Surgical Outcomes Post Neoadjuvant Chemotherapy in Stage IV cancers of Oral Cavity

To know the effect of neoadjuvant chemotherapy on surgical outcomes (R1 resections, post-operative complications, recurrence and follow up) in Stage IV borderline operable cancers of oral cavity.

Patients in group A (n=45) were those who were referred for neoadjuvant chemotherapy (NACT) with an intention to operate at a later date. These were compared with 45 patients of group B who were operated upfront. All 90 patients have stage IV squamous cell carcinoma of oral cavity. Details of patients were studied retrospectively from hospital records of surgical, medical, radiotherapy and pathology departments. All patients referred for NACT were wet lesions with perilesional edema and diffuse margins of lesions where the demarcation from normal tissue was not clear. Treatment response was assessed clinically and radiologically. Any reduction in tumor size on CT scan, MRI or clinically was considered response to chemotherapy. Various chemotherapy regimens were given in different patients - TPF (Taxol- Docetaxel or Paclitaxel, Cisplatin, 5 Fluoro Uracil), PMF (Cisplatin, Mitomycin C, 5 Fluoro Uracil), Cisplatin + Methotrexate and Cisplatin with 5 Fluoro Uracil. Inoperability was defined as involvement of the upper infratemporal fossa where R0 resection was difficult. Patients were followed up monthly after completion of treatment for one year and three monthly thereafter. Survival was calculated from the day of surgery to the death of the patient or last patient contact. The time of recurrence was also calculated from the day of surgery. Statistical methods used in the study were simple frequencies and proportion. Test of significance was Z test. Z = 2 was considered significant. Kaplan Meir survival analysis was used through SPSS software for disease free survival Results: Total 39 patients were operated in group A as remaining six progressed to inoperability while on chemotherapy. There were 3 R1 resections in group A and 9 R1 resections in group B (Z= 1.67). Eleven and three postoperative complications in group A and B respectively (Z= 2.67). There were nine and 16 recurrences so far in group A and B respectively (Z=1.27). DFS at one year was 90% and 55% respectively (p= 0.017).

Though the study shows a trend in favor of NACT when R1 resections, recurrences and survival at one year are considered but this was at the cost of those six patients who progressed on NACT and could have been operated initially. Such patients were present in each and every subset of chemotherapy used.