Induction chemotherapy in locally advanced T4b oral cavity squamous cell cancers: A regional cancer center experience

Prognostic impact of bridge or neoadjuvant induction chemotherapy in patients with resected oral cavity cancer: A nationwide cohort study

BACKGROUND

While surgery remains the primary treatment for oral squamous cell carcinoma (OCSCC), induction chemotherapy (IC) can be used as a bridging or neoadjuvant therapy. This nationwide study in Taiwan examines the survival outcomes of OCSCC patients who received IC before surgery.

METHODS

We analyzed data from 29,891 patients with OCSCC. Of these, 29,058 initially underwent surgery (OP group), whereas 833 received IC before surgery (IC + OP group). A propensity score (PS)-matched analysis (4, 1 ratio, 3260 vs. 815 patients) was performed considering tumor subsite, sex, age, Charlson comorbidity index, clinical T1-T4b tumors, clinical N0-3 disease, and clinical stage I-IV.

RESULTS

In the PS-matched cohort, the 5-year disease-specific survival (DSS) and overall survival (OS) rates were 65% and 57%, respectively. When comparing the OP and IC + OP groups, the 5-year DSS rates were 66% and 62%, respectively (p = 0.1162). Additionally, the 5-year OS rates were 57% and 56%, respectively (p = 0.9917). No significant intergroup differences in survival were observed for specific subgroups with cT4a tumors, cT4b tumors, cN3 disease, pT4b tumors, and pN3 disease. However, for patients with pT4a tumors, the OP group demonstrated superior 5-year outcomes compared to the IC + OP group, with a DSS of 62% versus 52% (p = 0.0006) and an OS of 53% versus 44% (p = 0.0060). Notably, patients with cT2-3, cN1, and c-Stage II disease in the IC + OP group were significantly more likely to achieve pT0-1 status (p < 0.05).

CONCLUSIONS

Following PS matching, the IC + OP group generally exhibited similar prognosis to the OP group. However, for pT4a tumors, the OP group showed superior 5-year outcomes. While IC may not universally improve survival, it could be advantageous for patients who respond positively to the treatment.

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.

The efficacy of neoadjuvant chemotherapy as compared to upfront surgery for the management of oral squamous cell carcinoma: a systematic review and meta-analysis

The efficacy of neoadjuvant chemotherapy in the field of head and neck oncology has always been debated. The aim of this study was to determine the efficacy of neoadjuvant chemotherapy followed by surgery in patients with oral squamous cell carcinoma (OSCC) by comparison to upfront surgery, in terms of overall survival, disease-free survival, response rates, positive surgical margins, loco-regional recurrence, distant metastasis, and toxicity. Prospective and retrospective studies were identified from a search of the PubMed, PubMed Central, and Cochrane Library databases (publication date between January 1, 1995 and January 1, 2022), as well as hand searches. Three randomized clinical trials and five retrospective studies reporting a total of 1373 patients were retrieved (493 treated with NACT, 880 treated with upfront surgery). All statistical analyses were done using RevMan 5.4. There was no statistically significant difference between the treatment groups for all outcomes (overall survival P = 0.41, disease-free survival P = 0.91, loco-regional recurrence P = 0.12, distant metastasis P = 0.23), except positive margins (P = 0.007); a reduced risk of positive margins was observed for neoadjuvant chemotherapy. The pooled proportion of patients with a complete pathological response (17%) was inadequate to obtain an improvement in survival. The lower margin positivity rate, leading to resectability with clear margins, may be a benefit of neoadjuvant chemotherapy in locally advanced OSCC; however, this treatment failed to provide a benefit in terms of survival and the response rate.

Impact of Positive-Margin Resection of External Auditory Canal Squamous Cell Carcinoma

BACKGROUND

Positive-margin resection of external auditory canal squamous cell carcinoma (EAC-SCC) is still a major cause of recurrence. The aim of this study is to examine the clinical impact of positive-margin resection of EAC-SCCs.

METHODS

We retrospectively reviewed 40 surgical cases with en bloc temporal bone resection of EAC-SCC at a tertiary referral center from October 2016 to March 2022.

RESULTS

Two-year disease-specific, overall, and disease-free survival rates for all 40 cases reviewed were 85.2%, 88.85%, and 76.96%, respectively. En bloc resection with a negative margin significantly improved patient prognosis (p < 0.001). Positive-margin resection was observed in 9/40 cases (22.5%). Insufficient assessment of preoperative images was the cause in two of these cases. Postoperative lymph node metastasis and distant metastasis were observed in cases in which vascular, lymphatic duct or perineural invasion was found on postoperative pathological examination. In addition, three cases in which no vascular, lymphatic duct, or perineural invasion was found exhibited local recurrence during the follow-up period. Of the nine positive-margin resection cases, only two showed no postoperative recurrence.

CONCLUSIONS

Once positive-margin resections are confirmed, cases might have a high risk of tumor recurrence, even with the addition of postoperative adjuvant chemoradiotherapy.

Therapeutic Options in Unresectable Oral Squamous Cell Carcinoma: A Systematic Review

Purpose

This review describes the current scientific evidence of therapeutic options in unresectable oral squamous cell carcinoma.

Methods

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched MEDLINE (Via PubMed) to identify studies assessing treatments for unresectable oral squamous cell carcinoma. The methodological quality assessment of the included studies was performed using the Joanna Briggs Institute (JBI) checklist tool. The evidence was organized and presented using tables and narrative synthesis.

Results

Thirty-three studies met the eligibility criteria. Most studies had an observational design. The sample size varied from 16 to 916 participants. The methodology quality of the included studies ranged from 2.5 to 10 using the JBI tool. Overall, the optimal treatment of patients with unresectable oral cancer is challenging, so there is a sprinkling of studies assessing a variety of therapeutic options, such as radiotherapy, chemotherapy, concurrent chemoradiotherapy, immunotherapy, targeted therapy plus chemotherapy or radiotherapy, and gene therapy plus chemotherapy.

Conclusion

There is lacking evidence about the benefits of some therapeutic options for unresectable oral squamous cell carcinoma. Overall, these patients can be treated using a multimodal approach such as concurrent chemoradiotherapy or induction chemotherapy followed by chemoradiotherapy, which have shown good clinical outcomes. However, other options could be considered depending on the assessment of risk/benefits, tumor extension, and patient values and preferences.

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.

Survival Impact of Surgical Resection in Locally Advanced T4b Oral Squamous Cell Carcinoma

OBJECTIVE/HYPOTHESIS

With non-surgical treatment, T4b oral squamous cell carcinoma (OSCC) have an unacceptably poor prognosis. A subset of patients if selected wisely for surgery, can have significantly improved survival. The present study aims to explore the feasibility of radical resection and neoadjuvant chemotherapy (NACT) in the T4b OSCC and their impact on survival, along with the factors affecting it.

STUDY DESIGN

This is a retrospective analysis of 302 consecutive patients with T4b OSCC presented at our institute between July 2015 and January 2016.

METHODS

Three different treatment protocols were decided depending on the extent of the disease-upfront resection, NACT (followed by surgery or chemo/radiation depending on the response), or upfront non-surgical treatment (chemotherapy and/or radiotherapy).

RESULTS

Upfront surgery was done in 67 (22.19%) patients and 155 (51.32%) patients received NACT. The rest of the patients received upfront non-surgical treatment. The overall response rate of NACT was 23.23% and the resectability rate was 36.13%. The median OS for the whole population was 12 months (30 months for the surgical group and 9 months for the non-surgical group). There was no survival difference between supra versus infra-notch tumors (P value = .552) or post-NACT versus upfront surgery (P value = .932). Nodal involvement was the most important poor prognostic factor affecting both DFS (P = .006) and OS (P = .002).

CONCLUSIONS

With proper patient selection after thorough clinico-radiological assessment, a subset of T4b OSCC can be operated with curative intention; either upfront or after downstaging with NACT, which ultimately translates into improved survival.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2266-E2274, 2021.

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.