Nonsmoking and Nondrinking Oral Squamous Cell Carcinoma Patients: A Different Entity

Contrasting clinical outcomes and socio-economic impact of young versus elderly-onset oral squamous cell carcinoma, a novel health economic analysis

OBJECTIVES

The incidence of young-onset oral squamous cell carcinoma (OSCC) is growing, even among non-smokers/drinkers. The effects of adverse histopathological features on long-term oncologic outcomes between the young and old are controversial and confounded by significant heterogeneity. Few studies have evaluated the socio-economic impact of premature mortality from OSCC. Our study seeks to quantify these differences and their economic impact on society.

MATERIALS AND METHODS

Four hundred and seventy-eight young (<45 years) and 1660 old patients (≥45 years) with OSCC were studied. Logistic regression determined predictors of recurrence and death. Survival analysis was calculated via the Kaplan-Meier method. A separate health economic analysis was conducted for India and Singapore. Years of Potential Productive Life Lost (YPPLL) were estimated with the Human Capital Approach, and premature mortality cost was derived using population-level data.

RESULTS

Adverse histopathological features were seen more frequently in young OSCC: PNI (42.9% vs. 35%, p = 0.002), LVI (22.4% vs. 17.3%, p = 0.013) and ENE (36% vs. 24.5%, p < 0.001). Although 5-year OS/DSS were similar, the young cohort had received more intensive adjuvant therapy (CCRT 26.9% vs. 16.6%, p < 0.001). Among Singaporean males, the premature mortality cost per death was US $396,528, and per YPPLL was US $45,486. This was US $397,402 and US $38,458 for females. Among Indian males, the premature mortality cost per death was US $30,641, and per YPPLL was US $595. This was US $ 21,038 and US $305 for females.

CONCLUSION

Young-onset OSCC is an aggressive disease, mitigated by the ability to receive intensive adjuvant treatment. From our loss of productivity analysis, the socio-economic costs from premature mortality are substantial. Early cancer screening and educational outreach campaigns should be tailored to this cohort. Alongside, more funding should be diverted to genetic research, developing novel biomarkers and improving the efficacy of adjuvant treatment in OSCC.

Umbrella Review on Cancer Stem Cell in Oral and Head and Neck Squamous Cell Carcinoma

Cancer stem cells (CSCs) are cells in a tumor which can begin to grow, develop, and induce resistance in the tumor. Recent studies have shown that as with mesenchymal stem cells, CSCs can also regenerate themselves and be involved in tumorigenesis. Recent advances in detection of biomarkers for identifying CSCs as well as development of new techniques for evaluating the tumorigenesis and carcinogenesis roles of CSCs have been considerable. In recent years, more systematic review papers have been published about CSCs and head and neck squamous cell carcinoma (HNSCC), highlighting the need to accumulate information and draw final conclusions from these studies. Methods: This research protocol for review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols (PRISMA-P) checklist. The protocol for this meta-analysis was registered on PROSPERO (International Prospective Register of Systematic Reviews) and the registration number is CRD42022301720. Results: We identified 8 review articles about CSCs in HNSCCs. Conclusions: This umbrella review provides a comprehensive summary of the body of published systematic reviews and reviews in CSCs and HNSCCs. There is strong evidence suggesting that targeting the cancer stem cells could lead to a more definitive response, since the cancer stem cells are the putative drivers of recurrence and metastatic spread in HNSCCs.

Prognostic value and clinicopathological status of PD-L1 expression and CD8+ TILs in oral squamous cell cancer patients with or without traditional risk factors

BACKGROUND

Non-smokers, non-drinkers, and non-betel quid chewers (NSNDNBs) with oral squamous cell carcinoma (OSCC) have poor survival outcomes. Tumor microenvironment based on PD-L1/CD8+ T cell infiltrated lymphocyte (TIL) proportion is proposed as a prognostic indicator.

METHODS

Immunohistochemistry staining was performed on OSCC samples from 64 patients. The PD-L1/CD8+ TILs were scored and stratified into four groups. Disease-free survival (DFS) was analyzed using a Cox regression model.

RESULTS

OSCC in NSNDNB patients was associated with female sex, T1-2 classification, and PD-L1 positivity. Low CD8+ TILs correlated with perineural invasion. High CD8+ TILs correlated with improved DFS. PD-L1 positivity was not correlated with DFS. Type IV tumor microenvironment yielded the highest DFS (85%).

CONCLUSION

NSNDNB status relates to PD-L1 expression regardless of CD8+ TILs infiltration. Type IV tumor microenvironment was associated with the best DFS. High CD8+ TILs resulted in better survival, while PD-L1 positivity alone was not correlated to DFS.

Evaluating Sensation Recovery in Noninnervated Free Flaps Used for Oral Reconstruction

PURPOSE

Association between time and sensation recovery in noninnervated flaps remains unclear. Our goal was to evaluate the recovery of sensation in noninnervated free flaps used for oral reconstruction.

MATERIALS AND METHODS

A prospective cohort study was designed and consecutive patients undergoing noninnervated free flap surgery for oral reconstruction from a tertiary medical center were enrolled. The primary outcome variable was sensory recovery of light touch, pain, hot, and cold temperature. Sensory recovery was scored as per the test on the central portion and 4 peripheral sections of every flap. The Kaplan-Meier method was used to estimate the functional recovery at different time points and the association between clinicopathologic variables and sensation recovery at 24 months after surgery was analyzed using the chi-squared test and logistic regression analysis.

RESULTS

Eighty patients were included with a median age of 50 years. At 3 months postoperatively, no patients exhibited sensation recovery. Positive flap sensitivity began to appear mildly at 6 months postoperatively and gradually increased for at least 24 months. The 24-month sensation recovery rates of light touch, pain, and temperature were 70.0% (95% confidence interval [CI]: 59.2 to 78.9%), 42.5% (95% CI: 32.3 to 53.4%), and 33.8% (95% CI: 24.45 to 44.6%), respectively. In univariate analysis, 80.5% (95% CI: 66.0 to 89.8%) of the free radial forearm flaps showed light touch sensation recovery, which was statistically higher than 59.0% (95% CI: 43.4 to 72.9%) in other flaps (P = .036). Flap size ≤ 65 cm² predicted better pain sensation recovery with 57.5% (95% CI: 42.2 to 71.5%) compared to 27.5% (95% CI: 16.1 to 42.8%) in flap size > 65 cm² groups (P = .007). Logistic regression analysis confirmed flap size ≤ 65 cm² (P = .032, odds ratio = 1.957, 95% CI: 1.034 to 4.389) and not smoking (P = .015, odds ratio = 2.564, 95% CI: 1.673-5.482) offered better sensation recovery of pain and hot temperature, respectively.

CONCLUSIONS

Sensation recovery in noninnervated free flaps was common and related to not smoking and flap size.

Orocutaneous Fistula Formation in Free Flap Reconstruction for Oral Squamous Cell Carcinoma

Objective

The aim of this study is to identify the risk factors associated with orocutaneous fistula (OCF) formation after free flap reconstruction for oral squamous cell carcinoma (SCC).

Methods

Patients undergoing free flap reconstruction for oral SCC were retrospectively enrolled. The relationship between clinicopathologic variables and OCF formation was analyzed by univariate and multivariate analyses.

Results

A total of 87 OCFs occurred in 856 patients. Univariate analysis revealed cachexia, tumor at the tongue/floor of the mouth (TFOM), T4 stage, preoperative hemoglobin level, pull-through procedure, preoperative albumin level, and surgical site infection were associated with the formation of OCF. Multivariate analysis confirmed the independence of cachexia, TFOM, T4 stage, and surgical site infection in predicting OCF development. Conventional wound care could achieve successful fistula closure in 82.4% of the patients with a median time of 28 days.

Conclusions

OCF formation was common after free flap reconstruction. The presence of cachexia, TFOM tumor site, T4 stage, and surgical site infection significantly increased the risk of OCF formation. Although it required a long period, conventional wound care can obtain satisfactory outcomes in OCF management.

Molecular drivers of oral cavity squamous cell carcinoma in non-smoking and non-drinking patients: what do we know so far?

Oral cavity squamous cell carcinoma (OCSCC) is one of the most common head and neck cancers worldwide. It is well known that risk factors for OCSCC include tobacco and excess alcohol consumption. However, in recent years, OCSCC incidence has been increasing in patients without these traditional risk factors. The cause of this increase is unclear and various genetic, environmental, and infectious factors have been hypothesized to play a role. Additionally, there are expert opinions that oral cancer in non-smoking, non-drinking (NSND) patients have a distinct phenotype resulting in more aggressive disease presentation and poorer prognosis. In this review, we summarize the current state of knowledge for oral cavity cancer in patients without traditional risk factors.

Alcohol and Head and Neck Cancer: Updates on the Role of Oxidative Stress, Genetic, Epigenetics, Oral Microbiota, Antioxidants, and Alkylating Agents

Head and neck cancer (HNC) concerns more than 890,000 patients worldwide annually and is associated with the advanced stage at presentation and heavy outcomes. Alcohol drinking, together with tobacco smoking, and human papillomavirus infection are the main recognized risk factors. The tumorigenesis of HNC represents an intricate sequential process that implicates a gradual acquisition of genetic and epigenetics alterations targeting crucial pathways regulating cell growth, motility, and stromal interactions. Tumor microenvironment and growth factors also play a major role in HNC. Alcohol toxicity is caused both directly by ethanol and indirectly by its metabolic products, with the involvement of the oral microbiota and oxidative stress; alcohol might enhance the exposure of epithelial cells to carcinogens, causing epigenetic modifications, DNA damage, and inaccurate DNA repair with the formation of DNA adducts. Long-term markers of alcohol consumption, especially those detected in the hair, may provide crucial information on the real alcohol drinking of HNC patients. Strategies for prevention could include food supplements as polyphenols, and alkylating drugs as therapy that play a key role in HNC management. Indeed, polyphenols throughout their antioxidant and anti-inflammatory actions may counteract or limit the toxic effect of alcohol whereas alkylating agents inhibiting cancer cells’ growth could reduce the carcinogenic damage induced by alcohol. Despite the established association between alcohol and HNC, a concerning pattern of alcohol consumption in survivors of HNC has been shown. It is of primary importance to increase the awareness of cancer risks associated with alcohol consumption, both in oncologic patients and the general population, to provide advice for reducing HNC prevalence and complications.

"Fact or fiction?": Oral cavity cancer in nonsmoking, nonalcohol drinking patients as a distinct entity-Scoping review

Oral cavity cancer is often described as a lifestyle-related malignancy due to its strong associations with habitual factors, including tobacco use, heavy alcohol consumption, and betel nut chewing. However, patients with no genetically predisposing conditions who do not indulge in these risk habits are still being encountered, albeit less commonly. The aim of this review is to summarize contemporaneous reports on these nonsmoking, nonalcohol drinking (NSND) patients. We performed database searching to identify relevant studies from January 1, 2000 to March 31, 2021. Twenty-six articles from 20 studies were included in this study. We found that these individuals were mostly females in their eighth decade with tumors involving the tongue and gingivobuccal mucosa. This review also observed that these patients were likely diagnosed with early stage tumors with overexpression of programmed death-ligand 1 (PD-L1) and increased intensity of tumor infiltrating lymphocytes. Treatment response and disease-specific prognosis were largely comparable between NSND and smoking/drinking patients.