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Purpose:Malignant progression exhibits a tightly orchestrated balance between immune effector response and tolerance. However, underlying molecular principles that drive the establishment and maintenance of the tumor immune phenotype remain to be elucidated.Experimental Design:We trained a novel molecular classifier based on immune cell subsets related to programmed death-ligand 1 (PD-L1) and interferon γ (IFNγ) expression, which revealed distinct subgroups with higher (cluster A) or lower (subcluster B3) cytotoxic immune phenotypes. Integrative analysis of multi-omics data was conducted to identify differences in genetic and epigenetic landscapes as well as their impact on differentially expressed genes (DEG) among immune phenotypes. A prognostic gene signature for immune checkpoint inhibition (ICI) was established by a least absolute shrinkage and selection operator (LASSO)-Cox regression model.Results:Mutational landscape analyses unraveled a higher frequency of CASP8 somatic mutations in subcluster A1, while subcluster B3 exhibited a characteristic pattern of copy-number alterations affecting chemokine signaling and immune effector response. The integrative multi-omics approach identified EGFR and PTGS2 as key nodes in a gene regulatory network related to the immune phenotype, and several DEGs related to the immune phenotypes were affected by EGFR inhibition in tumor cell lines. Finally, we established a prognostic gene signature by a LASSO-Cox regression model based on DEGs between nonprogressive disease and progressive disease subgroups for ICI.Conclusions:Our data highlight a complex interplay between genetic and epigenetic events in the establishment of the tumor immune phenotype and provide compelling experimental evidence that a patient with squamous cell carcinoma of the head and neck at higher risk for ICI treatment failure might benefit from a combination with EGFR inhibition.

Simple Summary In brief, this is the first prospective study using a multicentric approach to investigate the effectiveness of adjuvant radiotherapy in patients with early squamous cell carcinoma of the oral cavity (T1/2) and the oropharynx (T1) with one single ipsilateral cervical lymph node metastasis (pN1) in terms of overall survival, time to progression, and quality of life. After the inclusion of 209 patients into this prospective multicentric comprehensive cohort study (2009–2021) and analyzing the follow-up data, we can conclude that adjuvant radiotherapy in patients with early squamous cell carcinoma of the oral cavity and oropharynx does not seem to influence overall survival, but it positively affects the time to progression. However, irradiated patients report a significantly decreased quality of life up to three years after therapy compared to the observation group. Abstract (1) Background: Evaluation of impact of adjuvant radiation therapy (RT) in patients with oral squamous cell carcinoma of the oral cavity/oropharynx (OSCC) of up to 4 cm (pT1/pT2) and solitary ipsilateral lymph node metastasis (pN1). A non-irradiated group with clinical follow-up was chosen for control, and survival and quality of life (QL) were compared; (2) Methods: This prospective multicentric comprehensive cohort study included patients with resected OSCC (pT1/pT2, pN1, and cM0) who were allocated into adjuvant radiation therapy (RT) or observation. The primary endpoint was overall survival. Secondary endpoints were progression-free survival and QL after surgery; (3) Results: Out of 27 centers, 209 patients were enrolled with a median follow-up of 3.4 years. An amount of 137 patients were in the observation arm, and 72 received adjuvant irradiation. Overall survival did not differ between groups (hazard ratio (HR) 0.98 [0.55–1.73], p = 0.94). There were fewer neck metastases (HR 0.34 [0.15–0.77]; p = 0.01), as well as fewer local recurrences (HR 0.41 [0.19–0.89]; p = 0.02) under adjuvant RT. For QL, irradiated patients showed higher values for the symptom scale pain after 0.5, two, and three years (all p < 0.05). After six months and three years, irradiated patients reported higher symptom burdens (impaired swallowing, speech, as well as teeth-related problems (all p < 0.05)). Patients in the RT group had significantly more problems with mouth opening after six months, one, and two years (p < 0.05); (4) Conclusions: Adjuvant RT in patients with early SCC of the oral cavity and oropharynx does not seem to influence overall survival, but it positively affects progression-free survival. However, irradiated patients report a significantly decreased QL up to three years after therapy compared to the observation group.

Background Free flap reconstruction is the standard of care in extensive defects of the head and neck area, and although most patients may be treated sufficiently with one flap, recurrence of a malignant tumor or failure of a previous reconstruction may make the use of a second (or more) flap necessary. The aim of this study was to evaluate the indications and success rates of multiple consecutive reconstructive procedures in a large cohort of patients. Methods Nine hundred ninety-six free flap reconstructions were retrospectively analyzed and cases of sequential reconstructions in the same patient were identified. Indications, success rates, perioperative procedures, and frequently used flaps were evaluated. Results Two hundred twenty cases of sequential microvascular reconstructions were identified, ranging from two to six flaps per patient. The overall flap success rate was 89.1 percent. A history of diabetes was identified as a risk factor for flap failure (p = 0.029). There was no association of flap loss with the number of reconstructive procedures per patient. Conclusions The use of several free flaps in the same patient is a feasible option for patients suffering from recurrent tumors or to improve quality of life by a secondary reconstruction. A salvage free flap transfer to replace a lost transplant exhibits good success rates. Clinical question/level of evidence Therapeutic, IV.

Objectives Survival for patients with recurrent oral squamous cell carcinoma is usually poor, and the most effective treatment has not yet been clearly defined. The present study evaluates the outcome in radiotherapy-naïve patients after recurrence of oral squamous cell carcinoma with respect to different treatment modalities including surgery, radiation, chemoradiation, and palliative treatment. Patients and methods In this retrospective study, we included all patients with primary oral squamous cell carcinoma who received exclusively surgical therapy between 2010 and 2020 and who suffered from locoregional recurrence in their follow-up. Patients with previous adjuvant therapy were excluded from this protocol. Clinical and pathological parameters were collected and statistically evaluated. Survival analysis was performed according to Kaplan–Meier. The primary endpoints were overall and progression-free survival in dependance of treatment strategy for recurrent tumors. Results Out of a total of 538 patients with surgically treated primary oral squamous cell carcinoma, 76 patients met the inclusion criteria. The mean follow-up was 38 ± 32 months. Patients who received surgically based therapy had a significantly better outcome in terms of disease-free survival (DFS) and overall survival (OS) (DFS p p p Conclusion We recommend primary surgical therapy for radiotherapy-naïve patients with recurrent oral squamous cell carcinoma, supplemented by risk-adapted adjuvant therapy. Clinical relevance Surgical therapy continues to play a central role in the treatment of radiotherapy-naïve patients with recurrent oral squamous cell carcinoma.

Triggering receptor expressed on myeloid cells 2 (TREM2) is suggested to hamper antitumor immune response in multiple cancers. However, the role of TREM2 in oral squamous cell carcinoma (OSCC) and its expression in tumor-associated macrophages (TAMs) are unknown. In this study, TREM2 expression was analyzed in the primary tumors and corresponding lymph-node metastases of OSCC patients via immunohistochemistry on tissue microarrays. Human peripheral blood mononuclear cells (PBMCs) and single-cell suspensions of tumor and healthy adjacent tissues were analyzed for the presence of TREM2+ macrophages and TAMs using flow cytometry. The serum levels of soluble TREM2 (sTREM2) were quantified using an enzyme-linked immunosorbent assay. High TREM2 expression was associated with advanced UICC stages (Spearman’s rank correlation (SRC), p = 0.04) and significantly reduced survival rates in primary tumors (multivariate Cox regression, progression-free survival: hazard ratio (HR) of 2.548, 95% confidence interval (CI) of 1.089–5.964, p = 0.028; overall survival: HR of 2.17, 95% CI of 1.021–4.613, p = 0.044). TREM2 expression was significantly increased in the PBMCs of OSCC patients in UICC stage IV compared with healthy controls (ANOVA, p < 0.05). The serum levels of sTREM2 were higher in advanced UICC stages, but they narrowly missed significance (SRC, p = 0.059). We demonstrated that TREM2 was multi-factorially associated with advanced stages and inferior prognosis in OSCC patients and that it could serve as a prognostic biomarker in OSCC patients. Targeting TREM2 has the potential to reshape the local and systemic immune landscape for the potential enhancement of patients’ prognosis.

The aim of this study was to analyse the rates of metastatic events and clinical outcomes of patients with adenoid cystic carcinoma (ACC) of the minor salivary glands and to critically evaluate the role of surgical therapy. A retrospective cohort study was designed including all patients with ACC of the oral minor salivary glands treated in the study department during the years 2010-2017. Relevant clinicopathological data were analysed to determine factors with an impact on overall survival (OS) and progression-free survival (PFS). Forty-one patients with primary ACC of the oral cavity and the oropharynx were included. Cervical metastases were found in 14 patients (34.1%) and were shown to have a significant negative impact on OS (P=0.009) and PFS (P=0.03). Sixteen patients developed disease recurrence during follow-up (39.0%) and most patients exhibited local disease recurrence with or without regional or distant metastases (14/16, 87.5%). Local recurrence was treated successfully with surgery in five cases. We recommend surgical therapy for patients with ACC of the minor salivary glands, including elective neck dissection and microvascular reconstruction, to optimize the planning of adjuvant therapy.

Purpose Strategies for Indolamine-2,3-dioxygenase 1 (IDO1) inhibition in cancer immunotherapy once produced encouraging results, but failed in clinical trials. Recent evidence indicates that immune cells in the tumour microenvironment, especially macrophages, contribute to immune dysregulation and therefore might play a critical role in drug resistance. Methods In this study, we investigated the significance of IDO1 expressing immune cells in primary tumours and corresponding lymph node metastases (LNMs) in oral squamous cell carcinoma (OSCC) by immunohistochemistry. The link between IDO1 and macrophages was investigated by flow cytometry in tumour tissue, healthy adjacent tissue and peripheral blood mononuclear cells (PBMCs). IDO1 activity (measured as Kynurenine/Tryptophan ratio) was assessed by ELISAs. Results High IDO1 expression in tumour-infiltrating immune cells was significantly correlated with advanced stages [Spearman’s rank correlation (SRC), p = 0.027] and reduced progression-free survival (multivariate Cox regression, p = 0.034). IDO1 was significantly higher expressed in PBMCs of patients in advanced stages than in healthy controls (ANOVA, p + macrophages were more abundant in intratumoural areas than peritumoural (t test, p p t test, p Conclusion All in all, IDO1 expressing immune cells, especially macrophages, are more abundant in advanced stages of OSCC and are associated with reduced progression-free survival. Further investigations are needed to explore their role in local and systemic immune response. The IDO1 activity might be a suitable biomarker of metastasis in OSCC patients.

Purpose The adenoid cystic carcinoma (ACC), Erbitux, and Particle Therapy (ACCEPT) phase 1/2 trial (NCT01192087) evaluated a combined-modality approach (concurrent cetuximab and intensity modulated radiation therapy with carbon ion boost) for newly diagnosed nonmetastatic head and neck ACC. Methods and Materials Twenty-three patients with ACC were enrolled between June 2012 and June 2017 after initial diagnosis or postoperatively. All received a 400 mg/m2 cetuximab loading dose a week before radiation therapy, followed by weekly 250 mg/m2 doses starting on the first day of radiation therapy. The carbon ion radiation therapy boost was 24 Gy (relative biological effectiveness) in 8 daily fractions, followed by intensity modulated radiation therapy (54 Gy). The primary endpoint was safety and feasibility (defined based on Common Terminology Criteria for Adverse Events grade ≥3 events). Secondary endpoints included local and distant relapse, disease-free survival, and overall survival. Results Disease was most commonly in the paranasal sinuses (30%), palate (17%), and nasopharynx (17%). Nine (39%) patients underwent surgery (R1: 22%, R2: 78%). Median follow-up was 38.5 months. No patients experienced grade 4 to 5 events. Rates of grade 3 rash and radiation dermatitis were 17% and 22%, respectively. Grade 2 and 3 mucositis and dysgeusia occurred in 43% and 48% and in 9% and 0%, respectively. Grade 2 to 3 dysphagia and xerostomia were present in 43% and 4% and in 26% and 0%, respectively. At last follow-up, 5 (22%) patients experienced in-field relapse and 6 (26%) developed distant metastases. The 3-year disease-free survival was 67%, and median overall survival was 54 months. Conclusions Outcomes of this trial were satisfactory. Although the trial did not meet the predefined criteria of feasibility owing to the comparatively high rates of grade 3 dermatitis, numbers are comparable to existing data on cetuximab + radiation therapy.

In cases of simultaneous chemoradiotherapy (CRT), early recognition of toxic side effects is important, as drug discontinuation may prevent further injury. It appears favorable to undertake further steps to investigate whether patient subgroups behave differently depending on their toxicity profile. We retrospectively analyzed 125 consecutive patients with non-metastasized carcinoma of the head and neck who were treated with CRT (cisplatin 40 mg/m2 weekly) in 2013/2014. Patients were planned to receive six cycles of cisplatin. Statistical analyses were performed using the chi2 test, t-test, Kaplan–Meier method, and the log-rank test, as appropriate. Eighty-six patients did not reach the intended sixth cycle (68.8%; 60.0% of whom were ≥60 years, p

Modern head and neck reconstructive surgery offers a multitude of different reconstructive options. In such cases, donor site morbidity is an important factor in the affected patient's decision-making. The aim of this study was to perform an objective comparison of donor site morbidity for the five most frequent microvascular donor sites in head and neck reconstructive surgery (radial forearm, anterolateral thigh, fibula, iliac crest, and scapula) using a uniform testing system. In this cross-sectional study, 117 donor sites were analyzed (106 for malignant disease and 11 for non-malignant disease): 73 radial forearm, 14 scapula, 12 anterolateral thigh, 10 fibula, and eight iliac crest. Testing consisted of range of motion, muscle strength, and sensation. The non-affected side served as the control. Quality of life was assessed using the Washington Quality of Life Questionnaire version 4 in its German translation. Range of motion was restricted in 15 cases (12.8%). Muscle strength was decreased in 58 cases (49.6%). Sensation was reduced in 70 cases (60%). Concerning quality of life, 31.2% of patients were limited in their daily activities. The scapula flap showed the highest incidence of overall donor site morbidity. However, correlation between objective and subjective donor site impairment was weak and the majority of patients experienced only minor limitations.

Introduction The aim of this retrospective study was to evaluate the incidence of regional metastases in squamous cell carcinoma (SCC) of the tongue, in order to validate different neck management regime recommendations. Materials and methods A cohort of 97 patients suffering from primary SCC of the tongue was analyzed in regard to the development of primary and late neck node metastases, considering tumor stage and affected side. Survival analysis was performed to determine the impact of different relevant clinical and pathological factors on overall and progression-free survival. Results Regional metastases occurred in 29 patients (29.9%). In early-stage tumors (T1 and T2), the rates of primary metastases were 28.6% and 22.4%, respectively. Bilateral cervical metastases are rare but were detected in early-stage cancer in several cases (T1: 2.1%; T2: 11.8%). Conclusion The development of regional metastases in the ipsilateral and contralateral neck, even in early-stage SCC of the tongue, illustrates the importance of elective bilateral neck dissection in the treatment of affected patients.

BACKGROUND This study aimed on evaluating the expression levels of the immune checkpoint proteins, PD-L1 and PD-L2, in tissue specimens of 175 oral squamous cell carcinomas (OSCC) and 33 corresponding lymph node metastases (LNM). METHODS Tissue microarrays of primary OSCC and matched LNM were investigated via immunohistochemistry regarding PD-L1/PD-L2 expression. Results were compared for primary tumors and corresponding metastases and correlated with clinicopathological data. RESULTS PD-L1 expression in cancer cells correlated significantly with tumor size, and the presence of regional metastases (P < 0.01). PD-L1 expression was significantly higher in metastases as compared to primary OSCC (P < 0.05). Overall survival was significantly worse in patients with higher levels of PD-L1 and PD-L2 score (P < 0.05). CONCLUSIONS This is the first publication to compare PD-L1 and PD-L2 expression in primary OSCC and matched LNM. The results indicate that anti-PD-1 therapy may be of therapeutic use even in early stage OSCC to prevent further progression.

Survival for patients with recurrent oral squamous cell carcinoma is usually poor, and the most effective treatment has not yet been clearly defined. The present study evaluates the outcome in radiotherapy-naïve patients after recurrence of oral squamous cell carcinoma with respect to different treatment modalities including surgery, radiation, chemoradiation, and palliative treatment.In this retrospective study, we included all patients with primary oral squamous cell carcinoma who received exclusively surgical therapy between 2010 and 2020 and who suffered from locoregional recurrence in their follow-up. Patients with previous adjuvant therapy were excluded from this protocol. Clinical and pathological parameters were collected and statistically evaluated. Survival analysis was performed according to Kaplan-Meier. The primary endpoints were overall and progression-free survival in dependance of treatment strategy for recurrent tumors.Out of a total of 538 patients with surgically treated primary oral squamous cell carcinoma, 76 patients met the inclusion criteria. The mean follow-up was 38 ± 32 months. Patients who received surgically based therapy had a significantly better outcome in terms of disease-free survival (DFS) and overall survival (OS) (DFS p 0.001; OS p 0.001). The presence of regional metastases and a short disease-free interval (DFI) between primary and recurrent cancer were significant predictors for adverse outcomes (DFI p 0.001).We recommend primary surgical therapy for radiotherapy-naïve patients with recurrent oral squamous cell carcinoma, supplemented by risk-adapted adjuvant therapy.Surgical therapy continues to play a central role in the treatment of radiotherapy-naïve patients with recurrent oral squamous cell carcinoma.

Simple Summary Advanced malignant tumors of the oral cavity are challenging because they impose serious oncological and functional requirements on the treatment specialist. Depending on the localization and the extent of the primary tumor, a full-thickness resection affecting the facial skin may be necessary to achieve a complete tumor resection. The resulting defects need adequate reconstruction in order to restore the aesthetics and functionality of the orofacial system. In this retrospective analysis, the authors aimed to evaluate treatment techniques for these tumors and analyze the clinical outcome of the related procedures. Full-thickness tumor resection with free flap reconstruction due to advanced cancer was performed in 33 patients. Abstract Advanced tumors of the head and neck are challenging for the treatment specialist due to the need to synergize oncological and functional requirements. Free flap reconstruction has been established as the standard of care for defects following tumor resection. However, depending on the affected anatomic subsite, advanced tumors may impose specific difficulties regarding reconstruction, especially when full-thickness resection is required. This study aimed to evaluate reconstructive strategies and oncological outcomes in patients with full-thickness resection of the oral cavity. A total of 33 patients with extensive defects due to squamous cell carcinoma of the oral cavity were identified. Indications, reconstructive procedures, and clinical outcome were evaluated. Thirty-two patients (97%) presented locally advanced tumors (T3/T4). Complete tumor resection was achieved in 26 patients (78.8%). The anterolateral thigh flap was the most frequently used flap (47.1%), and the primary flap success rate was 84.8%. The cohort demonstrated a good local control rate and moderate overall and progression-free survival rates. Most patients regained full competence regarding oral alimentation and speech. Full-thickness tumor resections of the head and neck area may be necessary due to advanced tumors in critical anatomic areas. In many cases, radical surgical treatment leads to good oncological results. Free flap reconstruction has been shown to be a suitable option for extensive defects in aesthetically challenging regions.

Die Behandlung ausgedehnter Lokalrezidive der Mundhohle und des Oropharynx gehort zu den grosten Herausforderungen in der onkologischen Therapie der Kopf-Hals-Region. In der Regel erhielten diese Patienten im Rahmen der Therapie ihres Primartumors neben einer chirurgischen Resektion bereits eine adjuvante Radiotherapie. Aus diesem Grund ist eine erneute Bestrahlung der rezidivierenden Karzinome haufig nur noch in palliativer Intention moglich. Da trotz erstaunlicher Fortschritte in der Entwicklung moderner Wirkstoffe aktuell auch die medikamentose Systemtherapie lediglich der Symptomkontrolle dienen kann, hat die Rettungschirurgie in diesen Fallen den bedeutendsten Stellenwert. Die wichtigste Voraussetzung fur die Durchfuhrung einer solchen radikalen rettungschirurgischen Operation ist allerdings, dass es in der Tumorumfelddiagnostik keine Hinweise auf das Vorliegen von Fernmetastasen gibt. Daruber hinaus ist pratherapeutisch unbedingt zu klaren, ob eine R0-Resektion mit ausreichendem Sicherheitsabstand moglich sein wird, ohne vital notwendige Strukturen wie das Hirngewebe versorgende Endarterien oder essenziell zu erhaltende Anteile des Neurokraniums zu gefahrden. Auch ist darauf zu achten, dass bei der ablativen Therapie der Erhalt oder die Wiederherstellung von wichtigen Funktionen wie Sprechen und Schlucken berucksichtigt wird. Daher ist eine solche radikal-chirurgische Masnahme nur durch die sofortige Rekonstruktion des entfernten Gewebes durch z. T. ausgedehnte osteomyokutane Transplantate gerechtfertigt. Hier ist das gesamte Spektrum der rekonstruktiven Kopf-Hals-Chirurgie inklusive diversifizierter mikrovaskularer Techniken vorzuhalten, um dem individuellen Patient sowohl eine langfristige Prognose zu schaffen als auch eine angemessene Lebensqualitat zu erhalten.

Oral squamous cell carcinomas exhibit distinct patterns of disease progression, depending on their localisation. This study aimed to evaluate clinicopathological data in patients with tumors of the mandibular alveolar process, to facilitate risk assessment and therapy planning.A retrospective cohort study was designed including patients with squamous cell carcinoma of the mandibular gingiva. Clinical and pathological data were collected to determine the rate of cervical metastases and clinical outcomes depending on tumor stage, localization (anterior, intermediate and posterior) and the extent of tumor resection.120 patients were included in the analysis. Rate of metastases was 42.6%. Tumors of the anterior part of the mandible exhibited significantly higher rates of bilateral metastases (anterior: 85.7%, intermediate: 15.8%, posterior: 4%, p 0.001) and local recurrence (anterior: 25%, intermediate: 16.3%, posterior: 5.5%, p = 0.03) compared to posterior malignancies.Tumors of the anterior segment of the mandible are characterized by high rates of metastases and local recurrence. Therefore, we propose radical segmental resection and bilateral neck dissection in those patients.

The aim of this study was to investigate the impact of a prolonged treatment delay on survival in patients with primary oral squamous cell carcinoma. The investigators hypothesized that treatment delay affects survival, supposing a poor outcome in patients with prolonged treatment initiation. In addition, a critical treatment delay should be defined. Inclusion criteria were a histopathological diagnosis of primary squamous cell carcinoma of the oral cavity and a surgery-based treatment of the tumor. Patients with a history of previously diagnosed malignancies and patients with distant metastasis at the time of diagnosis were excluded from this protocol. Common clinical and histopathological data were assessed retrospectively. Treatment delay was analyzed for the interval between initial presentation and the date of surgery. A total of 484 patients could be included. Considering early-stage patients, the risk of death increases by 1.8% for each day that the treatment delay is prolonged if all other characteristics do not change (p = 0.0035). In patients with advanced disease, a prolonged treatment delay does not affect the risk of death (p = 0.9134). In terms of progression-free survival, treatment delay tends to be associated with a higher risk of recurrence in early-stage disease, but without being statistically significant (p = 0.0718). For patients with early-stage disease, a treatment delay of 20 days is critical regarding overall survival (p = 0.011). For patients with advanced-stage disease, no significant differences have been observed. As patients with early-stage oral squamous cell carcinoma profit from early treatment initiation, we suggest an acceptable maximum treatment delay of no more than 20 days in the surgical management of these patients.

Purpose:Malignant progression exhibits a tightly orchestrated balance between immune effector response and tolerance. However, underlying molecular principles that drive the establishment and maintenance of the tumor immune phenotype remain to be elucidated.Experimental Design:We trained a novel molecular classifier based on immune cell subsets related to programmed death-ligand 1 (PD-L1) and interferon γ (IFNγ) expression, which revealed distinct subgroups with higher (cluster A) or lower (subcluster B3) cytotoxic immune phenotypes. Integrative analysis of multi-omics data was conducted to identify differences in genetic and epigenetic landscapes as well as their impact on differentially expressed genes (DEG) among immune phenotypes. A prognostic gene signature for immune checkpoint inhibition (ICI) was established by a least absolute shrinkage and selection operator (LASSO)-Cox regression model.Results:Mutational landscape analyses unraveled a higher frequency of CASP8 somatic mutations in subcluster A1, while subcluster B3 exhibited a characteristic pattern of copy-number alterations affecting chemokine signaling and immune effector response. The integrative multi-omics approach identified EGFR and PTGS2 as key nodes in a gene regulatory network related to the immune phenotype, and several DEGs related to the immune phenotypes were affected by EGFR inhibition in tumor cell lines. Finally, we established a prognostic gene signature by a LASSO-Cox regression model based on DEGs between nonprogressive disease and progressive disease subgroups for ICI.Conclusions:Our data highlight a complex interplay between genetic and epigenetic events in the establishment of the tumor immune phenotype and provide compelling experimental evidence that a patient with squamous cell carcinoma of the head and neck at higher risk for ICI treatment failure might benefit from a combination with EGFR inhibition.

Genomic alterations are a driving force in the multistep process of head and neck cancer (HNC) and result from the interaction of exogenous environmental exposures and endogenous cellular processes. Each of these processes leaves a characteristic pattern of mutations on the tumor genome providing the unique opportunity to decipher specific signatures of mutational processes operative during HNC pathogenesis and to address their prognostic value. Computational analysis of whole exome sequencing data of the HIPO-HNC (Heidelberg Center for Personalized Oncology-head and neck cancer) (n = 83) and TCGA-HNSC (The Cancer Genome Atlas-Head and Neck Squamous Cell Carcinoma) (n = 506) cohorts revealed five common mutational signatures (Catalogue of Somatic Mutations in Cancer [COSMIC] Signatures 1, 2, 3, 13 and 16) and demonstrated their significant association with etiological risk factors (tobacco, alcohol and HPV16). Unsupervised hierarchical clustering identified four clusters (A, B, C1 and C2) of which Subcluster C2 was enriched for cases with a higher frequency of signature 16 mutations. Tumors of Subcluster C2 had significantly lower p16INK4A expression accompanied by homozygous CDKN2A deletion in almost one half of cases. Survival analysis revealed an unfavorable prognosis for patients with tumors characterized by a higher mutation burden attributed to signature 16 as well as cases in Subcluster C2. Finally, a LASSO-Cox regression model was applied to prioritize clinically relevant signatures and to establish a prognostic risk score for head and neck squamous cell carcinoma patients. In conclusion, our study provides a proof of concept that computational analysis of somatic mutational signatures is not only a powerful tool to decipher environmental and intrinsic processes in the pathogenesis of HNC, but could also pave the way to establish reliable prognostic patterns.

Objectives Routine panendoscopy is used to detect synchronous malignancies of the upper aerodigestive tract in staging of oral squamous cell carcinoma. The goal of this study was to investigate the occurrence of synchronous malignancies at time of diagnosis using panendoscopy. To challenge the role of panendoscopy as inherent part of routine staging procedures, we were especially interested in low risk patients. Materials and methods Retrospectively, a cohort of 484 patients with pathologically confirmed diagnosis of primary oral and oropharyngeal squamous cell carcinoma was investigated. Electronically recorded findings of in-house conducted panendoscopy were retrieved and evaluated for the occurrence of pathological changes of the mucosa. In case of synchronous malignancies, findings were correlated to preoperative radiographic imaging. Patients were classified as high or low risk. Patients with lacking risk factors (no smoking, no drinking in history) were defined as low risk patients. Results Overall, we detected three synchronous malignancies of the upper aerodigestive tract (3/484; 0.6%). Two non-small cell lung cancers were detected in patients with a smoking history of 60 pack years. One esophageal carcinoma in situ was detected in a patient with reported alcohol consumption. No synchronous malignancy was detected in patients without risk factors and no malignancy was previously detected by diagnostic imaging. Conclusion Pre-treatment panendoscopy can reveal synchronous malignancies of the upper aerodigestive tract in patients with primary oral squamous cell carcinoma. Risk stratification of patients can avoid unnecessarily conducted panendoscopy in patients without risk factors. This may lead to a higher cost-efficacy in public health system, less treatment-related complications and earlier treatment initiation.

The aim of this study was to validate the prognostic significance of the lymph node ratio (LNR) in patients suffering from oral squamous cell carcinoma in regard to different anatomical subsites. A cohort of 430 patients was investigated to determine the rates of primary metastasis and local and regional disease recurrence. Correlation analysis of the LNR with relevant clinical and pathological parameters was performed. Receiver operating characteristic (ROC) curve analysis was conducted to evaluate the prognostic impact for different subsites. Significantly differing rates of primary metastasis and loco-regional disease recurrence were found for cancer of different anatomical subsites of the head and neck. Furthermore, ROC curve analysis suggested that LNR has prognostic relevance in subsets of cancer (tongue, P< 0.001; alveolar process, P= 0.04; maxilla, P= 0.03; buccal mucosa, P= 0.02). The LNR of cancer located in the soft palate (P= 0.6) and floor of the mouth (P= 0.11) showed little or no association with the clinical outcome. There is the need for a more sensitive consideration of the LNR as a factor in the assessment of risk and the treatment decision, as the anatomical subsite plays a crucial role in its impact on the clinical outcome.

Background Treatment of post-resective defects of the maxilla can be challenging and usually requires dental obturation or microvascular reconstruction. As compared to soft-tissue microvascular grafts, bone reconstruction can additionally allow for facial support and retention of dental implants. The aim of this study was to evaluate scapular tip grafts with respect to their applicability for maxillary reconstruction and their potential to retain dental implants for later dental rehabilitation. Materials and methods In this retrospective study, 14 patients with hemimaxillectomy defects were reconstructed with free scapular tip grafts, oriented horizontally, to rebuild the palate and alveolar ridge. After bone healing, three-dimensional virtual implant planning was performed, and a radiographic guide was fabricated to enable implant placement in the optimal anatomic and prosthetic position. All patients' mastication and speech were evaluated, along with the extent of defect closure, suitability of the graft sites for implant placement, and soft-tissue stability. Pre- and postsurgical radiographs were also evaluated. Results A good postoperative outcome was achieved in all patients, with complete closure of maxillary defects that were class II, according to the system of Brown and Shaw. Additional bone augmentation was necessary in two patients in order to increase vertical bone height. Patients were subsequently treated with 50 dental implants to retain dental prostheses. In all cases, additional soft-tissue surgery was necessary to achieve a long-term stable periimplant situation. No implants were lost during the mean observation period of 34 months. Conclusions Due to its specific form, the scapular tip graft is well suited to reconstruct the palate and maxillary alveolar ridge and to enable subsequent implant-retained rehabilitation. Due to the limited bone volume, an accurate three-dimensional graft orientation is essential. Furthermore, most cases require additional soft-tissue surgery to achieve a long-term stable periimplant situation.

The goals of the present study were to analyze survival data of patients who received salvage surgery due to recurrent oral squamous cell carcinoma (OSCC) of the oral cavity with curative intent, and to investigate the feasibility of microvascular flap reconstruction in a heavily pretreated patient cohort.A total of 32 patients who received salvage surgery due to recurrent OSCC were included. The cohort was analyzed in regard to relevant clinical and pathological features. Survival was estimated by using Kaplan-Meier analysis and verified in a multivariate Cox regression model.All patients recovered well from surgery. The most common severe complication was free flap failure in 7 patients (24.1%). R0-resection was achieved in 16 patients (50%). Univariate Kaplan-Meier analysis showed that the estimated overall survival and disease-free survival of all patients after 24 months were 37.8% and 30.9%, respectively. Multivariate testing identified R1-resection was the only independent predictor of treatment failure.Salvage surgery is the only potential curative treatment option in recurrent OSCC. Microvascular reconstruction is feasible in heavily pretreated patients, but it is associated with a higher free flap failure rate. Recurrent OSCC in heavily pretreated patients shows different biological behavior. Further prospective clinical and molecular studies are needed to develop a better molecular understanding of recurrent OSCC and the best and safest individual therapeutic strategy.

The reconstruction of large cranial and scalp defects is a surgical and esthetic challenge. Single autologous tissue transfer can be insufficient due to the defect size and the anatomic complexity of the recipient site. Alloplastic patient-specific preformed implants can be used to recover hard tissue defects of the neurocranium. Nevertheless, for long-term success adequate soft tissue support is required. In this brief clinical study, the authors describe calvarian reconstruction in a 33-year-old patient with wound healing disorder after an initial resection of ependymoma. The patient suffered from osteonecrosis and wound breakdown in the fronto-parietal region. An alloplastic polymethylmethacrylate implant for hard tissue support was manufactured based on 3-dimensional visualization of a computed tomography scan. After the resection of remaining pathologic bone from earlier surgical procedures, the alloplastic implant was inserted to achieve functional coverage of the brain. Due to anatomic variation of donor site vessels during anterolateral thigh flap preparation, the authors performed a vastus intermedius free flap as a new muscular flap for craniofacial reconstruction. The authors achieved excellent functional and esthetic results. The muscular vastus intermedius free flap in combination with a split skin graft proves to be a new alternative to the anterolateral thigh flap for soft tissue reconstruction of the neurocranium.

Background: Head and neck squamous cell carcinomas (HNSCC) are phenotypically and molecularly heterogeneous and frequently develop therapy resistance. Reliable patient-derived 3D tumor models are urgently needed to further study the complex pathogenesis of these tumors and to overcome treatment failure. Methods: We developed a three-dimensional organotypic co-culture (3D-OTC) model for HNSCC that maintains the architecture and cell composition of the individual tumor. A dermal equivalent (DE), composed of healthy human-derived fibroblasts and viscose fibers, served as a scaffold for the patient sample. DEs were co-cultivated with 13 vital HNSCC explants (non-human papillomavirus (HPV) driven, n = 7, HPV-driven, n = 6). Fractionated irradiation was applied to 5 samples (non-HPV-driven, n = 2, HPV-driven n = 3). To evaluate expression of ki-67, cleaved caspase-3, pan-cytokeratin, p16INK4a, CD45, &prop, smooth muscle actin and vimentin over time, immunohistochemistry and immunofluorescence staining were performed Patient checkup data were collected for up to 32 months after first diagnosis. Results: All non-HPV-driven 3D-OTCs encompassed proliferative cancer cells during cultivation for up to 21 days. Proliferation indices of primaries and 3D-OTCs were comparable and consistent over time. Overall, tumor explants displayed heterogeneous growth patterns (i.e., invasive, expansive, silent). Cancer-associated fibroblasts and leukocytes could be detected for up to 21 days. HPV DNA was detectable in both primary and 3D-OTCs (day 14) of HPV-driven tumors. However, p16INK4a expression levels were varying. Morphological alterations and radioresistant tumor cells were detected in 3D-OTC after fractionated irradiation in HPV-driven and non-driven samples. Conclusions: Our 3D-OTC model for HNSCC supports cancer cell survival and proliferation in their original microenvironment. The model enables investigation of invasive cancer growth and might, in the future, serve as a platform to perform sensitivity testing upon treatment to predict therapy response.

Background. Head and neck squamous cell carcinomas (HNSCC) are histologically and molecularly heterogeneous tumors and frequently develop resistance mechanisms against treatment. Reliable patient-derived 3D tumor models are urgently needed to further study the complex pathogenesis of these tumors and how to overcome treatment failure. Methods. We developed a 3D organotypic co-culture (OTC) model for HNSCCs that maintains the architecture and cell composition of the patients' tumor. A dermal equivalent, composed of healthy, human-derived fibroblasts embedded into viscose fibers, grows in an insert for approximately 10 days in culture and serves as a scaffold for the patient sample. After outgrowth of fibroblast within the dermal equivalent, we cultivated vital HNSCC tumor explants from 13 patients (non-HPV driven, n=7; HPV-driven HNSCC, n=6) by carefully placing them on top of the scaffold. Fractionated irradiation (IR) was applied to 5 samples. To evaluate tumor proliferation and areas of apoptosis, we performed immunohistochemistry and immunofluorescence with antibodies against ki-67, cleaved caspase-3, pan-cytokeratin (PanCK), p16INK4a, and vimentin. Results. All 3D OTC models of non-HPV driven samples encompassed proliferative cancer cells during cultivation for up to 21 days. Proliferation indices of primary and 3D-OTC models were comparable and consistent over time. Overall, tumor explants displayed heterogeneous growth and invasion patterns. Radioresistant and clonally expanding tumor cells were enriched in 3D-OTC models after fractionated IR. HPV DNA was detectable in both primary and OTC (day 14) of HPV-driven tumors; However, p16INK4a expression levels were varying. Conclusion. Our 3D-dimensional organotypic co-culture model for HNSCC supports cancer cell survival and proliferation in their original microenvironment. The model enables investigation of invasive cancer growth as well as clonal expansion of resistant cancer cells upon treatment. In the future, the introduced model might serve as a platform to perform sensitivity testing upon treatment to predict the patients' individual response to therapy. Citation Format: Julia C. Thierauf, Luca Engelmann, Natalia Koerich Laureano, Hans-Jürgen Stark, Elena-Sophie Prigge, Dominik Horn, Kolja Freier, Niels Grabe, Philippe Federspil, Peter K. Plinkert, Magnus von Knebel Doeberitz, Jochen Hess, Annette Affolter. Organotypic co-cultures as a novel 3D model for head and neck squamous cell carcinoma [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 336.

Purpose The potential for donor-site morbidity in major maxillofacial reconstruction remains a concern. The purpose of this study was to compare the outcome of donor-site morbidity of deep circumflex iliac artery (DCIA) and scapula free flaps after radical treatment of the jaw and flap reconstruction. Patients and Methods We implemented a prospective cohort study design. Patients requiring segmental resection for benign pathology underwent reconstruction with either DCIA or scapula free flaps. The primary predictor variable was the use of DCIA versus scapula free flaps. The primary outcome variables were changes in orthopedic functional scores for both donor sites. The secondary outcome variable was neurosensory recovery at the recipient site. Results We included 8 patients in this study, comprising 3 women (38%) and 5 men (62%). Orthopedic scores were assigned preoperatively (T0) and at follow-up appointments at 1 to 3 months postoperatively (T1) and 6 to 12 months postoperatively (T2). In patients with DCIA flaps, a significant reduction (P = .0096) in the Larson I score between examination time points T0 and T1 was found. The score then improved on the operated side between T1 and T2 by an average of 29 points and showed no significant difference compared with the T0 level (P = .68). Patients with a scapular graft showed a significant reduction (P = .004) in the Constant-Murley score on the operated side between T0 and T1. The Constant-Murley score again improved significantly (P = .0136) between T1 and T2. Most of the patients (n = 7, 88%) had a neurologically unremarkable local situation of the recipient site at T0. At T1, 1 patient had level A (mild) neurosensory disorder and 1 had level B (moderate). At T2, all patients' initial neurologic scores were restored. Conclusions The donor-site morbidity associated with DCIA and scapula flap reconstruction is a short-term condition and returns to baseline by 3 to 6 months postoperatively.

Genomic sequencing projects unraveled the mutational landscape of head and neck squamous cell carcinoma (HNSCC) and provided a comprehensive catalog of somatic mutations. However, the limited number of significant cancer-related genes obtained so far only partially explains the biological complexity of HNSCC and hampers the development of novel diagnostic biomarkers and therapeutic targets. We pursued a multiscale omics approach based on whole-exome sequencing, global DNA methylation and gene expression profiling data derived from tumor samples of the HIPO-HNC cohort (n = 87), and confirmed new findings with datasets from The Cancer Genome Atlas (TCGA). Promoter methylation was confirmed by MassARRAY analysis and protein expression was assessed by immunohistochemistry and immunofluorescence staining. We discovered a set of cancer-related genes with frequent somatic mutations and high frequency of promoter methylation. This included the ryanodine receptor 2 (RYR2), which showed variable promoter methylation and expression in both tumor samples and cell lines. Immunohistochemical staining of tissue sections unraveled a gradual loss of RYR2 expression from normal mucosa via dysplastic lesion to invasive cancer and indicated that reduced RYR2 expression in adjacent tissue and precancerous lesions might serve as risk factor for unfavorable prognosis and upcoming malignant conversion. In summary, our data indicate that impaired RYR2 function by either somatic mutation or epigenetic silencing is a common event in HNSCC pathogenesis. Detection of RYR2 expression and/or promoter methylation might enable risk assessment for malignant conversion of dysplastic lesions.

To assess radiotherapy (RT) outcomes in patients with gingival carcinoma and growth up to or involvement of the lower jaw bone. This was a retrospective analysis of 51 patients with squamous cell carcinomas of the gingiva. Patients received definitive (group 1, 31.4%) or postoperative (group 2, 66.7%) RT between 2005 and 2017 at the Department of Radiation Oncology, University Hospital Heidelberg. The primary endpoint was overall survival (OS) in both treatment groups. Other endpoints were local-disease-free survival (LDFS), progression-free survival (PFS) and treatment-related toxicity (Common Terminology Criteria for Adverse Events, CTCAE, Version 4.03). Median age at first diagnosis was 63 years. All patients had a local advanced disease (American Joint Commission on Cancer [AJCC] stage III–IV). After a median follow-up of 22 months (range 3–145 months), 20 patients (39.2%) were still alive. At 5 years, OS rate was 36.6%. No significant differences in OS (p = 0.773), PFS (p = 0.350) and LDFS (p = 0.399) were observed between the two groups. Most common higher-grade acute RT-related complications (≥ grade 3) were dermatitis (78.2%), oral mucositis (61.7%), xerostomia (51.5%), and loss of taste (74.6%). Three cases (5.8%) of osteoradionecrosis (ORN) of the lower jaw were detected after 15–31 months. Definitive and postoperative RT have similar treatment outcomes for patients with lower gingiva carcinomas of the lower jaw. The most common acute complications (grade ≥3) were dermatitis, oral mucositis, xerostomia and loss of taste.

Background Cortactin (CTTN) is located on chromosome 11q13 and is associated with invasiveness in various cancer entities. CTTN protein expression could be a prognosticator of oral squamous cell carcinoma (OSCC) in terms of recurrence and survival. Methods CTTN-dependent invasion was performed using migration assay in human papillomavirus-negative head and neck squamous cell carcinoma (HNSCC) cells. Cortactin protein analysis in tissue microarrays was used for correlation with clinical parameters, as well as for survival analysis. Gene expression profiling in HNSCC cells was performed to unreveal CTTN signaling. Results Knockdown of CTTN in HNSCC cells showed less invasion in vitro. Gene expression profiling showed various deregulated genes known to be involved in progression. We confirmed the link between CTTN overexpression and progression in a large clinical cohort. High expression was associated with worse overall and progression-free survival. Conclusions We propose CTTN for managing OSCC in terms of adjuvant therapy and aftercare. Furthermore, our study reveals new potential targets in CTTN signaling for individualized OSCC therapy.

Background Despite new radiotherapeutic strategies, radioresistance in head and neck squamous cell carcinoma (HNSCC) remains a major problem. Preclinical model systems are needed to identify resistance mechanisms in this heterogeneous entity. Methods We elucidated the interplay among mitogen-activated protein kinase (MAPK)-inhibition, radiation, and p53 mutations in vitro and in a novel ex vivo model derived from vital human HNSCC samples. HNSCC cell lines (p53WT/mut) were treated with the mitogen-activated protein kinase (MEK)-inhibitor PD-0325901 and subsequently irradiated. Radiosensitization was functionally assessed and evaluated in the ex vivo model. Results We observed a pronounced irradiation-induced extracellular signal-regulated kinase (ERK) phosphorylation in 2 cell lines, which was independent of their p53 mutation status and associated with PD-0325901-related radiosensitization in a clonogenic assay. Heterogeneity in irradiation-induced ERK phosphorylation and in radiosensitization after MEK-inhibition was also reflected in the ex vivo model. Conclusion We provide experimental evidence for radiosensitizing effects of PD-0325901 in HNSCC. The ex vivo culture technology might offer a promising tool for individualized drug efficacy testing. © 2016 Wiley Periodicals, Inc. Head Neck, 2016

Purpose Locoregional control (LC) in malignant salivary gland tumors is dose-dependent, initial results with particle therapy were promising. We report our experience with raster-scanned, intensity-controlled carbon ion therapy (C12) and IMRT in 309 patients with pathologically confirmed adenoid cystic carcinoma (ACC) of the head and neck. Patients and methods Treatment records of patients treated with C12 between 08/1998 and 05/2013 were evaluated regarding tumor stage, treatment, toxicity (CTCAE v3), LC, progression-free survival (PFS) and overall survival (OS). Response assessment was carried out according to RECIST1.1. Results Tumor stages were mostly advanced (T4a/b: 60%, macroscopic disease: 71%), most common sites of origin were the paranasal sinus (37%). At a median follow-up at 33.9 months, LC, PFS, and OS at 3 and 5 year estimates are 83.7%/58.5%, 67.8%/56.1%, and 88.9%/74.6%. LC correlates with T-stage but neither nodal stage, age, relapse state, nor margin status. RECIST did not correlate with LC or survival rates. Conclusion IMRT plus C12 boost results in good control and survival rates at moderate toxicity. Margin status did not correlate with LC in T4 tumors, extensive and potentially mutilating surgical procedures may have to be re-evaluated. RECIST assessment did not correlate with either LC or survival rates; potentially more meaningful radiological parameters need to be developed.

Depending on the site and size of head and neck cancer, the disease affects patients' appearance and subsequently their quality of life. The aim of this study was to correlate subjective and objective evaluation of facial appearance and associated quality of life following ablative tumor surgery and microsurgical reconstruction.A total of 99 patients with combined ablative and reconstructive microsurgical procedure for head and neck malignancy and seven patients with non-malignant disease were examined by three-dimensional (3D) (photogrammetry at least 6 months post-surgery and were evaluated by two-dimensional (2D) and 3D means for symmetry and facial proportions. Measurements were correlated with subjective reporting from the University of Washington Quality of Life Questionnaire and observer ratings.Of the 106 patients, three patients scored themselves as significantly disfigured (2.8%), 19 were bothered by their appearance (17.9%), 27 (25.5%) reported no change, and 57 (53.8%) reported minor changes in their appearance. On 2D evaluation, 10 patients (9.4%) showed severely abnormal facial proportions. On 3D analysis, 17 patients showed major asymmetry. There was a high correlation (0.67) between patient and observer subjective rating (p 0.05). While 2D evaluation alone showed no significant correlation with subjective rating, 3D evaluation showed a moderate correlation (0.37; p 0.05). The best results were achieved by combining 2D and 3D measurements (0.5; p 0.05). Young female patients were most critical about their appearance.Following combined ablative and microsurgical reconstructive procedures, patients have a realistic perception of their appearance compared with observer ratings and a combination of 2D and 3D objective evaluation.