Head and neck cancers, Version 2.2014. Clinical practice guidelines in oncology.

This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Head and Neck Cancers focuses on glottic laryngeal cancer, which is the most common type of laryngeal cancer and has an excellent cure rate. The lymphatic drainage of the glottis is sparse, and early stage primaries rarely spread to regional nodes. Because hoarseness is an early symptom, most glottic laryngeal cancer is early stage at diagnosis. Updates to these guidelines for 2014 include revisions to "Principles of Radiation Therapy" for each site and "Principles of Surgery," and the addition of a new section on "Principles of Dental Evaluation and Management."

Osteocutaneous free tissue transplantation for mandibular osteoradionecrosis.

OBJECTIVE: To describe the success rate, complications, and functional outcomes of patients who are treated with osteocutaneous free tissue transplantation for grade 4 mandibular osteoradionecrosis (ORN). DESIGN: Retrospective case series. SETTING: Tertiary care academic medical center. PATIENTS: Twelve patients (8 males, 4 females; mean age, 57.6 years) with grade 4 mandibular ORN. Three patients (25%) had a history of primary radiotherapy, two (17%) had previous concurrent chemoradiation, and seven (58%) had undergone postoperative adjuvant radiotherapy. Ten patients (83%) had previous major ablative surgery to treat the primary tumor and five (50%) had been reconstructed with a free tissue transplant prior to the onset of ORN. INTERVENTIONS: All patients underwent reconstruction with an osteocutaneous free tissue transplant for grade 4 mandibular ORN between 1999 and 2006. MAIN OUTCOME MEASURES: Successful treatment of mandibular ORN; major, minor, and late complications; gastrostomy tube (G-tube) dependence; speech and swallowing scores. RESULTS: Grade 4 mandibular ORN was successfully treated in eight (73%) evaluable patients. One patient (8%) died of a second primary tumor before the 12-month assessment. Eight patients (67%) had a major complication, three (25%) had a minor complication, and nine (75%) had a late complication. Three of the five G-tube- dependent patients prior to mandibular reconstruction were able to discontinue the use of their G-tube. Seven of the eight successfully treated patients maintained their nutrition by mouth. Median "range of liquids" score was 6/6 (range, 4 to 6). Median "range of solids" score was 4/6 (range, 3 to 6). Median "understandability of speech" score was 4/5 (range, 2 to 5). CONCLUSIONS: Grade 4 mandibular ORN was treated successfully with an osteocutaneous free tissue transfer in eight evaluable patients (73%). In successfully treated patients, median speech/swallowing scores were highly functional, but the remaining radiated soft tissue resulted in higher local wound complications and a modified diet.

Salivary microbiome changes distinguish response to chemoradiotherapy in patients with oral cancer.

BACKGROUND: Oral squamous cell carcinoma (SCC) is associated with oral microbial dysbiosis. In this unique study, we compared pre- to post-treatment salivary microbiome in patients with SCC by 16S rRNA gene sequencing and examined how microbiome changes correlated with the expression of an anti-microbial protein. RESULTS: Treatment of SCC was associated with a reduction in overall bacterial richness and diversity. There were significant changes in the microbial community structure, including a decrease in the abundance of Porphyromonaceae and Prevotellaceae and an increase in Lactobacillaceae. There were also significant changes in the microbial community structure before and after treatment with chemoradiotherapy, but not with surgery alone. In patients treated with chemoradiotherapy alone, several bacterial populations were differentially abundant between responders and non-responders before and after therapy. Microbiome changes were associated with a change in the expression of DMBT1, an anti-microbial protein in human saliva. Additionally, we found that salivary DMBT1, which increases after treatment, could serve as a post-treatment salivary biomarker that links to microbial changes. Specifically, post-treatment increases in human salivary DMBT1 correlated with increased abundance of Gemella spp., Pasteurellaceae spp., Lactobacillus spp., and Oribacterium spp. This is the first longitudinal study to investigate treatment-associated changes (chemoradiotherapy and surgery) in the oral microbiome in patients with SCC along with changes in expression of an anti-microbial protein in saliva. CONCLUSIONS: The composition of the oral microbiota may predict treatment responses; salivary DMBT1 may have a role in modulating the oral microbiome in patients with SCC. After completion of treatment, 6 months after diagnosis, patients had a less diverse and less rich oral microbiome. Leptotrichia was a highly prevalent bacteria genus associated with disease. Expression of DMBT1 was higher after treatment and associated with microbiome changes, the most prominent genus being Gemella Video Abstract.

Efficacy of induction selection chemotherapy vs primary surgery for patients with advanced oral cavity carcinoma.

IMPORTANCE: The University of Michigan has investigated the use of induction selection (IS) with chemoradiotherapy (CRT) for patients who respond to CRT and found this approach effective in the management of advanced laryngeal cancer. The IS approach was extended to oral cavity squamous cell carcinoma (OCSCC) to help understand whether organ preservation or survival benefit resulted. OBJECTIVE: To evaluate the efficacy of an IS protocol vs primary surgical extirpation and selective postoperative radiotherapy for advanced OCSCC. DESIGN AND SETTING: Retrospective matched cohort study at a tertiary care hospital. PARTICIPANTS: Nineteen patients with resectable stages III and IV OCSCC were enrolled into a phase 2 IS trial. Patients with a response of at least 50% underwent concurrent CRT; those with a response of less than 50% underwent surgical treatment and radiotherapy. A comparison cohort of patients treated with primary surgical extirpation during a similar time period was frequency matched for inclusion criteria and patient characteristics to those patients included from the phase 2 IS trial. No difference was noted in age, sex, pretreatment American Joint Committee on Cancer stage, T and N classifications, smoking status, alcohol consumption, or tumor subsite between the IS and surgical cohorts. Median follow-up was 9.4 years in the IS cohort and 7.1 years in the surgical cohort. INTERVENTIONS: Induction selection and CRT vs primary surgical extirpation with or without postoperative radiotherapy. MAIN OUTCOMES AND MEASURES: Overall and disease-specific survival and locoregional control. RESULTS: The Kaplan-Meier estimate for overall survival at 5 years was 32% in the IS cohort and 65% in the surgical cohort. The Kaplan-Meier estimate for disease-specific survival at 5 years was 46% in the IS cohort and 75% in the surgical cohort. The Kaplan-Meier estimate for locoregional control at 5 years was 26% in the IS cohort and 72% in the surgical cohort. Multivariable analysis demonstrated significantly better overall and disease-specific survival and locoregional control outcomes (P = .03, P = .001, and P < .001, respectively) in the surgical cohort. CONCLUSIONS AND RELEVANCE: Primary surgical treatment showed significantly better survival and locoregional control compared with IS in this matched patient cohort. Despite success of organ preservation IS protocols in the larynx, comparative survival analysis of an IS protocol vs primary surgical extirpation for OCSCC demonstrates significantly better outcomes in the surgical cohort. These findings support surgery as the principal treatment for OCSCC.

Rectangle tongue template for reconstruction of the hemiglossectomy defect.

OBJECTIVE: To determine if a rectangular template free tissue transfer is effective for the reconstruction of the hemiglossectomy defect. DESIGN: Prospective case series. SETTING: Tertiary care academic medical center. PATIENTS: A total of 13 patients (male to female ratio, 8:5; mean age, 55 years) presenting with squamous cell carcinoma of the oral tongue from May 2000 to December 2002. INTERVENTIONS: Of the 13 patients, 7 received postoperative radiotherapy and 2 received prior radiotherapy. The radial forearm was the donor site in 11 patients and the lateral arm and anterolateral thigh in 1 patient each. The mean flap area was 50 cm(2) (range, 24-80 cm(2)). MAIN OUTCOME MEASURES: Major and minor complications, speech and swallowing assessment, oral cavity obliteration, premaxillary contact, tongue elevation, and tongue protrusion. RESULTS: There were no major complications, and 2 of the 13 patients experienced minor complications. Of the 13 patients, 12 achieved the goals of oral cavity obliteration and premaxillary contact and resumed solid oral intake. One patient remained G-tube dependent owing to toxic effects from previous chemoradiation treatment. The mean tongue tip protrusion was 0.7 cm (range, 0-1.7 cm), and the mean elevation was 1.7 cm (range, 1-3 cm). Patients with protrusion greater than 0.8 cm had better swallowing scores for "range of solids" (5.8 of 6 vs 3.9 of 6; P = .045) and "eating in public" (4.6 of 5 vs 3.5 of 5; P = .10). The average patient resumed a full range of liquid and solid intake with minimal restrictions and believed that their speech was mostly understandable with occasional repetition. CONCLUSIONS: The template-based rectangle tongue flap effectively restored speech and swallowing function in this group of patients. Tongue protrusion greater than 0.8 cm is associated with better swallowing results.

Lateral oromandibular defect: when is it appropriate to use a bridging reconstruction plate combined with a soft tissue revascularized flap?

BACKGROUND: A quasi-experimental retrospective study was undertaken to evaluate a new concept of free tissue volume restoration combined with bridging reconstruction plate (compartment approach) to reduce plate-related complication rates. METHODS: We evaluated 40 patients with large lateral mandible defects and associated complex soft tissue defects reconstructed with a revascularized soft tissue flap and titanium hollow screw reconstruction plates. A case-control comparison was performed based on reconstruction type: restoration of soft tissue defect (conventional approach-group 1) versus over-reconstruction of soft tissue defect (compartment approach-group 2). RESULTS: Plate exposure rate was 6 of 16 (38%) in group 1 versus 2 of 24 (8%) in group 2, and the difference was statistically significant (p = .04). The mean time to exposure was 10 months. Plate fracture rate was 6 of 23 (26.1%) in dentulous patients versus 1 of 17 (5.9%) in edentulous patients. Gastrostomy tube dependence was 6 of 16 (38%) in group 1 versus 6 of 24 (25%) in group 2. CONCLUSION: The "compartment approach" reduces plate exposure rate and gastrostomy tube dependence. Revascularized osseocutaneous reconstruction is still required in dentulous patients.