2018-19 Section 7-Neoplastic and Inflammatory Diseases of the Head and Neck eBook

Otolaryngology–Head and Neck Surgery 156(5)

difference in DFS with either of these factors. DOI has been shown to increase risk of recurrence in a number of studies; however, the threshold of increased risk has been consis- tently demonstrated at 2 mm, and only 3 of our patients had tumors with \ 2-mm DOI. 12-14 Lesion diameter has likewise been demonstrated to be a strong predictor of recurrence and survival more broadly in dermatologic series; however, this has been reported inconsistently in studies of head and neck CSCCs. 4,5,9,10,12,23-25 Haisma et al did find higher rates of recurrence if diameter was . 5 cm but no difference at 2 cm for a group of 366 patients with advanced head and neck CSCCs. 21 The presence of regional disease has been demonstrated in other studies to be a strong predictor of overall survival and disease-specific survival; however, its association with recur- rence is less well defined. 10,19-21,23-25 In our study, we did not see a significant association between the presence of regional disease and recurrence or DFS ( Figure 2 ), likely because the majority of recurrences that we observed were local (73%); that is, the factors that we found to be associated with recurrence pertain to properties of the primary tumor rather than to the presence or absence of regional disease. Furthermore, only 17.8% of the patients with regional disease at time of primary resection experienced regional failure, well below the overall failure rate of 31.6% for our entire cohort. These results illustrate the challenge and, therefore, the importance of achieving local control for this group of patients. We were unable to examine death and cause of death as an outcome, and given the limited success of salva- ging regional and distant failures, it is possible that regional disease is associated with these outcomes. Although 39.6% of our patients received postoperative adjuvant therapy, it was not associated with an improve- ment in RFS. Adjuvant radiation and chemoradiation have been associated with improved outcomes in a number of studies of patients with advanced head and neck CSCCs, 22,23,25,28 although the indications for adju- vant therapy are less well defined than for mucosal dis- ease. 17 Our results suggest that adjuvant therapy may be limited in its ability to prevent local recurrence for high- risk tumors such as those in this cohort. However, the ret- rospective nature of this study and the selection bias for patients who did receive adjuvant therapy limit any con- clusions that can be drawn from this result. A more detailed examination of the associations between treat- ment and outcomes for this cohort of patients is beyond the scope of our analysis. Conclusions We found that in patients with advanced head and neck CSCCs, the majority of recurrences are local and that the risk of recurrence is highest for patients with poorly differ- entiated tumors, recurrent tumors, or tumors with PNI. Aggressive local management of tumors with these features is therefore integral to achieving cure and should include wide surgical margins and consideration of local adjuvant therapy. Other factors that have been identified as predictors

of recurrence for less advanced disease, such as DOI and tumor diameter, were not significantly associated with recurrence and are perhaps less important in this patient population. In addition, primary tumors of the ear, cheek or temple, and lip as well as tumors with PNI were more likely to present with nodal disease. In these patients, the regional lymphatic basin should be carefully evaluated prior to sur- gery and elective neck dissection considered. Author Contributions Brianna N. Harris , concept and design, data acquisition and anal- ysis, drafting, final approval, accountability for all aspects of the work; Ahmed Bayoumi , data acquisition, drafting, final approval, accountability for all aspects of the work; Shyam Rao , concept and design, drafting, final approval, accountability for all aspects of the work; Michael G. Moore , concept and design, drafting, final approval, accountability for all aspects of the work; D. Gregory Farwell , concept and design, drafting, final approval, accountability for all aspects of the work; Arnaud F. Bewley , concept and design, data analysis, drafting, final approval, accountability for all aspects of the work. 1. Rogers HW, Weinstock MA, Harris AR, et al. Incidence esti- mate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol . 2010;146:283-287. 2. Chistenson LK, Borrowman TA, Vachon CM, et al. Incidence of basal cell and squamous cell carcinomas in a population younger than 40 years. JAMA . 2005;294:681-690. 3. Chen JG, Fleischer AB Jr, Smith ED, et al. Cost of nonmela- noma skin cancer treatment in the United States. Dermatol Surg . 2001;27:1035-1038. 4. Schmults CD, Karia PS, Carter JB, Han J, Quereshi AA. Factors predictive of recurrence and death from cutaneous squamous cell carcinoma: a 10-year, single-institution cohort study. JAMA Dermatol . 2013;149:541-547. 5. Jambusaria-Pahlajani A, Kanetsky PA, Karia PS, et al. Evaluation of AJCC tumor staging for cutaneous squamous cell carcinoma and a proposed alternative tumor staging system. JAMA Dermatol . 2013;149:402-410. 6. Estall V, Allen A, Webb A, Bressel M, McCormack C, Spillane J. Outcomes following management of squamous cell carcinoma of the scalp: a retrospective series of 235 patients treated at the Peter MacCallum Cancer Centre [published online June 10, 2016]. Australas J Dermatol . 7. Clayman GL, Lee J, Holsinger FC, et al. Mortality risk from squamous cell skin cancer. J Clin Oncol . 2005;23:759-765. 8. Sweeny L, Zimmerman T, Carroll WR, Schmalbach CE, Day KE, Rosenthal EL. Head and neck cutaneous squamous cell carcinoma requiring parotidectomy: prognostic indicators and treatment selection. Otolaryngol Head Neck Surg . 2014;150: 610-617. Disclosures Competing interests: None. Sponsorships: None. Funding source: None. References

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