Variation of resection margins in oral cancer in dependence of tumor stage and subsite - a retrospective cohort study

OBJECTIVES

Surgical resection is a key component of the treatment of head and neck cancer and the achievement of free surgical margins are essential for the patients' outcome in terms of survival. While there is a general recommendation for a free resection range of 5 mm, up to date, there is a lack of investigations on the quality of tumor resection in dependence of affected subsite and tumor stage. In the presented study, predictors for the achieved resection margins in surgically treated oral squamous cell carcinomas were analyzed.

MATERIALS AND METHODS

A cohort of 567 patients was included in a retrospective analysis and resection status with exact margin ranges were analysed. Tumor stage, affected subsite and the results of the intraoperative frozen section analysis were assessed. Primary endpoint was the achieved resection margin in mm, secondary endpoints were overall and progression-free survival.

RESULTS

The observed mean values of minimal resection margins differed significantly between the investigated subsites (p = 0.042),pathological tumor stages (p < 0.001) and in tumors which demonstrated perineural infiltration (Pn1, p = 0.002). Furthermore, there was a significant impact of the results of the intraoperative frozen section analysis on progression-free and overall survival (p < 0.001).

CONCLUSIONS

Our data clearly indicate that resection status differs between tumors of different subsites and tumor stages.

CLINICAL RELEVANCE

Clinical procedures should be adapted in order to achieve similar certainty in all resections, and, thus to improve patients' outcome.

Second primary squamous cell carcinoma of the oral cavity - a retrospective cohort study of therapeutic procedures and oncological outcome

OBJECTIVES

In the presented study, the occurrence rates of second primary oral carcinomas and their prognostic relevance were analyzed.

MATERIALS AND METHODS

All patients with surgically treated oral squamous cell carcinomas within the years 2010 and 2022 in our department were included in this retrospective cohort study. Two groups were designed including patients with second primary carcinomas and patients with local tumor recurrences. Occurrence rates, tumor stages and applied therapies were assessed. Primary outcome was overall survival in dependence of the index tumor. Secondary outcomes were overall survival in dependence of local recurrences or second primary tumors.

RESULTS

An overall number of 908 patients was included in the analysis. 98 patients (10.8%) developed a second primary oral squamous cell carcinoma. Patients with second primary tumors presented significantly (p < 0.001) better overall survival in dependence of the index tumor compared to patients suffering from local recurrences. There was no significant difference in overall survival (p = 0.4) in dependence of the date of second primary tumor or local recurrence. Patients with second primary tumors were more likely to receive surgery-based therapy compared to patients with local recurrences who more frequently received definitive radiotherapy.

CONCLUSION

Our data indicates different clinical courses in terms of therapy and survival of patients suffering from second primary tumors compared to patients with local tumor recurrences. This may be due to a more aggressive biology of local recurrences and earlier detection of second primaries due to oncological follow-up of the index tumor.

CLINICAL RELEVANCE

The differentiation of local tumor recurrences and second primary tumors is of clinical relevance, as applicable therapies and resulting prognosis may differ significantly.

Peri-implant health after microvascular head and neck reconstruction-A retrospective analysis

INTRODUCTION

Prosthodontic rehabilitation after reconstruction with microvascular revascularized free flaps following ablative tumor surgery is challenging due to the altered anatomical and functional conditions. The aim of this retrospective study was to determine whether the type of graft and the type of peri-implant tissue have an effect on peri-implant inflammatory parameters and implant survival.

MATERIALS AND METHODS

Patients who received a free flap reconstruction with subsequent implant-prosthetic rehabilitation between 2010 and 2022 were retrospectively included. The primary outcome variable was the probing depth (PPD) at a minimum of 1 year after completion of prosthetic restoration. Predictive variables were type of free flap, emergence profile, and history of radiation.

RESULTS

Seventy-one patients after free flap reconstruction were included in the analysis. At a minimum of 24 months after implant insertion the primary outcome, PPD showed no clinically relevant differences between the types of free flaps used. The emergence profile through a skin island resulted in an increase in BOP compared to native mucosa in the descriptive analysis (p-value > .05). The analysis showed a 5-year implant survival of 96.2% (95% CI: 0.929-0.996) in cases without irradiation and 87.6% (95% CI: 0.810-0.948) with irradiation of the region evaluated (p-value .034).

CONCLUSION

Flap and associated soft tissue type had no significant effect on 5-year implant survival or peri-implant inflammatory parameters. However, the large heterogeneity of the patient population indicates that further prolonged studies are required for a more differentiated assessment of the long-term success.

HLA-E and Its Soluble Form as Indicators of a Sex-Specific Immune Response in Patients with Oral Squamous Cell Carcinoma

The human leukocyte antigene E (HLA-E) is associated with tumorigenesis in various cancers. Immunoncology along with sex-specific aspects in cancer therapy are now in scientific focus. Therefore, immunohistochemical HLA-E expression was retrospectively analysed in a cohort of oral squamous cell carcinomas (OSCC) after surgical therapy. Then, serum concentration of HLA-E (sHLA-E) was quantified in a prospective cohort by enzyme-linked immunosorbent assay. High HLA-E expression was associated with advanced UICC stage (Spearman's correlation: p = 0.002) and worse survival (Cox-regression: progression-free survival: hazard ratio (HR) 3.129, confidence range (CI) 1.443-6.787, p = 0.004; overall survival: HR 2.328, CI 1.071-5.060, p = 0.033). The sHLA-E concentration was significantly higher in the control group than in tumor group (Mann-Whitney U-test (MW-U): p = 0.021). Within the tumor group, women showed significantly higher sHLA-E levels than men (MW-U: p = 0.049). A closer look at the tumor group and the control group showed that gender-specific differences exist: while no differences in sHLA-E concentration were detectable between female subjects of tumor group and control group (MW-U: p = 0.916), male subjects of tumor group had a significantly lower sHLA-E concentration compared to those of control group (MW-U: p = 0.001). In summary, our results provide evidence for sex-specific differences in immune responses in OSCC. This fact should be considered regarding future immunotherapy regimens.

Dynamic Up-Regulation of PD-L1 in the Progression of Oral Squamous Cell Carcinoma

The introduction of immune checkpoint inhibition for recurrent and metastatic head and neck cancer has brought a new treatment option for patients suffering from advanced oral cancers without a chance for curation using surgery or radiotherapy. The application of immune checkpoint inhibitors in most cases is based on the expression levels of PD-L1 in the tumor tissue. To date, there is a lack of data on the dynamic regulation of PD-L1 during disease progression. Therefore, this study aimed to evaluate the expression levels of PD-L1 in a large cohort of patients (n = 222) with oral squamous cell carcinoma including primary and recurrent tumors. Semiautomatic digital pathology scoring was used for the assessment of PD-L1 expression levels in primary and recurrent oral squamous cell carcinoma. Survival analysis was performed to evaluate the prognostic significance of the protein expression at different stages of the disease. We found a significant up-regulation of PD-L1 expression from primary disease to recurrent tumors (mean PD-L1 H-scores: primary tumors: 47.1 ± 31.4; recurrent tumors: 103.5 ± 62.8, p < 0.001). In several cases, a shift from low PD-L1 expression in primary tumors to high PD-L1 expression in recurrent tumors was identified. Multivariate Cox regression analysis did not reveal a significantly higher risk of death (p = 0.078) or recurrence (p = 0.926) in patients with higher PD-L1 expression. Our findings indicate that the exclusive analysis of primary tumor tissue prior to the application of checkpoint blockade may lead to the misjudgment of PD-L1 expression in recurrent tumors.

Impact of Salvage Surgery on Health-Related Quality of Life in Oral Squamous Cell Carcinoma: A Prospective Multi-Center Study

BACKGROUND

Patients with recurrent oral squamous cell carcinoma (OSCC) have limited treatment options. Salvage surgery offers potential curative therapy. The need for extensive ablative surgery together with microvascular reconstruction implies invasive and painful treatment with questionable functional outcome. To address the impact of salvage surgery on the health-related quality of life (HRQoL) of patients suffering from recurrent OSCC, a multi-center prospective analysis was initiated.

MATERIAL AND METHODS

Patients with recurrent OSCC from 2015 to 2022 at two German cancer centers were included. Interdisciplinary tumor board decisions determined surgery as the only curative treatment modality. HRQoL, was assessed via a EORTC questionnaire (European Organization for Research and Treatment of Cancer-EORTC: QLQ-C30 and QLQ-H&N35) in dependence of the recurrent tumor stage. Patients completed the questionnaires once before surgery (baseline) and then every 3 months during follow-up or up to the end of treatment.

RESULTS

In total, 55 patients were included. The mean follow-up period was 26.7 ± 19.3 months. Global health status showed superior mean scores after 12 months (60.83 ± 22.58) compared to baseline (53.33 ± 26.41) in stage 1 and 2 recurrent tumors. In advanced recurrent tumors' mean scores for global health showed only minor positive differences after 12 months (55.13 ± 22.7) compared to baseline (53.2 ± 25.58). In terms of the mouth pain, mean scores were lower after salvage surgery in small recurrent tumors after 12 months (20.37 ± 17.73) compared to baseline (41.67 ± 33.07; Wilcoxon two-sample signed-rank test p = 0.028). In advanced recurrent tumors, a significant reduction in mean scores was detected 3 months after salvage surgery (29.7 ± 22.94) compared to baseline (47.76 ± 25.77; Wilcoxon two-sample signed-rank test p = 0.003). Up to 12 months, swallowing function was evaluated inferior compared to baseline independent of tumor stage (Mean score recurrent stage I/II: 12-months 48.15 ± 27.57, baseline 28.7 ± 22.87; stage III/IV: 12-months 49.36.42 ± 27.53; baseline 30.13 ± 26.25).

CONCLUSION

Improved HRQoL could be obtained in advanced recurrent OSCC after salvage surgery despite reduced swallowing function. In small recurrent tumors, overall, HRQoL was superior to baseline. Salvage surgery positively affected pain burden. For advanced recurrent tumors, important pain relieve could be observed as soon as 3 months after surgery.

Comparison of Antero-Lateral Thigh Flap and Vastus Lateralis Muscle Flap for the Treatment of Extensive Scalp Defects-A Retrospective Cohort Study

Free flap reconstruction is the standard of care for extensive defects of the head and neck area. In this study, two types of free flaps, the antero-lateral thigh flap (ALT) and the vastus lateralis muscle flap, were compared. The primary endpoint was flap success, secondary endpoints were complication rates, hospitalization and surgery time. Cases with defect situations of the scalp and consecutive microvascular free flap reconstructions using either ALT flaps or vastus lateralis muscle flaps between 2014 and 2022 were retrospectively analyzed. Indications, perioperative handling and outcomes were compared. Twenty patients were included in the analysis. Ten patients (50%) received a free flap reconstruction using an ALT flap and ten patients (50%) received a vastus lateralis flap. A simultaneous two-team approach was possible in each case and the flap success rate was 100% with the need for one successful anastomosis revision. The mean defect size in our cohort was 147 ± 46 cm2. There were no significant differences in surgery time, duration of hospitalization or complication rate between both cohorts. Both free flaps, the ALT and the vastus lateralis flap, are suitable for the closure of large scalp defects. They provide high success rates, short surgery times without the need for patient repositioning and low donor-site morbidity. The vastus lateralis muscle flap bares the advantage of being perforator-independent and allows for the preparation of long vessels for anastomosis if needed while baring the disadvantage of a prolonged period of healing via granulation or the need for secondary surgery in terms of covering by split-thickness skin grafts which may interfere with necessary adjuvant treatment in oncological patients.

Surgical Treatment of Carcinomas of the Oral Minor Salivary Glands-Oncological Outcome in Dependence of Tumor Entity and Therapeutic Strategies

The aim of this study was to analyze the clinical outcomes of three types of minor salivary gland carcinomas (adenoid-cystic carcinomas (ACC), adeno carcinomas not otherwise specified (AC-NOS), and mucoepidermoid carcinomas (MEC)) after primary surgical therapy. A retrospective cohort study was designed and patients with cancer of the minor oral salivary glands treated in our department in the years 2011 to 2022 were included. Clinicopathological data were evaluated to compare overall survival and progression-free survival between the entities. Eighty-one patients were included. The rates of cervical metastases were 38.9% for ACC, 25% for MEC, and 9.1% for AC-NOS. ACC exhibited significantly higher rates of local and systemic disease recurrence (p = 0.02), and the presence of neck node metastases was confirmed as an independent prognostic factor for progression-free survival (p = 0.014). Treatment success in terms of oncological outcome varied significantly between the different entities and implies different treatment regimens for each tumor entity.

Free-Flap Reconstruction in Early-Stage Squamous Cell Carcinoma of the Oral Cavity-A Prospective Monocentric Trial to Evaluate Oncological Outcome and Quality of Life

Surgery is generally accepted as standard treatment in oral cancer, but the reconstructive procedures remain a matter of debate. The aim of this study was to evaluate oncological outcome and quality of life following surgical resection and free-flap reconstruction in patients with early oral squamous cell carcinoma. The presented trial was performed as a prospective, single-center observation study. Inclusion criteria were primary surgery in early-stage oral squamous cell carcinoma with free-flap reconstruction. Endpoints were overall and progression-free survival and quality of life up to 24 months after surgery. Twenty-six patients were included. Overall survival was 100% and progression-free survival was 92.3% in a maximum follow-up time of 21 months. Global quality of life showed no significant alteration after surgery. Patients reported a significant reduction in pain (p = 0.048) and a decreasing impairment of speech one year after surgery (p = 0.021). Free-flap reconstruction is a safe procedure that results in excellent oncological outcome and quality of life. Functional outcome is of high relevance in early-stage tumors of the head and neck and may mostly be affected by reconstructive procedures. Therefore, a prospective evaluation to explore success and the effects of surgical therapy is highly warranted.

Comparison of Different Antibiotic Regimes for Preventive Tooth Extractions in Patients with Antiresorptive Intake-A Retrospective Cohort Study

In the present study, the impacts on success rates between three different antibiotic regimes in patients receiving preventive tooth extraction during/after antiresorptive treatment were compared. For the retrospective analysis, we enrolled patients who had undergone tooth extraction from 2009 to 2019 according to the specified preventive conditions under antiresorptive therapy. Three antibiotic regimens were distinguished: (Group 1) intravenous for 7 days, (Group 2) oral for 14 days, and (Group 3) oral for 7 days of application. The primary endpoint was the occurrence of medication-related osteonecrosis of the jaw at 12 weeks after surgery. A total of 760 patients and 1143 extraction regions were evaluated (Group 1 n = 719; Group 2 n = 126; Group 3 n = 298). The primary endpoint showed no significant difference in the development of medication-related osteonecrosis of the jaw between the groups studied (Group 1 n = 50/669 (7%); Group 2 n = 9/117 (7%); Group 3 n = 17/281 (6%); p = 0.746). Overall, the success rate was 93% after intervention when preventive measures were followed. With the same success rate, a reduced, oral administration of antibiotics seems to be sufficient regarding the possible spectrum of side effects, the development of resistance and the health economic point of view.

Oral Sequelae after Head and Neck Radiotherapy: RCT Comparing 3D-Printed Tissue Retraction Devices with Conventional Dental Splints

OBJECTIVES

To evaluate oral sequelae after head and neck radiotherapy (RT) when using two different types of intraoral appliances. Thermoplastic dental splints (active control) protect against backscattered radiation from dental structures. Semi-individualized, 3D-printed tissue retraction devices (TRDs, study group) additionally spare healthy tissue from irradiation.

MATERIALS AND METHODS

A total of 29 patients with head and neck cancer were enrolled in a randomized controlled pilot trial and allocated to receive TRDs (n = 15) or conventional splints (n = 14). Saliva quality and quantity (Saliva-Check, GC), taste perception (Taste strips, Burghart-Messtechnik), and oral disability (JFLS-8, OHIP-14, maximum mouth opening) were recorded before and 3 months after RT start. Radiotherapy target volume, modality, total dose, fractionation, and imaging guidance were case-dependent. To evaluate intra-group developments between baseline and follow-up, nonparametric Wilcoxon tests were performed. Mann-Whitney-U tests were applied for inter-group comparisons.

RESULTS

At follow-up, taste perception was unimpaired (median difference in the total score; TRDs: 0, control: 0). No significant changes were found regarding oral disability. Saliva quantity (stimulated flow) was significantly reduced with conventional splints (median -4 mL, p = 0.016), while it decreased insignificantly with TRDs (median -2 mL, p = 0.07). Follow-up was attended by 9/15 study group participants (control 13/14). Inter-group comparisons showed no significant differences but a tendency towards a better outcome for disability and saliva quality in the intervention group.

CONCLUSION

Due to the small cohort size and the heterogeneity of the sample, the results must be interpreted with reservation. Further research must confirm the positive trends of TRD application. Negative side-effects of TRD application seem improbable.

Diagnostic accuracy comparing OPT and CBCT in the detection of non-vital bone changes before tooth extractions in patients with antiresorptive intake

OBJECTIVES

To compare the diagnostic accuracy in detecting early non-vital bone changes between orthopantomography (OPT) and cone-beam computed tomography (CBCT) in correlation with histopathological findings before tooth extractions in patients with antiresorptive (AR) intake.

SUBJECTS

Patients with an indication tooth extraction who had received OPT and CBCT preoperatively while or after undergoing AR treatment were prospectively enrolled over a 24-month period in the progesterone in spontaneous miscarriage (PRISM) trial. Imaging studies were randomly analyzed by three examiners for early non-vital bone changes using specific predefined characteristics and a 5-level scale (1 definite absence of criteria to 5 definite presence of criteria). Sensitivity and specificity values were calculated in correlation with the histopathologically evaluated bone samples at the time point of tooth extraction.

RESULTS

One hundred thirty patients with 237 treated extraction sites met the inclusion criteria. For all images evaluated by all examiners, CBCT (430/492; 87.4%; receiver operating characteristic [ROC]: area under the curve [AUC] = 0.88; p < 0.001) was more likely to detect histopathologically confirmed non-vital bone than the OPT (132/492; 26.8%; ROC: AUC = 0.562; p = 0.115).

CONCLUSIONS

In the detection of non-vital bone changes, CBCT is superior to OPT in both sensitivity and specificity. Specific imaging characteristics allow for the prediction of early non-vital bone changes already at the time before tooth extractions.

The value of prebent reconstruction plates and in-house 3D printing

INTRODUCTION

Reconstruction plates, prebent on 3D printed models, are a cheap, quick, and safe solution to improve mandibular reconstruction procedures. The European Medical Device Regulation has changed recently and severely affects 3D printing in hospitals. Therefore, its legitimation must be discussed. This retrospective observational Case-Control Study aimed to evaluate the impact of prebent reconstruction plates on the condylar position in the temporomandibular joint after continuity resection of the mandible in oncological cases.

MATERIALS AND METHODS

We included patients who underwent segmental mandibular resection without exarticulation of the condyle or history of prior surgery. The patients were divided into groups with prebent plates on a stereolithographic model and intraoperatively bent reconstruction plates. The segmental defects were categorized using the Jewer Classification. Computed Tomography (CT) scans before and after surgery were analyzed using a standardized method to measure the metric movement of the condyles, as well as their angulation to reference planes to quantify positional changes (primary outcome measures). The influence of the defect location, according to the Jewer classification, was evaluated as a secondary outcome measure.

RESULTS

73 patients, including 33 with preformed reconstruction plates, were included. We could show significantly fewer rotational deviations in cases of prefabricated osteosynthesis in the coronal plane (p<0,001) and in the sagittal plane (p<0,027).

DISCUSSION

Using preformed reconstruction plates on 3D printed models improves the correct anatomical position of the condyle after mandibular resection. Especially Jewer-class-L defects seem to benefit from individualized reconstruction plates.

TREM2 Is Associated with Advanced Stages and Inferior Prognosis in Oral Squamous Cell Carcinoma

Triggering receptor expressed on myeloid cells 2 (TREM2) is suggested to hamper antitumor immune response in multiple cancers. However, the role of TREM2 in oral squamous cell carcinoma (OSCC) and its expression in tumor-associated macrophages (TAMs) are unknown. In this study, TREM2 expression was analyzed in the primary tumors and corresponding lymph-node metastases of OSCC patients via immunohistochemistry on tissue microarrays. Human peripheral blood mononuclear cells (PBMCs) and single-cell suspensions of tumor and healthy adjacent tissues were analyzed for the presence of TREM2+ macrophages and TAMs using flow cytometry. The serum levels of soluble TREM2 (sTREM2) were quantified using an enzyme-linked immunosorbent assay. High TREM2 expression was associated with advanced UICC stages (Spearman’s rank correlation (SRC), p = 0.04) and significantly reduced survival rates in primary tumors (multivariate Cox regression, progression-free survival: hazard ratio (HR) of 2.548, 95% confidence interval (CI) of 1.089−5.964, p = 0.028; overall survival: HR of 2.17, 95% CI of 1.021−4.613, p = 0.044). TREM2 expression was significantly increased in the PBMCs of OSCC patients in UICC stage IV compared with healthy controls (ANOVA, p < 0.05). The serum levels of sTREM2 were higher in advanced UICC stages, but they narrowly missed significance (SRC, p = 0.059). We demonstrated that TREM2 was multi-factorially associated with advanced stages and inferior prognosis in OSCC patients and that it could serve as a prognostic biomarker in OSCC patients. Targeting TREM2 has the potential to reshape the local and systemic immune landscape for the potential enhancement of patients’ prognosis.

IDO1 is highly expressed in macrophages of patients in advanced tumour stages of oral squamous cell carcinoma

PURPOSE

Strategies for Indolamine-2,3-dioxygenase 1 (IDO1) inhibition in cancer immunotherapy once produced encouraging results, but failed in clinical trials. Recent evidence indicates that immune cells in the tumour microenvironment, especially macrophages, contribute to immune dysregulation and therefore might play a critical role in drug resistance.

METHODS

In this study, we investigated the significance of IDO1 expressing immune cells in primary tumours and corresponding lymph node metastases (LNMs) in oral squamous cell carcinoma (OSCC) by immunohistochemistry. The link between IDO1 and macrophages was investigated by flow cytometry in tumour tissue, healthy adjacent tissue and peripheral blood mononuclear cells (PBMCs). IDO1 activity (measured as Kynurenine/Tryptophan ratio) was assessed by ELISAs.

RESULTS

High IDO1 expression in tumour-infiltrating immune cells was significantly correlated with advanced stages [Spearman's rank correlation (SRC), p = 0.027] and reduced progression-free survival (multivariate Cox regression, p = 0.034). IDO1 was significantly higher expressed in PBMCs of patients in advanced stages than in healthy controls (ANOVA, p < 0.05) and IDO1⁺ macrophages were more abundant in intratumoural areas than peritumoural (t test, p < 0.001). IDO1 expression in PBMCs was significantly correlated with IDO1 activity in serum (SRC, p < 0.05). IDO1 activity was significantly higher in patients with LNMs (t test, p < 0.01).

CONCLUSION

All in all, IDO1 expressing immune cells, especially macrophages, are more abundant in advanced stages of OSCC and are associated with reduced progression-free survival. Further investigations are needed to explore their role in local and systemic immune response. The IDO1 activity might be a suitable biomarker of metastasis in OSCC patients.

Frequency of osteoradionecrosis of the lower jaw after radiotherapy of oral cancer patients correlated with dosimetric parameters and other risk factors

Objectives

Osteoradionecrosis (ORN) of the lower jaw is a serious late complication after radiotherapy in patients with oral cavity cancer. The aim of this study is to generate more insight into which patient- and treatment-related factors are associated with the development of ORN in oral cavity cancer patients undergoing postoperative radiotherapy.

Material and methods

Retrospective evaluation and comparison of 44 patients with ORN (event group 1) matched according to 45 patients without ORN (control group 2) who received postoperative radiotherapy of oral cavity squamous cell carcinoma at our institution between 2012 and 2020. Dosimetric factors that favor the occurrence of ORN should be detected. The cumulative occurrence rate of ORN was calculated according to the Kaplan–Meier method and analyzed by Cox regression and log-rank test.

Results

The median time to develop ORN was 18 months (3–93 months) after radiotherapy. Dental status before radiotherapy (RT) treatment (HR 4.5; 1.8–11.5) and dosimetric parameters including Dmean > 45 Gy (HR 2.4; 1.0–5.7), Dmax > 60 Gy (HR 1.3; 1.1–2.8) and planning target volume (PTV) proportion > 40% intersection with the lower jaw (HR 1.1; 1.0–1.1) were significantly associated with ORN.

Conclusion

The results of this retrospective study reveal that oral cavity cancer patients who underwent pre-RT dental surgery as well as dosimetric parameters using Dmax > 60 Gy, higher mean doses > 45 Gy and more than 40% PTV intersection with the lower jaw bone are independent risk factors for ORN. These findings can assist in the management of patients undergoing RT for head and neck cancer regarding ORN prevention.

Clinical relevance

Poor oral hygiene and desolate dental status as well as high radiation doses to the mandibular bone significantly increase the risk of developing osteoradionecrosis. Before irradiating a patient with oral cavity cancer, an appointment with the dentist should be made and teeth sanitized if necessary. Likewise, maximum radiation doses to the lower jaw should be minimized.

Screening and Psycho-Oncological Support for Patients With Head and Neck Cancer and Brain Malignancies Before Radiotherapy With Mask Fixation: Results of a Feasibility Study

This single-center, single-arm trial investigates the feasibility of a psycho-oncological care program, which aims to reduce psychological distress and improve compliance with radiotherapy with mask fixation in patients with head and neck cancer or brain malignancies. The care program comprised (1) a screening/needs assessment and (2) the provision of a psycho-oncological intervention using imaginative stabilization techniques for distressed patients (distress due to anxiety ≥5) or in a case of subjective interest in the psycho-oncological intervention. Another allocation path to the intervention was directly through the radiation oncologist in charge who classified the patient as: in need of support to tolerate the immobilization device. Of a total of 1,020 screened patients, 257 (25.2%) patients indicated a distress ≥5 and 141 (13.8%) patients reported panic attacks. 25% of the patients reported a subjective interest in psycho-oncological support. A total of 35 patients received the psycho-oncological intervention, of which 74% were assigned by radiation oncologists. In this small patient cohort, no significant pre-post effects in terms of depression, anxiety, distress, and quality of life (mental and physical component scores) could be detected. Our results indicate a good feasibility (interdisciplinary workflow and cooperation, allocation by physicians in charge) of the psycho-oncological care program for this cohort of patients before radiotherapy with mask fixation. The screening results underline the high psychological distress and demand for psycho-oncological support. However, since the utilization of our intervention was low, future studies should reduce the barriers and improve compliance to psycho-oncological services by these patients.Clinical Trial Registration: https://www.drks.de/drks_web/setLocale_EN.do #DRKS00013493

Treatment delay and tumor size in patients with oral cancer during the first year of the COVID-19 pandemic

Background

We set out to investigate how the ongoing coronavirus pandemic affected the size of tumors and the duration of treatment delay in patients with surgically treated oral squamous cell carcinoma.

Methods

Patients with surgically treated oral cavity squamous cell carcinoma were assessed retrospectively and divided into two groups depending on when they had first presented at our clinic. Patients presenting from 2010 to 2019, that is, before COVID‐19 onset (n = 566) were compared to patients presenting in 2020 (n = 58).

Results

A total of 624 patients were included. Treatment delay was significantly longer in 2020 (median = 45 days) versus 2010–2019 (median = 35 days) (p = 0.004). We observed a higher pathological T classification in 2020 (p = 0.046), whereas pathological N classification was unchanged between groups (p = 0.843).

Conclusions

While extraordinary efforts continue to be made in the context of the pandemic, it is imperative that this does not lead to significant disadvantages for many people with oral cancer.

Digital Pathology Scoring of Immunohistochemical Staining Reliably Identifies Prognostic Markers and Anatomical Associations in a Large Cohort of Oral Cancers

Utilizing digital pathology algorithms for the objective quantification of immunohistochemical staining, this study aimed to identify robust prognostic biomarkers for oral cancer. Tissue microarrays with specimens of a large cohort of oral squamous cell carcinoma (n=222) were immunohistochemically stained to determine the expression of PD-L1, EGFR, and COX-2 and the amount of infiltrating NK cells and CD8-positive T cells. Immunoreactivity scores were assessed using both a classical manual scoring procedure and a digital semi-automatic approach using QuPath. Digital scoring was successful in quantifying the expression levels of different prognostic biomarkers (CD8: p<0.001; NK cells: p=0.002, PD-L1: p=0.026) and high levels of concordance with manual scoring results were observed. A combined score integrating EGFR expression, neck node status and immune cell signatures with a significant impact on overall and progression-free survival was identified (p<0.001). These data may contribute to the ongoing research on the identification of reliable and clinically relevant biomarkers for the individualization of primary and adjuvant treatment in oral cancer.

EGFR and PI3K Pathway Activities Might Guide Drug Repurposing in HPV-Negative Head and Neck Cancers

While genetic alterations in Epidermal growth factor receptor (EGFR) and PI3K are common in head and neck squamous cell carcinomas (HNSCC), their impact on oncogenic signaling and cancer drug sensitivities remains elusive. To determine their consequences on the transcriptional network, pathway activities of EGFR, PI3K, and 12 additional oncogenic pathways were inferred in 498 HNSCC samples of The Cancer Genome Atlas using PROGENy. More than half of HPV-negative HNSCC showed a pathway activation in EGFR or PI3K. An amplification in EGFR and a mutation in PI3KCA resulted in a significantly higher activity of the respective pathway (p = 0.017 and p = 0.007). Interestingly, both pathway activations could only be explained by genetic alterations in less than 25% of cases indicating additional molecular events involved in the downstream signaling. Suitable in vitro pathway models could be identified in a published drug screen of 45 HPV-negative HNSCC cell lines. An active EGFR pathway was predictive for the response to the PI3K inhibitor buparlisib (p = 6.36E-03) and an inactive EGFR and PI3K pathway was associated with efficacy of the B-cell lymphoma (BCL) inhibitor navitoclax (p = 9.26E-03). In addition, an inactive PI3K pathway correlated with a response to multiple Histone deacetylase inhibitor (HDAC) inhibitors. These findings require validation in preclinical models and clinical studies.

A critical assessment of the medication-related osteonecrosis of the jaw classification in stage I patients: a retrospective analysis

Objectives

It is unclear whether the extent of intraoral mucosa defects in patients with medication-related osteonecrosis of the jaw indicates disease severity. Therefore, this study investigated whether mucosal lesions correlate with the true extent of osseous defects in stage I patients.

Materials and Methods

Retrospectively, all patients with stage I medication-related osteonecrosis of the jaw who underwent surgical treatment between April 2018 and April 2019 were enrolled. Preoperatively, the extent of their mucosal lesions was measured in clinical evaluations, and patients were assigned to either the visible or the probeable bone group. Intraoperatively, the extent of necrosis was measured manually and with fluorescence.

Results

Fifty-five patients (36 female, 19 male) with 86 lesions (46 visible bone, 40 probeable bone) were enrolled. Intraoperatively, the necrotic lesions were significantly larger (P<0.001) than the preoperative mucosal lesions in both groups. A significant (P<0.05) but very weak (R2<0.2) relationship was noted between the extent of the mucosal lesions and the necrotic bone area.

Conclusion

Preoperative mucosal defects (visible or probeable) in patients with medication-related osteonecrosis of the jaw do not indicate the extent of bone necrosis or disease severity.

Full-Thickness Tumor Resection of Oral Cancer Involving the Facial Skin-Microsurgical Reconstruction of Extensive Defects after Radical Treatment of Advanced Squamous Cell Carcinoma

Simple Summary

Advanced malignant tumors of the oral cavity are challenging because they impose serious oncological and functional requirements on the treatment specialist. Depending on the localization and the extent of the primary tumor, a full-thickness resection affecting the facial skin may be necessary to achieve a complete tumor resection. The resulting defects need adequate reconstruction in order to restore the aesthetics and functionality of the orofacial system. In this retrospective analysis, the authors aimed to evaluate treatment techniques for these tumors and analyze the clinical outcome of the related procedures. Full-thickness tumor resection with free flap reconstruction due to advanced cancer was performed in 33 patients.

Abstract

Advanced tumors of the head and neck are challenging for the treatment specialist due to the need to synergize oncological and functional requirements. Free flap reconstruction has been established as the standard of care for defects following tumor resection. However, depending on the affected anatomic subsite, advanced tumors may impose specific difficulties regarding reconstruction, especially when full-thickness resection is required. This study aimed to evaluate reconstructive strategies and oncological outcomes in patients with full-thickness resection of the oral cavity. A total of 33 patients with extensive defects due to squamous cell carcinoma of the oral cavity were identified. Indications, reconstructive procedures, and clinical outcome were evaluated. Thirty-two patients (97%) presented locally advanced tumors (T3/T4). Complete tumor resection was achieved in 26 patients (78.8%). The anterolateral thigh flap was the most frequently used flap (47.1%), and the primary flap success rate was 84.8%. The cohort demonstrated a good local control rate and moderate overall and progression-free survival rates. Most patients regained full competence regarding oral alimentation and speech. Full-thickness tumor resections of the head and neck area may be necessary due to advanced tumors in critical anatomic areas. In many cases, radical surgical treatment leads to good oncological results. Free flap reconstruction has been shown to be a suitable option for extensive defects in aesthetically challenging regions.

Neuralgia-inducing cavitational osteonecrosis - A systematic review

OBJECTIVE

To assess the aetiologic factors, proposed diagnostic means and treatment strategies for neuralgia-inducing cavitational osteonecrosis.

METHODS

A search of the literature published up to June 2020 was conducted using Medline, the Cochrane Library, PsycINFO, CINAHL and Web of Science. The scientific quality of the evidence was rated according to NIH Quality Assessment Tools.

RESULTS

4,051 articles were found, 59 were reviewed in full text, and 29 studies were included. With the exception of hereditary coagulopathies, which were identified as potential risk factors in five studies, suggestions concerning the aetiology varied widely. No gold standard diagnostic mean could be identified. Treatment was most often performed by surgical curettage of the affected bone. Surgical treatment outcomes were equally varied: significant facial pain remission was reported in 66%-100% for periods varying between 2 months to 18 years, whereas no or little relief and recurrences were reported in up to ⅓ of cases. All studies were observational in their design. All investigations were rated as poor quality because of high risk of bias and non-transparent reporting.

CONCLUSIONS

Evidence concerning the aetiology, diagnosis and treatment of NICO is poor. Prospective diagnostic and therapeutic studies are needed before the usefulness of invasive therapeutic procedures can be evaluated.

Metrics of pN-staging in oral squamous cell carcinoma: An analysis of 1,905 patients

BACKGROUND

We aimed to compare the predictive performance of pN-categories in oral squamous cell carcinoma (OSCC) encompassing the most recent 8th edition (TNM8), its predecessor (TNM7), and a newly proposed algorithm (pN-N⁺), which classifies patients according to the number of positive lymph nodes and extranodal extension.

METHODS

Consecutive, primary OSCC patients from seven previously published cohorts were included and classified according to the three pN-classifications: TNM7, TNM8 and pN-N⁺. Overall survival probabilities were summarised with the Kaplan-Meier method. We added each of the three metrics to a Cox regression adjusted for pT-category, lymph nodal yield, age, sex, radiotherapy and chemotherapy, and trained these models in one institution. We evaluated the predictive performance in the remaining six institutions and assessed the predicted 5-year risk of death using the area under the receiver operating characteristics curve (AUC) and Brier scores.

RESULTS

All 1,905 included patients were classified according to TNM7 and pN-N⁺. A subset of 1,575 patients was additionally classified according to TNM8, leading to upstaging in 27.0%. The pN-N⁺ ranked overall best determined by the obtained AUC and Brier scores. In contrast to pN-N⁺, TNM7 and TNM8 both suffered from disproportionate patient distribution across pN-categories and poor pN-categorial discrimination on overall survival.

CONCLUSIONS

The TNM8 pN-classification designates a larger subset to more advanced disease stages but failed to show improvement of its predictive performance compared to TNM7. The pN-categories of TNM7/8 are disproportionate and inconsistently discriminated. The pN-N⁺ conveyed the best measures of prognosis and should be considered in future TNM iterations.

3D-printed individualized tooth-borne tissue retraction devices compared to conventional dental splints for head and neck cancer radiotherapy: a randomized controlled trial

BACKGROUND

Despite modern treatment techniques, radiotherapy (RT) in patients with head and neck cancer (HNC) may be associated with high rates of acute and late treatment-related toxicity. The most effective approach to reduce sequelae after RT is to avoid as best as possible healthy tissues and organs at risk from the radiation target volume. Even small geometric changes can lead to a significant dose reduction in normal tissue and better treatment tolerability. The major objective of the current study is to investigate 3D printed, tooth-borne tissue retraction devices (TRDs) compared to conventional dental splints for head and neck RT.

METHODS

In the current two-arm randomized controlled phase II trial, a maximum of 34 patients with HNC will be enrolled. Patients will receive either TRDs or conventional dental splints (randomization ratio 1:1) for the RT. The definition of the target volume, modality, total dose, fractionation, and imaging guidance is not study-specific. The primary endpoint of the study is the rate of acute radiation-induced oral mucositis after RT. The quality of life, local control and overall survival 12 months after RT are the secondary endpoints. Also, patient-reported outcomes and dental status, as well as RT plan comparisons and robustness analyzes, will be assessed as exploratory endpoints. Finally, mesenchymal stem cells, derived from the patients' gingiva, will be tested in vitro for regenerative and radioprotective properties.

DISCUSSION

The preliminary clinical application of TRD showed a high potential for reducing acute and late toxicity of RT in patients with HNC. The current randomized study is the first to prospectively investigate the clinical tolerability and efficacy of TRDs for radiation treatment of head and neck tumors.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT04454697; July 1st 2020; https://clinicaltrials.gov/ct2/show/record/NCT04454697 .

Individualized 3D-Printed Tissue Retraction Devices for Head and Neck Radiotherapy

Background

Radiotherapy for head and neck cancer may cause various oral sequelae, such as radiation-induced mucositis. To protect healthy tissue from irradiation, intraoral devices can be used. Current tissue retraction devices (TRDs) have to be either individually manufactured at considerable cost and time expenditure or they are limited in their variability. In this context, a 3D-printed, tooth-borne TRD might further facilitate clinical use.

Methods

A novel approach for the manufacturing of TRDs is described and its clinical application is analysed retrospectively. The devices were virtually designed for fabrication by 3D-printing technology, enabling—in only a single printing design—caudal or bi-lateral tongue displacement, as well as stabilization of a tongue-out position. For a total of 10 patients undergoing radiotherapy of head and neck tumors, the devices were individually adapted after pre-fabrication. Technical and clinical feasibility was assessed along with patient adherence. Tissue spacing was calculated by volumetric analysis of tongue retraction. In one exemplary case, radiotherapy treatment plans before and after tissue displacement were generated and compared. The reproducibility of maxillomandibular relation at device re-positioning was quantified by repeated intraoral optical scanning in a voluntary participant.

Results

3D-printing was useful for the simplification of TRD manufacture, resulting in a total patient treatment time of less than 30 min. The devices were tolerated well by all tested patients over the entire radiation treatment period. No technical complications occurred with the devices. The TRDs caused an effective spacing of the healthy adjacent tissue, e.g., the tongue. Position changes of maxillomandibular relation were limited to a mean value of 98.1 µm ± 29.4 µm root mean square deviation between initial reference and follow-up positions.

Conclusions

The presented method allows a resource-efficient fabrication of individualized, tooth-bourne TRDs. A high reproducibility of maxillomandibular relation was found and the first clinical experiences underline the high potential of such devices for radiotherapy in the head and neck area.

Treatment delay in early-stage oral squamous cell carcinoma and its relation to survival

The aim of this study was to investigate the impact of a prolonged treatment delay on survival in patients with primary oral squamous cell carcinoma. The investigators hypothesized that treatment delay affects survival, supposing a poor outcome in patients with prolonged treatment initiation. In addition, a critical treatment delay should be defined. Inclusion criteria were a histopathological diagnosis of primary squamous cell carcinoma of the oral cavity and a surgery-based treatment of the tumor. Patients with a history of previously diagnosed malignancies and patients with distant metastasis at the time of diagnosis were excluded from this protocol. Common clinical and histopathological data were assessed retrospectively. Treatment delay was analyzed for the interval between initial presentation and the date of surgery. A total of 484 patients could be included. Considering early-stage patients, the risk of death increases by 1.8% for each day that the treatment delay is prolonged if all other characteristics do not change (p = 0.0035). In patients with advanced disease, a prolonged treatment delay does not affect the risk of death (p = 0.9134). In terms of progression-free survival, treatment delay tends to be associated with a higher risk of recurrence in early-stage disease, but without being statistically significant (p = 0.0718). For patients with early-stage disease, a treatment delay of 20 days is critical regarding overall survival (p = 0.011). For patients with advanced-stage disease, no significant differences have been observed. As patients with early-stage oral squamous cell carcinoma profit from early treatment initiation, we suggest an acceptable maximum treatment delay of no more than 20 days in the surgical management of these patients.

Squamous cell carcinoma of the mandible - Patterns of metastasis and disease recurrence in dependence of localization and therapy

INTRODUCTION

Oral squamous cell carcinomas exhibit distinct patterns of disease progression, depending on their localisation. This study aimed to evaluate clinicopathological data in patients with tumors of the mandibular alveolar process, to facilitate risk assessment and therapy planning.

MATERIALS AND METHODS

A retrospective cohort study was designed including patients with squamous cell carcinoma of the mandibular gingiva. Clinical and pathological data were collected to determine the rate of cervical metastases and clinical outcomes depending on tumor stage, localization (anterior, intermediate and posterior) and the extent of tumor resection.

RESULTS

120 patients were included in the analysis. Rate of metastases was 42.6%. Tumors of the anterior part of the mandible exhibited significantly higher rates of bilateral metastases (anterior: 85.7%, intermediate: 15.8%, posterior: 4%, p < 0.001) and local recurrence (anterior: 25%, intermediate: 16.3%, posterior: 5.5%, p = 0.03) compared to posterior malignancies.

CONCLUSION

Tumors of the anterior segment of the mandible are characterized by high rates of metastases and local recurrence. Therefore, we propose radical segmental resection and bilateral neck dissection in those patients.

Head motion during cone-beam computed tomography: Analysis of frequency and influence on image quality

Purpose

Image artifacts caused by patient motion cause problems in cone-beam computed tomography (CBCT) because they lead to distortion of the 3-dimensional reconstruction. This prospective study was performed to quantify patient movement during CBCT acquisition and its influence on image quality.

Materials and Methods

In total, 412 patients receiving CBCT imaging were equipped with a wireless head sensor system that detected inertial, gyroscopic, and magnetometric movements with 6 dimensions of freedom. The type and amplitude of movements during CBCT acquisition were evaluated and image quality was rated in 7 different anatomical regions of interest. For continuous variables, significance was calculated using the Student t-test. A linear regression model was applied to identify associations of the type and extent of motion with image quality scores. Kappa statistics were used to assess intra- and inter-rater agreement. Chi-square testing was used to analyze the impact of age and sex on head movement.

Results

All CBCT images were acquired in a 10-month period. In 24% of the investigations, movement was recorded (acceleration: >0.10 [m/s²]; angular velocity: >0.018 [°/s]). In all examined regions of interest, head motion during CBCT acquisition resulted in significant impairment of image quality (P<0.001). Movement in the horizontal and vertical axes was most relevant for image quality (R²>0.7).

Conclusion

Relevant head motions during CBCT imaging were frequently detected, leading to image quality loss and potentially impairing diagnosis and therapy planning. The presented data illustrate the need for digital correction algorithms and hardware to minimize motion artefacts in CBCT imaging.

Wound closure and alveoplasty after preventive tooth extractions in patients with antiresorptive intake-A randomized pilot trial

OBJECTIVES

To compare success rates between the sub-periosteal prepared (SPP) muco-periosteal flap and the epi-periosteal prepared (EPP) mucosa flap and the feasibility of alveoplasty after surgical tooth extractions in patients undergoing/after antiresorptive treatment.

SUBJECTS

Patients with an indication for preventive tooth extraction undergoing/after antiresorptive treatment were enrolled over a 24-month period in a parallel-group randomized clinical pilot trial and randomly assigned for primary wound closure to either the SPP or the EPP group. The primary outcome was treatment failure 8 weeks after surgery. To assess the feasibility of alveoplasty, necrotic bone changes at the time point of tooth extraction were evaluated.

RESULTS

One hundred and sixty patients were randomized to the SSP (n = 82) or the EPP (n = 78) group. One hundred and fifty-seven patients met the primary endpoint 8 weeks after surgery with five treatment failures for the SPP group (6.3%) and 18 (23.4%) for the EPP group (p = .004). A significant relationship (p < .0001) was observed between symptomatic teeth and non-vital bone found in 54.8% of all biopsies.

CONCLUSIONS

The strong superiority of the muco-periosteal flap as primary wound closure revealed the feasibility and effectiveness of the study. The large number of necrotic biopsies emphasizes the importance of alveoplasty as a preventive measure.

Carbon ion reirradiation compared to intensity-modulated re-radiotherapy for recurrent head and neck cancer (CARE): a randomized controlled trial

BACKGROUND

Intensity-modulated re-radiotherapy (reIMRT) has been established as a standard local treatment option in patients with non-resectable, recurrent head and neck cancer (rHNC). However, the clinical outcome is unfavorable and severe toxicities (≥grade III) occurred in 30-40% of patients. The primary aim of the current trial is to investigate carbon ion reirradiation (reCIRT) compared to reIMRT in patients with rHNC regarding safety/toxicity as well as local control, overall survival (OS), and quality of life (QoL).

METHODS

The present trial will be performed as a single center, two-armed, prospective phase II study. A maximum of 72 patients will be treated with either reIMRT or reCIRT to evaluate severe (≥grade III) treatment-related toxicities (randomization ratio 1:1). The primary target value is to generate less than 35% acute/subacute severe toxicity (≥grade III), according to the Common Terminology Criteria for Adverse Events v5.0, within 6 months after study treatment. The total dose of reirradiation will range between 51 and 60 Gy or Gy (RBE), depending primarily on the radiotherapy interval and the cumulative dose to organs at risk. Individual dose prescription will be at the discretion of the treating radiation oncologist. The local and distant progression-free survival 12 months after reirradiation, the OS, and the QoL are the secondary endpoints of the trial. Explorative trial objectives are the longitudinal investigation of clinical patient-related parameters, tumor parameters on radiological imaging, and blood-based tumor analytics.

DISCUSSION

Recent retrospective studies suggested that reCIRT could represent a feasible and effective treatment modality for rHNC. This current randomized prospective trial is the first to investigate the toxicity and clinical outcome of reCIRT compared to reIMRT in patients with rHNC.

TRIAL REGISTRATION

ClinicalTrials.gov ; NCT04185974 ; December 4th 2019.

Sensitization of head and neck squamous cell carcinoma to apoptosis by combinational SMAC mimetic and Fas ligand-Fc treatment in vitro

This study aimed to investigate the in vitro efficacy of three different SMAC mimetics for pro-apoptotic sensitization of HNSCC cells. We evaluated BV-6 in comparison to Birinapant and LCL161, for which pro-apoptotic sensitization effects have been demonstrated. Concentration-dependent response was measured for BV-6 in each cell line with an average IC₅₀ value 8-fold lower than of aforementioned SMAC mimetics. Combination treatment of FasL (log2) and BV-6 (IC₁₀) showed highly significant cell count reductions even in the lowest applied concentration in five cell lines (PCI-1: p = 0.0002, PCI-13: p = 0.0002, Detroit 562: p: p < 0.0001, FaDu: p < 0.0001, SCC-25: p = 0.0047). Synergistic effects (y < 1) were evident in eight out of 10 cell lines (PCI-1, PCI-9, PCI-13, PCI-68, Detroit 562, FaDu, SCC-25 and HaCaT). Annexin V assays revealed in nine cell lines very highly significant (p < 0.001) pro-apoptotic effects of BV-6. Western blots showed a heterogeneous IAP expression following SMAC mimetic treatment. Except for two cell lines, at least the cellular inhibitor of apoptosis protein 1 (cIAP1) was degraded in response to BV-6. For prospective targeted HNSCC therapy, this study identifies SMAC mimetics, particularly BV-6 as the compound with the highest pro-apoptotic potency, as promising antitumor agents.

Differences between auto-fluorescence and tetracycline-fluorescence in medication-related osteonecrosis of the jaw-a preclinical proof of concept study in the mini-pig

Objectives

Fluorescence-guided bone surgery is a well-established technique in the treatment of medication-related osteonecrosis of the jaw. No histopathological evidence for bone auto-fluorescence is currently available, and thus, any differences from tetracycline-fluorescence remain unclear. Therefore, the goals of this study were to find out if macroscopic and histological differences occur between the auto- and tetracycline-fluorescence in the delineation of viable and necrotic jawbone in the mini-pig.

Materials and methods

According to the proof of concept, osteonecrosis was provoked in eight Göttingen minipigs. Pigs were divided into two groups (AF group: no fluorochrome label; TF group: tetracycline label). Delineation of necrosis and viable bone was evaluated in vivo and in vitro macro−/microscopically, correlated to fluorescence properties and compared between the two study groups.

Results

No macroscopic and microscopic clinical differences were seen in fluorescence between the AF and TF groups. Macroscopic and microscopic viable bone fluoresced green, whereas necrotic bone showed no or only pale fluorescence in both groups. The auto-fluorescence was attributable to the arrangements and structure of collagen and the cell-filled bone lacunae.

Conclusion

Neither in vivo nor in vitro macroscopically differences are apparent between the auto-fluorescence and the tetracycline-fluorescence of bone. The auto-fluorescence is attributable to the arrangements and structure of collagen and the cell-filled bone lacunae. Tetracycline-fluorescence is a mixture of tetracycline (at the bone edges with increased bone formation) and large components of auto-fluorescence.

Clinical relevance

Because auto-fluorescence is easy to apply, reproducible, and does not rely on the subjective impression of the surgeon, it promises to be an important standardized alternative to tetracycline-labeled MRONJ therapy.

Prospective feasibility analysis of salvage surgery in recurrent oral cancer in terms of quality of life

OBJECTIVES

The goals of the present study were to prospectively analyze salvage surgery with microvascular reconstruction in recurrent squamous cell carcinoma of the oral cavity (OSCC) in terms of oncological outcome and quality of life.

PATIENTS AND METHODS

From 2012 to 2015, 28 patients underwent salvage surgery due to recurrent OSCC or second primary OSCC without the option of curative re-irradiation. Endpoints were disease-specific survival and progression-free survival after 12 months. The survival was estimated by using the Kaplan-Meier blotting. Quality of life data (European Organization for Research and Treatment of Cancer - EORTC: QLQ-C30 and QLQ-H&N35) was assessed at baseline and subsequently every 3 months up to one year.

RESULTS

Estimated 1-year-survival was 68.4% and progression-free survival was 38.5%. Overall quality of life was significantly reduced three months after salvage surgery [baseline (mean 64.15) versus time 1 (mean 53.04); p = 0.002]. However, the patients experienced a recovery within the first year [baseline (mean 64.15) versus time 4 (mean 70.33); p = 0.176]. Furthermore, the sensation of pain is significantly reduced after salvage surgery [baseline (mean 47.53) versus time 2 (mean 31.25); p = 0.036]. Microvascular reconstruction success rate was 93.1%.

CONCLUSION

Salvage surgery is a curative treatment option in recurrent and intensively pretreated OSCC. Microvascular reconstruction is feasible with acceptable morbidity and high success rates. Quality of life can be preserved. Further studies combining checkpoint inhibition with salvage surgery are justified.

Is panendoscopy a necessary staging procedure in patients with lacking risk factors and oral squamous cell carcinoma?

OBJECTIVES

Routine panendoscopy is used to detect synchronous malignancies of the upper aerodigestive tract in staging of oral squamous cell carcinoma. The goal of this study was to investigate the occurrence of synchronous malignancies at time of diagnosis using panendoscopy. To challenge the role of panendoscopy as inherent part of routine staging procedures, we were especially interested in low risk patients.

MATERIALS AND METHODS

Retrospectively, a cohort of 484 patients with pathologically confirmed diagnosis of primary oral and oropharyngeal squamous cell carcinoma was investigated. Electronically recorded findings of in-house conducted panendoscopy were retrieved and evaluated for the occurrence of pathological changes of the mucosa. In case of synchronous malignancies, findings were correlated to preoperative radiographic imaging. Patients were classified as high or low risk. Patients with lacking risk factors (no smoking, no drinking in history) were defined as low risk patients.

RESULTS

Overall, we detected three synchronous malignancies of the upper aerodigestive tract (3/484; 0.6%). Two non-small cell lung cancers were detected in patients with a smoking history of 60 pack years. One esophageal carcinoma in situ was detected in a patient with reported alcohol consumption. No synchronous malignancy was detected in patients without risk factors and no malignancy was previously detected by diagnostic imaging.

CONCLUSION

Pre-treatment panendoscopy can reveal synchronous malignancies of the upper aerodigestive tract in patients with primary oral squamous cell carcinoma. Risk stratification of patients can avoid unnecessarily conducted panendoscopy in patients without risk factors. This may lead to a higher cost-efficacy in public health system, less treatment-related complications and earlier treatment initiation.

The prognostic significance of the lymph node ratio in oral cancer differs for anatomical subsites

The aim of this study was to validate the prognostic significance of the lymph node ratio (LNR) in patients suffering from oral squamous cell carcinoma in regard to different anatomical subsites. A cohort of 430 patients was investigated to determine the rates of primary metastasis and local and regional disease recurrence. Correlation analysis of the LNR with relevant clinical and pathological parameters was performed. Receiver operating characteristic (ROC) curve analysis was conducted to evaluate the prognostic impact for different subsites. Significantly differing rates of primary metastasis and loco-regional disease recurrence were found for cancer of different anatomical subsites of the head and neck. Furthermore, ROC curve analysis suggested that LNR has prognostic relevance in subsets of cancer (tongue, P< 0.001; alveolar process, P= 0.04; maxilla, P= 0.03; buccal mucosa, P= 0.02). The LNR of cancer located in the soft palate (P= 0.6) and floor of the mouth (P= 0.11) showed little or no association with the clinical outcome. There is the need for a more sensitive consideration of the LNR as a factor in the assessment of risk and the treatment decision, as the anatomical subsite plays a crucial role in its impact on the clinical outcome.

MicroRNA expression correlates with disease recurrence and overall survival in oral squamous cell carcinoma

OBJECTIVES

Locoregional disease recurrence and metastatic events are the leading causes of death and the most important prognostic factors in patients with head and neck squamous cell carcinoma (HNSCC). A major goal of oncology is the identification of clinical and molecular parameters to evaluate the individual risk of recurrence. MicroRNAs (miRNAs) have been shown to correlate well with tumor size and differentiation. Therefore, they are candidate biomarkers for estimating clinical outcomes.

MATERIALS AND METHODS

In this study, the expression levels of distinct miRNAs extracted from formalin-fixed, paraffin-embedded (FFPE) samples of oral squamous cell carcinoma were compared.

RESULTS

Statistical analysis revealed significant correlations between distinct miRNAs and disease recurrence (miR-99*, miR-194*; p < 0.05) and overall survival (miR-99*; p < 0.05). The results were then validated via data from The Cancer Genome Atlas (TCGA).

CONCLUSIONS

Our data show that miR-99* and miR-194* can possibly serve as biomarkers for clinical outcome in HNSCC. These findings may help to identify high-risk patients, who could profit from a more individualized treatment and follow-up.