an added benefit.

When does skin excision allow the achievement of an adequate local control rate in patients with squamous cell carcinoma involving the buccal mucosa?

BACKGROUND

The role of cheek skin excision in patients with squamous cell carcinoma of the buccal mucosa (BSCC) remains controversial. We sought to investigate when skin excision is needed to achieve an adequate local control.

METHODS

A total of 331 patients with BSCC were reviewed. Skin preservation was pursued when the distance between the tumor and the skin as determined by imaging was >or=13 mm (1 cm surgical margin plus 0.3 cm skin preservation). Two hundred and thirty patients (69.5%) underwent skin excision. Postoperative adjuvant radiotherapy (n = 182) was performed in patients with pathological T4 disease, metastases in cervical lymph nodes or close pathological margins (<or=4 mm). The 5-year local control rate was plotted by Kaplan-Meier analysis.

RESULTS

Twenty-four patients (7.3%) had close pathological margins. The 5-year local control rate did not differ significantly between patients treated either with or without skin excision. This was verified both in subjects who received surgery alone (94% versus 91%) and in those who received surgery plus adjuvant therapy (82% versus 86%).

CONCLUSION

In patients with BSCC, a good 5-year local control rate may be equally achieved either with or without skin excision. In patients with pT3 disease, postoperative radiotherapy is not recommended in the absence of close pathological margins. Our findings may guide clinical decision-making on skin excision in this patient group.

Interventions for the treatment of oral and oropharyngeal cancers: surgical treatment

BACKGROUND

Oral and oropharyngeal cancers can be managed by surgery alone or with any combination of radiotherapy, chemotherapy and immunotherapy/biotherapy. Opinions on the surgical treatment, the optimal combinational therapy and the sequence of treatments in combinational therapy varies enormously.

OBJECTIVES

To determine which surgical treatment modalities for oral and oropharyngeal cancers lead to the best outcomes compared with other surgical, radiotherapy, chemotherapy or immunotherapy/biotherapy combinations.

SEARCH STRATEGY

Electronic search of the Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE, OLDMEDLINE, EMBASE, AMED and the National Cancer Trials Database. Reference lists from relevant articles were searched and the authors of eligible trials were contacted. Date of the most recent searches: July 2007.

SELECTION CRITERIA

Randomised controlled trials of surgery alone or in combination with chemotherapy, radiotherapy or immunotherapy/biotherapy for the treatment of primary oral or oropharyngeal cancer or both.

DATA COLLECTION AND ANALYSIS

A minimum of two review authors conducted data extraction. Risk ratios were calculated for dichotomous outcomes at different time intervals, and hazard ratios were extracted or calculated for disease-free survival, total mortality, and disease-related mortality. Additional information from trial authors was sought. Data on adverse events were collected from the trial reports.

MAIN RESULTS

Thirty-one trials satisfied the inclusion criteria, only 13 of which were assessed as low risk of bias. Trials were grouped into 12 main comparisons. There were no trials that compared different surgical modalities of the primary tumour itself. However, there were a number of trials comparing different approaches to managing the cervical lymph nodes. The majority of treatment regimens under evaluation were surgery in combination with other modalities. As individual treatment regimens within each comparison varied, meta-analysis was inappropriate in most instances. Only two trials could be pooled, comparing concomitant radio/chemotherapy (with surgery) versus radiotherapy (with surgery). A statistically significant difference was shown for disease-free survival (hazard ratio 0.77, 95% confidence interval (CI): 0.64 to 0.92) and total mortality (hazard ratio 0.78, 95% CI: 0.64 to 0.95) in favour of the concomitant chemotherapy and radiotherapy (with surgery) arm. No other treatment regimens showed consistent statistically significant results across the outcomes measured.

AUTHORS' CONCLUSIONS

There is some evidence that concomitant radio/chemotherapy (with surgery) is more effective than radiotherapy (with surgery) and may benefit outcomes in patients with more advanced oral and oropharyngeal cancers. As these trials were based on head and neck studies, future studies should evaluate this treatment regimen specifically in oral and oropharyngeal cancers separately and also address tumour staging and its impact on outcomes. In general, future studies are encouraged to evaluate site-specific and stage-specific data for oral and oropharyngeal cancers. Future trials should include health-related quality of life assessment as an outcome measure. There is a need for a consolidated standardised approach to reporting adverse events.

T4b oral cavity cancer below the mandibular notch is resectable with a favorable outcome

According to the AJCC 2002 staging system, squamous cell carcinoma of the oral cavity (OSCC) with T4b is unresectable. Herein, we report on our surgical outcome for T4b OSCC. All patients were enrolled before 2002. From January 1996 to December 2000, 45 consecutive untreated T4b OSCC patients were included. According to the trans-axial plane of the mandibular notch on CT/MRI, seven were supra-notch T4b and 38 were infra-notch T4b tumors. Significantly higher 5-year loco-regional control and survivals were observed in patients with infra-notch T4b than with supra-notch T4b. In the infra-notch group, pN0-1 patients had a significantly higher 5-year loco-regional control and survivals than pN2 patients. Nerve invasion was the sole significant adverse factor for loco-regional control and survivals in the infra-notch T4b group with pN0-1. Our retrospective study demonstrated that OSCC patients of infra-notch T4b with pN0-1 and no nerve invasion might have a favorable surgical outcome.

Clinicopathologic evaluation of prognostic factors for squamous cell carcinoma of the buccal mucosa

BACKGROUND

The purpose of this research was to evaluate the prognostic significance of clinicopathologic variables on the survival rate for squamous cell carcinoma of the buccal mucosa (BMSCC). We analyzed the outcomes of surgical therapy for this aggressive cancer and compared these results with those in the literature.

METHODS

We reviewed the medical charts of 172 patients treated in our institution between 1990 and 2005. There were 22 patients excluded from our studies: 20 patients with advanced tumors who received no treatment or palliative treatment, and 2 patients who had received preoperative radiotherapy (RT). The remaining 150 patients were treated with surgeries and among them, 56 patients had undergone postoperative RT. The influence of clinicopathologic factors on the survival rate was analyzed with the Kaplan-Meier method and log-rank test. Multivariate analysis was assessed with Cox's regression model.

RESULTS

There were 148 males and 2 females, with a mean age of 53.5 years. The prevalence rate of habitual betel quid chewing documented in charts among 113 patients was 75%. The 5-year overall survival rate and disease-specific survival rate for all patients were 64% and 69%, respectively. For patients with stages I, II, III, and IV disease, the 5-year disease-specific survival rates were 90%, 77%, 52%, and 47%, respectively (p<0.001). According to the multivariate analysis, the pathologic staging and histologic grading of the tumor were independently the important prognostic factors affecting survival rate. There were 80 patients who developed locoregional recurrence in lymph nodes in the follow-up diagnoses. Distant metastases occurred in 14 patients, with 11 of them also having locoregional recurrence. The distant metastases were found in the lungs (8/14), T-spine (3/14), liver (2/14) and brain (1/14).

CONCLUSION

Pathologic stage and histologic grade are the most important prognostic factors.

Combined-modality treatment for advanced oral tongue squamous cell carcinoma

PURPOSE

The aim of this study was to investigate prognostic factors in advanced-stage oral tongue cancer treated with postoperative adjuvant therapy and to identify indications for adjuvant concomitant chemoradiotherapy (CCRT).

METHODS AND MATERIALS

We retrospectively reviewed the records of 201 patients with advanced squamous cell carcinoma of the oral tongue managed between January 1995 and November 2002. All had undergone wide excision and neck dissection plus adjuvant radiotherapy or CCRT. Based on postoperative staging, 123 (61.2%) patients had Stage IV and 78 (38.8%) had Stage III disease. All patients were followed for at least 18 months after completion of radiotherapy or until death. The median follow-up was 40.4 months for surviving patients. The median dose of radiotherapy was 64.8 Gy (range, 58.8-72.8 Gy). Cisplatin-based regimens were used for chemotherapy.

RESULTS

The 3-year overall survival (OS) and recurrence-free survival (RFS) rates were 48% and 50.8%, respectively. Stage, multiple nodal metastases, differentiation, and extracapsular spread (ECS) significantly affected disease-specific survival on univariate analysis. On multivariate analysis, multiple nodal metastases, differentiation, ECS, and CCRT were independent prognostic factors. If ECS was present, only CCRT significantly improved survival (3-year RFS with ECS and with CCRT = 48.2% vs. without CCRT = 15%, p = 0.038). In the presence of other poor prognostic factors, results of the two treatment strategies did not significantly differ.

CONCLUSIONS

Based on this study, ECS appears to be an absolute indication for adjuvant CCRT. CCRT can not be shown to be statistically better than radiotherapy alone in this retrospective series when ECS is not present.

Surgical outcome of T4a and resected T4b oral cavity cancer

BACKGROUND

The American Joint Committee on Cancer (AJCC) 2002 staging system (AJCC 2002) suggested that squamous cell carcinoma of the oral cavity (OSCC) with T4b is unresectable. The current retrospective results show that selected T4b patients were resectable with favorable outcomes.

METHODS

From January 1996 to December 2000, 103 consecutive untreated T4 OSCC patients (reclassified by AJCC 2002) without carotid artery encasement and skull base extension were eligible for radical treatment. All received head-and-neck magnetic resonance imaging (MRI) and/or computed tomography (CT) scans before operation. The surgical principles were safety margins of > or =1 cm for primary tumors, modified/radical neck dissections for clinical lymph node-positive disease, and supraomohyoid neck dissection for lymph node-negative disease. In all, 95.1% of patients (98 of 103 patients) underwent free-flap reconstructions. Adjuvant radiotherapy or concomitant chemoradiotherapy was administered to those with pathological T4 (AJCC 1997), cervical lymph node metastasis, or close margins (< or =4 mm). Survivals were calculated according to the method of Kaplan and Meier.

RESULTS

In all, 58 patients were classified as having T4a disease and 45 were classified as having T4b disease. No statistical difference was observed in the 5-year local control, neck control, disease-free survival, and overall survival rates between the T4a and T4b groups. In multivariate analyses, pathologic lymph node status (pN0-1 vs. pN2) was found to be the sole independent predictor for T4b for local control (P = .012), disease-free survival (P = .005), and overall survival (P = .008).

CONCLUSIONS

Selected T4b OSCC patients were found to be resectable with outcomes that were comparable to those of T4a OSCC patients and may benefit from radical surgery, free-flap reconstruction, and adjuvant therapy. A pathologic lymph node status of > or =2 was found to be the sole independent predictor for T4b disease in local control and survival.

Good tumor control and survivals of squamous cell carcinoma of buccal mucosa treated with radical surgery with or without neck dissection in Taiwan

The aim was to analyze the survival and prognostic factors in 232 patients with squamous cell carcinoma of the buccal mucosa (BSCC) treated with radical surgery with or without neck dissection (ND). The 5-year survivals for local, locoregional control, overall, disease-free, and disease-specific were demonstrated. Pathologic nodal status was the independent risk factor for local and locoregional control. Both pathologic nodal status and cell differentiation were the significant prognostic factors of disease-free survival. For cT1N0, 11.1% had neck metastases. All were tumor depth of > or =6 mm. Our result showed a relatively better tumor control and survivals in BSCC with radical surgery with or without ND. The possible reason may be due to the benefit from widely surgical resection with ND and post-operative radiotherapy or concurrent chemoradiotherapy in those with risk factors. In treating early cT1N0, we suggest that elective ND is indicated only when tumor depth > or =6 mm.

Carcinoma of the buccal mucosa: Analysis of clinical presentation, outcome and prognostic factors

Records of 100 consecutive cases of carcinoma of the buccal mucosa treated in our institute between January 2000 and December 2003 were analyzed for clinical presentation, patterns of care, disease-free survival (DFS) and prognostic factors. There were 75 males and 25 females. The mean age was 50 years. Ninety five gave a history of abuse of oral tobacco products. Only 20 patients were in Stage I or II. Sixty one patients had Stage IV disease. Sixty six patients were treated with radical intent while 34 were suitable only for palliative radiation. The 2-year DFS for the entire group was 47.94%. All failures occurred by 12 months. However, the 2-year DFS in radically treated patients was 76.4%. On univariate analysis, late overall stage, T3/T4 disease, node positivity and palliative treatment were significant poor prognostic factors. On multivariate analysis, T3/T4 disease and palliative treatment were independent poor prognostic factors. Early detection can improve outcomes considerably in this disease.

Squamous cell carcinoma of the buccal mucosa: An aggressive cancer requiring multimodality treatment

BACKGROUND

In our clinical practice, we have observed a high incidence of locoregional failure in squamous cell carcinoma (SCC) of the buccal mucosa. We analyze our treatment results of this cancer and compare these results with those in the literature. We intend to define the pattern and incidence of failure of buccal cancer and provide information for the design of a better multimodality treatment.

METHODS

During the period from 1983 through 2003, 121 previously untreated patients with M0 stage SCC of the buccal mucosa were treated with a curative intent at our hospital. Twenty-seven patients received surgery alone, 36 had radiotherapy alone, and 58 underwent surgery plus postoperative radiotherapy.

RESULTS

The 5-year locoregional control, overall survival, and cause-specific survival rates for all patients were 36.3%, 34.3%, and 36.9%, respectively. The locoregional recurrence rate was 57% for all patients, with 80% occurring in the primary site alone. Patients with T1-2N0 disease who received surgery alone still had a high local recurrence incidence of 41%. For patients with locally advanced disease, surgery plus postoperative radiotherapy achieved better overall survival and locoregional control rates than surgery alone or radiotherapy alone. T classification was the only prognostic factor affecting locoregional control and survival in the surgery alone group, whereas N classification and skin invasion predicted a poorer survival for the surgery plus postoperative radiotherapy group.

CONCLUSIONS

SCC of the buccal mucosa is an aggressive cancer with a high locoregional failure rate even in patients with T1-2N0 disease. Possible reasons include inadequate treatment and an intrinsically aggressive nature. Postoperative radiotherapy has resulted in a better locoregional control rate for patients with T3-4 or N+ disease and should also be considered for patients with T1-2N0 disease for whom adjuvant therapy after radical surgery currently is not recommended by most guidelines.

Advanced squamous cell carcinoma of lower gingivobuccal complex: patterns of spread and failure

BACKGROUND

Carcinoma of the gingivobuccal complex is commonly associated with the use of smokeless tobacco known as "quid."

METHODS

We conducted a retrospective chart review of 511 patients with advanced cancer of gingivobuccal complex surgically treated during 1994 to 1995. We evaluated patterns of disease failure in these patients and correlated disease-free survival with various prognostic factors.

RESULTS

During a median follow-up of 46 months, 159 locoregional recurrences and 11 distant metastases were detected in 148 patients. Seventy-nine percent of the recurrences appeared within 18 months of surgery, and the median survival for patients with recurrent disease was less than 4 months. Two-year and 5-year disease-free survival rates were 64% and 57%, respectively. On multivariate analysis, disease-free survival showed significant correlation with skin involvement and extracapsular spread.

CONCLUSIONS

Gingivobuccal cancers usually fail locoregionally. Soft tissue infiltration and extracapsular spread of nodal disease influence disease-free survival.

Trends of oral and oropharyngeal cancer survival over five decades in 3267 patients treated in a single institution

The objective of this study was to analyze the influence of changes in the treatment on the prognosis of patients treated over 44 years in a single institution. The 5-decade trends in treatment approach and 5-year survival of 3267 patients treated between 1953 and 1997 were analyzed. An increase was observed in primary surgical treatment and its association with radiotherapy. In the 1950s, 29.1% of the patients were treated by surgery, 54.5% by radiotherapy and 16.4% by combined treatment; in the 1990s, these proportions were 39.7, 9.7 and 50.6%, respectively (P<0.001). There was a significant increase in the 5-year survival rates from 28.7% for patients treated in the 1950s to 43.2% in the 1990s (P<0.001). The changes in treatment approach for oral and oropharyngeal cancer over the last 5 decades, with an increase of surgical treatment and its combination with radiotherapy significantly improved the survival rates.

Sites of recurrence in oral and oropharyngeal cancers according to the treatment approach

OBJECTIVE

The purpose of this study is to evaluate the rates and the sites of tumour recurrence in patients with oral and oropharyngeal carcinomas.

DESIGN

This is a retrospective study of a series of cases treated in a single institution.

PATIENTS AND METHODS

A series of 2067 patients with oral and oropharyngeal squamous carcinoma, treated from 1954 to 1998 were analysed. The treatment approach was: surgery, 624 cases (30.2%); radiotherapy alone, 729 cases (35.3%); radiotherapy and surgery, 552 cases (26.7%) and radiotherapy and chemotherapy, 162 cases (7.8%).

MAIN OUTCOME MEASURES

Tumour recurrence was observed in 1079 patients (52.2%): 561 cases of local recurrences (27.1%); 168 neck recurrences (8.1%); 252 locoregional recurrences (12.2%); 59, distant metastasis (2.9%) and 39 (1.9%), combination of distant metastasis with local, neck or locoregional recurrence.

RESULTS

The rates of recurrence varied significantly according to the treatment performed. Oral cavity cancer patients undergoing radiotherapy alone or in combination with chemotherapy presented the highest rates of neck recurrences (22.5 and 40.0%, respectively) for clinical stage (CS) I/II and of local (41.2 and 30.1%) and locoregional (21.7 and 31.1%) recurrences for CS III/IV; yet, for CS III/IV, surgery without neck dissection was associated with the highest rates of neck recurrences (20.7%), but no differences were observed in the rates of local or locoregional recurrences for CS I/II patients. For oropharynx cancer patients with CS I/II there was no difference in the rate of locoregional failures according to the treatment. However, patients with CS III/IV undergoing radiotherapy present a highest rate of local (42.3%) and locoregional (28.8%) failures.

CONCLUSION

The results suggest that surgery should be the first option for initial clinical stage oral and oropharyngeal cancers. For advanced cases independently of the site of the tumour, surgery and postoperative radiotherapy should be the standard of care because it is associated with the lowest rates of locoregional recurrence.

Carcinoma of the buccal mucosa

OBJECTIVE

The goal was to analyze the outcome of surgical therapy for buccal carcinoma.

STUDY DESIGN

A retrospective chart review was done.

SETTING

The study took place in a major tertiary-care hospital.

RESULTS

Twenty-seven patients received first-time surgical therapy for buccal carcinoma. Treatment was surgery alone in 15 and surgery followed by radiation therapy in 6 patients. Six additional patients received surgical salvage for radiation therapy failure. Composite resection of the tumor was performed in 16 patients (59%). Five-year observed actuarial survival rates were 100%, 45%, 67%, and 78%, and locoregional recurrence rates were 0%, 27%, 44%, and 0% for stages I to IV, respectively. The 5-year actuarial survival rates were 80% after surgery and 82% after surgery and postoperative radiation therapy. Patients who underwent surgical salvage after radiation therapy failure had a 1-year survival rate of 0%.

CONCLUSION

Aggressive surgical treatment of buccal carcinoma may result in better survival rates.

SIGNIFICANCE

The article analyzes buccal carcinoma in regards to the patterns of presentation, treatments rendered, and patterns of failure.