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Amezaga-Fernandez I, Aguirre-Urizar JM, Suárez-Peñaranda JM, Chamorro-Petronacci C, Lafuente-Ibáñez de Mendoza I, Marichalar-Mendia X, Somoza-Martín JM, Blanco-Carrión A, Antúnez-López J, García-García A. Comparative clinicopathological study of the main anatomic locations of oral squamous cell carcinoma. Oral Dis 2024. [PMID: 38693647 DOI: 10.1111/odi.14971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/01/2024] [Accepted: 04/12/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE To analyze the clinicopathological and evolutionary profile of the main locations of oral squamous cell carcinoma (OSCC). MATERIALS AND METHODS This is a retrospective study on 133 patients treated for OSCC. The group was composed of 48 women and 85 men, with a mean age 63.9 ± 12.73 years. Most cases involved the lingual border of tongue (63), followed by the gingiva (36) and the floor of mouth (34). A comparative analysis was performed using multinomial regression. RESULTS There were significant differences regarding age, sex, tobacco and alcohol consumption, liver pathology, oral potentially malignant disorders, and bone and perineural invasion. In multivariate regression, tobacco consumption, and bone invasion remained significant. There were no significant differences in relation to prognosis. CONCLUSION The location of OSCC is an important factor in the clinicopathological assessment of this neoplasm. The main locations of OSCC show differential etiopathogenic and clinicopathological aspects. Tobacco consumption has a great relevance in the floor of mouth; nonetheless, it is less important in the tongue border and the gum, which suggests other pathogenic factors. It is necessary to consider the anatomical location of OSCC in preventive protocols, with the aim of reducing its high mortality.
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Affiliation(s)
| | | | - José Manuel Suárez-Peñaranda
- Department or Forensic Sciences and Pathology, Faculty of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain
- Department of Pathology, Clinical Hospital, Santiago de Compostela, Spain
| | | | | | | | - José Manuel Somoza-Martín
- Faculty of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Andrés Blanco-Carrión
- Faculty of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - José Antúnez-López
- Department or Forensic Sciences and Pathology, Faculty of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain
- Department of Pathology, Clinical Hospital, Santiago de Compostela, Spain
| | - Abel García-García
- Faculty of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain
- Maxillofacial Surgery Service, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
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2
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Trevisani LFM, Kulcsar IF, Kulcsar MAV, Dedivitis RA, Kowalski LP, Matos LL. Prognostic Value of Hematological Parameters in Oral Squamous Cell Carcinoma. Cancers (Basel) 2023; 15:5245. [PMID: 37958419 PMCID: PMC10649982 DOI: 10.3390/cancers15215245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION Oral squamous cell carcinoma (OSCC) remains a significant public health concern. The variables utilized to determine appropriate treatment for this disease also represent its most unfavorable prognostic factors, with these parameters solely determined by the neoplasm and its behavior. However, a lack of well-established indices is evident in the literature that specifically relate to the patient and indicate a worse prognosis. OBJECTIVE To assess the prognostic impact of hematological indices in patients with OSCC. METHODS This retrospective cohort study included patients with oral squamous cell carcinoma (OSCC) who underwent curative-intent treatment. Treatment encompassed surgery, followed by adjuvant therapy, as necessary. Laboratory tests were conducted immediately prior to surgery, and demographic information was obtained from medical records. RESULTS The cohort comprised 600 patients, with 73.5% being male subjects. Adjuvant treatment was recommended for 60.3% of patients. Throughout the follow-up period, 48.8% of participants died. Univariate analysis indicated that perineural invasion, angiolymphatic invasion, pT4 tumors, lymph node metastases, extranodal extravasation, RDW > 14.3%, NLR (neutrophil-lymphocyte ratio) > 3.38, PLR (platelet-lymphocyte ratio) > 167.3, and SII (systemic inflammatory/immune response index) > 416.1 were factors associated with increased mortality. These threshold values were established through ROC curve analysis. In the multivariate analysis, angiolymphatic invasion (HR = 1.43; 95% CI: 1.076-1.925; p = 0.014), pT4a/b tumors (HR = 1.761; 95% CI: 1.327-2.337; p < 0.001), extranodal extravasation (HR = 1.420; 95% CI: 1.047-1.926; p = 0.024), and RDW (HR = 1.541; 95% CI: 1.153-2.056; p = 0.003) were identified as independent risk factors for decreased overall survival. CONCLUSIONS RDW > 14.3% was proven to be a reliable parameter for assessing overall survival in patients with OSCC. Further studies are required to evaluate the clinical applicability of other hematological indices.
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Affiliation(s)
- Lorenzo Fernandes Moça Trevisani
- Programa de Pós-Graduação em Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, Faculdade de Medicina, Universidade de São Paulo, São Paulo 01246-903, Brazil;
| | - Isabelle Fernandes Kulcsar
- Instituto do Câncer do Estado de São Paulo (Icesp), Faculdade de Medicina, Universidade de São Paulo, São Paulo 01246-000, Brazil;
| | - Marco Aurélio Vamondes Kulcsar
- Head and Neck Surgery Department, Instituto do Câncer do Estado de São Paulo (Icesp), Faculdade de Medicina, Universidade de São Paulo, São Paulo 01246-000, Brazil;
| | - Rogerio Aparecido Dedivitis
- Head and Neck Surgery Department, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo 01246-000, Brazil;
| | - Luiz Paulo Kowalski
- Head and Neck Surgery Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo 01246-000, Brazil;
| | - Leandro Luongo Matos
- Head and Neck Surgery Department, Instituto do Câncer do Estado de São Paulo (Icesp), Faculdade de Medicina, Universidade de São Paulo, São Paulo 01246-000, Brazil;
- Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo 05652-000, Brazil
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3
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Mohd Afandi MF, Liew YT. Floor of Mouth Squamous Cell Carcinoma Presenting as an Abscess. Indian J Otolaryngol Head Neck Surg 2023; 75:902-904. [PMID: 37274978 PMCID: PMC10234886 DOI: 10.1007/s12070-022-03128-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/10/2022] [Indexed: 11/27/2022] Open
Abstract
Oral squamous cell carcinoma (OSCC) is the most common malignancy encountered in oral cavity. Etiology is often multifactorial but strongly associated with chronic tobacco smoking, excessive alcohol consumption and tobacco chewing. Factors such as poor oral hygiene, ill-fitting dentures causing chronic mucosal irritation can also contribute to the cancer development. In recent years, studies shown association of HPV infections, especially subtypes 16 and 18 in malignant transformation of head and neck squamous cell carcinoma, as it present may change prognosis, outcomes and management strategies from HPV-negative OSCC. OSCC have variable presentation, and most of the patients tend to seek treatment at later stage of disease. The lesion may present as leukoplakia or erythroplakia and may be ulcerated with indurated base and rolled out edges. We describe an uncommon presentation of floor of mouth squamous cell carcinoma which presented as localized abscess.
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Affiliation(s)
| | - Yew Toong Liew
- Present Address: Otorhinolaryngology Department Universii Malaya, Kuala Lumpur, Malaysia
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Li T, Xiang X, Wang Y, Chen C. Association of Elective Neck Dissection With Survival in cT1N0M0 Floor of Mouth Squamous Cell Carcinoma: A Population-Based Propensity Score Matching Analysis. EAR, NOSE & THROAT JOURNAL 2023:1455613231170705. [PMID: 37122112 DOI: 10.1177/01455613231170705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Studies on neck management of early-stage floor of mouth (FOM) squamous cell carcinoma (SCC) are very few and controversial. We aimed to study whether elective neck dissection (END) for patients with clinically stage T1N0M0 (cT1N0M0) FOM SCC is beneficial for survival. METHODS Information on patients diagnosed with cT1N0M0 FOM SCC between 2004 and 2015 was collected from the Surveillance, Epidemiology and End Results (SEER) database. Cox proportional risk models and Kaplan-Meier curves were used for survival analysis and log-rank tests were performed to compare whether overall survival (OS) and cancer-specific survival (CSS) differed. Propensity score matching (PSM) was performed to eliminate the effect of confounding variables. RESULTS There were 1014 patients with cT1N0M0 FOM SCC. Among them, END group: 455 cases; observation group: 559 cases. COX regression analysis before PSM demonstrated hazard ratio (HR) in the observation group compared to END (OS: 1.108 (.926-1.326), P = .262; CSS: 1.033 (.772-1.382), P = .827). There was no survival difference between END and observation survival before PSM (5-year OS: 71.8% vs. 67.8%, P = .180; 5-year CSS: 84.5% vs. 84.8%, P = .930); the matched results were the same as before PSM. CONCLUSION Observation may be a more appropriate option compared with END in cT1N0M0 FOM SCC.
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Affiliation(s)
- Tao Li
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, P.R. China
- Wan Nan Medical College, Wuhu, China
| | - Xianwang Xiang
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, P.R. China
| | - Yi Wang
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, P.R. China
| | - Chuanjun Chen
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, P.R. China
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5
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Cao Y, Liu W, Gu D. A nomogram for predicting overall survival of patients with squamous cell carcinoma of the floor of the mouth: a population-based study. Eur Arch Otorhinolaryngol 2023:10.1007/s00405-023-07971-5. [PMID: 37071145 DOI: 10.1007/s00405-023-07971-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 04/06/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Floor of mouth squamous cell carcinoma (SCCFOM) is a rare but aggressive malignancy with 5-year overall survival (OS) rates below 40% in published studies. However, the clinicopathological predictors of the prognosis of SCCFOM remain undefined. We aimed to establish a model to predict the survival outcomes of SCCFOM. METHODS We searched the Surveillance, Epidemiology, and End Results (SEER) database for patients diagnosed with SCCFOM between 2000 and 2017. Data on patient demographics, treatment modalities, and survival outcomes were retrieved. Risk factors for OS were evaluated by survival and Cox regression analyses. A nomogram for OS was developed based on the multivariate model and split the patients into high- and low-risk cohorts based on cutoff values. RESULTS Overall, 2014 SCCFOM patients were included in this population-based study. Multivariate Cox regression showed that age, married status, grade, American Joint Committee on Cancer stage, radiotherapy, chemotherapy, and surgery were significant risk factors for survival. A nomogram was established using the regression model. The C-indices, areas under the receiver operating characteristic curves, and calibration plots demonstrated the reliable performance of the nomogram. Patients assigned to the high-risk group had a significantly lower survival rate. CONCLUSIONS The nomogram predicting survival outcomes of SCCFOM patients based on clinical information showed good discriminative ability and prognostic accuracy. Our nomogram could be used to predict the survival probabilities for SCCFOM patients at different timepoints.
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Affiliation(s)
- Yuxiao Cao
- School of Stomatology, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, People's Republic of China
- The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, People's Republic of China
| | - Wenyi Liu
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Shanghai Bluecross Medical Science Institute, Shanghai, People's Republic of China
- Institute for Hospital Management, Tsing Hua University, Shenzhen Campus, Beijing, People's Republic of China
| | - Dantong Gu
- Institute of Otolaryngology, Clinical Research Center, Eye and ENT Hospital, Fudan University, Shanghai, 200031, People's Republic of China.
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Costa AM, Pontes FS, Souza LL, Lopes MA, Santos-Silva AR, Vargas PA, Andrade BA, Bezerra KT, Romañach MJ, Gomez RS, Costa RF, Júnior DD. What is the frequency of floor of the mouth lesions? A descritive study of 4,016 cases. Med Oral Patol Oral Cir Bucal 2021; 26:e738-e747. [PMID: 34704985 PMCID: PMC8601650 DOI: 10.4317/medoral.24537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 09/06/2021] [Indexed: 01/07/2023] Open
Abstract
Background The aim of this study was to investigate the frequency of oral lesions in the floor of the mouth from representative oral pathology centres in Latin America. Material and Methods This study was conducted on biopsies obtained from January of 1978 to December of 2018 at nine Latin America oral and maxillofacial pathology centres. Gender, age and histopathological diagnosis were evaluated. Data were analysed using descriptive methods. Chi-square test was used for pairwise comparisons. Results From 114,893 samples, 4,016 lesions (3.49%) occurred in the floor of the mouth. Brazil showed 3,777 cases (94%), Mexico 182 cases (4.5%) and Argentina 57 cases (1.4%). Benign lesions represented 65.1% (2,617 cases), followed by 34.9% (1,404 cases) of malignant disorders. Lesions of epithelial origin were more frequent (1,964 cases; 48.9%), followed by salivary glands (1,245 cases; 31%) and soft tissue lesions (475 cases; 11.7%). The most common histological subtypes were oral squamous cell carcinoma (1,347 cases; 33.5%), ranula (724 cases; 18%), oral leukoplakia (476 cases; 11.8%) and inflammatory fibrous hyperplasia (239 cases; 5.9%). The lesion affected males in 2,129 cases and females in 1,897 cases. Conclusions In the current study, lesions in the floor of the mouth represented 3.49% of biopsies submitted to oral pathology services and oral squamous cell carcinoma, ranula and leukoplakia were the most common lesions. Key words:Epidemiology, floor of the mouth, benign, malignant.
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Affiliation(s)
- A-M Costa
- João de Barros Barreto University Hospital Department of Surgery and Oral Pathology Mundurucus Street, nº 4487 Zip Code 66073-000, Belém, Pará, Brazil
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Blažek T, Zděblová Čermáková Z, Knybel L, Hurník P, Štembírek J, Resová K, Paračková T, Formánek M, Cvek J, Soumarová R. Dose escalation in advanced floor of the mouth cancer: a pilot study using a combination of IMRT and stereotactic boost. Radiat Oncol 2021; 16:122. [PMID: 34187494 PMCID: PMC8243893 DOI: 10.1186/s13014-021-01842-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/07/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE We evaluated the efficiency and toxicity of stereotactic hypofractionated boost in combination with conventionally fractionated radiotherapy in the treatment of advanced floor of the mouth cancer. METHODS Thirty-seven patients with advanced stage of the floor of the mouth cancer, histologically confirmed squamous cell carcinoma (p16 negative) ineligible for surgical treatment, were indicated for radiochemotherapy or hyperfractionated accelerated radiotherapy (HART). The radiotherapy protocol combined external beam radiotherapy (EBRT) and a stereotactic hypofractionated boost to the primary tumor. The dose delivered from EBRT was 70-72.5 Gy in 35/50 fractions. The hypofractionated boost followed with 10 Gy in two fractions. For the variables-tumor volume, stage and grade a multivariate analysis was performed to find the relationship between overall survival, local progression and metastasis. Toxicity was evaluated according to CTCAE scale version 4. RESULTS After a median follow-up of 16 months, 23 patients (62%) achieved complete remission. The median time to local progression and metastasis was 7 months. Local control (LC) at 2 and 5-years was 70% and 62%, respectively. Progression-free survival (PFS) and overall survival (OS) were 57% and 49% at 2 years and 41% and 27% at 5 years, respectively. Statistical analysis revealed that larger tumors had worse overall survival and a greater chance of metastasis. Log-Rank GTV > 44 ccm (HR = 1.96; [95% CI (0.87; 4.38)]; p = 0.11). No boost-related severe acute toxicity was observed. Late osteonecrosis was observed in 3 patients (8%). CONCLUSION The combination of EBRT and stereotactic hypofractionated boost is safe and seems to be an effective option for dose escalation in patients with advanced floor of the mouth tumors who are ineligible for surgical treatment and require a non-invasive approach.
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Affiliation(s)
- Tomáš Blažek
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic.,Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,3Rd Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Zuzana Zděblová Čermáková
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic. .,Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.
| | - Lukáš Knybel
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Pavel Hurník
- Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Department of Pathology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jan Štembírek
- Department of Oral and Maxillofacial Surgery, University Hospital Ostrava, Ostrava, Czech Republic.,Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Brno, Czech Republic
| | - Kamila Resová
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic.,Faculty of Medicine, Palacký University Olomouc, Olomouc, Czech Republic
| | - Tereza Paračková
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic.,Faculty of Medicine, Palacký University Olomouc, Olomouc, Czech Republic
| | - Martin Formánek
- Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Department of Otorhinolaryngology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jakub Cvek
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic.,Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Renata Soumarová
- 3Rd Faculty of Medicine, Charles University Prague, Prague, Czech Republic.,Department of Oncology, University Hospital Královské Vinohrady Prague, Prague, Czech Republic
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8
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Kim TH, Cha IH, Choi EC, Kim HR, Kim HJ, Kim SH, Keum KC, Lee CG. Postoperative Concurrent Chemoradiotherapy Versus Radiotherapy Alone for Advanced Oral Cavity Cancer in the Era of Modern Radiation Techniques. Front Oncol 2021; 11:619372. [PMID: 33777764 PMCID: PMC7994509 DOI: 10.3389/fonc.2021.619372] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/20/2021] [Indexed: 11/13/2022] Open
Abstract
Background/Purpose Surgery followed by postoperative radiotherapy (RT) has been considered the standard treatment for oral cavity squamous cell carcinoma (OCSCC) of advanced stages or with adverse prognostic factors. In this study, we compared the outcomes in patients with OCSCC who received postoperative concurrent chemoradiotherapy (CCRT) or postoperative RT alone using modern RT techniques. Methods A total of 275 patients with OCSCC treated between 2002 and 2018 were retrospectively analyzed. Adverse prognostic factor was defined as extranodal extension (ENE), microscopically involved surgical margin, involvement of ≥2 lymph nodes, perineural disease, and/or lymphovascular invasion (LVI). In total, 148 patients (54%) received CCRT and 127 patients (46%) received RT alone. More patients in the CCRT group had N3 disease and stage IVB disease (46.6% vs. 10.2%, p<0.001), ENE (56.1% vs. 15.7%, p<0.001), LVI (28.4% vs. 13.4%, p=0.033). Results With a median follow-up of 40 (range, 5–203) months, there were no significant differences in the 5-year overall survival (OS) and PFS between treatment groups. In the subgroup analysis according to high risk, the concurrent use of chemotherapy showed significantly improved OS in patients with ENE (HR 0.39, p=0.003). Conclusion Our retrospective study showed that postoperative CCRT group had comparable survival outcomes to those in the RT alone group for advanced OCSCC in the era of modern RT techniques and indicated that concurrent chemotherapy should be administered to patients with ENE. Prospective randomized studies for confirmation are needed.
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Affiliation(s)
- Tae Hyung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea.,Department of Radiation Oncology, Eulji General Hospital, College of Medicine, Eulji University, Seoul, South Korea
| | - In-Ho Cha
- Department of Oral and Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul, South Korea
| | - Eun Chang Choi
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Hye Ryun Kim
- Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyung Jun Kim
- Department of Oral and Maxillofacial Surgery, Yonsei University College of Dentistry, Seoul, South Korea
| | - Se-Heon Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Ki Chang Keum
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Chang Geol Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
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Zhang J, Wang Y, Han X, Chen H. Comparison of Clinical Results and Quality-of-Life in Tongue Cancer Patients Undergoing Submental Island Flap and Radial Forearm Free Flap Reconstruction. J Oral Maxillofac Surg 2020; 78:1639-1644. [DOI: 10.1016/j.joms.2020.04.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 12/19/2022]
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10
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De Herdt MJ, Koljenović S, van der Steen B, Willems SM, Wieringa MH, Nieboer D, Hardillo JA, Gruver AM, Zeng W, Liu L, Baatenburg de Jong RJ, Looijenga LHJ. A novel immunohistochemical scoring system reveals associations of C-terminal MET, ectodomain shedding, and loss of E-cadherin with poor prognosis in oral squamous cell carcinoma. Hum Pathol 2020; 104:42-53. [PMID: 32702402 DOI: 10.1016/j.humpath.2020.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/13/2020] [Indexed: 01/02/2023]
Abstract
Using tissue microarrays, it was shown that membranous C-terminal MET immunoreactivity and ectodomain (ECD) shedding are associated with poor prognosis in oral cancer. Seen the potential diagnostic value, extrapolation of these results to whole-tissue sections was investigated. Because MET orchestrates epithelial-to-mesenchymal transition (EMT), the results were benchmarked to loss of E-cadherin, a readout for EMT known to be associated with poor prognosis. C-terminal MET, N-terminal MET, and E-cadherin immunoreactivities were examined on formalin-fixed paraffin-embedded parallel sections of 203 oral cancers using antibody clones D1C2, A2H2-3, and NCH-38. Interantibody and intra-antibody relations were examined using a novel scoring system, nonparametric distribution, and median tests. Survival analyses were used to examine the prognostic value of the observed immunoreactivities. Assessment of the three clones revealed MET protein status (no, decoy, transmembranous C-terminal positive), ECD shedding, and EMT. For C-terminal MET-positive cancers, D1C2 immunoreactivity is independently associated with poor overall survival (hazard ratio [HR] = 2.40; 95% confidence interval [CI] = 1.25 to 4.61; and P = 0.008) and disease-free survival (HR = 1.83; 95% CI = 1.07-3.14; P = 0.027). For both survival measures, this is also the case for ECD shedding (43.4%, with HR = 2.30; 95% CI = 1.38 to 3.83; and P = 0.001 versus HR = 1.87; 95% CI = 1.19-2.92; P = 0.006) and loss of E-cadherin (55.3%, with HR = 2.21; 95% CI = 1.30 to 3.77; and P = 0.004 versus HR = 1.90; 95% CI = 1.20-3.01; P = 0.007). The developed scoring system accounts for MET protein status, ECD shedding, and EMT and is prognostically informative. These findings may contribute to development of companion diagnostics for MET-based targeted therapy.
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Affiliation(s)
- Maria J De Herdt
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Cancer Institute, 3015 GD, Rotterdam, the Netherlands.
| | - Senada Koljenović
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Cancer Institute, 3015 GD, Rotterdam, the Netherlands.
| | - Berdine van der Steen
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Cancer Institute, 3015 GD, Rotterdam, the Netherlands.
| | - Stefan M Willems
- Department of Pathology, University Medical Center Groningen, 9713 GZ, Groningen, the Netherlands.
| | - Marjan H Wieringa
- Department of Education, Office of Science, Elisabeth TweeSteden Ziekenhuis, 5022 GC, Tilburg, the Netherlands.
| | - Daan Nieboer
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3015 GD, Rotterdam, the Netherlands.
| | - Jose A Hardillo
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Cancer Institute, 3015 GD, Rotterdam, the Netherlands.
| | - Aaron M Gruver
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, 46225, USA.
| | - Wei Zeng
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, 46225, USA.
| | - Ling Liu
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, 46225, USA.
| | - Robert J Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Cancer Institute, 3015 GD, Rotterdam, the Netherlands.
| | - Leendert H J Looijenga
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Cancer Institute, 3015 GD, Rotterdam, the Netherlands; Princess Maxima Center for Pediatric Oncology, 3584 CS, Utrecht, the Netherlands.
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Vassiliou LV, Acero J, Gulati A, Hölzle F, Hutchison IL, Prabhu S, Testelin S, Wolff KD, Kalavrezos N. Management of the clinically N 0 neck in early-stage oral squamous cell carcinoma (OSCC). An EACMFS position paper. J Craniomaxillofac Surg 2020; 48:711-718. [PMID: 32718880 DOI: 10.1016/j.jcms.2020.06.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 06/20/2020] [Indexed: 12/12/2022] Open
Abstract
Metastasis of oral squamous cell carcinoma (OSCC) to the cervical lymph nodes has a significant impact on prognosis. Accurate staging of the neck is important in order to deliver appropriate treatment for locoregional control of the disease and for prognosis. The management of the neck in early, low volume disease (clinically T1/T2 oral cavity tumours) has long been debated. The risk of occult nodal involvement in cT1/T2 OSCC is estimated around 20-30%. We describe the natural evolutionary history of OSCC and its patterns of spread and metastasis to the local lymphatic basins. We discuss most published literature and studies on management of the clinically negative neck (cN0). Particular focus is given to prospective randomized trials comparing the outcomes of upfront elective neck dissection against the observational stance, and we summarize the results of the sentinel node biopsy studies. The paper discusses the significance of the primary tumour histological characteristics and specifically the tumour's depth of invasion (DOI) and its impact on predicting nodal metastasis. The DOI has been incorporated in the TNM staging highlighting its significance in aiding the treatment decision making and this is reflected in world-wide oncological guidelines. The critical analysis of all available literature amalgamates the existing evidence in early OSCC and provides recommendations in the management of the clinically N0 neck.
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Affiliation(s)
- Leandros V Vassiliou
- Department of Oral and Maxillofacial Surgery, Royal Blackburn Hospital, Haslingden Road, Blackburn, UK
| | - Julio Acero
- Department of Oral and Maxillofacial Surgery, Ramon y Cajal University Hospital, Alcala University, Madrid, Spain
| | - Aakshay Gulati
- Maxillofacial Unit, Queen Victoria Hospital, Holtye Road, East Grinstead, UK
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, Aachen University Hospital, Aachen, Germany
| | - Iain L Hutchison
- Department of Oral & Maxillofacial Surgery, Barts Health NHS Trust, Saving Faces-The Facial Surgery Research Foundation, London, UK
| | - Satheesh Prabhu
- Division of Oral & Maxillofacial Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Sylvie Testelin
- Department of Maxillo-Facial Surgery, University Hospital of Amiens, Amiens, France
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, University Hospital Rechts der Isar, Munich, Germany
| | - Nicholas Kalavrezos
- Department of Head & Neck Surgery, University College London Hospital, London, UK.
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MET ectodomain shedding is associated with poor disease-free survival of patients diagnosed with oral squamous cell carcinoma. Mod Pathol 2020; 33:1015-1032. [PMID: 31857683 DOI: 10.1038/s41379-019-0426-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 01/07/2023]
Abstract
Ectodomain shedding unleashes the aggressive nature of the MET oncogene product. Using specific C- and N-terminal MET antibodies (D1C2 and A2H2-3), MET protein status (i.e., no MET, decoy MET, transmembranous C-terminal MET with or without the ectodomain) was investigated in oral squamous cell carcinoma. For the cancers showing transmembranous C-terminal MET, the impact of ectodomain shedding on prognosis was investigated. To examine ectodomain shedding, reduced lysates of oral squamous cell carcinoma cell lines were immunoblotted using D1C2 and an ELISA was performed on culture media using A2H2-3. In addition, reduced lysates of fresh frozen tissues of 30 oral squamous cell carcinoma were immunoblotted using D1C2 and immunohistochemistry was performed on corresponding formalin-fixed paraffin-embedded tissues using both antibodies on parallel sections. To examine MET protein status, differences between membranous D1C2 and A2H2-3 immunoreactivities were scored using parallel tissue microarray sections representing 156 oral squamous cell carcinoma. The prognostic value of ectodomain shedding was examined using Cox regression analysis for disease-free survival and overall survival. Ectodomain shedding was observed in all cell lines, 43% (n = 13) of fresh frozen and 50% (n = 15) of formalin-fixed paraffin-embedded cancers (27% overlap, n = 8). The tissue microarray showed no MET in 23% (n = 36), decoy MET in 9% (n = 14), and transmembranous C-terminal MET in 68% (n = 106) of examined cancers. Within the latter group, ectodomain shedding occurs in 36% (n = 38) of the cases and is independently associated with poor disease-free survival (HR = 2.41; 95% CI, 1.35-4.30 and P = 0.003)-though not overall survival (HR = 1.64; 95% CI, 0.92-2.94 and P = 0.095)-after correcting for factors known to influence survival. In conclusion, MET ectodomain shedding occurs in transmembranous C-terminal MET positive oral squamous cell carcinoma and is independently associated with disease-free survival. These findings might aid in designing companion diagnostics for targeted therapies directed against MET.
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Krouse JH. Highlights from the Current Issue: July 2018. Otolaryngol Head Neck Surg 2019; 159:1-2. [PMID: 29968524 DOI: 10.1177/0194599818779352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- John H Krouse
- 1 University of Texas Rio Grande Valley, Edinburg, Texas, USA
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Kim BY, Cho KR, Sohn JH, Kim JY. Sarcomatoid carcinoma after radiotherapy for early-stage oral squamous cell carcinoma: Case report. Medicine (Baltimore) 2019; 98:e16003. [PMID: 31277093 PMCID: PMC6635294 DOI: 10.1097/md.0000000000016003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/22/2019] [Accepted: 05/17/2019] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Sarcomatoid carcinoma is a rare variant of squamous cell carcinoma (SCC) with poor prognosis. Previous radiation has been reported as one of the etiologic factors. PATIENT CONCERNS We describe a case of a 57-year-old man presented with a painless mass in the left supraclavicular area. Five years before, he was diagnosed with SCC in floor of mouth (FOM) and underwent radiotherapy (RT). DIAGNOSES Sonography-guided biopsy on the supraclavicular lymph node revealed diffuse spindle cell proliferation with a focus of squamous differentiation. Local recurrence on primary site or distant metastasis was not obvious on both computed tomography (CT) of the neck and F-fluorodeoxyglucose positron emission tomography CT. The final diagnosis was confirmed as sarcomatoid carcinoma via surgery. INTERVENTIONS The patient underwent surgery including explorative resection of the mouth floor, excision of the submandibular gland, and modified radical neck dissection. Following surgery, the patient received adjuvant radiation therapy. OUTCOMES There were no complications according to the surgery. Six months after adjuvant therapy, distant metastasis to liver was identified. The patient is currently undergoing palliative chemotherapy. LESSONS This may be the first reported case of sarcomatoid carcinoma arising from early-stage SCC in FOM that was previously treated with RT alone. When RT is performed as a single modality for oral SCC, even in an early stage, rigorous follow-up should be performed.
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Affiliation(s)
- Bo Young Kim
- Departments of Otorhinolaryngology—Head and Neck Surgery, Sanggye Paik Hospital
| | - Kyoung Rai Cho
- Departments of Otorhinolaryngology—Head and Neck Surgery, Sanggye Paik Hospital
| | - Jung Heob Sohn
- Departments of Otorhinolaryngology—Head and Neck Surgery, Sanggye Paik Hospital
| | - Jung Yeon Kim
- Department of Pathology, Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
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Lee KC, Chuang SK, Philipone EM, Peters SM. Which Clinicopathologic Factors Affect the Prognosis of Gingival Squamous Cell Carcinoma: A Population Analysis of 4,345 Cases. J Oral Maxillofac Surg 2019; 77:986-993. [DOI: 10.1016/j.joms.2019.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/06/2019] [Accepted: 01/06/2019] [Indexed: 10/27/2022]
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16
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Zanoni DK, Montero PH, Migliacci JC, Shah JP, Wong RJ, Ganly I, Patel SG. Survival outcomes after treatment of cancer of the oral cavity (1985-2015). Oral Oncol 2019; 90:115-121. [PMID: 30846169 DOI: 10.1016/j.oraloncology.2019.02.001] [Citation(s) in RCA: 223] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/28/2019] [Accepted: 02/04/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To present treatment results of oral squamous cell carcinoma (OSCC) at a tertiary cancer care center from 1985 to 2015. MATERIALS AND METHODS A total of 2082 patients were eligible for this study. Main outcomes measured were overall survival (OS) and disease specific survival (DSS). Prognostic variables were identified with bivariate analyses using Kaplan-Meier curves and log-rank testing for comparison. A p-value < 0.05 was considered statistically significant and significant factors were entered into multivariate analysis. Median age was 62 years (16-100), 56% were men, 66% reported a history of tobacco use and 71% of alcohol consumption. The most common subsite was tongue (51%). Seventy-three percent of patients had cT1-2 and 71% had clinically negative necks (cN0). Surgery alone was performed in 1348 patients (65%), adjuvant postoperative radiotherapy in 608 patients (29%) and postoperative chemoradiation in 126 patients (6%). Neck dissection was performed in 920 patients with cN0, and in 585 patients with a clinically involved neck. The median follow-up was 37.6 months (range 1-382). RESULTS The 5-year OS and DSS were 64.4% and 79.3%, respectively. Age, comorbidities, margin status, vascular invasion, perineural invasion, AJCC 8th edition pT, and pN were independent prognostic factors of OS (p < 0.05). History of alcohol consumption, margin status, vascular invasion, perineural invasion, pT, and pN were independent prognostic factors of DSS (p < 0.05). CONCLUSION pN stage is the most powerful and consistent predictor of outcome in patients with OSCC treated with primary surgery and appropriate adjuvant therapy.
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Affiliation(s)
- Daniella Karassawa Zanoni
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Pablo H Montero
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jocelyn C Migliacci
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jatin P Shah
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Richard J Wong
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ian Ganly
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Snehal G Patel
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
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Xu Q, Wang C, Li B, Kim K, Li J, Mao M, Qin L, Li H, Huang X, Xing R, Han Z, Feng Z. The impact of age on oral squamous cell carcinoma: A longitudinal cohort study of 2,782 patients. Oral Dis 2019; 25:730-741. [PMID: 30548550 DOI: 10.1111/odi.13015] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 12/03/2018] [Accepted: 12/05/2018] [Indexed: 01/26/2023]
Affiliation(s)
- Qiaoshi Xu
- Department of Oral and Maxillofacial‐Head and Neck Oncology, Beijing Stomatological Hospital Capital Medical University Beijing China
| | - Chong Wang
- Department of Oral and Maxillofacial‐Head and Neck Oncology, Beijing Stomatological Hospital Capital Medical University Beijing China
| | - Bo Li
- Department of Oral and Maxillofacial‐Head and Neck Oncology, Beijing Stomatological Hospital Capital Medical University Beijing China
| | - Kyojin Kim
- Department of Oral and Maxillofacial‐Head and Neck Oncology, Beijing Stomatological Hospital Capital Medical University Beijing China
| | - Jinzhong Li
- Department of Oral and Maxillofacial‐Head and Neck Oncology, Beijing Stomatological Hospital Capital Medical University Beijing China
| | - Minghui Mao
- Department of Oral and Maxillofacial‐Head and Neck Oncology, Beijing Stomatological Hospital Capital Medical University Beijing China
| | - Lizheng Qin
- Department of Oral and Maxillofacial‐Head and Neck Oncology, Beijing Stomatological Hospital Capital Medical University Beijing China
| | - Hua Li
- Department of Oral and Maxillofacial‐Head and Neck Oncology, Beijing Stomatological Hospital Capital Medical University Beijing China
| | - Xin Huang
- Department of Oral and Maxillofacial‐Head and Neck Oncology, Beijing Stomatological Hospital Capital Medical University Beijing China
| | - Rudong Xing
- Department of Oral and Maxillofacial‐Head and Neck Oncology, Beijing Stomatological Hospital Capital Medical University Beijing China
| | - Zhengxue Han
- Department of Oral and Maxillofacial‐Head and Neck Oncology, Beijing Stomatological Hospital Capital Medical University Beijing China
| | - Zhien Feng
- Department of Oral and Maxillofacial‐Head and Neck Oncology, Beijing Stomatological Hospital Capital Medical University Beijing China
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18
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Zhu X, Liu M, Lv J, Guo L, Li C, Dong L, Liu B. Good local tumor control but lethal hemorrhage after apatinib treatment for intractable squamous carcinoma of the floor of the mouth: a case report. Onco Targets Ther 2018; 11:8909-8913. [PMID: 30573977 PMCID: PMC6290870 DOI: 10.2147/ott.s180358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The treatment of repeatedly recurrent carcinoma of the floor of the mouth (FOM) is challenging. There is no standard strategy for such patients with poor physical condition after multiple lines of treatment. Angiogenesis is a key in tumor initiation, growth, and dissemination. Apatinib, a potent tyrosine kinase inhibitor targeting vascular endothelial growth factor receptor 2 (VEGFR2), has been approved for the treatment of late-stage gastric or gastroesophageal junction adenocarcinoma that is resistant to at least two lines of chemotherapy. Its application in intractable FOM squamous carcinoma has never been described before. Herein, we present the case of a heavily treated patient with FOM squamous carcinoma undergoing a third local relapse in the right region of the neck and anterior cervical region. Oral apatinib was administered daily at a dose of 250 mg. There was clear and rapid efficacy that led to complete remission. However, giant, deep ulcers formed due to tumor necrosis. The patient eventually died of massive bleeding resulting from the major cervical vascular rupture caused by tumor necrosis and erosion. This case is novel and instructional, highlighting that apatinib might be effective, with manageable toxicity, for certain patients with refractory head and neck squamous cell carcinoma (HNSCC). The advantages and disadvantages of apatinib should be carefully evaluated, and close surveillance and quick intervention as required are critical to reduce fatal cancer-associated complications. The role of apatinib in recurrent or metastatic HNSCC needs to be clarified by multicenter trials in the near future.
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Affiliation(s)
- Xiaopeng Zhu
- Department of Radiation Oncology, The First Hospital, Jilin University, Changchun 130021, China, ;
| | - Min Liu
- Department of Radiation Oncology, The First Hospital, Jilin University, Changchun 130021, China, ;
| | - Jincai Lv
- Department of Radiation Oncology, The First Hospital, Jilin University, Changchun 130021, China, ;
| | - Liang Guo
- Department of Pathology, The First Hospital, Jilin University, Changchun 130021, China
| | - Cheng Li
- Department of Radiation Oncology, The First Hospital, Jilin University, Changchun 130021, China, ;
| | - Lihua Dong
- Department of Radiation Oncology, The First Hospital, Jilin University, Changchun 130021, China, ;
| | - Bailong Liu
- Department of Radiation Oncology, The First Hospital, Jilin University, Changchun 130021, China, ;
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Abstract
Management of oral cavity squamous cell carcinoma has become increasingly driven by emerging evidence as a result of the improved quality of clinical research associating clinicopathologic risk factors with oncologic and survival outcomes. Multiple significant recent changes to treatment guidelines and staging algorithms for oral cavity squamous cell carcinoma reflect evolving understanding of tumor biology and the need for adequately extensive treatment of aggressive disease. This article provides clinicians with a synopsis of the most contemporary management strategies for oral cavity squamous cell carcinoma, framed within the context of historical treatment philosophies.
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Affiliation(s)
- Kyle S Ettinger
- Division of Oral and Maxillofacial Surgery, Department of Surgery, Section of Head and Neck Oncologic Surgery and Reconstruction, Mayo Clinic, Mayo College of Medicine, Mail Code: ro_ma_12_12econ, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Oral and Maxillofacial Surgery, Division of Head and Neck Surgery, University of Florida College of Medicine - Jacksonville, 653-1 West 8th Street 2nd FL/LRC, Jacksonville, FL 32209, USA
| | - Laurent Ganry
- Department of Oral and Maxillofacial Surgery, Division of Head and Neck Surgery, University of Florida College of Medicine - Jacksonville, 653-1 West 8th Street 2nd FL/LRC, Jacksonville, FL 32209, USA; Department of Maxillo-facial, Plastic, Reconstructive and Aesthetic Surgery, Henri Mondor Hospital, 51 avenue du Maréchal de Lattre de Tassigny, Créteil 94010, France
| | - Rui P Fernandes
- Division of Head and Neck Surgery, Head and Neck Oncologic Surgery and Microvascular Reconstruction Fellowship, Department of Oral and Maxillofacial Surgery, University of Florida College of Medicine - Jacksonville, University of Florida - Jacksonville, 653-1 West 8th Street 2nd FL/LRC, Jacksonville, FL 32209, USA.
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