Induction chemotherapy in technically unresectable locally advanced oral cavity cancers: does it make a difference?

Latin American Consensus on the Treatment of Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.

Evaluation of response to neoadjuvant chemotherapy in technically unresectable moderately advanced oral cavity cancers

BACKGROUND

Moderately advanced and technically unresectable oral cavity cancers have a poor prognosis. Neoadjuvant chemotherapy might be beneficial in such patients by reducing tumour bulk and allowing definitive surgery.

AIM

To evaluate the response of neoadjuvant chemotherapy in moderately advanced technically unresectable oral cavity cancers.

METHODOLOGY

Prospective observational study - secondary data analysis of patients with moderately advanced oral cavity cancer, which were treated with neoadjuvant chemotherapy (NACT) during the period November 2014-April 2016. Data was analysed for information on patient characteristics, chemotherapy received, toxicity, clinical response rates, local treatment offered and pathological response rates. The statistical analysis was performed with SPSS version 20.

RESULTS

30 patients, with a median age of 52 years were analyzed. Buccal mucosa was the most common sub site (50%). Three drug regimen was utilized in all patients. Resectability was achieved in 14 patients (46.67%). Febrile neutropenia was seen in 3 patients (10%). The overall response rate was 31%.

CONCLUSION

NACT was effective in converting moderately advanced technically unresectable oral cavity cancers to operable disease in approximately 47% of patients. Post NACT, there is significant association between clinical and pathological findings of response rates. There is no increase in surgical complication rates following NACT.

Locally Advanced oral Squamous cell Carcinomas: Auditing and Outcome Appraisal

Introduction: Patients with OSCC in India (oral squamous cell carcinoma) presents at a later stage with approximately 28% presenting at stage III and 64% at stage IV disease. In this retrospective study we have reviewed the treatment modalities rendered and outcomes associated for the management of locally advanced oral squamous cell carcinoma in our Institute. We evaluated the survival data and the factors effecting survival. Methods: Kaplan Meir method was used to evaluate OS and DFS rate and log rank test was used to compare the survival amongst groups. Cox regression analysis (univariate and multivariate) was used to evaluate the hazard ratio to find out the possible factors influencing risk of death and disease. Results: The median OS and DFS in our study were 32 and 24 months respectively. On a subset analysis of only T4b patients who underwent either upfront surgery or induction chemotherapy followed by surgery there was no significant difference in OS and DFS. All patients with TURD had partial response after induction chemotherapy and were subjected to surgical resection followed by adjuvant therapy. Conclusion: Extracapsular spread, bone involvement, skin infiltration, treatments, surgical margins and Lymph node size are the prime predictors of survival.Upfront surgery remains the standard of care for resectable LAOSCC. Induction chemotherapy might improve the resectability in technically unresectable OSCC. There is no difference in survival between concurrent chemoradiation, sequential chemoradiation and radical radiotherapy in the management of unresectable disease.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04168-4.

Comparative Evaluation of Surgical Operability with and without Induction Chemotherapy in Locally Advanced Head and Neck Squamous Cell Carcinoma

To compare and evaluation of surgical operability with and without induction chemotherapy in locally advanced head and neck squamous cell carcinoma. Head and neck malignancy grossly refers to squamous cell carcinomas of head and neck (HNSCC) have multiple treatment modalities and strategies, when opted in an appropriate manner renders tumours curable. The aim of this study is to compare and evaluation of surgical operability with and without induction chemotherapy in locally advanced head and neck squamous cell carcinoma. A prospective observational study involving 50 patients of histologically proven squamous cell carcinoma of head and neck region. Patients were categorized into two major groups, group-1 patients included resectable tumour stage and group-2 included unresectable tumour stage. Both groups were compared after appropriate chemotherapy and surgical intervention. There were a total of 78% males and 22% females with majority of patients in age group of 41-60 years. 54% patients had ulcerative type of growth pattern and most patients had primary site of lesion in oral cavity. 50% patients had moderately differentiated squamous cell carcinoma. Induction chemotherapy was considered in 70% of patients, while majority of patients were belonging to T4N2M0 stage. In this study, we recommend that the borderline category of patients who are initially in an unresectable tumour stage can undergo induction chemotherapy to downstage and shrink the tumour to a resectable stage following which the appropriate surgical intervention should be done with a close monitoring and sustained follow up to prevent recurrence.

Long-term outcomes of neo-adjuvant chemotherapy on borderline resectable oral cavity cancers: Real-world data of 3266 patients and implications for clinical practice

BACKGROUND

Neo-adjuvant chemotherapy (NACT) followed by response assessment is the standard treatment algorithm for locally advanced oral cavity squamous cell carcinomas (OCSCC) in the Indian subcontinent. The 3-drug NACT regimen (Docetaxel-Cisplatin-5-FU) has shown improvement in overall survival over 2-drug regimen (Docetaxel-Cisplatin) in a phase-3 randomised study. We have analysed the 10-year outcomes with this treatment algorithm.

METHODS

This was an institutional review board approved retrospective analysis of a prospectively collected dataset of borderline resectable OCSCC patients who underwent NACT. Patients who became resectable after NACT underwent surgery followed by appropriate adjuvant therapy. Patients who were unresectable received definitive chemoradiation (CTRT), palliative chemotherapy, radiotherapy or best supportive care based on general condition.

RESULTS

A total of 3266 patients were included. The most common subsite was buccal mucosa and the most frequent indication was peri-tumoral edema upto zygoma. More than 2-drugs NACT was offered to 32.9% patients. Overall, 32.5% patients had a response to NACT. A total of 1358 patients were offered curative treatment, of which 929 (32%) underwent surgery and the rest underwent definitive chemo-radiation (14.8%). Patients who received more than 2-drugs NACT versus those who received 2-drugs had a 10-years OS of 21% vs 5.1% (p < 0.001). Patients who underwent surgery versus those who did not had a 10-year OS of 21.8% vs 4.1% (p < 0.001). Patients who achieved pCR had a 5-year OS of 45.3% vs 13.3% for those who did not (p < 0.001).

CONCLUSION

NACT leads to long term survival benefit in patients of borderline resectable oral cavity cancer.

Neoadjuvant chemotherapy for locally advanced head and neck squamous cell carcinoma - Is it still relevant? A practice pattern survey among oncologists of India

Objectives

Concurrent chemotherapy is the recommended treatment for locally advanced head and neck (H&N) squamous cell carcinoma, and neoadjuvant chemotherapy (NACT) is debated with a few special indications. NACT for advanced head and neck cancer has been studied in clinical trials for more than 2 decades without clear demonstration of the benefit for loco regional tumor control or overall patient survival. Its benefit remains controversial in the absence of clear evidence to define its role. However, there is widespread use of NACT among oncologists. We conducted an online survey to find out the frequency, pattern, prevalence, and aims for use of NACT in locally advanced head and neck cancers among radiation, medical, and surgical oncologists.

Materials and Methods

Oncologists across India who expressed interest to participate in our survey were asked to complete a short online questionnaire designed to identify the current practice pattern of NACT in head and neck cancer. A mobile app-based questionnaire was sent to 200 oncologists across the country to assess the pattern of NACT use and to solicit their most frequent therapy approach for patients with locoregionally advanced head and neck cancer.

Results

One hundred and fifty (150) oncologists completed and returned the survey (75%), and 130 were finalized (94 radiation oncologists, 19 medical oncologists, and 17 surgical oncologists). The single most common treatment approach reported for patients with locoregionally advanced H&N cancer was that of sequential chemoradiation (61%), specifically NACT with the TPF regimen (78.5%), followed by radiation therapy. The primary objectives cited by respondents for the use of NACT included the desire to buy time for definitive treatment (20%) and to achieve R0 resection (19.2%). Use of NACT in most patients was more preferred by medical oncologists (21.1%) and radiation oncologists (19.1%) than surgical oncologists (11.8%). Thus, there is not much difference in perception in practice of NACT in radiation, medical, and surgical oncologists. A minimum of two cycles of NACT was preferred by more than half of the doctors (55.4%) with 59.6% radiation oncologists using it before further assessment.

Conclusion

Although level I evidence for inferior outcomes with NACT as compared to concurrent chemoradiation therapy is there, the use of NACT is quite common among various oncologists in the country because of reasons such as buying time for definitive treatment, achieving R0 resection, better outcome and survival, partial response, better tolerability, better distant control, LN size regression, down-staging of primary tumor, selection of chemosensitive patients, reducing the volume of the radiation field, and better tolerability of subsequent Chemoradiation (CTRT) intensity of subsequent chemoradiation therapy.

Management and outcome of locally advanced oral squamous cell carcinoma

Management of locally advanced OSCC is multimodal. No single therapy has been proved to be efficacious. However there is a trend towards surgical intervention in operable disease. In this review we appraise the various therapies used for the management of locally advanced OSCC. We review the literature with regards to the various treatment options for locally advanced OSCC. We categorically divided the manuscript into resectable, unresectable and technically unresectable disease. Surgery is the ideal treatment modality for resectable disease. For unresectable disease concurrent chemoradiation appears to improve survival compared to radiotherapy alone. Induction therapy might downstage tumors in the unresectable category. Targeted and Immunotherapy is reserved for recurrent, metastatic or platinum refractory OSCC. Management of locally advanced OSCC is multimodal with surgery playing the primary role. In the event where the tumor is in operable concurrent chemoradiotherapy is regarded as the best treatment modality. Induction chemotherapy currently cannot be recommended for resectable or even unresectable oral squamous cell carcinomas. However for technically unresectable disease it might play a role in improving respectability but it depends on the response of the tumor. Targeted therapy and immunotherapy is currently used for recurrent, metastatic and/or platinum refractory Head and Neck cancers. Currently it is not recommended for initial management of locally advanced disease.

Neoadjuvant chemotherapy in technically unresectable head and neck cancers: a retrospective audit

Background

The data regarding the use of neoadjuvant chemotherapy in technically unresectable head and neck cancer (HNC) is limited and real-world studies are needed to look for the efficacy and toxicities of this approach.

Patients and methods

This is a retrospective study conducted in the Medical Oncology department of our hospital. All technically unresectable HNC patients who underwent neoadjuvant chemotherapy between May 2018 and May 2020 were included in this analysis. Patients received three-drug regimen docetaxel, cisplatin and 5-fluorouracil (DCF) regimen, two-drug regimens included docetaxel + cisplatin, paclitaxel + carboplatin both weekly and 3-weekly. The resectability assessment was done clinically and radiologically after completing three neoadjuvant cycles. Overall survival was calculated from the first day of chemotherapy to the date of last follow-up or date of death.

Results

A total of 119 patients received neoadjuvant chemotherapy during the specified time. Response assessment showed partial response in 41.9% of patients with three-drug regimens and 37.5% of patients with other regimens. Out of 119 patients, 56 (47%) patients were offered radical intent therapy. Resectability was achieved in 32.3% of three-drug regimen patients and 26.1% of other patients. Surgery was feasible in 33 (27.7%) patients, and postoperative radiotherapy and concurrent chemotherapy were done in 30 patients (25.2%), and surgery with only postoperative radiotherapy was done in 3 patients (2.5%). Radical chemoradiotherapy was done in 23 patients (19.3%). The estimated median survival for patients who could undergo surgery was 18 months [95% confidence interval (CI), 14.9-21.0], and nonsurgical patients were 9 months (95% CI, 7.3-10.6) (p = 0.0001).

Conclusion

Our study shows that neoadjuvant chemotherapy in technically unresectable HNC patients can make the disease resectable in around one-third of the patients. The patients who could undergo surgery after neoadjuvant chemotherapy had significantly improved survival as compared to those who could not.

Outcome Analysis of Advanced Oral Cancers Requiring Large Composite Fibular Osteocutaneous Flap Reconstruction: Experience From a Tertiary Care Cancer Hospital

BACKGROUND

Advanced oral cancer entailing extensive resection of large parts of the mucosa, bone, and skin require reconstructions with composite free flaps. Our aim was to analyze the outcomes of those oral squamous cell carcinomas requiring fibular osteocutaneous free flaps with large skin defects.

METHODS

Perioperative course and histopathological and survival outcomes of 246 consecutive patients warranting composite fibular flaps from January 2010 to June 2015 at Tata Memorial Hospital, Mumbai, India, were retrospectively analyzed.

RESULTS

Despite majority of T4 disease (88.2%) and stage IV disease (92%) patients, the 5-year overall survival was 52.1% and the 5-year recurrence-free survival was 48.6% with a median follow-up of 42 months with minimal complications.

CONCLUSIONS

Reconstruction with composite fibular osteocutaneous flaps has comparable outcomes of survival with acceptable complications in mega oral squamous cell carcinomas requiring extensive resection.

Retrospective analysis of adjuvant radiotherapy in oral cavity or oropharyngeal cancer: Feasibility of omitting lower-neck irradiation

Objectives

Adjuvant radiotherapy is the standard of care in locally advanced head and neck cancers. The radiation field is correlated with the surgical field in the adjuvant radiotherapy setting; therefore, tailoring the irradiation field is reasonable.

Materials and methods

We retrospectively analyzed patients with oral cavity and oropharyngeal cancers included in the cancer registry between 2015 and 2019 in the study hospital. Patients who underwent whole-neck irradiation (WNI) were compared with those who underwent lower-neck–sparing (LNS) irradiation.

Results

A total of 167 patients with oral cavity and oropharyngeal cancers were included in the study. Cancer recurrence was recorded in 33% of the patients. The rate of recurrence of oral cavity and oropharyngeal cancer at neck level IV was 8%. The 2-year incidence of level IV recurrence was lower in the WNI group than in the LNS group (2% vs. 10%; p = 0.04). The 2-year disease-free survival rates were 75% and 63% in the WNI and LNS groups, respectively (p = 0.08).

Conclusion

The rate of level IV recurrence was higher in the LNS group than in the WNI group. Trends of improvement in disease-free survival with lower-neck irradiation suggested that it is premature to consider LNS irradiation as daily practice in patients with oral cavity and oropharyngeal cancer.

Efficacy and safety of neoadjuvant chemotherapy (NACT) with paclitaxel plus carboplatin and oral metronomic chemotherapy (OMCT) in patients with technically unresectable oral squamous cell carcinoma (OSCC)

A combination of maximum tolerated dose and metronomic chemotherapy schedule may lead to synergistic effects with acceptable toxicity. We assessed the efficacy and safety of this combination as neoadjuvant chemotherapy (NACT) in 14 patients with technically unresectable oral squamous cell carcinoma. They received NACT with paclitaxel-carboplatin and triple oral metronomic chemotherapy (OMCT) (methotrexate, celecoxib and erlotinib). Patients were assessed clinically and radiologically after a minimum of two cycles for resectability. Primary tumour site was buccal mucosa and oral tongue in 12 (86%) and 2 (14%) patients, respectively. The median number of NACT administered was three. The tumours of nine (65%) patients showed partial response and none of the patients had tumour progression. The tumours of nine patients (65%) were deemed resectable after NACT. Median progression free survival was 11.4 months (95% CI = 7.9–15 months) and median overall survival (OS) was not reached. OS at 15 months was 63.5% (95% CI = 37.8%–89.2%). Grade 3 or 4 haematological toxicities were seen in eight (57%) patients. Paclitaxel-carboplatin combined with OMCT is a well-tolerated and less resource intensive NACT regimen which leads to favourable resection rate and survival.

Prospective Phase II Open-Label Randomized Controlled Trial to Compare Mandibular Preservation in Upfront Surgery With Neoadjuvant Chemotherapy Followed by Surgery in Operable Oral Cavity Cancer

PURPOSE

The objective of this study was to explore the potential role and safety of neoadjuvant chemotherapy (NACT) in tumor shrinkage and resultant mandibular preservation in oral cancers compared with conventional surgical treatment.

METHODS

This study was a single-center, randomized, phase II trial of treatment-naive histologically confirmed squamous cell carcinoma of the oral cavity with cT2-T4 and N0/N+, M0 (American Joint Committee on Cancer, seventh edition) stage, necessitating resection of the mandible for paramandibular disease in the absence of clinicoradiologic evidence of bone erosion. The patients were randomly assigned (1:1) to either upfront surgery (segmental resection) followed by adjuvant treatment (standard arm [SA]) or two cycles of NACT (docetaxel, cisplatin, and fluorouracil) at 3-week intervals (intervention arm [IA]), followed by surgery dictated by postchemotherapy disease extent. All patients in the IA received adjuvant chemoradiotherapy, and patients in the SA were treated as per final histopathology report. The primary end point was mandible preservation rate. The secondary end points were disease-free survival and treatment-related toxicity.

RESULTS

Sixty-eight patients were enrolled over 3 years and randomly assigned to either SA (34 patients) or IA (34 patients). The median follow-up was 3.6 years (interquartile range 0.95-7.05 years). Mandibular preservation was achieved in 16 of 34 patients (47% [95% CI, 31.49 to 63.24]) in the IA. The disease-free survival (P = .715, hazard ratio 0.911 [95% CI, 0.516 to 1.607]) and overall survival (P = .747, hazard ratio 0.899 [95% CI, 0.510 to 1.587]) were similar in both the arms. Complications were similar in both arms, but chemotherapy-induced toxicity was observed in the majority of patients (grade III: 14, 41.2%; grade IV: 11, 32.4%) in the IA.

CONCLUSION

NACT plays a potential role in mandibular preservation in oral cancers with acceptable toxicities and no compromise in survival. However, this needs to be validated in a larger phase III randomized trial.

Oral and dental health status in patients undergoing neoadjuvant chemotherapy for locally advanced head and neck cancer

OBJECTIVE

A prospective, longitudinal assessment of oral and dental health status was done from baseline until treatment completion in patients scheduled to receive neoadjuvant chemotherapy (NACT) for locally advanced head and neck cancer (LAHNC).

STUDY DESIGN

One hundred fifty consecutive, treatment-naïve adult patients with biopsy-proven LAHNC scheduled to receive NACT were recruited. One hundred thirty-five patients completed all assessments at 3 designated time points: baseline (T0), midtreatment (T1), and posttreatment (T2). Variables assessed were: Oral Hygiene Index-Simplified (OHI-S) score; decayed, missing, or filled teeth (DMFT) score; mucositis grade; pain score; and grade of trismus.

RESULTS

Median OHI-S scores showed a statistically significant increase (higher the score, poorer the oral hygiene) when the patients were evaluated from baseline to completion of NACT (T1 vs. T2; T0 vs. T2; P < .001), which indicated a decrease in oral health. There was no change in median DMFT score (P = .32), but a significant change was seen in all-grade mucositis over time (P < .001). Median pain scores and trismus grades decreased significantly (P < .001) over time.

CONCLUSIONS

There was a decrease in oral health status without any change in dental health seen in patients undergoing NACT. Mucositis was initially noted as an aftermath of chemotherapy, which resolved with time.

Induction Chemotherapy for Advanced Oral Cavity Cancer

PURPOSE OF REVIEW

Head and neck cancer is a heterogeneous disease, comprising multiple subsites with diverse etiologic factors, pathology and molecular features, response to treatment, and prognosis. Systemic treatment is usually incorporated in the management of locally advanced head and neck squamous cell carcinoma, and the use of induction chemotherapy has theoretical benefits on reducing the risk of distant metastasis, provide an in vivo testing of response and tumor biology and the potential to allow a more personalized and less toxic local treatment after downstaging. The aim of this review is to access the role of induction chemotherapy in patients with locally advanced oral cavity cancer.

RECENT FINDINGS

Clinical trials analyzing this treatment strategy in patients with resectable disease, followed by surgery, and in unresectable disease, followed by (chemo)radiotherapy or surgery are discussed, pointing out strengths and limitations of this data and highlighting the standard treatment in each clinical scenario. Future perspectives, including the incorporation of checkpoint inhibitors and biomarkers for patient selection are discussed. Surgery followed by (chemo)radiation is the standard of care for resectable oral cavity cancer patients, and chemoradiation is the standard for those considered as unresectable. Future trials with the incorporation of immunotherapy and better patient selection based on clinical and molecular biomarkers can bring new hopes for better therapeutic results in these patients.

Chemoradiation in Unresectable Oral Cavity Cancer: A Myth or Reality!

Objective  Earlier studies have shown that chemoradiation (CTRT) has benefits in the head-and-neck cancer, but how far it is true for oral cavity subset that has not been exactly explored. Keeping the null hypothesis as CTRT has no benefit in oral cavity cancer, we studied the outcome of patients undergoing chemoradiation in unresectable oral cavity cancers. The aim of this study is to study whether overall survival (OS) increases with chemoradiation in unresectable oral cavity cancers.

Patients and Methods  Between December 2014 and February 2017, 23 patients aged 18 years and above were planned chemoradiation for unresectable oral cavity cancer and were included for this analysis.

Results  The median age of patients was 43 years and all patients were addicted to tobacco. In total, 12 of 23 (52%) completed CTRT. One patient (1/23) was alive at the time of final analysis with median OS of 5.83 (2.73–9.60) months. The median progression free survival and OS in patients who completed chemoradiation were 6.42 months (95% confidence interval [CI]: 3.67–10.53) and 8.9 months (95% CI: 4.4–23.07), respectively.

Conclusion  CTRT has a limited role in unresectable oral cancers.

Melatonin effect on hypoxia inducible factor-1α and clinical response in patients with oral squamous cell carcinoma receiving neoadjuvant chemotherapy: A randomized controlled trial

CONTEXT

Chemoresistance is a major issue in patients with locally advanced oral squamous cell carcinoma (OSCC). In this study, we evaluated the effectiveness of melatonin in conjunction with neoadjuvant chemotherapy (NC) on hypoxia-inducible factor-1α (HIF-1α) expression and clinical response in locally advanced OSCC patients.

AIMS

To study the effects of melatonin on HIF-1α expression and its effect on the clinical response of patients with locally advanced OSCC.

SETTINGS AND DESIGN

A randomized controlled trial was conducted, wherein patients were recruited from several hospitals in Jakarta, Indonesia. Patients were randomized into two groups using computerized block randomization.

SUBJECTS AND METHODS

Both groups were given NC, with treatment group receiving melatonin. Outcomes measured in this study were HIF-1α expression from tissue samples and clinical response based on the RECIST 1.1 criteria. Twenty-five patients completed the study protocol and were included in the data analysis.

STATISTICAL ANALYSIS USED

Shapiro-Wilk test was used to test the data normality. For data with normal distribution, we conducted an independent t-test to compare between the two groups. Data with abnormal distribution were analyzed using Mann-Whitney U-test. The mean difference between the two groups was analyzed using Shapiro-Wilk normality test.

RESULTS

Our study showed a significant decrease in HIF-1α expression in the melatonin group compared to the placebo group (P < 0.05, relative risk 3.08). However, the degree of reduction of HIF-1α expression in the melatonin group did not differ significantly (P = 0.301).

CONCLUSIONS

Our study showed that melatonin administered at 20 mg/day could reduce the expression of HIF-1α and residual tumor percentage, but did not affect the clinical response in OSCC patients.

Locally Advanced Oral Cavity Cancers: What Is The Optimal Care?

Patients with oral cavity cancers often present late to seek medical care. Surgery is usually the preferred upfront treatment. However, surgical resection cannot be achieved in many cases with advanced disease without major impact on patient’s quality of life. On the other hand, radiotherapy (RT) and chemotherapy (CT) have not been employed routinely to replace surgery as curative treatment or to facilitate surgery as neoadjuvant therapy. The optimal care of these patients is challenging when surgical treatment is not feasible. In this review, we aimed to summarize the best available evidence-based treatment approaches for patients with locally advanced oral cavity cancer. Surgery followed by RT with or without CT is the standard of care for locally advanced oral cavity squamous cell carcinoma. In the case of unresectable disease, induction CT prior to surgery or chemoradiotherapy (CRT) can be attempted with curative intent. For inoperable patients or when surgery is expected to result in poor functional outcome, patients may be candidates for possibly curative CRT or palliative RT with a focus on quality of life.

Neoadjuvant chemotherapy in geriatric head and neck cancers

BACKGROUND

The purpose of this study was to present our findings on the treatment completion rates and outcomes in geriatric patients with head and neck cancer treated with neoadjuvant chemotherapy followed by definitive therapy.

METHODS

Geriatric patients with locally advanced head and neck cancer who received neoadjuvant chemotherapy were selected for this analysis. Overall survival (OS) and progression-free survival (PFS) were estimated.

RESULTS

Forty-six of 49 patients completed neoadjuvant chemotherapy (93.9%). The compliance to local treatment was 73.3% and the median OS was 49.9 months (95% confidence interval [CI] = 22.0-77.8 months) in patients who received neoadjuvant chemotherapy for organ preservation (n = 15). In patients receiving neoadjuvant chemotherapy for technically unresectable disease, the corresponding figures were 82.06% and 9.0 months (95% CI = 5.9-12.1 months), respectively.

CONCLUSION

Individualized neoadjuvant chemotherapy protocols in geriatric patients have high compliance rates to treatment and the median OS in geriatric patients treated for organ preservation is similar to that of young patients. © 2017 Wiley Periodicals, Inc. Head Neck 39: 886-892, 2017.

Induction Chemotherapy in Technically Unresectable Locally Advanced T4a Oral Cavity Squamous Cell Cancers: Experience from a Regional Cancer Center of South India

Objectives:

The present study aimed to investigate the efficacy, toxicity, and impact of induction chemotherapy (IC) in technically unresectable T4a oral cavity squamous cell cancers (OSCCs).

Materials and Methods:

Patients diagnosed with technically unresectable locally advanced T4a OSCC from January 2013 and November 2016 at our center, who received 2–3 cycles of IC and then assessed for resectability, were reviewed retrospectively. Patients' profile, response rates and toxicity of IC, resectability status, and overall survival (OS) were evaluated. Statistical analyses were performed using SPSS version 17.0 for Windows (SPSS Inc., Chicago, IL, USA).

Results:

Totally 80 patients received IC, and of them 58 (72.5%) were males. Median age at diagnosis was 44 years (range, 34–62 years). All our patients received IC with doublet regimen. Majority of the patients had buccal mucosa cancers (73.8%), followed by gingivobuccal complex (21.2%) and oral tongue (5%) primaries. After IC, partial response was achieved in 17 (21.3%) patients, stable disease in 49 (61.3%) patients and disease progression was noted in 14 (17.4%) patients. Post-IC, resectability was achieved in 19 (23.8%) of 80 patients, but 4 of them did not undergo surgery due to logistic and personal reasons. The median OS of patients who underwent surgery followed by adjuvant local therapy (n = 15) was 16.9 months (95% CI: 15.2–19.8 months) and for those treated with nonsurgical local therapy (n = 65) was 8.8 months (95% CI: 6.8–10.6 months) (log-rank P = 0.000).

Conclusions:

IC had a manageable toxicity profile and achieved resectability in 23.8% of our patients with technically unresectable T4a OSCC. Patients underwent resection had a significantly better median OS than those who received nonsurgical local treatment.

Dihydropyrimidine dehydrogenase mutation in neoadjuvant chemotherapy in head and neck cancers: Myth or reality?

PURPOSE

The docetaxel, 5-fluorouracil (5-FU), and cisplatin (TPF) regimen in India is associated with high percentages of Grade 3-4 toxicity. This analysis was planned to evaluate the incidence of dihydropyrimidine dehydrogenase (DPD) mutation in patients with severe gastrointestinal toxicity, to assess whether the mutation could be predicted by a set of clinical criteria and whether it has any impact on postneoadjuvant chemotherapy response.

METHODS

All consecutive patients who received TPF regimen in head and neck cancers between January 2015 and April 2015 were selected. Patients who had predefined set of toxicities in Cycle 1 were selected for DPD mutation testing. Depending on the results, C2 doses were modified. Postcompletion of two cycles, patients underwent radiological response assessment. Descriptive statistics has been performed. The normally distributed continuous variables were compared by unpaired Student's t-test, whereas variables which were not normally distributed by Wilcoxon sum rank test. For noncontinuous variables, comparison was performed by Fisher's exact test.

RESULTS

Out of 34 patients, who received TPF, 12 were selected for DPD testing, and 11 (32.4%, 95% confidence interval [95% CI]: 19.1-49.3%) had DPD mutation. The predictive accuracy of the criteria for the tested DPD mutations was 81.3% (95% CI: 62.1-100%). Of the 11 DPD mutation positive patients, except for one patient, all others received the second cycle of TPF. The dose adjustments done in 5-FU were 50% dose reduction in 9 patients and no dose reduction in one patient. The response rate in DPD mutated patients was 27.3% (3/11) and that in DPD nonmutated/nontested was 39.1% (9/23) (P = 0.70).

CONCLUSION

In this small study, it seems that the incidence of DPD mutation is more common in Indian then it's in the Caucasian population. Clinical toxicity criteria can accurately predict for DPD mutation. Postdose adjustments of 5-FU from C2 onward, TPF can safely be delivered in the majority of patients with DPD heterozygous mutations without decrement in efficacy.

Impact of EGFR and p53 expressions on survival and quality of life in locally advanced oral squamous cell carcinoma patients treated with chemoradiation

EGFR and p53 are molecular markers which play important role in tumor progression and development. The objective of this study was to assess the association between EGFR and p53 expression and survival, and to determine whether EGFR and p53 expression levels were associated with differences quality of life in OSCC patients undergoing chemoradiation. A total of 120 OSCC patients aged 20-67 y and stage III/IV were recruited. Treatment response was assessed according to W.H.O. (1979). EGFR and p53 expression in tumor tissue was estimated by immunohistochemical (IHC) method and quantified as percentage positive nuclei. Molecular marker expressions of both EGFR and p53 were found significantly (P < 0.01 or P < 0.001) associated with overall response, survivals and quality of life. Neither EGFR nor p53 expression was associated with hematologic or non-hematologic toxicity. EGFR and p53 molecular marker expressions may have significant association with survival and QOL in OSCC patients undergoing chemoradiation.

Indian Council of Medical Research consensus document for the management of tongue cancer

The document is based on consensus among the experts and best available evidence pertaining to Indian population and is meant for practice in India.

Early diagnosis is imperative in improving outcomes and preserving quality of life. High index of suspicion is to be maintained for leukoplakia (high risk site).

Evaluation of a patient with newly diagnosed tongue cancer should include essential tests: Magnetic resonance imaging (MRI) is investigative modality of choice when indicated. Computed tomography (CT) scan is an option when MRI is unavailable. In early lesions when imaging is not warranted ultrasound may help guide management of the neck.

Early stage cancers (stage I & II) require single modality treatment – either surgery or radiotherapy. Surgery is preferred. Adjuvant radiotherapy is indicated for T3/T4 cancers, presence of high risk features [lymphovascular emboli (LVE), perineural invasion (PNI), poorly differentiated, node +, close margins). Adjuvant chemoradiation (CTRT) is indicated for positive margins and extranodal disease.

Locally advanced operable cancers (stage III & IVA) require combined multimodality treatment - surgery + adjuvant treatment. Adjuvant treatment is indicated in all and in the presence of high risk features as described above.

Locally advanced inoperable cancers (stage IVB) are treated with palliative chemo-radiotherapy, chemotherapy, radiotherapy, or symptomatic treatment depending upon the performance status. Select cases may be considered for neoadjuvant chemotherapy followed by surgical salvage.

Metastatic disease (stage IVC) should be treated with a goal for palliation. Chemotherapy may be offered to patients with good performance status. Local treatment in the form of radiotherapy may be added for palliation of symptoms.

Intense follow-up every 3 months is required for initial 2 years as most recurrences occur in the first 24 months. After 2^nd year follow up is done at 4-6 months interval. At each follow up screening for local/regional recurrence and second primary is done. Imaging is done only when indicated.

Comparison of postoperative complications in advanced head and neck cancer patients receiving neoadjuvant chemotherapy followed by surgery versus surgery alone

Background:

Head and neck cancer is the third most common cancer in India with 60% presenting in advanced stages. There is the emerging role of neoadjuvant chemotherapy (NACT) in the management of these advanced cancers. There is a general perception that complication rates are higher with the use of NACT.

Materials and Methods:

This is a retrospectively collected data of head and neck cancer patients operated at our hospital from March 2013 to September 2014. A total of 205 patients were included in the study. These patients were studied in two groups. Group 1 included 153 patients who underwent surgery alone, and Group 2 included 52 patients who received 2-3 cycles of NACT followed by surgery.

Results:

The mean age of the population was 51 years in the Group 1 and 45 years in Group 2. The hospital stay and readmissions in postoperative period were similar in the two groups. In this study, the complication rate was 37.9% in the surgery patients and 30.8% in the NACT patients (P = 0.424).

Conclusion:

The postoperative complication rates in patients who received NACT followed by surgery were not significantly different from those who underwent surgery.

Neoadjuvant chemotherapy in oral cancers: Selecting the right patients

The standard of care treatment for oral squamous cell carcinoma (OSCC) at present, consist of surgical resection followed by adjuvant radiotherapy and chemotherapy as indicated. Despite recent advances the overall prognosis remains guarded. Role of neoadjuvant chemotherapy is being explored with premise of reducing extent of surgical resection, improving loco-regional control and decreasing distant metastasis, thereby improving treatment outcomes by decreasing mortality and morbidity. However, indications of neoadjuvant chemotherapy in oral cancers are not clearly defined. Majority of studies have failed to demonstrate a significant benefit of neoadjuvant chemotherapy in terms of loco regional control and overall survival in resectable OSCC. In a select subset of patients with locally very advanced and unresectable OSCC, neoadjuvant chemotherapy has been shown to cause tumor shrinkage and improve resectability. These hypothesis generating findings of reduction in distant metastasis, improved resectability and functional outcome, however need further validation. In summary, the role of neoadjuvant chemotherapy for OSCC remains investigational and has a limited role outside clinical trial.

Locally advanced oral cavity squamous cell carcinoma: Barriers related to effective treatment

BACKGROUND

Oral cavity cancer is a significant health problem in India. Majority of patients present with locally advanced disease requiring multimodality treatment. Compliance to recommended treatment is an important factor affecting outcome.

AIMS

The aim was to evaluate the outcome of locally advanced oral cavity cancer patients with regards to treatment adherence and to assess reasons of noncompliance.

MATERIALS AND METHODS

This was a prospective observational study. We included patients referred to Department of Medical Oncology for induction chemotherapy in view of locally advanced oral cavity cancer.

RESULTS

Only 15 (26%) patients completed planned treatment schedule. Their 1 year overall survival was 93%. The remaining 43 patients who received inadequate treatment had a dismal 21% 1 year overall survival. Illiteracy, poverty, long waiting list for surgery, prolonged delay for health scheme treatment plan approval and dissatisfaction with attitude of hospital staffs are major barriers related to effective treatment of these patients.

CONCLUSIONS

A detailed discussion with patient and their relatives regarding recommended treatment, proper implementation of health schemes, increasing trained manpower to avoid long waiting list for surgery, provision of additional financial support for family member accompanying the patient and a sympathetic approach toward patients are needed to help these patients overcome the battle.

Neoadjuvant chemotherapy followed by surgery in very locally advanced technically unresectable oral cavity cancers

BACKGROUND

The median survival of technically unresectable oral-cavity cancers (T4a and T4b) with non surgical therapy is 2-12 months. We hypothesized that neoadjuvant chemotherapy (NACT) could reduce the tumour size and result in successful resection and ultimately improved outcomes. We present a retrospective analysis of consecutive patients who received NACT at our centre between January 2008 and August 2012.

PATIENTS AND METHODS

All patients with technically unresectable oral cancers were assessed in a multidisciplinary clinic and received 2 cycles of NACT. After 2 cycles, patients were reassessed and planned for either surgery with subsequent CTRT or nonsurgical therapy including CT-RT, RT or palliation. SPSS version 16 was used for analysis of locoregional control and overall survival (OS). Univariate and multivariate analysis was done for factors affecting the OS.

RESULTS

721 patients with stage IV oral-cavity cancer received NACT. 310 patients (43%) had sufficient reduction in tumour size and underwent surgical resection. Of the remaining patients, 167 received chemoradiation, 3 radical radiation and 241 palliative treatment alone The locoregional control rate at 24 months was 20.6% for the overall cohort, 32% in patients undergoing surgery and 15% in patients undergoing non surgical treatment (p=0.0001). The median estimated OS in patients undergoing surgery was 19.6 months (95% CI, 9.59-25.21 months) and 8.16 months (95%, CI 7.57-8.76) in patients treated with non surgical treatment (p=0.0001).

CONCLUSION

In our analysis, NACT led to successful resection and improved overall survival in a significant proportion of technically unresectable oral-cancer patients.

Induction chemotherapy in technically unresectable locally advanced carcinoma of maxillary sinus

Background. Locally advanced carcinoma of maxillary sinus has been historically reported to have poor prognosis. We evaluated the role of NACT in improving the outcome in these patients. Methods. 41 patients with locally advanced technically unresectable (stage IVa) or unresectable maxillary carcinoma (stage IVb) were treated with induction chemotherapy between 2008 and 2011. The demographic profile, response and toxicity of chemotherapy, definitive treatment received, progression free survival (PFS), and overall survival (OS) were analyzed. Univariate and multivariate analysis were performed to determine factors associated with PFS and OS. Results. The chemotherapy included two drugs (platinum and taxane) in 34 patients (82.9%) and three drugs (platinum, taxane, and 5 FU) in 7 (17.1%). There was no complete response seen in any of the patients, stable disease in 18 (43.9%), partial response in 16 (39%), and progression in 7 (17.1%) patients. After induction, the treatment planned included surgery in 12 (29.3%), CT-RT in 24 (58.5%), radical RT in 1 (2.4%), palliative RT in 1 (2.4%), and palliative chemotherapy in 3 (7.3%) patients. Overall, the median PFS was 10.0 months. The OS at 24 months and 36 months was 41% and 35%, respectively. Conclusion. In unresectable maxillary carcinoma, induction chemotherapy has clinically significant benefit with acceptable toxicity.