Top Line: Does neoadjuvant chemotherapy allow for mandible preservation in patients who would otherwise require segmental mandibulectomy for oral cavity cancer?
The Study: Oral cavity cancer is primarily managed with surgical resection followed by adjuvant therapy guided by risk factors. Neoadjuvant chemotherapy has been evaluated for locally advanced oral cavity cancer, however randomized trials have shown no improvement in overall or disease-free survival. Many patients with locally advanced oral cavity cancer require partial mandibular resection to achieve adequate soft tissue margins. This randomized phase 2 trial sought to determine if neoadjuvant chemotherapy (NAC) could help spare some patients from mandibular resection. Sixty-eight patients were enrolled with resectable oral cavity cancer that approximated, but did not invade the mandible such that two blinded surgeons deemed that a segmental mandibulectomy was necessary. They were randomized to receive NAC prior to surgical resection, which consisted of two cycles of TPF (docetaxel, cisplatin, fluorouracil). All patients in the standard arm had segmental mandibulectomy while in the NAC arm, the surgeon determined the extent of resection and whether segmental mandibulectomy was necessary. All patients had ipsilateral neck dissection and adjuvant radiation, but patients in the NAC arm also received concurrent chemotherapy due to concerns about the uncertainty of margin status after neoadjuvant chemo. The rates of grade 3 and 4 toxicity during NAC were 41.2% and 32.4%, respectively. The NAC response rate was 38%. The mandible preservation rate with NAC was 47%, and no patients had positive resection margins. There were no differences between arms with respect to locoregional control, disease-free survival, and overall survival. An important question is whether a 47% mandible preservation rate is worth the significant increase in NAC toxicity and adjuvant chemoradiation.
TBL: Nearly half of patients with locally advanced oral cavity cancer may avoid segmental mandibulectomy at the expense of increased chemo toxicity and adjuvant chemoradiation. | Chaukar, J Clin Oncol 2021