In Brazil's Nationalk Cancer Institute (INCA) we have a large number of patients submited to radiotherapy in the post operatory for SCC in the oral cavity, for some reasons: Hystological tumor type, localization (as tongue or floor of the mouth, places with the highest recurrence rates in oral cavity for SCC, and because, if you plan to do radiotherapy, it's much better do it post operative, cause the tissues around the tumor are not affected by radiation acute or late effects, such as epithelium atrophy, xeostomia (for irradiation in the major salivary glands, wich get in the way of the beam), infection for the reduction of the physic and immune defenses. I can send you a protocol from the Head and Neck surgery to make it clear and bring the evidences bases. Thanks a lot for your question, it's a very important matter, and I hope I could contribute. Saludos de BRASIL!

The most recent issue of the British Journal of Oral and Maxillofacial Surgerys first article addresses this very point and is well worth a read (as is the entire journal). The authors of this article (from the Aintree centre in Liverpool which has a wealth of experience) attempted to establish a multicentre study in the UK to attempt to create some form of evidence base for the so called "intermediate risk" oral cancers but my understanding is that people have been slow to recruit.

There is no doubt that higher stage tumours and those with positive margins and extracapsular spread (perhaps not "close margins" - there is another excellent paper in BJOMS this time from the Glasgow group which shows strong evidence to suggest there is little difference in outcome between a 5 and 2 mm post formalin fixation clear margin in SCC) benefit in terms of overall and disease free survival from PORT and that the integrated combination of surgery and PORT remains the gold standard but particularly since the arrival of chemoradiotherapy regimens we have all seen a dramatic increase in the sometimes devastating morbidity associated with non surgical oncological treatment. So the question is - what patients with what stage of which disease are the ones where the risk benefit is in favour of PORT? The answer is - we don't know, but some people are probably getting it unnecessarily and some who should get it are not. The evidence outside high stage, positive margins and ECS is actually pretty contradictory.

Read those papers and catch up on the de-escalation of non smoker HPV driven oropharyngeal SCC which is also very pertinent to those concerned with the rise of non surgical oncological treatment morbidity. In years to come we may find we have repeated the mistake of fast neutrons simply because we didn't know about HPV when the EORTC and RTOG trials of chemoradiotherapy came out.

Dear David,

Thank you for your answer. I agree with you in that the main question should be how to elucidate which patients are the best candidates for PORT in this group with intermediate risk of recurrence. Brown et al., in their paper at BJOMS that you are also referring to, remark that the heterogeneity within this group is one of the main problems to extract clear indications for PORT. In a paper by our group (González-Garcia et al. Local recurrentes and second primary tumors from squamous cell carcinoma of the oral cavity: a retrospective analytic study of 500 patients. Head Neck 2009;31:1168-1180. -you can download the paper from my publications´ list-), we also observed for the whole series of patients with oral SCC that PORT was an independent risk factor for recurrence. Before reading the paper by Brown et al., we were "a little bit shocked" by this finding. What if we were overtreating patients with the addition of PORT? We also observed that in patients with a recurrence, salvage surgery alone rescued a 35% of them, while radiotherapy in addition to surgery only rescued 19%, and RT alone 0%. The work of Brown and colleagues also signaled that PORT decreases the success rate of the treatment performed for the recurrent disease. It seems clear that new controlled and randomized trials have to be performed for a better understanding of the role of PORT in this particular group of patients suffering oral SCC, including the study of the role of HPV.

Dear Alexandre,

Thank you your offering. It would be great to have a look to the protocol for cancer from your Head and Neck Dept. I agree with you in that RT should be better administered post-operatively to avoid important pitfalls such as tissue fibrosis or retraction, which would make surgery very arduous. My question was more in relation to the suitability of administering RT or not administering RT in that particular group of patients with intermediate risk of recurrence. I know about the variability of protocols from one institution to another (in fact the literature is so contradictory), so it will be good to compare with that from your institution. Thank you for your help.

Dear Raul,

Thank you for raising such an important matter. I agree that the subject of PORT in particular group of patients with intermediate risk of recurrence is very controversial. It is in need of research and publications by many medical centres from all around the world. From my experience, I can say that we are used to administering PORT but our observations are far from positive. Especially when performing a recurring surgery, we often struggle with difficulties on form of radiated tissues. The other issue is the research of HPV and its influence on positive outcome of oncological tratment. Regards from Warsaw.

Thank you Danuta,

It is also our observations that PORT decrease the success rate following a relapse. It seems that more and more institutions are getting conscience about the poor sucess rate obtained with PORT in this particular group of patients. Making new observations may be the beginning of a new concept in treating patients with oral cancer, as up to date radiotherapy seems to be extended so far in terms of indications and institutions.

I did a retrospective analysis of patients with and without PORT in patients with close margins on initial resection in N0 patients with oral cancer......initially patients with PORT did well. However survival was equal after 24 months.  Same trend was seen in N0 tongue cases with tumor depth greater than 4mm too.

According to the analyis from SEER data base (Kao 2008) PORT decreases the risk of death in patients with lymph node metastases (including N1 and oral cavity cancer, HR 0,844 P = 0,025) but previously Langendijk et al published a Risk-group definition by recursive partitioning analysis of patients with squamous cell head and neck carcinoma treated with surgery and postoperative radiotherapy. RPA Group I  (margin free and no extra nodal spread had an excellent locoregional control (88% at 5 years) Selected patients with T1-2 N-1 can be correctly treated with with surgery and without PORT. Choice of therapy should be made on the bases of a multidisciplinary meeting and the patient should be informed accordingly. There is no randomized trials on this topic and probably never wiil be.

No randomized trial with PORT to any cancer site had ever shown an increase in locoregional relapse, retrospective series showing a detrimental effect in LR control due to PORT probably suffer from a biased selection of patients.

Surgery is the treatment of choice for relapsed head and neck cancer (as we know) Patients with low tumor volume, young and healthy are operated. Patients not amenable to surgery because their tumor is too advanced or the patient had poor condition are refered to radiotherapy and do badly (no surprise)

Outside randomized trials surgical series and radiotherapy series will never be totally comparable.

We should offer the patient the best chance for cure at first diagnosis. Most expert advise against the practice of spare a treatment properly addressed for the sake of a potential recurrence.