Close Surgical Margins in Oral and Oropharyngeal Cancer: Do They Impact Prognosis?

Lee, Dong-Hyun; Kim, Geun‐Jeon; Kim, Hyun-Bum; Shin, Hyun-Il; Kim, Choung-Soo; Nam, Inn‐Chul; Cho, Jung-Hae; Joo, Young Hoon; Cho, Kwang-Jae; Sun, Dong‐Il; Park, Young-Hak; Park, Jun‐Ook

doi:10.3390/cancers14122990

Cited by 12 publications

(9 citation statements)

References 24 publications

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“…19 Multiple investigators have also obtained excellent oncologic local control using much smaller margins, as low as 1-2 mm, in the oropharynx. 20,21 The NCCN guidelines reflect this evolving area of research for appropriate margin size during transoral and robotic approaches for HPV-associated OPC. 22 Our study has several limitations.…”

Section: Resultsmentioning

confidence: 99%

Effect of palatine tonsil tumor resection on postoperative velopharyngeal insufficiency in transoral surgery

Wistermayer,

Brown,

Cave

et al. 2024

Head & Neck

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BackgroundVelopharyngeal insufficiency (VPI) is a known complication of transoral surgery (TOS) for oropharyngeal HPV‐mediated squamous cell carcinoma. Controversy exists regarding adequate resection margins for balancing functional and oncologic outcomes.MethodsThis retrospective study was exempted by the IRB. Patients who underwent TOS from January 2017 to October 2022 were included. Patient characteristics, treatment details, and oncologic and functional outcomes were evaluated.ResultsFifty‐five patients were included. Mean and median follow‐up was 34 months. 98% of patients were AJCC stage I/II. Recurrence‐free survival was 96% with no local recurrences.Univariate analysis demonstrated an association between VPI and pT stage (p = 0.035), medial pterygoid resection (p = 0.049), and palatal attachment sacrifice (p < 0.001). Multivariate analysis showed sacrifice of the palatal attachments remained a significant risk for VPI (p = 0.009).ConclusionLoss of soft palate pharyngeal attachments is an independent risk factor for VPI. When oncologically appropriate, the palatal attachments to the pharynx may be preserved.

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Section: Resultsmentioning

confidence: 99%

Effect of palatine tonsil tumor resection on postoperative velopharyngeal insufficiency in transoral surgery

Wistermayer,

Brown,

Cave

et al. 2024

Head & Neck

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“…Margins were defined as positive or negative; negative and close margins were adequate . Research on adequate margin distance in HPV-OPSCC has shown that close margins (ie, >1 mm to ≤5 mm) have similar disease-free and overall survival rates than those with margins greater than 5 mm . In a prior report from our research group, patients treated with NECTORS with negative margins (n = 52) have been free of disease on follow-up; 2 patients with positive margins developed distant metastases to the lungs (n = 1) and local recurrence and death (n = 1).…”

Section: Discussionmentioning

confidence: 99%

“…18 Research on adequate margin distance in HPV-OPSCC has shown that close margins (ie, >1 mm to ≤5 mm) have similar disease-free and overall survival rates than those with margins greater than 5 mm. 32,33 In a prior report from our research group, 18 patients treated with NECTORS with negative margins (n = 52) have been free of disease on follow-up; 2 patients with positive margins developed distant metastases to the lungs (n = 1) and local recurrence and death (n = 1). That study cohort of patients treated with this same NECTORS protocol demonstrated pathologic complete response in the primary site (72%) and neck (56%).…”

Section: Description and Benefits Of Nectorsmentioning

confidence: 98%

Quality of Life After Neoadjuvant Chemotherapy and Transoral Robotic Surgery for Oropharynx Cancer

Silver,

Bouganim,

Richardson

et al. 2024

JAMA Otolaryngol Head Neck Surg

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ImportanceEfforts are underway to deintensified treatment protocols for patients with human papillomavirus virus−associated oropharyngeal squamous cell carcinoma (HPV-OPSCC) to achieve similar excellent oncologic outcomes while reducing treatment-related adverse effects. Transoral robotic surgery (TORS) as primary treatment often requires adjuvant therapy due to the high incidence of nodal metastasis. Treatment with neoadjuvant chemotherapy followed by TORS and neck dissection (NECTORS), reserving radiation therapy for salvage, yields excellent oncologic outcomes.ObjectiveTo assess patient-reported quality of life (QOL) and functional outcomes among patients with HPV-OPSCC who undergo NECTORS.Design, Settings, and ParticipantsThis was a multicenter prospective cohort study of patients with HPV-OPSCC treated with the NECTORS protocol in 2017 to 2022. Consecutive patients with stage III or IVa HPV-OPSCC treated with NECTORS in 2017 to 2022 who had completed the primary QOL questionnaire at baseline and at least once during the 24-month follow-up period were included. Ninety-four patients were eligible, and 67 were included in the analyses.Outcome MeasuresQOL questionnaires at baseline, and at month 1, 3, 6, 12, 18, and 24 posttreatment. Global score on the 30-item European Organization for Research and Treatment of Cancer Core quality of life questionnaire (EORTC QLQ-C30) was the primary outcome; the head and neck extension module (EORTC QLQ-HN35); the MD Anderson Dysphagia Inventory for dysphagia-related QOL; and the Decision Regret Scale were also used. Paired t tests assessed change between the baseline and 12- or 24-month patient-reported outcomes.ResultsAmong the study population of 67 patients (median [range] age, 63 [58-67] years; 54 [80.6%] male) with HPV-OPSCC, the most frequent cancer subsites were palatine tonsil (41 [61%]) and base of tongue (26 [39%]); none required adjuvant RT. Global QOL at 24 months improved compared with baseline (mean difference, 9.49; 95% CI, 2.45 to 16.53). All EORTC QLQ-C30 functional scores returned to baseline or improved within 3 to 6 months posttreatment and remained stable at 24 months. EORTC QLQ-HN35 symptom scale scores improved or were stable at 24 months. The MD Anderson Dysphagia Inventory scores demonstrated no significant difference between baseline and month 12 for global scores (mean difference, 6.15; 95% CI, −4.18 to 16.49) and composite scores (mean difference, 2.73; 95% CI, −1.62 to 7.09). Median (range) score on the Decision Regret Scale was 5 of 100 (0-30), representing mild overall regret.Conclusion and RelevanceThe findings of this multicenter cohort study indicate that use of the NECTORS protocol is associated with excellent QOL outcomes. QOL measures returned to baseline levels or were better than baseline, which represents positive outcomes for patients with HPV-OPSCC who undergo this treatment regimen.

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“…However, no association was found between dysplasia in the surrounding tissue and time to LRTF, which was more pronounced in patients without ENE. Literature regarding surgical margin distance in SCCHN 4,5,7,16 has mainly been retrospective and focused on outcomes of patients with OC cancer resections, with some debate about what is an adequate surgical resection margin. Retrospective studies by Varvares et al 4 and Lee et al 16 found that patients with less than 5-mm margins had significantly worse survival that those with margins of 5 mm or greater.…”

Section: Discussionmentioning

confidence: 99%

“…Literature regarding surgical margin distance in SCCHN 4,5,7,16 has mainly been retrospective and focused on outcomes of patients with OC cancer resections, with some debate about what is an adequate surgical resection margin. Retrospective studies by Varvares et al 4 and Lee et al 16 found that patients with less than 5-mm margins had significantly worse survival that those with margins of 5 mm or greater. Similarly, a meta-analysis by Anderson et al 5 found that there was a significant reduction in absolute risk (21%) for local recurrence of OC cancer when margins of 5 mm or greater were used as the cutoff for clear margins.…”

Section: Discussionmentioning

confidence: 99%

Association of Surgical Margin Distance With Survival in Patients With Resected Head and Neck Squamous Cell Carcinoma

Sunkara

Graff

Cramer

2023

JAMA Otolaryngol Head Neck Surg

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ImportanceClear surgical margins reduce the risk of local recurrence, improve survival, and determine decision-making with regard to adjuvant treatment of squamous cell carcinoma of the head and neck (SCCHN). However, the definitions of clear, close, or positive surgical margins vary in both the literature and in practice.ObjectiveTo examine whether the association between surgical margin distance and survival varies by primary tumor site.Design, Setting, and ParticipantsThis was a secondary analysis of a multi-institutional, multinational randomized clinical trial. The trial enrolled patients from January 22, 2007, to March 29, 2013, with stage II to IVA resected SCCHN with extranodal extension (ENE) or positive margins (&lt;5 mm from invasive tumor to the resected margin). The current analysis included those patients with known ENE and margin status and was conducted from April 29, 2022, to December 19, 2022.InterventionsPatients received adjuvant chemoradiotherapy plus either placebo or lapatinib.Main Outcomes and MeasuresOverall survival (OS) was calculated to examine association with surgical margin distance, primary site, and survival, with stratification by ENE status.ResultsAmong 688 patients enrolled in the trial, 630 patients with known ENE and margin status were included. Exact patient ages were not made available; 523 (83%) patients were male, and 415 (66%) patients were White. Patients with 1 high-risk feature (positive margins or ENE) had significantly better OS vs 2 high-risk features (hazard ratio [HR], 0.65; 95% CI, 0.49-0.87), although most other results were not statistically significant. For example, in the cohort with ENE-negative disease, multivariable adjusted analysis showed nonsignificant improvements with shorter surgical margin distance (1- to 5-mm margins), and no association with OS was found in the cohort with ENE-positive status (either &gt;5 mm margins or 1-5 mm margins). The association between survival and margin distance varied based on primary site, human papillomavirus (HPV) status, and ENE status. For example, HPV-positive status was associated with a significant and clinically meaningful increase in survival (adjusted HR, 0.33; 95% CI, 0.11-0.97). The improvement was greatest, although not significantly so, in patients with ENE- and HPV-negative oropharynx (OP), hypopharynx (HP), and larynx cancer (HR, 0.57; 95% CI, 0.30-1.10). No survival benefit was seen in ENE-negative oral cavity cancer (HR, 0.89; 95% CI, 0.45-1.77), nor was an association observed between margins and OS in HPV-positive OP cancer.Conclusions and RelevanceIn this secondary analysis of a randomized clinical trial, the presence of high-risk features (extranodal extension, positive margins, or both) was associated with worse survival; longer survival was observed with greater surgical margin distance among patients with oral cavity tumors and human papillomavirus–negative tumors of the OP, larynx, or HP. No other significant differences were found. These findings support variable interpretation of surgical margin distance based on the primary site and HPV status.Trial RegistrationClinicalTrials.gov Identifier: NCT00424255

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Close Surgical Margins in Oral and Oropharyngeal Cancer: Do They Impact Prognosis?

Cited by 12 publications

References 24 publications

Effect of palatine tonsil tumor resection on postoperative velopharyngeal insufficiency in transoral surgery

Effect of palatine tonsil tumor resection on postoperative velopharyngeal insufficiency in transoral surgery

Quality of Life After Neoadjuvant Chemotherapy and Transoral Robotic Surgery for Oropharynx Cancer

Association of Surgical Margin Distance With Survival in Patients With Resected Head and Neck Squamous Cell Carcinoma

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