|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 389-390
Neoadjuvant chemotherapy in oral cancer: Current status and future possibilities - Its benefit for T4 oral cancer is yet to be tested
Devendra Chaukar, Shivakumar Thiagarajan
Division of Head and Neck Oncology, Department of Surgical Oncology, Tata Memorial Centre, Parel; Homi Bhabha National Insttitute, Mumbai, Maharashtra, India
|Date of Submission||20-Mar-2020|
|Date of Decision||20-Mar-2020|
|Date of Acceptance||20-Mar-2020|
|Date of Web Publication||19-Jun-2020|
Division of Head and Neck Oncology, Department of Surgical Oncology, Tata Memorial Centre, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chaukar D, Thiagarajan S. Neoadjuvant chemotherapy in oral cancer: Current status and future possibilities - Its benefit for T4 oral cancer is yet to be tested. Cancer Res Stat Treat 2020;3:389-90
|How to cite this URL:|
Chaukar D, Thiagarajan S. Neoadjuvant chemotherapy in oral cancer: Current status and future possibilities - Its benefit for T4 oral cancer is yet to be tested. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jul 9];3:389-90. Available from: http://www.crstonline.com/text.asp?2020/3/2/389/287289
We would like to congratulate the authors for their extensive review of the role of neoadjuvant chemotherapy (NACT) in patients with oral squamous cell carcinoma (OSCC). The role of NACT in OSCC is unrealized as of today. This is mainly because of the two randomized trials and the subsequent meta-analysis that showed no benefits in terms of improvement in the overall survival (OS) as a result of the addition of NACT to the standard of care in these patients. The results could be mainly attributed to the fact that the majority of the patients included in both the randomized trials were T1–T3. Less than 20% of the patients in both the randomized trials had T4 disease, which forms the major bulk of the patients with OSCC to whom we offer NACT in our practice. Thiagarajan et al. in their matched-pair analysis looked at the possible benefits of NACT in patients with T4 OSCC. They showed that patients with T4b OSCC disease who received NACT before surgery had a prolongation of both OS and disease-free survival (DFS); however, there was no difference in the pattern of failure after treatment completion. Besides survival, the authors have mentioned the other benefits of NACT in oral cancer such as advanced disease (borderline resectable) and organ (mandible) preservation; both these are exciting areas for research in the future.
The authors state that for patients with technically unresectable OSCC NACT followed by surgery for responders should be considered as the standard of care, which is included in multiple guidelines. This statement needs to be interpreted with caution as an alternative of doing upfront surgery exits in selected situations. The definition for technically unresectable is variable and the review by Goel A, et al. tries to define and standardize the definition as done in pancreatic cancer. This would be useful in future studies. However, OSCC involving the prevertebral fascia, carotid vessels, and the pterygopalatine fissure would be definitely considered as unresectable. Pillai, et al. in their single centre study have performed upfront surgery in advanced T4 disease involving the supranotch masticator space (n = 51/281), many of which would fit into the criteria given by Patil, et al. as technically unresectable. Pillai, et al. report an envious margin negative rates in these cases, along with an impressive 2 year OS and DFS. They have essentially divided the masticator space as type I (infra-notch infratemporal fossa-ITF), type II (supranotch ITF without the involvement of the pterygopalatine fissure, infraorbital fissure and intracranial extension) and type III (involvement of the pterygopalatine fissure, infraorbital fissure, and intracranial extension). This is yet to be validated by other centres. Clearly there is an overlap of the criteria's and it does not help the clinician at large to decided which classification is to be followed for decision making.
A randomized trial looking at the advantage of NACT in comparison to upfront surgery in this category of patients would probably help answer this question and help the clinician choose the best treatment approach for these patients. In light of the available evidence patients with unresectable disease would probably not benefit from NACT. The role of NACT in upfront resectable OSCC has shown not to offer any survival advantage as of today. There is however equipoise regarding the role of NACT in patients with borderline resectable that needs to be tested in a randomised trial.,,
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Conflicts of interest
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| References|| |
Goel A, Singla A, Prabhash K. Neoadjuvant chemotherapy in oral cancer: Current status and future possibilities. Cancer Res Stat Treat 2020;3:51-9. [Full text]
Marta GN, Riera R, Bossi P, Zhong LP, Licitra L, Macedo CR, et al
. Induction chemotherapy prior to surgery with or without postoperative radiotherapy for oral cavity cancer patients: Systematic review and meta-analysis. Eur J Cancer 2015;51:2596-603.
Thiagarajan S, Dhar H, Bhattacharjee A, Fatehi KS, Shah SB, Chaukar D, et al
. Patterns of failure and outcomes in cT4 oral squamous cell carcinoma (OSCC) undergoing upfront surgery in comparison to neo-adjuvant chemotherapy (NACT) followed by surgery: A matched pair analysis. Oral Oncol 2020;100:104455.
Pillai V, Yadav V, Kekatpure V, Trivedi N, Chandrashekar NH, Shetty V, et al
. Prognostic determinants of locally advanced buccal mucosa cancer: Do we need to relook the current staging criteria? Oral Oncol 2019;95:43-51.
Patil VM, Prabhash K, Noronha V, Joshi A, Muddu V, Dhumal S, et al
. Neoadjuvant chemotherapy followed by surgery in very locally advanced technically unresectable oral cavity cancers. Oral Oncol 2014;50:1000-4.