Outcomes of surgically treated oral cancer patients at a tertiary cancer center in India

When should patients with T1N0 oral squamous cell carcinoma be considered for elective neck dissection?

AIMS

To identify adverse pathological features (APF) predicting nodal failure in clinically node negative T1 oral squamous cell carcinoma (OSCC).

METHODOLOGY

This study evaluated patients with T1N0 (≤5 mm depth of invasion (DOI) and ≤2 cm diameter) oral cancers from a prospectively maintained database between 1988 and 2020. All patients underwent surgical excision of the primary lesion without neck dissection. Patients underwent three monthly clinical surveillance and salvage neck dissection was performed if nodal relapse was diagnosed.

RESULTS

Overall, 141 patients were included. Nodal relapse was reported in 16/141 (11.3%) patients. Factors impacting regional recurrence-free survival were DOI ≥3 mm (HR: 2.4, P < 0.001), maximum tumour diameter ≥12 mm (HR: 1.1, P = 0.009), perineural invasion (PNI) (HR 7.5, P = 0.002) and poor differentiation (HR 5.3, P = 0.01). Rates of nodal relapse increased from 2% amongst patients with no APFs to 100% for those with four APFs. Patients with two or more APFs had significantly poorer 5-year regional recurrence-free survival (94.8% vs. 56.3%, P < 0.001).

CONCLUSION

Patients with T1N0 OSCC with two or more APFs (DOI ≥3 mm, diameter ≥12 mm, PNI or poor differentiations) should be considered for elective neck dissection.

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.

Comparison of postoperative complications in early versus delayed tracheostomy decannulation in patients undergoing oral cancer surgery with microvascular reconstruction

The purpose of this study was to determine the relationship of early and delayed tracheostomy decannulation protocols on the length of stay, time to oral feeding and incidence of postoperative complications in patients undergoing microvascular reconstruction for oral cancer. A review of all patients who underwent surgical management of oral squamous cell carcinoma (OSCC) over the study period from 01/07/2017 to 31/06/2021 was performed. Patients who underwent elective tracheostomy as part of their microvascular reconstruction were included. Two cohorts were identified based on distinct postoperative tracheostomy decannulation protocols; early (Within 7 days) and delayed (≥7 days). Time to oral feeding, length of stay and complication rates was determined for both groups for statistical analysis. A total of 103 patients with OSCC were included in the study. The overall complication rate was 35.9% and were more likely in node positive patients (53.7% vs 23.2%; p = 0.003) and in cases where the geniohyoid muscle complex was disrupted during tumour resection (66.7% vs 31.9%; p = 0.026). Early decannulation was significantly associated with shorter length of hospital stay (10 days vs 15 days) and earlier removal of nasogastric feeding tubes (7 vs 10 days). There was no difference in the overall complication rate between the two groups (33.3% vs 37.5%; p = 0.833). Early decannulation in appropriately selected patients is recommended as it significantly reduces the length of hospital stay and aids in early resumption of oral intake. Furthermore, this approach is not associated with increased rates of complications.

Survival of Dental Implants on Irradiated Jaws: A Systematic Review and Meta-analysis

Objectives

Dental implants play a significant role in functional rehabilitation of the oral cavity after debilitating jaw surgeries for oral cavity cancers followed by radiotherapy.

Design

The meta-analysis was done using Preferred Reporting Items for Systematic Review (PRISMA) guidelines published from January 1947 till August 2020. Twenty three articles consisting of 1246 participants with 4838 implants were included in our analysis.

Results

The mean age of the included participants was 51.4 years. 2186 and 1685 implants were placed on irradiated and non-irradiated jaws and showed a success rate of 82.47% and 89.37% respectively. Correspondingly, publication bias of p value = 0.2129 and p-value = 0.6525 was found by Egger's and Begg's test respectively for pooled data of 16 studies. The implant success rate of 70.4% on maxillary bone and 94.5% were observed on mandibular bone. Timing of implant placement and its influence on survival rate have resulted in a 75.5% survival rate of dental implants when placed primarily in comparison with 87.7% on delayed placement. The waiting interval of 14 months in delayed implant placement has shown better results.

Conclusion

Presence of radiotherapy does not play a significant role in the success rate of dental implants in oral cavity cancers. However, delayed implant placement may have a better chance of survival.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12663-022-01686-6.

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.

Distant metastasis in oral squamous cell carcinoma: Does the neutrophil-to-lymphocyte ratio act as a surrogate of the host immune status?

OBJECTIVES

Distant metastasis (DM) is an important prognostic factor for oral squamous cell carcinoma (OSCC). The aim of this study is to evaluate the influence of host and tumor factors in development of DM.

MATERIALS AND METHODS

After IRB approval, 1369 patients with OSCC undergoing primary surgery were eligible for the study. The primary endpoint was the development of distant metastasis (DM). Patients were pathologically staged according to the American Joint Committee on Cancer, 8th Edition. Pre-operative peripheral blood counts were used to calculate neutrophil-to-lymphocyte ratio (NLR).

RESULTS

Median follow-up was 39 months (range 1-221). DM were identified in 126 patients during follow-up. When analyzed as a time-dependent covariate, neck recurrence (NR) was a significant predictor of DM (HR 16.35, 95% CI: 11.39-23.47, p < 0.001). NLR, margin status, vascular invasion, perineural invasion (PNI), grade, pT, number of metastatic lymph nodes, level IV involvement, and extra nodal-extension (ENE) were also significant. In multivariable analysis, NLR, margins, PNI, number of metastatic lymph nodes, and ENE maintained independent predictive capacity. Patients with NLR ≥ 5.7 were 3 times more likely to develop DM compared to NLR ≤ 2.9 (95% CI: 1.74-5.59, p < 0.001), patients with ≥ 5 metastatic lymph nodes were 2 times more likely to develop DM (95% CI: 1.18-3.60, p = 0.011), and those with ENE were 4 times more likely (95% CI: 2.67-8.20, p < 0.001) when compared to pNx/pN0 patients.

CONCLUSIONS

NLR, number of metastatic lymph nodes, and ENE were the strongest independent predictors of DM in OSCC treated with primary surgery and appropriate adjuvant therapy.

ET-1 Promotes Epithelial-Mesenchymal Transition in Oral Squamous Cell Carcinoma Cells via the microRNA-489-3p /TWIST Axis

OBJECTIVE

Oral squamous cell carcinoma (OSCC) constitutes almost 90% of head and neck malignancies and has a poor prognosis. To improve the efficacy of OSCC therapy, it is of great significance to explore other therapy for OSCC. Endothelin-1 (ET-1), a potent vasoconstrictor peptide, is implicated in cancer pathogenesis. Moreover, ET-1 promotes epithelial-mesenchymal transition (EMT) during the development of human cancers. We further to found that ET-1 exposure induced EMT in human squamous cell carcinoma cell lines SCC4 and SAS, by enhancing the expression of EMT biomarkers N-cadherin and vimentin and reducing E-cadherin expression via upregulation of the transcription factor TWIST.

MATERIALS AND METHODS

Cell motility was examined by migration, invasion and wound-healing assays. Quantitative real time polymerase chain reaction (q-PCR), and promoter assays confirmed the inhibitory effects of ET-1 on miRNAs expression in oral cancer cells. We demonstrate an intravenous injection model of lung metastasis followed by an advanced method for quantifying metastatic tumor using image analysis software.

RESULTS

In addition, ET-1/ETAR reduced levels of microRNA-489-3p (miR-489-3p), a transcriptional repressor of TWIST. We have identified a novel bypass mechanism through which ET-1/ETAR are involved in TWIST signaling and downregulate miR-489-3p expression, enabling OSCC cells to acquire the EMT phenotype. Notably, ET-1 knockdown dramatically decreased levels of EMT markers and cell migration potential.

CONCLUSION

The role of ET-1 in OSCC progression is supported by our findings from an in vivo murine model of OSCC. ET-1 may therefore represent a novel molecular therapeutic target in OSCC metastasis.

Orocutaneous Fistula After Oral Cavity Resection and Reconstruction: Systematic Review and Meta-Analysis

OBJECTIVE

Orocutaneous fistula (OCF) after reconstruction for oral cavity resection can lead to prolonged hospitalization and adjuvant treatment delay. Few studies have examined factors leading to OCF after oral cavity resection. Primary objective: evaluate overall incidence and factors associated with OCF after oral cavity reconstruction.

DATA SOURCES

Scopus 1960-database was searched for terms: "orocutaneous fistula," "oro cutaneous fistula," "oral cutaneous fistula," "orocervical fistula," "oral cavity salivary fistula."

REVIEW METHODS

English language studies with >5 patients undergoing reconstruction after oral cavity cancer resection were included. About 1057 records initially screened; 214 full texts assessed; 78 full-texts included. PRISMA guidelines were followed, and MINORS criteria used to assess risk of bias. Data were pooled using random-effects model. Primary outcome was OCF incidence. Meta-analysis to determine the effect of preoperative radiation on OCF conducted on 12 eligible studies. Pre-collection hypothesis was that prior radiation therapy is associated with increased OCF incidence. Post-collection analyses: free versus pedicled flaps; mandible-sparing versus segmental mandibulectomy.

RESULTS

Seventy-eight studies were included in meta-analysis of overall OCF incidence. Pooled effect size showed overall incidence of OCF to be 7.71% (95% CI, 6.28%-9.13%) among 5400 patients. Meta-analysis of preoperative radiation therapy on OCF showed a pooled odds ratio of 1.68 (95% CI, 0.93-3.06). OCF incidence was similar between patients undergoing free versus pedicled reconstruction, or segmental mandibulectomy versus mandible-sparing resection.

CONCLUSION

Orocutaneous fistula after oral cavity resection has significant incidence and clinical impact. Risk of OCF persists despite advances in reconstructive options; there is a trend toward higher risk after prior radiation.

A prospective study to determine the cost of illness for oral cancer in India

India accounts for almost a third of the global burden of oral cancer, a situation worsened by the inability to afford care. When available, aid is often insufficient, and costing is based on informal estimations. This study objectively determines direct healthcare costs of oral cancer in India. The study was performed from a healthcare provider's perspective using a validated bottom-up method. Care pathways were determined by prospectively observing the natural management of 100 oral cancer patients treated between October 2019 and March 2020. Specific costing categories were built across services, and apportioned values for each interaction was averaged. Costs of treatment and service utilisation were obtained using probabilistic sensitivity analyses. The unit cost of treating advanced stages (United States Dollar (USD) 2,717) was found to be 42% greater than early stages (USD1,568). There was an 11% reduction in unit costs with increases in socioeconomic status. Medical equipment accounted for 97.8% of capital costs, with the highest contributor being imaging services. Variable costs for surgery in advanced stages were 1.4 times higher than early stages. Compared to surgery alone, the average cost of treatment increased by 44.6% with adjuvant therapy. These results show that over the next decade, India will incur an economic burden of USD 3 billion towards the direct healthcare of oral cancer. Early detection and prevention strategies leading to 20% reduction in advanced stage disease could save USD 30 million annually. These results are critical to deliver a disease-driven and objective reform for oral cancer care.

Oral Cancer in the Indian Subcontinent-Survival Outcomes and Risk Factors with Primary Surgery

OBJECTIVE

To assess the oncological outcome and prognostic factors for primary Oral Squamous Cell Cancer (OSCC) staged as per AJCC 8th pTNM, and treated by the contemporary standard of primary surgery and pathology directed adjuvant radiation-chemoradiation.

METHODS

A single institution cohort from a tertiary care academic institution in North India. Case inclusion 2013 to 2016; n = 218, median follow-up 35 months. All patients were restaged as per the AJCC 8th pTNM classification. Analysis for Overall Survival (OS), Disease-free Survival(DFS), and factors impacting outcome (Cox proportionate model Multivariate analysis).

RESULTS

AJCC pTNM 7th to 8th edition conversion led to upstaging in 16.5%. Stage-II demonstrated greatest stage migration and apparent improvement in OS and DFS (P < .09). Discordance was noted between the presurgical (clinico-radiologic) and postsurgical (pathological) nodal status in 40.3% (88/218; 54 pathologically upstaged;34 downstaged). Pathological downstaging was particularly significant with advanced stage Gingivo-Buccal Cancers (25/73-34.7%). Stage-I-II early cancers had 3 years. OS-86.7% and DFS-78.8%; Stage-III-IV advanced cancers had 3 years. OS-56.7% and DFS-46.6%. Multivariate analysis identified poorer OS and DFS for age < 40 years (HR-1.8; 2.0), skin involvement (HR-2.1; 2.6) and pN+ status (HR-2.4; 3.5). Bone involvement did not compromise survival in this surgically treated set of patients.

CONCLUSION

Age < 45 is newly identified as significantly compromising DFS and OS in Oral Cancer. Established factors of skin involvement and pN+ are confirmed as impacting DFS-OS. An apparent improvement in survival in Stage II Cancers is noted as consequent to adoption of AJCC 8th edition staging.

LEVEL OF EVIDENCE

II (OCEBM 2011-Inception Cohort Study for Prognosis) Laryngoscope, 2021.

Making the Best of Limited Resources: Improving Outcomes in Head and Neck Cancer

The overwhelming majority of head and neck cancers and related deaths occur in low- and middle-income countries, which have challenges related to burden of disease versus access to care. Yet the additional health care burden of the COVID-19 pandemic has also impacted access to care for patients with head and neck cancer in the United States. This article focuses on challenges and innovation in prioritizing head and neck cancer care in Sub-Saharan Africa, the Indian experience of value-added head and neck cancer care in busy and densely populated regions, and strategies to optimize the management of head and neck cancer in the United States during the COVID-19 pandemic.

Addressing the contralateral neck for ipsilateral disease recurrence in oral cavity cancers

BACKGROUND

Evidence for performing contralateral neck dissection (CND) of recurrent oral cavity squamous cell cancers (OCSCC) is lacking.

MATERIAL AND METHODS

This is a retrospective study of 78 consecutive OCSCC having ipsilateral recurrence recorded over five years. We screened 1658 OCSCC patients and selected those patients who underwent CND as part of treatment for ipsilateral recurrence.

RESULTS

The median disease-free interval was 32 months. Incidence of contralateral nodal metastasis (CNM) in recurrent OCSCC was 23.1% and of which 14% were occult. The factor significantly influencing CNM was the depth of invasion (DOI) > 10 mm (p < 0.01). In our study, imaging had suboptimal PPV (33%) while it had high NPV (88%) in diagnosing nodal metastasis in recurrent OCSCC.

CONCLUSION

DOI is the most important factor predicting CNM in case of ipsilateral primary recurrence. PET-CECT has a high NPV and contralateral neck should be addressed in case of tumours with higher DOI.

Compartmental Surgery With Microvascular Free Flap Reconstruction in Patients With T1-T4 Squamous Cell Carcinoma of the Tongue: Analysis of Risk Factors, and Prognostic Value of the 8th Edition AJCC TNM Staging System

Compartmental surgery and primary reconstruction with microvascular free flaps represent the gold-standard in the treatment of oral tongue squamous cell carcinoma (OTSCC). However, there are still unclear clinical features that negatively affect the outcomes. This retrospective study included 80 consecutive patients with OTSCC who underwent compartmental surgery and primary reconstruction by free flap. The oncologic outcomes, the reliability of the 8th edition American Joint Committee on Cancer (AJCC) staging system and the prognostic factors were evaluated. Fifty-nine males and 21 females (mean age 57.8 years, range 27-81 years) were treated between November 2010 and March 2018 (one patient had two metachronous primaries). Seventy-one patients (88.75%, 52 males, 19 females, mean age of 57.9 years, range of 27-81 years) had no clinical history of previous head and neck radiotherapy and were considered as naive. Histology showed radical surgery on 80/81 lesions (98.8%), with excision margins >0.5 cm, while in 1 case (1.2%), a close posterior margin was found. According to the 8th AJCC classification, 37 patients (45.7%) were upstaged shifting from the clinical to the pathological stage, and 39 (48.1%) showed an upstaging while shifting from the 7th to the 8th AJCC staging system (no tumors were downstaged). Nodal involvement was confirmed in 33 patients (40.7%). Perineural and lymphovascular invasion were present in 9 (11.1%) and 11 (13.6%) cases, respectively. Twenty-two patients (27.1%) underwent adjuvant therapy. The 5-years disease-specific, overall, overall relapse-free, locoregional relapse-free and distant metastasis-free survival rates were 73.2, 66.8, 62.6, 67.4, and 86%, respectively. Patients with a lymph node ratio >0.09 experienced significantly worse outcomes. Univariate analysis showed that patients with previous radiotherapy, stage IV disease, nodal involvement, and lymphovascular invasion had significantly worse outcomes. Multivariate analysis focused naive patients and showed that lymphovascular invasion, advanced stage of disease, and node involvement resulted reliable prognostic factors, and patients with the same tumor stage and histological risk factors who did not undergo adjuvant therapy experienced significantly worse outcomes. In our series, surgery played a major role in the treatment of local extension; adjuvant therapy resulted strictly indicated in patients with advanced-stage disease associated with risk factors.

Should we wait or not? The preferable option for patients with stage IV oral cancer in COVID-19 pandemic

BACKGROUND

The coronavirus infection is rapidly spreading, putting a strain on health care services across the globe. Patients with oral cancer are susceptible often immunosuppressed due to the disease and/or the treatment received.

METHODS

We performed a simulation of the currently available data using a multistate and hazards model to provide an objective model for counseling and decision making for health care workers.

RESULTS

Stage IV patients with oral cancer who did not receive treatment had progression of disease and an increased mortality rate compared to patients who receive treatment but did not contract COVID-19. The patients who received treatment and got affected with COVID-19 had a far worse impact and higher mortality rate than all other groups.

CONCLUSION

Isolation and deferring treatment for stage IV patients with oral cancer, so as to avoid hospital visits and contraction of COVID-19, is an advisable strategy based on this model.

Management of early oral cavity squamous cancers

Early oral cavity cancers comprise a favorable entity, amenable to clinical staging and single modality treatment. Surgery typically forms the mainstay of treatment and should ideally address both the primary and the neck in all cases. Careful attention must be paid to reconstruction and rehabilitation of such patients. Radical radiotherapy mainly in the form of brachytherapy can achieve excellent disease related and functional outcomes in a carefully chosen subset of patients. Increasingly, a subset of patients is being recognized, who harbor single or multiple adverse features on histopathology and may therefore benefit from escalation of adjuvant therapy. This review discusses the management of early oral cavity squamous carcinomas (Early OSCCs) in detail and highlights the dilemmas and controversies faced in the management of the same.

Factors predisposing to the development of orocutaneous fistula following surgery for oral cancer: Experience from a tertiary cancer center

BACKGROUND

Orocutaneous fistula (OCF) is one of the frequently encountered postoperative complications following surgery for oral cancer, leading to prolonged hospital stay and delay in the initiation of adjuvant therapy.

METHODS

We included all patients with oral cancer operated between January 2016 to December 2017 and at risk to develop an OCF. We assessed the incidence of OCF, its management, and factors predisposing to its development.

RESULTS

Of 587 eligible patients, 9% developed OCF. On univariate and multivariate analysis, patients undergoing bilateral neck dissection or with surgical site infection (SSI) (P < .001) were at maximum risk. On univariate analysis, the incidence was higher following resections for tongue-floor of mouth sub site (P = .002), irrespective of the type of flap used for reconstruction. Majority (57%) required surgical intervention for management.

CONCLUSION

The presence of SSI and performing bilateral neck dissection posed the maximum risk for developing OCF in patients undergoing surgery for oral cancer.

Oral Cavity Cancer in the Indian Subcontinent - Challenges and Opportunities

Oral cavity cancer (OCC) poses a global challenge that plagues both the Orient and the Occident, accounting for an estimated 350 000 new cases and 177 000 deaths in 2018. OCC is a major public health problem in the Indian subcontinent, where it ranks among the top three cancer types in both incidence and mortality. Major risk factors are the use of tobacco, betel quid and alcohol consumption. OCC is a heterogeneous group of multiple histologies that affects multiple subsites. The oral cavity includes the lips, buccal mucosa, teeth, gingiva, anterior two-thirds of the tongue, floor of the mouth and hard palate. OCC is defined as cancer of lips, mouth and tongue as defined by the International Classification of Diseases coding scheme. The epidemiology, aetio-pathogenesis and treatment philosophy are similar within this group. Although salivary gland malignancies, sarcomas, mucosal melanomas and lymphomas can also arise within the oral cavity, this review will focus on squamous cell cancer, which is the predominant histology in OCC. We review and contrast data from developing and developed countries. We also highlight the unique regional challenges that countries in the East face; citing India as an example, we elaborate on the opportunities and scope for improvement in the management of OCC.