Fazilet Bekiroglu

Systematic review of the current evidence in the use of postoperative radiotherapy for oral squamous cell carcinoma

Improved disease-free survival for oral squamous cell carcinoma (SCC) with the use of postoperative radiotherapy (PORT) has to be balanced against the risk of recurrence, the relative morbidity of radiotherapy, reduced options for treatment, and survival with recurrent disease. In the absence of randomised trials, a review of current evidence is timely because of increasing differences in outcome and response to treatment for cancers of the larynx, oropharynx, and oral cavity. From a search of 109 papers, 25 presented relevant data in tabular form, and reported local, regional, and total recurrence, and overall survival. Most data come from non-randomised studies that compared the effects of interventions with previous or historical information. A summary of the results shows local recurrence of 11%, 17%, and 15% for early, late, and all stages after operation alone, compared with 13%, 16%, and 19% after PORT. Regional recurrence is reported as 13%, 12%, and 11% for early, late, and all stages after operation alone compared with 6%, 11%, and 9% after PORT. Overall survival is reported as 76%, 74%, and 77% for operation alone compared with 65%, 62%, and 62% for early, late and all stages of oral SCC, respectively. It is acknowledged that this is a weak level of evidence as patients who have PORT probably have a high pathological-stage of disease. Knowing that PORT increases morbidity and reduces salvage rates and options for treating recurrent disease, this difference in overall survival emphasises the need for randomised studies or a re-evaluation of our current protocols.

Indications for the scapular flap in reconstructions of the head and neck

Composite free flaps that are available for reconstructions of the head and neck include those from the fibula, iliac crest, radial forearm, and scapula, but only that from the scapula precludes two-team operating, and consequently adds a further 2-3h to the operating time. Here we clarify the indications for the subscapular system of composite flaps, and discuss their unique properties in terms of reliability of the bony segment, their resistance to atherosclerosis, and the diversity of the skin and muscular components that are available. We have had favourable results in composite resections of the anterior mandible that required substantial resections of the anterior tongue. In extensive oropharyngeal resections that require a segmental resection of the mandible, the skin island is reliable and provides sufficient bulk to reduce the risk of dehiscence and maintain a narrowed oropharynx to improve speech and swallowing. In reconstructions of the midface a combination of the latissimus dorsi and the scapula that is based on the angular branch of the thoracodorsal vessel (thoracodorsal angular flap) allows for a long pedicle, and adequate muscle and bone for high and low maxillectomy defects. We present a consecutive series of 46 patients who document the use of this option in routine head and neck practice.

Management of the neck and regional recurrence in squamous cell carcinoma of the maxillary alveolus and hard palate compared with other sites in the oral cavity

The aim of this article was to assess the management of the neck and regional recurrence for squamous cell carcinoma of the maxillary alveolus and hard palate (n = 43) and compare that to the rest of the oral cancer sites (n = 465).

Salvage outcomes of free tissue transfer in Liverpool: trends over 18 years (1992–2009)

Reconstruction of surgical defects in the head and neck using microvascular free tissue transfer is reliable with success rates in excess of 95%. Our previous audit (1992-1998) showed that 16% of patients required an early return to theatre, and the overall free flap salvage rate was 73%. The medical records of 37 patients who had required early return to theatre (within 7 days) after free tissue transfer were analysed to ascertain the indication for reoperation, and whether surgical intervention had been successful, taking into account the timing and cause of compromise. The results of a retrospective re-audit (1999-2004 and 2005-2009) showed that the return to theatre rate had reduced to 4% overall because of a reduction in the number of cases: those that required evacuation of a neck haematoma, and venous compromise of fasciocutaneous or perforator free flaps. Salvage of flaps was most successful when done within the first 24h, and in cases of venous compromise. Three percent of free flaps failed without attempted salvage; most were late failures. Overall survival (1992-2009) for composite free flaps (93%) was lower than for fasciocutaneous or perforator free flaps (96%). Between 2005 and 2009 our overall free flap survival rate was 98%.

Adjuvant radiotherapy and health-related quality of life of patients at intermediate risk of recurrence following primary surgery for oral squamous cell carcinoma.

Controversy surrounds who should receive adjuvant radiotherapy in patients with intermediate risk of recurrence of oral squamous cell carcinoma following primary surgery. The aim of this study was to compare health-related quality of life (HRQOL) outcomes of those who received adjuvant radiotherapy to those who did not in patients at intermediate-risk of recurrence. A total of 765 oral cancer patients were treated at the Regional Maxillofacial Unit, Liverpool from 1995 to 2007. After excluding 124 patients (87 primary radiotherapy, 23 died within 90 days, 14 had insufficient information for determining risk group status), 169 were low-risk, 271 intermediate-risk and 201 were high-risk. In the intermediate-risk group, 33% had adjuvant radiotherapy. Allowing for attrition, more than 70% had University of Washington quality of life data (UW-QOL). Cumulative survival was similar in those with and without adjuvant radiotherapy in a subset of patients at intermediate risk. There was little difference in overall HRQOL scores and in the socio-emotional subscale scores of the UW-QOL. However, there was a significant difference in physical subscale scores and the issue most affected was saliva. These findings support better stratification of risk in the intermediate group, and the plausibility of withholding radiotherapy without compromising survival. This can have dramatic positive benefits on patient physical outcomes, in particular saliva. Where adjuvant radiotherapy is necessary, it is appropriate to minimise adverse effects through measures such as intensity-modulated radiation therapy.

Influence of surgical margins on local recurrence in T1/T2 oral squamous cell carcinoma.

The purpose of this study was to explore the significance of resection margin status on local recurrence and survival for early (T1/T2) oral cancer and to determine if the significance of the resection margin varies with the biological aggression of the tumor as determined by pN status.

First report of elective selective neck dissection in the management of squamous cell carcinoma of the maxillary sinus.

Controversy remains about management of the neck in squamous cell carcinoma (SCC) of the maxillary sinus and we know of no reports of the use of elective selective neck dissection for management in this site. We retrospectively reviewed 18 consecutive patients with SCC of the maxillary sinus who were managed by primary operation with curative intent. A total of 13 patients had an elective selective neck dissection, which was invaded in one case 8%. Four patients had regional metastases, two with positive nodal disease confirmed after elective selective neck dissection, and two who developed regional recurrence (both after elective selective neck dissections which were negative (pN0)). A review of other published articles in the English language showed no cases of elective selective neck dissections reported. The mean regional recurrence rate was 12% (range 0-26%) and total mean regional metastases rate 21% (range 5-36%). Elective selective neck dissection did not contribute to an improved rate of neck control with regional recurrence of 11% (2/18) compared with 12% in the review. There is no evidence in this report to indicate that elective selective neck dissections for maxillary sinus SCC will result in better disease control. Future research may indicate fewer radiotherapy fields for necks with pathologically clear nodes after elective selective neck dissection.

De-escalation of surgery for early oral cancer - is it oncologically safe?

This study is a review of practice for patients with T1 or T2 squamous cell carcinoma (SCC) of the anterior tongue and floor of the mouth who presented to the regional maxillofacial unit in Liverpool between 1992 and 2007. We examined trends in management and analysed their effects on resection margins, recurrence, and survival. The Liverpool head and neck oncology database was used to identify patients, and to retrieve their clinical, surgical, and pathological data. When data were missing the case notes and pathology records were reviewed. Follow up was taken to January 2011. A total of 382 patients were included. Despite more conservative treatment with closer resection margins (27% in 1992-1995 and 60% in 2004-2007), fewer free flaps (79% in 1992-1995 and 38% in 2004-2007), and less adjuvant radiotherapy (37% in 1992-1995 and 22% in 2004-2007), there has been no significant increase in local recurrence (14% in 1992-1996 and 8% in 2004-2007), and overall survival has not been adversely affected. This is most striking when T1 tumours are considered in isolation with a consistent trend towards fewer clear margins (95% in 1992-1995 and 28% in 2004-2007) and fewer free flaps (53% in 1992-1995 and 11% in 2004-2007). The case mix was similar over the study period. These data support a more conservative approach to the management of early oral cancer.

The Patient Concerns Inventory: A Tool to Uncover Unmet Needs in a Cancer Outpatient Clinic

The Patient Concerns Inventory (PCI) is a holistic, patient reported tool that aids in identifying concerns and issues. it is a 55-item checklist of issues that may be grouped into categories of general function, specific head and neck function, emotional-psychological and others, which include finances, treatment related matters and social care. The PCI also gives patients an opportunity to identify from a list of 15 multidisciplinary team (MDT) members whom they would like to see or be referred on to.

Transoral laser microsurgery for oropharyngeal squamous cell carcinoma: A paradigm shift in therapeutic approach.

The contemporary treatment of oropharyngeal squamous cell carcinoma (SCC) is an area of debate. We report outcomes of a minimally invasive approach involving transoral laser microsurgery (TLM).Background The contemporary treatment of oropharyngeal squamous cell carcinoma (SCC) is an area of debate. We report outcomes of a minimally invasive approach involving transoral laser microsurgery (TLM). Methods A consecutive series of patients (n = 153) undergoing primary TLM for oropharyngeal SCC from 2006 to 2013 was studied. Human papillomavirus (HPV) status was determined by p16 immunohistochemistry and high-risk HPV DNA in situ hybridization. Survival analyses were evaluated using Kaplan–Meier statistics. Results Tumor subsites included tonsil (n = 94; 61.5%), tongue base (n = 38; 24.8%), and soft palate (n = 21; 13.7%), with the majority being American Joint Committee on Cancer (AJCC) stage III/IVa (n = 124; 81.0%) and HPV-positive (n = 101; 66.0%). Three-year overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were 84.5%, 91.7%, and 78.2%, respectively. HPV-positivity portended favorable oncologic outcomes. One-year gastrostomy tube (G-tube) dependency was 1.3%. Conclusion To the best of our knowledge, this is the largest single-center TLM oropharyngeal SCC series to date. Our data suggest that TLM +/− postoperative radiotherapy (PORT) results in at least as good oncologic outcomes as chemoradiotherapy (CRT), while conferring swallowing function advantages.