Management of locoregional recurrence in oral squamous cell carcinoma.

Oral squamous cell carcinoma (OSCC) is the sixth most common malignant tumor worldwide, affecting more than 25% of 1 million people annually [1,2]. It accounts for 4% of all cancers and 2% of all cancer-related deaths worldwide [3]. In Southeast Asia, particularly in India, OSCC is the most common malignant tumor, accounting for 30% to 50% of all tumors [4,5] .I n the United States, approximately 30,000 new cases of OSCC are diagnosed annually, and most are seen in patients older than the age of 40 years, with a mean age at diagnosis of 60 years [6–8]. Although a strong male predilection was seen at the turn of the century, incidence rates between men and women are now almost equal. The incidence in young patients (!40 years old) ranges between 0.4% and 4% [9]. Unfortunately, the rate of second primary (synchronous or metachronous) tumors in the aerodigestive tract continues to be high, at 3.7% per year [10,11]. This contributes to the high death and registration index, which is 0.45 for OSCC compared with 0.48 for carcinoma of the uterine cervix and greater than 0.38 for melanoma [3,12]. Early-stage tumors (T1 and T2) are associated with a 60% to 80% 5-year survival rate. The status of the cervical lymph nodes is the single most important prognostic factor in OSCC, with the development of neck metastases reducing the 5-year survival rate by 50% [13– 15]. Despite advances in surgical and adjuvant chemoradiotherapy, the diagnosis of OSCC continues to portend a poor prognosis, with an overall 5-year survival rate remaining essentially unchanged at 50% for the past several decades [13,16]. The mainstay of primary treatment of OSCC is surgical resection with or without adjuvant radiotherapy. The goal of all primary resection aimed at cure is complete eradication of all local disease with adequate treatment of the cervical lymph nodes. Despite adequate local control of OSCC, recurrence rates of 25% to 48% have been reported [17–19]. There are several considerations in dealing with patients with local or regional recurrence. Most recurrences from OSCC occur in the first 24 to 36 months; therefore, it is important to maintain a strict follow-up schedule for tumor surveillance [15]. To reduce the risk of recurrence, it is important for patients to abstain from tobacco and alcohol consumption so as to minimize the risk associated with second primary lesions. Although the oral cavity is amenable to easy examination, the presence of a reconstructive flap may make the diagnosis of deep recurrent disease difficult. This is in contrast to superficial or marginal recurrent disease, which is more easily detected. The regular scheduled use of imaging modalities, such as CT, MRI, and, more recently, positron electron tomography (PET), is assuming an increasing role in tumor surveillance. PET scanning uses a radiolabeled glucose isotope (18fluorodeoxyglucose [FDG]) to label areas of hypermetabolism. Although PET is proving to be a valuable tool in oncologic surveillance, it should be recognized that in the immediate postsurgical setting, PET scanning may remain positive at the primary or postoperative site for several months. It is therefore recommended that for