Comment to: “Head and neck osteosarcomas: An analysis of treatment trends and survival outcomes in the United States (2004–2016)”

Abstract

Rs e e p a g e 4 0 2 0 -4 0 2 1 Comment to: "Head and neck osteosarcomas: An analysis of treatment trends and survival outcomes in the United States (2004States ( -2016"We read, with great enthusiasm, the article by Shim et al., reporting the survival analysis of 821 patients diagnosed with head and neck osteosarcomas (HNOSs) from the National Cancer Database. 1 We would like to acknowledge the authors for this effort, which reflects the conflicting results regarding the benefits of neoadjuvant chemotherapy (neoCT). The authors concluded that "short-term survival improvement in patients receiving both neoadjuvant and adjuvant chemotherapy displays promise." We would like to bring some precisions regarding this conclusion. While large, the studied cohort is retrospective and heterogeneous. Indeed, patients who have received neoCT (108/841) had significantly more mandible, pT1, nonmetastatic, and early American Joint Committee on Cancer (AJCC) stage tumors, which are known to be easier resectable as shown by the significant higher rate of negative surgical margin in these patients. Nevertheless, we recently reported that small tumor size and R0 (clear margins) surgical resections are significantly and independently associated with better outcomes for HNOS patients. 2 Beside these biases, no significant result is shown in all the Cox regression models. Moreover, pathological response to neoCT (>90% of tumor cell necrosis), which has been previously reported to be significantly associated with better overall survival (OS), 3 is not evaluated in the Shim et al. study. Of note, less than 30% of HNOS patients achieve good histological response after neo-CT 4 and no significant benefit of neoCT on OS has been reported in recent large series. 5,6 In the present study, the primary outcome was OS while comparing disease-free survivals between neoCT versus non-neoCT HNOS patients seems to be more relevant to assess the benefit of such treatment, especially when their using is still debated. Finally, the authors discuss results published by the Canadian Society of Otolaryngology 6 (35 HNOS patients) and stated that the reported trend toward improved early survival with adjuvant chemotherapy "may be due in part to benefits of neoCT in decreasing the confines of the tumor allowing for a more complete surgical resection." However,