ET Prognoses of Oral Basaloid Squamous Cell Carcinoma and Squamous Cell Carcinoma A Comparison Fernanda C. Grizzo dle Sampaio Goes, DDS, MDS; Denise Tostes Oliveira, DDS, PhD; Regina Garcia Dorta, DDS, MDS; Ines Nobuko Nishimoto, MS; Gilles Landman, MD, PhD; Luiz Paulo Kowalski, MD, PhD Objectives To compare clinical and prognostic fea- tues in patients with basaloid squamous cell carcinoma (BSC), poorly differentiated squamous cell carcinoma (PSCC), and well to moderately differentiated squa- ‘mous cell carcinoma (W/MSCC) of the oral cavity Design: Retrospective cohort. Setting: Referral tertiary center Patients: Seventeen patients with primary oral BSC, 27 with PDSCC, and 27 with SCC. Intervention: The 71 patients all had surgery and 52 had postoperative radiotherapy Main Outcome Measures: Recurrences and sur vival Results: The median follow-up time was 52.4 months for patients with BSCC, 22.2 months for those with PDSCC, and 13.8 months for those with SCC. No sta- istically significant differences on survival were found among the BSCC, PSCC, and SCC groups. The 5-year cancer-specific survival rates were 50% for patients with BSC, 37% for those with PSCC, and 49% for those with W/MSCC (P=.71); the 5-year overall survival rates were 46% for patients with BSSC, 18% for those with PSCC, and 419% for those with W/MSCC (P=.25). Disease-free survival was not significantly different among the BSC, PSCC, and W/MSCC groups (P=.57). The 5-year rate of disease-free survival was 40% for patients with BSCC, 37% for those with PSCC, and 53% for those with W/MSCC. Conelusions: The clinical course of BSCC fs similar to the courses of PSCC and W/MSCC when clinical T and N classifications are matched. Prognosis does not differ {or patients with BSCC of the oral cavity and those with conventional oral squamous cell carcinomas PSCC and WIMScc, Arch Otolaryngol Head Neck Surg. 2004;130:83-86 ASALOID SQUAMOUS CELL CAR- cinoma (BSC) is consid cred a high-grade variant of squamous cell carcinoma that with conventional squamous cell earel- noma (SCC) and have the same etiologi- cal risk factors, eg, tobacco and aleohol consumption." sit From the Deparment of Stomatology-Arca of Pathology, Bauru Dentistry School, University of Sao Paul, Bauru, Brazil (Drs de Sampaio Ges, Oliveira, and Dortay and the Department of Head and [Neck Surgery and torhinolaryngology (Qs Nishimoto and Dr Kowalski) and Pathology (Dr Landman), Cancer Hospital A. C. Camargo, Sao Paulo, Brazil, The authors have no relevant financial interest inthis article arises preferentially inthe up- per acrodigestive tract, te, the base of the tongue, larynx, and hypopharynx: In the oral eavity, BSCC has. predilection for the tongue, though it has been described in other locations such as the floor of the ® palate,”*” retromolar trigone,’ buccal mucosa,” and gingiva." The ag- gressive biological behavior of BSCC of the head and neck has been associated with carly recurrence, cervical lymph node in- volvement, and distant metastasis!" and with spread to the hangs and liver Most BSCCs are diagnosed at advanced clinical stages)?” and have an tnfavor- able prognosis because of poor overall pa- tient survival rates 25035!" Clinically, patients with BSCC pre- sent features similar to those of patients mouth, (©2004 American Med The comparative analysis of the clini- cal course and prognosis of BSC and conventional SCC has aroused contro- versy in the literature. Although some au- thors have observed that BSCC has a more aggressive behavior than SCC**°""* oth ers consider that it has a similar progno- sis.""2!5 To compare the biological features and clinical courses of oral BSCC and conventional otal SCC in groups of ‘matched patients is a difficult task. Rec- rds are sometimes incomplete and in- consistent, which precludes an approps ate prognosis and treatment design. ‘moreover, as there is only’a limited mum- ber of records of cases of BSCC affecting, exclusively the oral cavity few data about the biological properties influenc- {ng prognosishave been published ***” The 1 Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/otol/18333/ on 04/17/2017Table 1. Patient Characteristic ad Cinical Findings {or Basalold Squamous Cel Carcinoma and Conventional Squamaus Cell Carcinoma ofthe Oal Cavity aan Soe ‘le 15(882) 250053) 250083) Fele 2a) ian ten) TU12) 151558) 15686) 55 1o(ses) Tada) r2(44a) 15(e82) 231052) 22015) pita) ata) sas) ) 121857 BOLD 221885) 75 243) 2083) 24r7) 81750) 210675) 211808) gg 31250) 3(128) 3(118) Cn at ot in es Ontong 41238) 759) 71250) Foxrathe auth 9(528) 71259) re39 | at Ravonobgngva 4(235) 131481) 13/481), Welsstesion 112 5(208) 6022) 71059 gg tat s2(708) 210778) z0(r41) no 5(204) 81208) 81208) 9g Ne ‘2(708) 191704) 19(704) Abbreviations: BSCC, basal squamous cal carcinoma: NA, at salable PSCC, pony diferented squamous callcarcinama: WSCC, ‘tll modaratalyaierntnted squamous cal archos, “The Palisa for the maximum bthaod eats im ofthis study was to compare the clinical features and prognoses of BSC, poorly differentiated squamous cell carcinoma (PSCC), and well to moderately differenti- ated squamous cell carcinoma (W/MSCC) ofthe oral eav- ity, in groups matched by T and N classifications. EES Seventeen cases previously classified as SCCs and surgically treated from June 8, 1970, to November 4, 2000, at the De- partment of tlesd and Neck Surgery and Otorbinolaryngology fof the Cancer Hospital A.C. Camargo, Sao Paulo, Brazil, were reviewed and reclassified as BSCCs alter staining with hema- toxylin-cosin and periodic aeid-Schiff and evaluation by ight microscopy. These tumors fulilled the histologic criteria pro- posed by Wain etl’ and were included inthis study only after 5 pathologists (F.C.G.S.G.,D.T.0,and G.L.) agreed on the mi- ‘roscopic diagnosis of BCC. A retrospective review of 54 cases ‘of clinical T and N classifications allowed to match ou 17 cases ‘with 27 cases of WIMSCC and 27 cases of PSCC for compara live clinial analysis and prognostic evaluation. The T and N classifications were determined according tothe criteria pro- posed by the International Union Against Cancer (available at ‘www wiley com/go/tnm). ‘Al patients included in this retrospective study under- sent surgical treatment, alone or followed by postoperative ra- diotherapy and/or chemotherapy. The inlision criteria were W) abistopathologically confirmed diagnosis of SCC of the oral (©2004 American Med tongue, floor ofthe mouth, infeior gingiva, or retromolar ares (G)no previous treatment; and (3) crative surgery asfirt reat tment Hheexcinon enter were (1) sconiraindication for sit gery. 68 the pallet was inoperable or the tumor unesect- SHE: ) distam metastases tthe time of admission; (3) the ence of ther primary mors: (4) previous eaten nd 5) palient refusal of surgical treatment "The patient’ data were collected from their medical e- cords and included sex, ag, ethne group, obacco and/or al Cakol consumption, tumor location an se evidence of nodal metastases, T and N sag, treatment (surgery, postoperative radiotherapy, and/or adjuvant chemotherapy), and adverse Cents during clinical follow-up (recurrence, accurrence of second primary tumor, or death. “Analysis or the eof patents, continuous variable, was performed using the nonparsmeric Kruskal-Walls est. Cat {gorical variables were analyzed using the test or the Fisher act test, with signiicance a P=03: Survival rates wee cal calated by the Kaplan-Meier method and analyzed with the loge fank test. The overall survival time was defined as the interval between the date of surgery and the date ofthe last consul tion (for censored obseFvations) or date of death (Tor uncen sored observations). The cancer-specific survival ime was de- fined asthe interval between the dae of surgery and the date of telat consultation (or censored observation) othe date ofdeath due othe primary tumor or uncensored aberations). The disease-free survival me was defined athe interval be- tween the date of sngery snd dhe date ofthe last consultation (For censored observation) othe date of first tumor recur rence (for uncensored observations). We used the Sata stats tical software, release 7.0 (StataCorp, College tation, Tex). Es The clinical and demographic parameters of patients with oral BSCC and conventional oral PSCC oF W/MSCC were similar, as summarized in Table 1 The age of patients ranged from 43 to 77 years (mean, 59 years) for those with oral BSCC, from 33 to 78 years, (mean, 58 years) for those with PSCC, and from 35 to 74 years (mean, 54 years) for those with W/MSCC. The Kruskal-Wallis test revealed no statistically significant dif ferences in age among patients with BSCC, PSCC, and WIMSCC (P=.33). There was a predominance of white ‘men in the 3 groups (Table 1). Macroscopically, BSCC tumors were infiltrative in 10 (59%) cases, SCC tumors were infiltrative in 41 (76%) cases, and most of them were detected at an advanced clinical stage ‘Regarding treatment and clinical course, 9 patients with BSCC (53%) underwent surgery and simultaneous ipsilateral neck dissection, 15 patients (88%) received postoperative radiotherapy, and 3 patients (18%) r ceived adjuvant chemotherapy. Twenty patients (74%) with PSCC and 22 (82%) with W/MSCC underwent sur- gery and simultaneous ipsilateral neck dissection. A total of 23 patients (85%) with PSCC and 14 (52%) with WIMSCC received postoperative radiotherapy. Nine pa- tients with conventional SCC (8 with PSCC and 1 with W/MSCO) underwent adjuvant chemotherapy (Tale 2). No statistically significant differences among BSC, PSCC, and W/MSCC patients were found regarding tu- mor recurrence (Table 2). Three patients (18%) with BSC presented local recurrence, 5 patients (20%) had 1 Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/otol/18333/ on 04/17/2017Table 2. Treatment and Cinieal Outeomes {or Gasalold Squamous Cll Carcinoma and Conventional Squamous CellCareinoma ofthe Oral Caily 90) Tesmer tek dsaton ipiawal a29 wren 20187 Ase sa) 789) 5188) Peso racbucny ‘es 15(882) 23652) 4051997 p95 i 2) 4(as) 138: Cheeta ‘es 376) 805) 187) 7 9 bs 128) 191708) 25183) Girl oucone caren ‘es ges) 15655) 14077 4 % 7ai2) 124s) 161693) Patent sued Wihrocideesst — 3(178) 0(0) 8206) doe rm 169 187 00) 81) 4618) 1348117. yp Craters 40288) 11407) 448) Patetstofelowap 1689) 17) 2028) MA ‘Abrvinions SOO, aslo squamous eal coma NA, ot all SCO, poor tested squamous all carom: WIMSCE, wel to moet fronted squamous ol carenora, "The Ptaes ae forte maximum aon tates, neck recurrence, and + patients (24%) developed dis- tant metastases, Eleven patients (41%) with PSCC had local recurrence, 5 patients (19%) developed neck re- ‘currence, and 2 patients (10%) developed distant me- tastasis. Seven patients (26%) with W/MSCC had local recurrence, 5 patients (19%) had neck recurrence, and ‘only 1 patient (4%) developed distant metastasis. No pa- tent with W/MSCC developed a second primary tumor, however, 3 patients (18%) with BSCC and 4 patients (25%) with PSCC developed second primary tumors. Follow-up time ranged from 3 10 169 months (mean SD, 5747 months) for patients with BSCC; from 15 to 188 months (37443 months) for patients with PSCC; and from 11 days to 178 months (5464 months) for patients with W/MSCC. The clinical outcome of pa- tients with BSCC, PSCC, and WMSCC are summarized in Table 2 ‘As shown in Figure 1 and Figure 2 there were no differences in the 5-and 10-year survival rates among the BSCC, PSCC, and W/MSCC groups, The 5-and 10- year cancer-specific survival rates were, respectively, 50% ‘and 50% for patients with oral BSCC; 37% and 28% for patients with PSCC; and 40% and 40% for patients with WIMSCC (P=.71). The 5- and 10-year overall survival rates were, respectively, 46% and 219% for patients with BSC; 18% and 13% for patients with PSCC; and 41% and 419% for patients with W/MSCC (P=.25). The 5-and 10-year disease-free survival rates were, respectively, 40% and 40% for patients with oral BSCC; 37% and 25% for (©2004 American Med sot ina Rt a |) Mente Cuma ance pei sural probably carves by ooupe nats basi squamous cal carcnema, PSCC, poaty od equaus eal earinoma ana WMC, wel a moderately ted squamous ell carcinoma va Bom Bas. vse 3 isc aos. ft ow. Mente Figure 2, Cima date rea sural pobablty carves by groupe. SCC indicates basso squameus call carcinoma, PSC, poaty ‘iterantted squamous esl sarnams: and WARSCC. wk to modestly Sierantated squamous call eco, patients with PSCC; and 53% and 53% for patients with WIMSCC (P=.57) eee In the head and neck, including the oral eavity, BSC has been considered to be biologically more aggressive than conventional SCC and associated with a poor elini- cal outcome.*#!9 However, there are few studies**” evaluating the clinical course of BSCC located exclu- sively within the mouth. Some of these studies analyzed smal samples, which does not allow to confirm ifthe clini cal prognosis of BSCC is worse than that of conven- onal SCC. Histologically, BSCC shows specific characteris les; however, in most eases, the tumor presents clinical features similar to those associated with conventional SCC of the same anatomic sites inthe head and neck."!=!5" (Our series confirmed that the clinical findings for pa- Lents with BSCC did not differ from those who had con- ventional SCC matched for T and N classification, site, and treatment. Tumors were more frequent among men fm their fifth decade of fe and with ahistory of smoking, and alcohol abuse. Moreover, BSCC was usually ob- served atan advanced stage, as is usually the ease?!" 1 Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/otol/18333/ on 04/17/2017and 47% ofthe patients died because of the disease. The aggressive behavior of BSCC and conventional SCC ob- served in this study was characterized by local and ecr- vical lymph node recurrences and distant metastasis spreading to the lungs Inourscres, in agreement with previous reports for the oral cavity,” BSCC arose predominantly inthe floor ‘of the mouth and most ofthe lesions were infiltrative Wi mors. On the other hand, conventional oral SCC 0c- ‘curred with a higher frequency in the retzomolar area and inferior gingiva than BSCC (Table 1). All patients in the BSC, PSCC, and WIMSCC groups received treatment for conventional SCC in advanced clinical tage gical excision ofthe primary tumor with ipsilateral orbi- lateral neck dissection. Postoperative radiotherapy was administered to most ofthe patients with BSCC and PSCC (Table 2) but adjuvant chemotherapy, as recommended by some authors?!" for patients with BSC, was of- fered to few patients Regarding the clinical outcome of BSCC, this study showed ahigher frequency focal (18%) and neck (29%) recurrences compared with the recurrences to the head and neck found by Ferlito etal" and Banks etl" How- ‘ver, the clinical outcome of patients with conventional SCC in our series, including local and neck recurrences and distant metastasis, did not differ rom the outcome of patients with BSC, as shown in our previous re- ports. Although no statically significant dillerencesre- lated to clinical outcome were found among the BSCC and conventional SCC groups, local recurrence pre= vile in patients with SCC but rates of neck recurrence and distant metastases were higher in patients with BSC, as described by others." “Although no patient with well to moderately differ ‘entiated SCC developed a second primary tumor, 3 pa- tients (188) with BSC and 4 patients (15%) with poorly dillerntiated SCC exhibited second primary tumors. The frequency of asecond primary tumor in patients with oral BSCC was higher than that observed by Banks et al!* (5.0%) but it was close to that detected by Ferlito eal” (20.0%) in paticts with head and neck BSC. There were no significant dilferences in cancer- specific and disease-free survival rates among the BSC, PSCC, and W/MSCC groups. In conclusion, ths clinical study supports the opin- ton thatthe prognosis of BSCC does not differ Irom that ‘of conventional SCC ofthe oral cavity when matched for Clinical T and N classification. Therefore, patients with BSCC oF conventional SCC (PSCC 0 W/MSCC) of the tongue, floor of the mouth, inferior gingiva, or etromo- lar area matched by stage may undergo the sane thers- peutic protocols, e, a combination of surgery and post- operative radiotherapy, 1o prevent local and neck recurrences and distant metastasis. Further compara- live studies between oral BSCC and conventional SCC ofthe ora cavity are necessary to define thelr clinical be- havior and prognostic significance ‘Submitted for publication April 18, 2003; accepted July 1 2003, This study was supported by grant 00/13337-3 from the Fundacao de Amparo a Pesquisa do Estado de Sao Paulo, (werminreD) TECH OTOL (©2004 American Medical Ass ROUT NIT and by CAPES (Coordenacao de Aperfeicamento de Pes- soal de Ensino Superior) This study was presented in poster form al the annual meeting ofthe American Head and Neck Society; May 2: 2003; Nashville, Tenn Corresponding author: Luiz Paulo Kowalski, MD, PRD, Department of Head and Neck Surgery and Otorhinolar- “yngology, Hospital do Cancer A. C. Camargo, R. Professor “Antonio Prudente 211, Sao Paulo 01509-900, Brazil (e-mail: Ip_kowalski@uol.com.br) LES} 1. Wain, KerR,lmer RT Basen, Bsi-qusmous acorn the tongue, rypophary and ayn repr of 1035. Hm Pata 198617 ibe 16 2 Aiko , Okumura K, Ohh, KoishT, Knazaa M, Kak. Basao Squanos cel inona ofthe ofthe nou chaactrzaan ta calli 1 Path Me. 10072667370, 2 lla 6 Manns GM, ino AR, Feito AB quamou a a= naa or eanyand pha ORL J trina Re Spc 180, err 4 Compra 5, Gandou-Eanards RF, Stes JM, asad squamous carcinoma tft nd ec rp cas cc urngn be arr oor a hema. ‘ra Pal ab Md 109-18 120-1232 5 Coppi, Calan, Tang CX tenon, Hanick Moh A asd sua Ime cl carcinoma ot or of be math, Cancer 003.722200- 205, 6 Lowi HM, Mathews BL asla-quanouscarcrama of he pala. Ot aya! eas ok Surg. 1062 106:180-162 7 WederbergO, essen. Lungs, Lundgan J Hels 8. asl squa- Ios ct earcioms fh mail, il Ono 157234148 «aj Ve, Bas ER, Moree NP Fare TA Mead RM. Baad sua us catcher czy eportctacase. Supa Med rl Patal ‘ona 572 05, 8. Cadir MA, Kay AS, Parkhouse Bough AD. Baal squamous acnoma ofthe eal cavity. Hed Meck 100214387301 10. le Shimoyama T Suns Hare Poypoicarcnanact tetanus Jr Path Mod 108250092 1. Abn. Saar alu, Met. Mori Magu, Bsei-quamous ‘arena ofthe esophagus: cncopatlog, ONA pay animus techs yo sen aes. Sur Pahl BOG 208526, 12 BaMksER Freon Mls SE, George Zarb Ry, Soason PE Basar Imes elesonama ah etd and ela incaptholog and rns tocar sya £0 cas J Sur Pata 102 16990-46, 18 Fart A Atl 6 Rea DoginiC. Balog squamous cal carcnonact the yc andhypophayn: Ann Ot ine ang! 197061024105, 14. Id, Shimoyama Hore Kise Baa! squamous carcinoma ot the of moe cae andrea of 5 cate nthe eee. rl Ooo 00238 20-128, 1. Lane MI, ogo, ParchatlanndP Weber RS, Basa JG Baad mu mas cainanact he up aodgesiveac-clniapabalage angDNA ow yonstre aus. Gace 1BD66 837502 16 Wncaburg SM, Mebane GA, Georg ,Day K. Adams GL. sald us mous carcitoma: adic anparion af wo sola pes uth pou feared squamous elcrcoma,Coayngat Head Neck Sr. 18510: avis 17, Sara, Vrs. itngarF tal Bs squanusclleacrams of te ‘soptags: dagnasi an rogies. Cancer 00771871878 1 Lamar M Malar ts SE. ron HF. Bans ER Lavin PA, Rao therapy or basal squamous ela otha ead an ec. ea ok sanes200202 19, Paina AS, SoghB, Shah P aos A.B squamaus cl carcinoma ft a and ck Laprgoscope 200010 147-142 20. Cols Com Vila tal seal suamauscarnama tho vy: repost eases and study of AgNO, PNA and MMP xressin ‘ral Surg Oral Me al Puta Raiol Endod 200131 $6356, 21, Kei Kile Sac, Aman Us, age. munohiechen- ‘alemyessin ofc? prin squamous el carcinona and bso ex rama of te esophagus Sug Toy. 1872765 401 22 Lam KY, Law La J, Wong Oesophageal eit squamous cel ate ams uniulinzopatalog oat wih sana aya progasic inde Jato 201-195435-42 lation, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/otol/18333/ on 04/17/2017