Review| Volume 50, ISSUE 6, P481-489, September 2012

Systematic review of the current evidence in the use of postoperative radiotherapy for oral squamous cell carcinoma

Published:December 26, 2011DOI:


      Improved disease-free survival for oral squamous cell carcinoma (SCC) with the use of postoperative radiotherapy (PORT) has to be balanced against the risk of recurrence, the relative morbidity of radiotherapy, reduced options for treatment, and survival with recurrent disease. In the absence of randomised trials, a review of current evidence is timely because of increasing differences in outcome and response to treatment for cancers of the larynx, oropharynx, and oral cavity. From a search of 109 papers, 25 presented relevant data in tabular form, and reported local, regional, and total recurrence, and overall survival. Most data come from non-randomised studies that compared the effects of interventions with previous or historical information. A summary of the results shows local recurrence of 11%, 17%, and 15% for early, late, and all stages after operation alone, compared with 13%, 16%, and 19% after PORT. Regional recurrence is reported as 13%, 12%, and 11% for early, late, and all stages after operation alone compared with 6%, 11%, and 9% after PORT. Overall survival is reported as 76%, 74%, and 77% for operation alone compared with 65%, 62%, and 62% for early, late and all stages of oral SCC, respectively. It is acknowledged that this is a weak level of evidence as patients who have PORT probably have a high pathological-stage of disease. Knowing that PORT increases morbidity and reduces salvage rates and options for treating recurrent disease, this difference in overall survival emphasises the need for randomised studies or a re-evaluation of our current protocols.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to British Journal of Oral and Maxillofacial Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Amdur R.J.
        • Parsons J.T.
        • Mendenhall W.M.
        • Million R.R.
        • Stringer S.P.
        • Cassisi N.J.
        Postoperative irradiation for squamous cell carcinoma of the head and neck: an analysis of treatment results and complications.
        Int J Radiat Oncol Biol Phys. 1989; 16: 25-36
        • Dinshaw K.A.
        • Agarwal J.P.
        • Laskar S.G.
        • Gupta T.
        • Shrivastava S.K.
        • Cruz A.D.
        Head and neck squamous cell carcinoma: the role of postoperative adjuvant radiotherapy.
        J Surg Oncol. 2005; 91: 48-55
        • Brown J.S.
        • Blackburn T.K.
        • Woolgar J.A.
        • Lowe D.
        • Errington D.E.
        • Vaughan E.D.
        • et al.
        A comparison of outcomes for patients with oral squamous cell carcinoma at intermediate risk of recurrence treated by surgery alone or with postoperative radiotherapy.
        Oral Oncol. 2007; 43: 764-773
        • Langendijk J.A.
        • Ferlito A.
        • Takes R.P.
        • Rodrigo J.P.
        • Suarez C.
        • Strojan P.
        • et al.
        Postoperative strategies after primary surgery for squamous cell carcinoma of the head and neck.
        Oral Oncol. 2010; 46: 577-585
        • Rogers S.N.
        • Lowe D.
        • Brown J.S.
        • Vaughan E.D.
        A prospective quality of life study for patients treated with primary surgery for oral cancer.
        Head Neck. 1999; 21: 394-401
        • Cooper J.S.
        • Pajak T.F.
        • Forasteire A.A.
        • Jacobs J.
        • Campbell B.
        • Saxman S.
        • et al.
        Postoperative concurrent radiotherapy and chemotherapy for high risk squamous cell carcinoma of the head and neck.
        N Engl J Med. 2004; 350: 1937-1944
        • Bernier J.
        • Domenge C.
        • Ozsahin M.
        • Matuszewska K.
        Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer.
        N Engl J Med. 2004; 350: 1945-1952
        • Mehanna H.
        • Jones T.M.
        • Gregoire V.
        • Ang K.K.
        Oropharyngeal carcinoma related to human papillomavirus.
        BMJ. 2010; 340: c1436
        • Carvalho A.L.
        • Magrin J.
        • Kowalski L.P.
        Sites of recurrence in oral and oropharyngeal cancers according to the treatment approach.
        Oral Dis. 2003; 9: 112-118
        • Dixit S.
        • Vyas R.K.
        • Toparani R.B.
        • Baboo H.A.
        • Patel D.D.
        Surgery versus surgery and postoperative radiotherapy in squamous cell carcinoma of the buccal mucosa: a comparative study.
        Ann Surg Oncol. 1998; 5: 502-510
        • Magge K.T.
        • Myers E.N.
        • Johnson J.T.
        Radiation following surgery for oral cancer: impact on local control.
        Laryngoscope. 2003; 113: 933-935
        • Liao C.T.
        • Chang J.T.
        • Wang H.M.
        • Ng S.-H.
        • Hsueh C.
        • Lee L.-Y.
        • et al.
        Does adjuvant radiation therapy improve outcomes in pT1–3N0 oral cavity cancer with tumor-free margins and perineural invasion?.
        Int J Radiat Oncol Biol Phys. 2008; 71: 371-376
        • Chen T.C.
        • Wang C.T.
        • Ko J.Y.
        • Lou P.-J.
        • Yang T.-L.
        • Ting L.-L.
        • et al.
        Postoperative radiotherapy for primary early oral tongue cancer with pathologic N1 neck.
        Head Neck. 2010; 32: 555-561
        • Shim S.J.
        • Cha J.
        • Koom W.S.
        • Kim G.E.
        • Lee C.G.
        • Choi E.C.
        • et al.
        Clinical outcomes for T1–2N0–1 oral tongue cancer patients underwent surgery with and without postoperative radiotherapy.
        Radiat Oncol. 2010; 5: 43-50
        • Loree T.R.
        • Strong E.W.
        Significance of positive margins in oral cavity squamous carcinoma.
        Am J Surg. 1990; 160: 410-414
        • Van Es R.J.
        • van Nieuw Amerongen N.
        • Slootweg P.J.
        • Egyedi P.
        Resection margin as a predictor of recurrence at the primary site for T1 and T2 oral cancers.
        Arch Otolaryngol Head Neck Surg. 1996; 122: 521-525
        • Mishra R.C.
        • Singh D.N.
        • Mishra T.K.
        Postoperative radiotherapy in carcinoma of buccal mucosa, a prospective randomized trial.
        Eur J Surg Oncol. 1996; 22: 502-504
        • Franceschi D.
        • Gupta R.
        • Spiro R.H.
        • Shah J.P.
        Improved survival in the treatment of squamous cell carcinoma of the oral tongue.
        Am J Surg. 1993; 166: 360-365
        • Schiff B.A.
        • Roberts D.B.
        • El-Naggar A.
        • Garden A.S.
        • Myers J.N.
        Selective vs modified radical neck dissection and postoperative radiotherapy vs observation in the treatment of squamous cell carcinoma of the oral tongue.
        Arch Otolaryngol Head Neck Surg. 2005; 131: 874-878
        • Shrime M.G.
        • Gullane P.J.
        • Dawson L.
        • Kim J.
        • Gilbert R.W.
        • Irish J.C.
        • et al.
        The impact of adjuvant radiotherapy on survival in T1–2N1 squamous cell carcinoma of the oral cavity.
        Arch Otolaryngol Head Neck Surg. 2010; 136: 225-228
        • El-Husseiny G.
        • Kandil A.
        • Jamshed A.
        • Khafaga Y.
        • Saleem M.
        • Allam A.
        • et al.
        Squamous cell carcinoma of the oral tongue: an analysis of prognostic factors.
        Br J Oral Maxillofac Surg. 2000; 38: 193-199
        • Kowalski L.P.
        Results of salvage treatment of the neck in patients with oral cancer.
        Arch Otolaryngol Head Neck Surg. 2002; 128: 58-62
        • Garzino-Demo P.
        • Dell’Acqua A.
        • Dalmasso P.
        • Fasolis M.
        • La Terra Maggiore G.M.
        • Ramieri G.
        • et al.
        Clinicopathological parameters and outcome of 245 patients operated for oral squamous cell carcinoma.
        J Craniomaxillofac Surg. 2006; 34: 344-350
        • Binahmed A.
        • Nason R.W.
        • Abdoh A.A.
        The clinical significance of the positive surgical margin in oral cancer.
        Oral Oncol. 2007; 43: 780-784
        • Liao C.T.
        • Chang J.T.
        • Wang H.M.
        • Ng S.-H.
        • Hsueh C.
        • Lee L.-L.
        • et al.
        Analysis of risk factors of predictive local tumor control in oral cavity cancer.
        Ann Surg Oncol. 2008; 15: 915-922
        • Iype E.M.
        • Sebastian P.
        • Mathew A.
        • Balagopal P.G.
        • Varghese B.T.
        • Thomas S.
        The role of selective neck dissection (I–III) in the treatment of node negative (N0) neck in oral cancer.
        Oral Oncol. 2008; 44: 1134-1138
        • Weijers M.
        • Snow G.B.
        • Bezemer D.P.
        • van der Wal J.E.
        • van der Waal I.
        The status of the deep surgical margins in tongue and floor of mouth squamous cell carcinoma and risk of local recurrence; an analysis of 68 patients.
        Int J Oral Maxillofac Surg. 2004; 33: 146-149
        • Ravasz L.A.
        • Slootweg P.J.
        • Hordijk G.J.
        • Smit F.
        • van der Tweel I.
        The status of the resection margin as a prognostic factor in the treatment of head and neck carcinoma.
        J Craniomaxillofac Surg. 1991; 19: 314-318
        • Parsons J.T.
        • Mendenhall W.M.
        • Stringer S.P.
        • Cassisi N.J.
        • Million R.R.
        An analysis of factors influencing the outcome of postoperative irradiation for squamous cell carcinoma of the oral cavity.
        Int J Radiat Oncol Biol Phys. 1997; 39: 137-148
        • Lapeyre M.
        • Bollet M.A.
        • Racadot S.
        • Geoffrois L.
        • Kaminsky M.-C.
        • Hoffstetter S.
        • et al.
        Postoperative brachytherapy alone and combined postoperative radiotherapy and brachytherapy boost for squamous cell carcinoma of the oral cavity, with positive or close margins.
        Head Neck. 2004; 26: 216-223
        • Hinerman R.W.
        • Mendenhall W.M.
        • Morris C.G.
        • Amdur R.J.
        • Werning J.W.
        • Villaret D.B.
        Postoperative irradiation for squamous cell carcinoma of the oral cavity: 35-year experience.
        Head Neck. 2004; 26: 984-994
        • Fan K.H.
        • Wang H.M.
        • Kang C.J.
        • Lee L.-L.
        • Huang S.-F.
        • Lin C.-Y.
        • et al.
        Treatment results of postoperative radiotherapy on squamous cell carcinoma of the oral cavity: coexistence of multiple minor risk factors results in higher recurrence rates.
        Int J Radiat Oncol Biol Phys. 2010; 77: 1024-1029
        • Kokal W.A.
        • Neifeld J.P.
        • Eisert D.
        • Lipsett J.A.
        • Lawrence W.
        • Beatty J.D.
        • et al.
        Postoperative radiation as adjuvant treatment for carcinoma of the oral cavity, larynx and pharynx: preliminary report of a prospective randomized trial.
        J Surg Oncol. 1988; 38: 71-76
        • Rodrigo J.P.
        • Maseda E.
        • Maldonado M.
        • Aldama P.
        • Puente M.
        • Llorente J.L.
        • et al.
        Efficacy of postoperative radiation therapy for squamous cell carcinoma of the head and neck: results of a prospective randomized clinical trial.
        Acta Otorrhinolaryngol Esp. 2004; 55 (in Spanish): 415-419
        • Rogers S.N.
        • Brown J.S.
        • Woolgar J.A.
        • Lowe D.
        • Magennis P.
        • Shaw R.J.
        • et al.
        Survival following primary surgery for oral cancer.
        Oral Oncol. 2009; 45: 201-211
        • Nason R.W.
        • Binahmed A.
        • Pathak K.
        • Abdoh A.A.
        • Sandor G.K.
        What is the adequate margin of surgical resection in oral cancer.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 107: 625-629
        • Brandwein-Gensler M.
        • Teixeira M.S.
        • Lewis C.M.
        • Lee B.
        • Rolnitzky L.
        • Hille J.J.
        • et al.
        Oral squamous cell carcinoma: histologic risk assessment, but not margin status, is strongly predictive of local disease-free and overall survival.
        Am J Surg Pathol. 2005; 29: 167-178
        • Ambrosch P.
        • Kron M.
        • Pradier O.
        • Steiner W.
        Efficacy of selective neck dissection: a review of 503 cases of elective and therapeutic treatment of the neck in squamous cell carcinoma of the upper aerodigestive tract.
        Otolaryngol Head Neck Surg. 2001; 124: 180-187
        • Padegar N.A.
        • Gilbert R.W.
        Selective neck dissection: a review of the evidence.
        Oral Oncol. 2009; 45: 416-420
        • Moergel M.
        • Jahn-Eimermacher A.
        • Krummenauer F.
        • Reichert T.E.
        • Wagner W.
        • Wendt T.G.
        • et al.
        Effectiveness of adjuvant radiotherapy in patients with oropharyngeal and floor of mouth squamous cell carcinoma and concomitant histological verification of singular ipsilateral cervical lymph node metastasis (pN1-state)—a prospective multicenter randomized controlled clinical trial using a comprehensive cohort design.
        Trials. 2009; 10: 118-130
        • Tinterri C.
        • Gatzemeier W.
        • Zanini V.
        • Regolo L.
        • Pedrazzoli C.
        • Rondini E.
        • et al.
        Conservation surgery with and without radiotherapy in elderly patients with early stage breast cancer: a prospective randomised multicentre trial.
        Breast. 2009; 18: 373-377
        • Fisher B.
        • Anderson S.
        • Bryant J.
        • Margolese R.G.
        • Deutsch M.
        • Fisher E.R.
        • et al.
        Twenty year follow-up of a randomized trial comparing total mastectomy, lumpectomy and lumpectomy and irradiation for the treatment of invasive breast cancer.
        New Eng J Med. 2002; 347: 1233-1241
        • Barnett G.C.
        • West C.M.
        • Dunning A.M.
        • Elliott R.M.
        • Coles C.E.
        • Pharoah P.D.P.
        • et al.
        Normal tissue reactions to radiotherapy: towards tailoring treatment dose by genotype.
        Nat Rev Cancer. 2009; 9: 134-142
        • Lyons A.J.
        • West C.M.
        • Risk J.M.
        • Slevin N.J.
        • Chan C.
        • Crichton S.
        • et al.
        Osteoradionecrosis in head and neck cancer has a distinct genotype-dependent cause.
        Int J Radiat Oncol Biol Phys. 2011; (Epub ahead of print) PMID: 21708430