Oral cavity cancer surgery in focus
medwireNews: Three chart reviews shed light on various aspects of surgery for oral cavity cancer, including the definition of an optimal surgical margin, postsurgical opioid use, and survival after salvage surgery.
The first of the studies, all of which appear in JAMA Otolaryngology–Head & Neck Surgery, showed that local recurrence rates were high among patients with up to 1 mm between the invasive cancer and the inked main specimen margin, decreasing rapidly thereafter, with no appreciable differences at greater distances.
Specifically, the recurrence rate was 44% for individuals with microscopic positive margins (ie, invasive cancer at the inked specimen edge), 28% for those with margins less than 1 mm, and 17%, 13%, 13%, 14%, and 11% among those with margins of 1, 2, 3, 4, and 5 mm or more.
Previously, margins of less than 5 mm have been considered close, but the researchers from the University of Iowa Hospitals and Clinics in Iowa City say that the definition is “arbitrary.” And on the basis of area under the receiver operating characteristic curve analysis, they recommend “a cutoff of less than 1 mm as appropriate for classifying higher risk of local recurrence.”
To reach these conclusions, Steven Sperry and colleagues assessed the records of 432 patients with oral cavity squamous cell carcinoma (OCSCC) who underwent surgical resection at their institution between 2005 and 2014.
The second study – led by John Pang, from the University of California San Diego in the USA – found that postsurgical chronic opioid use was “quite high” among 99 oral cavity cancer patients, with 41% still taking opioids more than 90 days after undergoing surgery.
Of note, estimated overall survival was significantly shorter for those who had versus had not used opioids prior to surgery (hazard ratio [HR]=3.2) and disease-free survival was reduced for chronic opioid users relative to their counterparts not considered chronic users (HR=2.7).
After adjusting for confounders, preoperative opioid use, tobacco use, and development of persistence, recurrence, or a second primary cancer were significantly associated with chronic opioid use, suggesting that “[s]trategies to reduce the likelihood of opioid dependence after oral cavity cancer surgery” should focus on these patient groups, say the study authors.
However, in light of the small sample size, they urge caution and point out that “[a] larger cohort would have allowed for more precise determination of factors associated with chronic opioid use and to more soundly assess the association between opioid use and survival.”
The final study comprised 293 patients diagnosed with OCSCC between 1999 and 2011 at a Canadian center. Of these, 59 experienced locoregional recurrence after primary surgery with or without adjuvant treatment, with 66% receiving salvage surgery with curative intent.
Recursive partitioning analysis identified adjuvant radiotherapy or chemoradiotherapy after initial surgery, and age of 62 years or more as the key negative prognostic factors for survival following salvage surgery, report Anthony Nichols (Western University, London, Ontario, Canada) and co-workers.
Using these parameters, the cohort could be subdivided into three groups: the high-risk group consisting of patients who received adjuvant therapy, the intermediate-risk group of those who did not receive adjuvant treatment but were aged at least 62 years, while the low-risk group had neither risk factor.
The corresponding 5-year overall survival (OS) rates were 10%, 39%, and 74%, with median OS times of 6 and 31 months for the high- and intermediate-risk groups, respectively, whereas the median was not reached for low-risk patients.
Nichols et al say that “[t]he modality of the initial treatment for our patients was offered based on the nature and initial presentation of the tumor. Therefore, patients with poor tumor biology (eg, advanced T category), advanced nodal disease, and adverse pathological features would likely receive adjuvant radiotherapy or chemoradiotherapy at the time of initial treatment.”
Nonetheless, they write: “This marked difference in OS should be taken into consideration with patient comorbidities, potential morbidity of surgery, and patient goals when deciding treatment options for patients with recurrent OCSCC.”
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