Interventional laser surgery for oral potentially malignant disorders: a longitudinal patient cohort study

Abstract

Oral squamous cell carcinoma (OSCC) is a lethal disease, with rising incidence. There were 6767 new OSCC cases and 2056 deaths in the UK in 2011. Cancers are preceded by oral potentially malignant disorders (PMDs), recognizable mucosal diseases harbouring increased SCC risk, offering clinicians a 'therapeutic window' to intervene. Contemporary practice remains unable to predict lesion behaviour or quantify malignant transformation risk. No clear management guidelines exist and it is unclear from the literature whether early diagnosis and intervention prevents cancer. Between 1996 and 2014, 773 laser treatments were performed on 590 PMD patients in Newcastle maxillofacial surgery departments. The efficacy of the intervention was examined by review of the clinicopathological details and clinical outcomes of the patients (mean follow-up 7.3 years). Histopathology required up-grading in 36.1% on examining excision specimens. Seventy-five percent of patients were disease-free, mostly younger patients with low-grade dysplasia; 9% exhibited persistent disease and were generally older with proliferative verrucous leukoplakia. Disease-free status was less likely for erythroleukoplakia (P=0.022), 'high-grade' dysplasia (P<0.0001), and with lichenoid inflammation (P=0.028). Unexpected OSCC was identified in 12.0%, whilst 4.8% transformed to malignancy. Interventional laser surgery facilitates definitive diagnosis and treatment, allows early diagnosis of OSCC, identifies progressive disease, and defines outcome categories. Evidence is lacking that intervention halts carcinogenesis. Multicentre, prospective, randomized controlled trials are needed to confirm the efficacy of surgery.

Perspectives on oral squamous cell carcinoma prevention—proliferation, position, progression and prediction

“…For many years, early diagnosis of OSCC and PMD management have been areas of clinical practice in which variability in decision making and lack of high‐quality evidence confounded treatment . It is hoped that recent clarification and rationalization of interventional management strategies will facilitate demonstrable improvements in clinical care, although it is recognized that it takes time to change established patterns of clinicians’ decision making …”

“…As a challenging management problem, a pragmatic approach to rationalize diagnosis and targeted intervention utilizes a multiple “field mapping” biopsy technique . The soft palate, faucial pillars, floor of mouth and ventral tongue are recognized as sites most at risk of severe dysplasia; individual PMD lesions, however, respond well to CO 2 laser excision …”

“…It is recognized that PMD appearance, specifically proliferative verrucous leucoplakia (PVL), non‐homogenous leucoplakia, erythroleucoplakic lesions and erythroplakia, may be associated with persistent and progressive disease, but these are generalized observations and do not reliably inform individual patient management …”

The“Newcastle Nomogram”—Statistical modelling predicts malignant transformation in potentially malignant disorders

“…The study re‐visited the database of a previously reported 590 PMD patient treatment cohort from Northern England . Caldicott Approval from Newcastle University/Newcastle upon Tyne Hospitals NHS Foundation Trust facilitated anonymized, retrospective and prospective data collection from medical records, operating books and histopathology reports from newly presenting PMD patients managed via a coordinated interventional laser surgery protocol between August 1996 and December 2014.…”

“…Contemporaneous clinical practice is based upon lesion assessment and incision biopsy for provisional diagnosis, with patients deemed to be “high risk” for SCC undergoing excision surgery for definitive diagnosis and management. It is recognized, however, that such decisions are subjective, based primarily upon observational studies and open to clinician preference and bias …”