|Year : 2017 | Volume
| Issue : 4 | Page : 616-620
Outcomes of surgically treated oral cancer patients at a tertiary cancer center in India
Deepa Nair1, Hitesh Singhvi1, Manish Mair1, Burhanuddin Qayyumi1, Anuja Deshmukh1, Gouri Pantvaidya1, Sudhir Nair1, Pankaj Chaturvedi1, Sarbani Ghosh Laskar2, Kumar Prabhash3, Anil DCruz4
1 Department of Head and Neck Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
2 Radiation Oncologist, Tata Memorial Centre, Mumbai, Maharashtra, India
3 Medical Oncologist, Tata Memorial Centre, Mumbai, Maharashtra, India
4 Director, Tata Memorial Centre, Mumbai, Maharashtra, India
|Date of Web Publication||30-Jul-2018|
Dr. Deepa Nair
Department of Head and Neck Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
BACKGROUND: Oral cancers are one of the most common cancers in India. Surgery is the main modality of treatment for oral cancer patients. It is important to understand the postoperative morbidity and mortality as it influences patient outcomes. AIM: The aim of this study was to determine oral cancer patients' characteristics, treatment details, 30-day morbidity and mortality, and survival outcomes. SETTINGS AND DESIGN: This was a retrospective analysis of prospectively collected data in a tertiary cancer center. MATERIALS AND METHODS: This study included 850 surgically treated oral cancer cases between January and December 2012. STATISTICAL ANALYSIS: We performed univariate survival analysis by log-rank test, and all significant (P < 0.05) variables underwent multivariate analysis using Cox regression. RESULTS: The median age was 52 years and the male-to-female ratio was 3.4:1. Nearly one-third of the patients received some form of prior treatment. Buccal mucosa (BM) was the most common subsite (64.94%). BM cancers (81.1%) were more likely to present in advanced stage compared to tongue cancers (52%) (P = 0.000). The incidence of postoperative morbidity and mortality was 36.4% and 0.9%, respectively. Complications were higher in cT3-4 (P = 0.000), cN positive (P = 0.000), and those requiring microvascular reconstruction (P = 0.004). The 5-year overall survival of the entire study group was 70.4%. The survival of early and locally advanced stages was 75.1% and 68.4%, respectively. The factors influencing survival were age (>50 years), advanced cT stage, nodal metastasis, overall stage, and presence of orocutaneous fistula. CONCLUSION: The morbidity, mortality, and long-term outcomes of surgically treated oral cancer patients at our center are comparable to those treated in the developed world. Aggressive management of postoperative complications is crucial for early recovery and timely initiation of adjuvant treatment.
Keywords: Complications, oral concers, outcomes, surgery
|How to cite this article:|
Nair D, Singhvi H, Mair M, Qayyumi B, Deshmukh A, Pantvaidya G, Nair S, Chaturvedi P, Laskar SG, Prabhash K, DCruz A. Outcomes of surgically treated oral cancer patients at a tertiary cancer center in India. Indian J Cancer 2017;54:616-20
|How to cite this URL:|
Nair D, Singhvi H, Mair M, Qayyumi B, Deshmukh A, Pantvaidya G, Nair S, Chaturvedi P, Laskar SG, Prabhash K, DCruz A. Outcomes of surgically treated oral cancer patients at a tertiary cancer center in India. Indian J Cancer [serial online] 2017 [cited 2019 Aug 21];54:616-20. Available from: http://www.indianjcancer.com/text.asp?2017/54/4/616/237898
| » Introduction|| |
Head and neck cancers are common in the Indian subcontinent, and oral cavity cancers (oral squamous cell carcinoma [OSCC]) is the most common among them. OSCC is the second most common cancers in males with an incidence of 10.1 (age-standardized ratio [ASR]). Similarly, in females, OSCC is among the top 10 cancers with an incidence of 6.7 (ASR). The high incidence of OSCC in India can be attributed to the high prevalence of tobacco,,, areca nut, alcohol consumption, and poor oral hygiene. The mainstay of treatment for OSCC remains surgery with appropriate adjuvant treatment. However, surgical complication has an impact on treatment outcomes. These complications increase treatment duration, cost, and may affect the quality of life. It is important to identify factors responsible for perioperative morbidity and modality, which will enable surgeons to optimize treatment by anticipating problems that are likely to occur. This approach will help improve outcomes with reduced treatment morbidity. We present a descriptive audit of OSCC operated in a single tertiary cancer center in India. Demographics, clinical presentations, treatment details, 30-day morbidity and mortality associated with surgery, and survival outcomes were analyzed in this study.
| » Materials and Methods|| |
We retrospectively reviewed the prospectively maintained database of surgically treated oral cancers between January and December 2012. All patients underwent routine investigations including imaging as per the institutional protocol. Thick tumors (>10 mm) or the presence of adverse features such as perineural invasion/lymphovascular emboli/poor grade of differentiation and nodal metastases were given adjuvant RT. Adjuvant Concurrent chemoradiation (CCRT) was given in cases of positive margins and/or nodes with extracapsular spread.
Statistical analysis was done using the software SPSS 20.0 (IBM, Armonk, NY, USA). Overall survival (OS) was calculated by Kaplan–Meier method. OS is defined as the duration from the date of surgery until death from any cause. We performed univariate survival analysis by log-rank test and all significant (P < 0.05) variables were subsequently tested (multivariate) with Cox regression analysis using forward stepwise selection.
| » Results|| |
A total of 3624 new cases of OSCC were registered in our outpatient department in 2012. We included the 850 cases operated between January and December 2012 in this study. The median age of presentation of our patients was 52 years (range: 14–86 years). The majority of cases were males (77.5%) with a male-to-female ratio of 3.4:1. Most patients had a good performance status – the Eastern Cooperative Oncology Group 0 or 1, and approximately 30% of them had comorbidities such as the presence of hypertension, diabetes mellitus, ischemic heart disease, anemia, and hepatitis. The demographics and clinical characteristics of the patients are described in [Table 1].
For the convenience of analysis, we have clubbed cancers arising from the buccal mucosa (BM) and gingivobuccal sulcus (GBS) together as BM complex cancers. Similarly, we clubbed tongue and floor of mouth cancers together as tongue complex cancers. The most common subsite affected was buccal mucosa (64.94%). Most patients presented with advanced Stage III and IV (74.1%) disease. Among treatment-naïve patients, more cases of BM/GBS complex (81.1%) presented in advanced stages compared to tongue cancers (52%) (P = 0.000). Nodal positivity at presentation was more likely to be seen in tongue cancers (46.1%) compared to BM/GBS complex cancers (42.5%) (P = 0.191), although statistically not significant.
Prior treatment details
A significant number of patients (266/850) received some treatment prior to the surgery. Among these, 20.11% (171/850) of the patients underwent prior surgery, 11.4% (82/850) received neoadjuvant chemotherapy, 1.1% (9/850) received CCRT, and 0.5% (4/850) of patients received RT alone.
The extent of surgery varied with respect to the clinical presentation of the disease [Table 2]. Early lesions underwent wide excisions alone (29.2%). In advanced cases of BM/GBS complex, 22.7% required composite segmental resections of the mandible (posterior segmental resection, hemimandibulectomy, mid-third mandibular resections, etc.). Approximately 10.9% of the cases had a tumor involving both GBS, requiring bialveolar composite resections. Marginal mandibulectomy was done in 9.2% of the patients, wherever the tumor was abutting the mandible but not eroding it. Neck dissection was performed in 712/850 (83.76%) while neck was not addressed in 138/850 (16.2%) patients. Among these, 65.41% (556/850) underwent only ipsilateral neck dissection, 17.41% (148/850) underwent bilateral neck dissection, and 0.94% (8/850) had isolated contralateral neck dissection.
Most cases required some form of reconstruction after excision of primary tumor [Table 3]. Primary closure was possible in 33.4% (284/850) of the patients while some form of reconstruction was required in the remaining 66.5% (566/850) of the patients. Among patients requiring reconstruction, local flaps were used in 6.82% (58/850), pedicled flaps in 24.7% (210/850), and microvascular flaps were used in 25.88% (220/850).
Overall, surgery for OSCC is relatively safe with a 30-day mortality rate of 0.9%. However, because of the advanced nature of the disease and extensive surgeries, the morbidity of the procedure continues to be high, with an overall morbidity rate of 36.4%. The complications were more likely in cT3-4 (P = 0.000), cN positive (P = 0.000) cases, and where microvascular flaps were used for reconstruction (P = 0.004). Higher complication rates, where microvascular flaps were used for reconstruction, may be fallacious as these are typically cases with advanced disease. Complication rate was independent of age (P = 0.782), gender (P = 0.859), and site of malignancy (P = 0.552). A detailed list of complications has been described in [Table 4]. One of the most common complications after oral cancer surgery is the presence of orocutaneous fistula (OCF), which was seen in 8.8% of the patients. We classified them as major OCF if the management of the same required prolonged hospitalization or surgical intervention under general anesthesia. Major OCF was reported in 3.4%. Minor OCF was classified as one requiring limited interventions such as minor debridements and resuturing, which was seen in 5.4% of the patients. Major flap loss was a significant complication seen more in microvascular flap (P = 0.000) as compared to other types of reconstruction, often leading to the need for a second flap. A second flap was required in 7.9% (17/220) of the cases when microvascular flaps were used for reconstruction compared to 1.7% (5/279) of the cases where local or pedicled flaps were used. Thus, major flap loss was seen in 22 patients and all required a second flap. Seroma is a collection of clear fluid at the surgical site. It was significantly (P = 0.023) higher in microvascular flaps (11.4% vs. 7.7%) compared to local or pedicled flaps. Higher incidence of seroma may again be fallacious as microvascular flap was used mainly in advanced cases. The incidence of serious medical complications such as pulmonary embolism, deep vein thrombosis, and myocardial infarction was <2%.
Follow-up information were not available for 7.8% (66/850) of the patients. The median follow-up of the study group was 31 months and the mean was 30 months. At the last follow-up, 512/850 (60.2%) were alive and disease free, 105/850 (12.4%) were alive with disease, 154/850 (18.1%) died due to cancer, and 13/850 (1.5%) patients died due to other causes. On survival analysis, we found age >50 years (P = 0.007), cN stage (P = 0.000), cT stage (P = 0.003), overall stage (P = 0.024), and postoperative OCF (P = 0.003) as significant predictors of OS [Table 5]. Gender (P = 0.064), site of malignancy (P = 0.119), and associated comorbidities (P = 0.120) did not have any impact on OS [Figure 1] and [Figure 2]. The OS of the entire study group at 5 years was 70.4%, and the mean survival time of 54 months. Five-year OS of Stage I and II oral cancers was 75.1% and of Stage III and IV oral cancers was 68.4%, with a mean survival of 57 and 50 months, respectively.
|Figure 1: Kaplan–Meier survival curves showing (a) overall survival as per overall stage, (b) overall survival as per T stage, (c) overall survival as per nodal metastasis|
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|Figure 2: Kaplan–Meier survival curves showing (a) overall survival as per age (>50 years), (b) overall survival as per comorbidities, (c) overall survival as per postoperative orocutaneous fistula|
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| » Discussion|| |
This study comprised patients surgically treated at a single tertiary cancer center with uniform treatment protocols. The objective of this study was to analyze the demographic, treatment details, complications, and outcomes of surgically treated oral cancers presenting to our hospital. Complications and outcome data were maintained prospectively.
Most of our patients (74.1%) presented in locally advanced stages of the disease. This is similar to other studies that report 70%–80% of patients with BM cancers presenting at an advanced stage. This can be attributed to the lack of awareness, lack of affordable health-care facilities, low socioeconomic status, and scarcity of trained workforce. Owing to the rampant tobacco chewing habit, BM was the most commonly affected subsite of the oral cavity.
Postoperative complications often result in prolonged hospital stay, poor quality of life, delayed adjuvant treatment, and augmented late sequelae. The incidence of postoperative complications in our study was 36.4%, which is similar to the incidence of complications reported by Farwell et al., i.e., 34%. However, higher complication rates of 47% and 50% were reported in other studies by McGurk et al. and de Melo et al., respectively. Overall, the incidence of complications in published literature varies from 15% to 50%.,,, The most important complications in our study were OCF and flap necrosis seen in 8.8% and 9.6% of the patients, respectively. The most common complications seen in other studies were wound dehiscence (5.6%) and wound infection (5.2%) followed by OCF (4.7%) and total/partial flap loss (4.6%). de Melo et al. also reported that OCF was seen in 9.1% of the cases and flap necrosis seen in 20.9% of the cases. Chyle mainly consists of lymph fluid, emulsified fat (1%–3%), and triglycerides. Approximately 2–4 L of chyle is carried by the thoracic duct every day. Thus, the presence of chyle leak might delay wound healing and deteriorate the nutritional status of the patient. The incidence of chyle leak in our study was 1.5% which is similar to the reported literature.,, We reported a 30-day mortality rate of 0.9% in our study. Other studies have reported a mortality rate between 0.15% and 3.6%.,, The causes of mortality in the postoperative period were sudden cardiac arrest, arterial rupture, hypovolemic shock, respiratory distress, and tracheoesophageal fistula.
Out of the 850 patients, follow-up data of 67 patients (7.8%) were not available. In general, maintenance of follow-up data is difficult in developing countries. Patients move from villages and small towns to cities for treatment, causing a significant financial strain. Subsequent follow-ups at regular intervals may additionally burden them. Hence, a lot of patients would never follow-up with the treating center, preferring medical care nearer to their home. The incidence of lost to follow-up in a study by Priante et al. was 13.5% similar to our experience.
The 5-year OS of 70% seen in our study is comparable to the published literature. Wang et al. studied 275 OSCC patients and reported a 5-year survival of 79.9%. van Dijk et al. extracted data from the Netherlands Cancer Registry and reported a 5-year OS of 60%. Seo et al. studied 700 Korean patients with OSCC reporting a 5-year OS of 63.5%. An International Collaborative Study including patients from seven international cancer centers also showed a 5-year OS of 70%. We found advanced cT stage (P = 0.003), cN stage (P = 0.000), and overall stage (P = 0.024) as significant predictors of OS which is also reported by various other studies., The impact of age on survival varied across studies. Roger et al. showed a decrease in survival with advancing age; however, Liu et al. showed that there was no impact of age on survival. We used receiver operating characteristic curves to identify the ideal cutoff of age having the best sensitivity and specificity for OS. We found that age more 50 years was a significant factor affecting OS (P = 0.007). Rosenthal et al. reported that a total treatment package time of <100 days is associated with improved tumor control and survival. Postoperative OCF also had a significant impact on OS. This may be due to the delayed healing, impacting timely start of adjuvant therapy and prolonged overall treatment duration.,
| » Conclusions|| |
BM cancer is the most common OSCC and most of these patients present at an advanced stage. The overall 30-day morbidity rate was 36.4% and 30-day mortality was 0.9%. Advanced tumors, nodal metastasis, and those requiring microvascular reconstruction have a higher incidence of complications. However, early detection and aggressive management of these complications may reduce the overall morbidity and help receive timely adjuvant treatment. OS of the study group was 70.4% at 5 years. Old age (>50 years), advanced cT stage, nodal metastasis, overall stage, and OCF are associated with poor survival. This study also highlights that adherence to uniform treatment protocols may still result in good survival outcomes even in locally advanced oral cancer.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]