Salvage surgery as the primary treatment for recurrent oral squamous cell carcinoma

Predictors of survival in advanced oral cancers after salvage surgery with free tissue flap reconstruction

OBJECTIVE

To identify prognostic factors for patients with advanced persistent, recurrent, or 2nd primary oral cavity squamous cell carcinoma (OCSCC) potentially unsuitable for salvage surgery with free tissue flap (FTF) reconstruction.

MATERIALS AND METHODS

A population-based cohort of 83 consecutive patients with advanced OCSCC who underwent salvage surgery with FTF reconstruction at a tertiary referral centre between 1990 and 2017. Retrospective uni- and multivariable analyses were performed to identify factors affecting all-cause mortality (ACM), i.e., overall survival (OS), as well as disease-specific mortality (DSM), i.e., disease-specific survival (DSS) after salvage surgery.

RESULTS

Median disease-free interval until recurrence was 15 months with recurrent stage I/II in 31% and III/IV in 69%. Median age at salvage surgery was 67 years (range 31-87) and the median follow-up (alive patients) 126 months. At 2, 5, and 10 years after salvage surgery, respectively, DSS rates were 61%, 44%, and 37% and OS rates 52%, 30%, and 22%. Median DSS was 26 and OS 43 months. Multivariable analysis identified recurrent clinical regional (cN-plus) disease [HR 3.57; p < .001] and elevated gamma-glutamyl transferase (GGT) [HR 3.30; p = .003] as independent pre-salvage predictors for poor OS after salvage, whereas initial cN-plus [HR 2.07; p = .039] and recurrent cN-plus disease [HR 5.14; p < .001] predicted poor DSS. Among post-salvage factors, extranodal extension according to histopathology [HR ACM 6.11; HR DSM 9.99; p < .001] as well as positive [HR ACM 4.98; DSM 7.51; p < 0.001] and narrow surgical margins [HR ACM 2.12; DSM HR 2.80; p < 0.01] emerged as independent factors for poor survival.

CONCLUSION

While salvage surgery with FTF reconstruction is the primary curative option for patients with advanced recurrent OCSCC, the present findings may help guide discussions with patients who have advanced recurrent regional disease and high GGT preoperatively, especially if there is a small chance of reaching surgical radicality.

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.

Salvage surgery for recurrent carcinoma of the oral cavity: assessment of prognostic factors

Salvage surgery is the most acceptable therapeutic option for disease control of loco-regional recurrences in oral cancers. Prognostic factors need to be assessed to select patients for salvage surgery who would benefit the most. This was a single-centre retrospective observational study conducted between 2015 and 2018. A total of 168 patients with recurrent oral cavity carcinoma who underwent salvage surgery were included for analysis. The primary endpoints of the study were to evaluate overall survival (rOS) after salvage surgery and prognostic factors affecting survival. In this study, the median rOS was 18 months and the median disease-free survival (rDFS) was 14 months. Advanced stage (hazard ratio (HR) 2.387, 95% confidence interval (CI) 1.496-3.808; P = 0.001) and multimodality treatment (HR 1.642, 95% CI 1.139-2.367; P = 0.008) in the initial disease, as well as nodal spread (HR 3.794, 95% CI 1.580-9.111; P = 0.008) and perineural invasion (HR 2.167, 95% CI 1.358-3.455; P = 0.001) in the recurrent disease, were found to adversely affect survival after salvage surgery. With thorough assessment of the prognostic factors and appropriate patient selection, survival may be favourable after salvage surgery for recurrent oral cavity carcinoma.

Opportunities and Limits in Salvage Surgery in Persistent or Recurrent Head and Neck Squamous Cell Carcinoma

Except for HPV-induced cancers of the oropharynx, survival rates in patients with squamous cell carcinoma of the head and neck (HNSCC) have not changed substantially over the last decades. Salvage surgery plays an important role where primary treatment was unsuccessful since 50% of advanced-stage patients relapse after nonsurgical primary treatment. Depending on a variety of factors, a considerable number of patients in whom primary treatment was not successful can still be cured by salvage surgery. It is the goal of this review to elucidate these factors with the aim to counsel patients and their relatives realistically about the chances of being cured.

The utility of postoperative radiotherapy in intermediate-risk oral squamous cell carcinoma

The effectiveness of postoperative radiotherapy (PORT) in improving outcomes remains debatable for oral squamous cell carcinoma (OSCC) patients with pathological intermediate-risk factors (IRFs) after surgery. A retrospective analysis was conducted on 432 intermediate-risk OSCC patients defined by histological reporting of close margin (<5mm), early nodal disease (pN1), depth of invasion/tumour thickness ≥5mm, perineural invasion, and/or lymphovascular invasion. Outcomes measured were disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). PORT was associated with an improvement in 5-year DFS on univariable analysis (80% vs 71%; P=0.044), but this did not remain significant on multivariable analysis. PORT was not associated with differences in DSS or OS. The surgical salvage rate was similar in the PORT and surgery-only groups (41% vs 47%; P=0.972). Perineural invasion was found to be an independent predictor of inferior DSS (hazard ratio (HR) 2.19), DFS (HR 1.89), and OS (HR 1.97). Significantly worse outcomes were observed for patients with ≥4 concurrent IRFs. The application of PORT was associated with lower rates of recurrence, but the benefit was less apparent on mortality. Patients with perineural invasion and multiple concurrent IRFs were found to be at greatest risk, representing a subset of intermediate-risk OSCC patients who may benefit from PORT.

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.

Effect of preoperative immunonutrition on complications after salvage surgery in head and neck cancer

Background

Patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma are at high risk of postoperative complications due to the adverse effects of radiotherapy on wound healing. Malnutrition is an additional risk factor and we tested the hypothesis that preoperative administration of immunonutrition would decrease complications in this high risk population.

Methods

This single armed study with historical control included consecutive patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma. We compared outcomes before and after implementation of preoperative immunonutrition and adjusted the regression analysis for gender, age, body mass index, Nutritional Risk Screening (NRS 2002), tobacco and alcohol consumption, tumor localization, tumor stage, and type of surgery. The primary endpoint was overall complications from surgery within a follow-up of 30 days.

Results

Ninety-six patients were included (intervention group: 51, control group: 45). Use of preoperative immunonutrition was associated with a significant reduction in overall complications (35% vs. 58%, fully-adjusted odds ratio 0.30 (95%CI 0.10–0.91, p = 0.034). Length of hospital stay was also significantly reduced (17 days vs. 6 days, p = < 0.001). No differences in mortality and hospital readmission were found. These results remained robust in multivariate analysis.

Conclusions

In patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma, preoperative immunonutrition exhibited favorable effects on the complication rate and consequently reduced the length of hospital stay. By improving both tissue regeneration and immune response, immunonutrition may help to improve surgical outcomes in this high-risk population.

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.

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.

Breast Cancer in a Pectoralis Major Myocutaneous Flap Used for the Reconstruction of Tongue Cancer: A Case Report

Breast cancers are the most common cancers in women. However, breast cancer occurring in a pectoralis major myocutaneous flap is extremely rare. This article describes a case of breast cancer occurring in such a flap used for reconstruction of the tongue in a 72-year-old woman. Follow-up computed tomogram depicted a slowly growing mass in the flap. Thirty-nine months postoperatively, a fine-needle aspiration biopsy specimen taken from the lesion suggested glandular carcinoma. The patient was diagnosed with breast cancer in the neck area of the flap and tumor excision was performed. Histologic examination of the excised tumor showed tumor cells arranged in cords, with tubular and cribriform carcinomas near the pectoral muscle with adipose tissue. The cytoplasm was abundant and eosinophilic. Thus, the patient was diagnosed with invasive ductal carcinoma in the pectoralis major flap. Sequential radiotherapy was performed to the neck with a total radiation dose of 50 Gy. Furthermore, the patient received oral anastrozole 1 mg daily as systemic adjuvant therapy for the receptor-positive breast malignancy. One year after surgery, the patient was alive with no evidence of disease. Including this case, only 2 cases of breast cancer in a pectoralis major myocutaneous flap used for reconstruction in the head and neck region have been reported.

Indications and outcomes for 100 patients managed with a pectoralis major flap within a UK maxillofacial unit

There are few studies reporting the role of the pedicled pectoralis major (PPM) flap in modern maxillofacial practice. The outcomes of 100 patients (102 flaps) managed between 1996 and 2012 in a UK maxillofacial unit that preferentially practices free tissue reconstruction are reported. The majority (88.2%) of PPM flaps were for oral squamous cell carcinoma (SCC), stage IV (75.6%) disease, and there was substantial co-morbidity (47.0% American Society of Anesthesiologists 3 or 4). The PPM flap was the preferred reconstruction on 80.4% of occasions; 19.6% followed free flap failure. Over half of the patients (57%) had previously undergone major surgery and/or chemoradiotherapy. Ischaemic heart disease (P=0.028), diabetes mellitus (P=0.040), and methicillin-resistant Staphylococcus aureus (MRSA) infection (P=0.013) were independently associated with flap loss (any degree). Free flap failure was independently associated with total (2.0%) and major (6.9%) partial flap loss (P=0.044). Cancer-specific 5-year survival for stage IV primary SCC and salvage surgery improved in the second half (2005-2012) of the study period (22.2% vs. 79.8%, P=0.002, and 0% vs. 55.7%, P=0.064, respectively). There were also declines in recurrent disease (P=0.008), MRSA (P<0.001), and duration of admission (P=0.014). The PPM flap retains a valuable role in the management of advanced disease combined with substantial co-morbidity, and following free flap failure.

Elective neck dissection versus "wait and watch" policy in tongue carcinoma

Aim:

To evaluate the efficacy of elective neck dissection versus the “wait and watch” policy in the treatment of early squamous cell carcinoma of tongue.

Materials and Methods:

This is a retrospective study of 21 patients with surgical treatment between April 2009 and July 2011. The patients were divided into two groups, with Group 1 consisting of patients who underwent wide excision glossectomy with elective neck dissection and Group 2 consisting of patients who underwent glossectomy without the neck being surgically addressed. The selection of patients was done by the random double-blinded method and the review was done by a single reviewer. All patients were examined for an average period of 1 year postoperatively.

Results:

Twenty-one cases were treated, among which there were 17 T1 and 4 T2 carcinomas. All the patients had primary carcinoma involving only the tongue with no clinical neck palpable neck nodes. Eleven patients underwent wide excision of primary tumor with elective neck dissection (Group 1) and 10 patients underwent only resection of primary tumor without the neck being surgically addressed (Group 2). In Group 1, there were no recurrences, and in Group 2, there were two patients who developed subsequent cervical node metastasis with one patient undergoing further surgery to address the positive neck and the other patient was lost to follow-up.

Conclusions:

Regional recurrence was the most common cause of failure after surgical treatment of oral tongue carcinoma. Elective neck dissection significantly reduced mortality due to regional recurrence and also increased the overall survival. Our study suggests that elective neck dissection is a treatment strategy of choice for stages I and II carcinoma of the oral tongue. A prospective, randomized study is worthwhile to further evaluate the benefit of elective neck dissection in the treatment of early carcinoma of the tongue with a larger pool of patients and a lengthier follow-up period.

Expression and prognostic impact of indoleamine 2,3-dioxygenase in oral squamous cell carcinomas

Indoleamine 2,3 dioxygenase (IDO) is a negative immune regulator and was found to be a prognostic marker in several tumor entities. In this study, we analysed IDO expression in oral squamous cell carcinoma (OSCC) regarding patient's prognosis. Additionally, expression of IDO like-1 gene (INDOL-1) was analysed. Tumor tissue from 88 patients with OSCC was analysed by immunohistochemistry for IDO expression. The influence of IDO expression on survival was studied by multivariate Cox regression, adjusting for established clinical prognostic parameters. Real time PCR of tumor samples was performed in a subgroup of patients to analyse mRNA expression of IDO and INDOL-1. IDO high-expression was observed in 44.2% of OSCC patients. No significant correlation was found between IDO expression and clinical stage, sex, age, tumor site, tumor size, metastasis or tumor grade. The median overall survival time was 3.1 years for patients with IDO low tumors, compared to 1.36 years for IDO high tumors (P=.028). Subset analysis of patients receiving adjuvant radio-chemotherapy showed a significant difference (P=.0046) in overall survival between IDO low tumors (3.35 years) and IDO high tumors (1.26 years). In contrast, the impact of IDO expression on survival time in patients without adjuvant therapy was not significant (P=.574). Interestingly, INDOL-1 was not expressed in OSCC. IDO high expression represents a significant negative prognostic factor in patients with OSCC, especially in those patients undergoing adjuvant radiochemotherapy. Our data support the suggestion, co-administration of small-molecule IDO inhibitors could represent a promising new strategy to increase the anti-tumor activity of radio-chemotherapy in patients with IDO positive OSCC.

Clinical significance of genome-wide minimally deleted regions in oral squamous cell carcinomas

Oral squamous cell carcinoma (OSCC) has the highest rate of increase among male cancers in Taiwan. An understanding of the molecular pathogenesis of this disease as well as the development of prognostic markers for the clinical management of this disease is very important. Thus, a systematic loss of heterozygosity (LOH) analysis was performed to define minimally deleted regions (MDRs) in 63 male OSCCs using 400 polymorphic microsatellite markers. For increasing reliability, genomic DNA was extracted from >90% tumor cells that had been purified by LCM, and only when a microsatellite marker provided LOH information in >30% of the OSCCs was there considered to be successful allelotyping. A correlation of the various MDRs with clinicopathological parameters and prognosis was carried out. In total, 32 MDRs were identified and ten were noted as novel. In addition, six MDRs were found to be associated with cigarette smoking. Among these markers, a loss of MDR c7r2 (7q32.2-q35) was significantly associated with poor disease-free survival (DFS) and ten MDRs were associated with allelic imbalance (AI) in tumors. Among the latter, a loss of MDR c14r1 (14q24.2-q32.12) and c11r1 (11q13.4-q25) had a synergistic effect on poor DFS and were able to reduce further the DFS rate in patients with MDR c7r2 loss. Taken together, the results generated in this study provide new insights that help with exploring the molecular mechanisms associated with OSCC tumorigenesis and cigarette smoking. They also should aid the development of potential prognostic markers for the clinical management of OSCC.

[A case report: multiple air embolism after the laryngopharyngoesophagectomy occurred by the cervical infection from postoperative fistula]

Systemic air embolism, a very rare clinical condition, has many causes. We report a case of multiple air embolisms following laryngopharyngoesophagectomy salvage surgery for hypopharyngeal residual cancer after concurrent chemoradiotherapy. Cervical infection arose from a fistula caused by postoperative suture failure in which the 56-year-old man suddenly lost consciousness and went into shock. A few days post operation, an air embolism happened and caused in the brain, pulmonary, myocardiac and cerebral infarction. The man died two months after initial occurrence. We suspect that air entered through the ruptured left internal jugular vein via infection due to aspiration at the injury site. Air embolisms are associated with different medical maneuvers, and it is necessary to recognize that they may become a serious perioperative complication.

Salvage treatment for recurrent oral squamous cell carcinoma

The treatment failures of oral squamous cell carcinoma (OSCC) are mostly local and regional recurrences. The aim was to estimate the prognosis of patients with recurrent OSCC through the prognostic staging system. We reviewed 81 patients with recurrent OSCC from April 1, 1999, to April 1, 2005. The independent prognostic factors for the patients with recurrent OSCC were identified by the univariate and multivariate Cox regression analyses. Then, to develop a prognostic staging system, and according to this staging system, the patients with recurrent OSCC were divided to 4 stages. By the Kaplan-Meier and log-rank statistical analyses, we found that the survival rate of patients with recurrent OSCC was significantly different at the different developmental stages. The primary TNM cancer stage before initial treatment, the extent of recurrence, and the recurrent tumor size are the independent prognostic factors for the patients with recurrent OSCC. Through this clinical study, the earlier-stage cases (stages I and II) for the patients with recurrent OSCC had a significantly better survival outcome compared with the advanced-stage cases (stages III and IV), and at the early recurrent stage, the salvage surgery represented a reliable and feasible treatment method.

Nomogram for deciding adjuvant treatment after surgery for oral cavity squamous cell carcinoma

BACKGROUND

The application of appropriate adjuvant treatment after surgery for oral cavity squamous cell carcinoma (OCSCC) is predicated on accurate patient risk stratification.

METHODS

A nomogram for estimating locoregional recurrence-free survival (LRFS) after treatment of OCSCC was constructed from a cohort of 590 patients with OCSCC who were treated at Memorial Sloan-Kettering Cancer Center (MSKCC). The nomogram was validated using a series of 417 patients with OCSCC who were treated at Hospital do Cancer AC Camargo (HACC) in São Paulo, Brazil.

RESULTS

Despite significant differences between the MSKCC and HACC cohorts, the nomogram was able to predict LRFS from OCSCC with a concordance index of 0.693. Further statistical analysis showed that the nomogram was well calibrated.

CONCLUSIONS

This preliminary nomogram is the first prognostic model developed and externally validated to predict the likelihood of LRFS after treatment for an individual patient with OCSCC and may have practical utility for deciding adjuvant treatment.

Salvage Reconstruction of Extensive Recurrent Oral Cancer Defects With the Pectoralis Major Myocutaneous Flap

PURPOSE

This study aimed to evaluate the usefulness of the pectoralis major myocutaneous flap for reconstruction of oral and facial defects after excision of recurrent oral cancer and the results of salvage surgery.

PATIENTS AND METHODS

Twenty-four patients with recurrent squamous cell carcinoma of the oral cavity underwent salvage surgical treatment. Pectoralis major flaps were used for reconstruction of the extensive defects caused by excision of the tumors. The complications of the flap and the prognosis of the patients were analyzed with a follow-up from 5 to 65 months (mean = 18.5 months).

RESULTS

Fourteen flaps were used for mucosal lining of the mouth, and 10 flaps were used for reconstruction of the cutaneous defects. The overall success rate of the flap was 70.8%. Flap-related complications developed in 13 patients (54.2%). Major complications occurred in 7 patients (29.2%), and minor complications occurred in 6 (25.0%). Three patients (12.5%) had complications unrelated to the flap. The reconstruction of the base of the tongue, the floor of the mouth, and the oropharynx emerged as a significant risk factor for flap necrosis on binary logistic regression analysis (P < .05). The overall 1-, 3-, and 5-year overall survival rate was 72.8%, 30.9%, and 20.6%, respectively.

CONCLUSION

The pectoralis major myocutaneous flap is a reliable choice for reconstruction of extensive soft tissue defects caused by excision of recurrent oral cancer. The major complications correlate with the site of reconstruction. Many patients benefit from salvage surgery, and some of them can survive 2 to 4 years postoperatively.

Salvage Surgery for Radiation Failure in Oral, Oropharyngeal, and Hypopharyngeal Squamous Cell Carcinoma

Few reports have covered salvage surgery after radiotherapy, especially with chemotherapy for oral, oropharyngeal, and hypopharyngeal squamous cell carcinoma. The feasibility of salvage surgery is unclear. We analyzed postoperative complications and prognosis after salvage surgery for local recurrence after definitive radiotherapy. Subjects were 37 patients with oral, oropharyngeal, and hypopharyngeal squamous cell carcinoma treated from 1994 to 2003. Of these, 14 (37.8%) had postoperative complications. The complication rate was significantly high in the reconstructive operation group (p = 0.031) and the chemotherapy group (p = 0.049). The 5-year overall survival rate after salvage surgery was 70.7%. Although there was no significant improvement, the prognosis was good in early-stage groups with primary tumors. We found that salvage surgery after definitive radiotherapy was effective for recurrent oral, oropharyngeal, and hypopharyngeal squamous cell carcinoma. We stress the need to pay attention to postoperative complications in reconstructive operation and chemotherapy groups.

Surgical Salvage for Local and Regional Recurrence in Oral Cancer

PURPOSE

To evaluate local and regional recurrence and the outcomes for salvage surgery in patients for oral cancer.

PATIENTS AND METHODS

This study analyzed 354 consecutive patients with oral cancer treated primarily by surgery or surgery combined with adjuvant therapy by 1 surgeon (R.A.O.) between February 1991 and September 2001.

RESULTS

Overall recurrence rate was 15.5%; with 5.4% local, 8.5% regional, and 1.4% locoregional. Overall salvage for local recurrence was 52.6% 3-year survival, and statistically significant favorable prognostic factors were salvaged by surgery alone and initial cancer staging of I/II. Overall salvage for regional recurrence was 50%, with recurrence in a previously untreated neck and salvage with radical neck dissection plus radiotherapy giving the best prognosis. No patients with locoregional recurrence were salvaged.

CONCLUSIONS

Patients who were stage I/II and were treated initially by surgery alone were the best candidates for salvage if they recurred. Salvage was best achieved with surgery or surgery + adjuvant therapy, and patients recurring within 6 months had a worse survival. Patients with locoregional recurrence or treated with RT +/- chemotherapy alone have negligible survival.

S100A2, a potential marker for early recurrence in early-stage oral cancer

Early-stage oral cancer patients may have distinct clinical outcomes and respond differently to the same treatment. Up to now, there is still no individual marker to identify such patients with poor outcome. Down-regulation of a tumor suppressor gene, S100A2, in oral cancer cells was identified by mRNA profiling analysis then confirmed by RT-PCR and Southern blotting. The expression of nuclear S100A2 protein examined by immunohistochemistry was not significantly associated with any patient characteristic among the 70 early-stage oral squamous cell carcinoma (SCC) patients. Intriguingly, the loss of nuclear S100A2 positivity was significantly associated with shorter disease-free survival (p=0.019) while having no effect on the overall survival of these patients. Cox regression analysis with backward elimination identified S100A2 (p=0.006), tobacco smoking (p=0.013), and betel quid chewing (p=0.019) as independent predictors of disease-free survival. This is a first study to demonstrate that loss of nuclear S100A2 may serve as an independent prognostic marker for early-stage oral cancer patients at high risk of recurrence. A more aggressive treatment modality and intensive follow-up may be recommended for the patients with reduced expression of S100A2 in tumor cell nuclei.

Multivariate analysis of risk factors for wound infection in head and neck squamous cell carcinoma surgery with opening of mucosa. Study of 260 surgical procedures

The goal of this prospective study was to determine risk factors for wound infections (WI) for patients with head and neck cancer who had undergone surgical procedures with opening of upper aerodigestive tract mucosa in multimodal therapeutic approaches. Two hundred and sixty consecutive surgical procedures were studied at Oscar Lambret Cancer Center over a 36-month period. Twenty-five variables were recorded for each patient. Statistical evaluation used chi2 test analysis (categorical data) and Mann-Whitney test (continuous variables). Multivariate analysis was performed with logistic regression model. The overall rate of WI was 45% (117/260). Univariate analysis indicated that five variables were significantly related to the likelihood of WI: male sex (p = 0.03), previous chemotherapy (p = 0.009), duration of previous hospital stay (p = 0.013), hypopharyngeal location (p = 0.003), post-laryngectomy tracheostoma (p < 0.001). Multivariate analysis identified only one major risk factor for WI: post-laryngectomy tracheostoma (Odd Ratio 1.9 [95% CI 1.3-3]; 33% versus 64%; p = 0.001). Despite antibiotic prophylaxis, WI occurrence is high. This study identified one major risk factor, post-laryngectomy tracheostomy. Long-term curative antibiotherapy must be evaluated in cancer head and neck surgery requiring post-laryngectomy tracheostoma.