What is the recommended neoadjuvant treatment approach for an elderly patient with right buccal carcinoma?

Neoadjuvant Treatment for Right Buccal Carcinoma in Elderly Patients

Primary Recommendation

For elderly patients with buccal carcinoma, proceed directly to surgical resection without neoadjuvant therapy, followed by adjuvant treatment based on pathologic findings. 1, 2, 3

Evidence-Based Rationale

Surgery-First Approach is Superior

• Surgical treatment achieves superior outcomes compared to radiation therapy alone across all T and N categories in buccal mucosa carcinoma, with 5-year survival rates of 80% after surgery versus significantly lower rates with radiation-only approaches. 4, 3

• Aggressive surgical treatment with composite resection (when indicated) results in 5-year actuarial survival rates of 100% for stage I, 45% for stage II, 67% for stage III, and 78% for stage IV disease. 3

• Surgical margins ≤3 mm predict locoregional recurrence (71% vs 95% locoregional control for ≤3 mm vs >3 mm margins), making adequate initial resection critical—neoadjuvant therapy does not improve surgical outcomes in this disease. 2

Evidence Against Neoadjuvant Therapy in Elderly Patients

• Elderly patients (≥75 years) treated with neoadjuvant chemotherapy experience significantly higher incidence and severity of postoperative complications compared to younger patients, with no difference in postoperative mortality. 5, 1

• The risk-benefit ratio has not been adequately studied in patients over 80 years of age, and extrapolation from highly selected trial populations to the general elderly population should be made with extreme caution. 5, 1

• Neoadjuvant therapy for buccal carcinoma lacks evidence of survival benefit—unlike breast cancer or rectal cancer where neoadjuvant therapy enables organ preservation, head and neck cancers (including buccal carcinoma) do not demonstrate improved overall survival with neoadjuvant approaches. 6

Recommended Treatment Algorithm

Step 1: Surgical Evaluation and Resection

• Refer immediately to a high-volume head and neck surgical center for evaluation. 5, 1
• Perform wide surgical excision with composite resection if tumor involves adjacent structures (bone, skin, or muscle). 3
• Ensure surgical margins >3 mm to minimize locoregional recurrence risk. 2
• Do not deny surgical treatment based on chronological age alone—functional status and comorbidities are more relevant. 5, 1

Step 2: Pathologic Assessment

• Evaluate final pathology for margin status, depth of invasion, perineural invasion, and lymph node involvement. 2
• Margins ≤3 mm, positive nodes (pN+), or adverse pathologic features mandate adjuvant therapy. 2

Step 3: Adjuvant Treatment Based on Pathology

• For margins ≤3 mm or positive nodes: Adjuvant concurrent chemoradiotherapy improves locoregional control. 2
• For adequate margins (>3 mm) without high-risk features: Consider observation or adjuvant radiotherapy alone. 2, 3
• Adjuvant chemotherapy should not be denied to elderly patients based on age alone, as tolerability is similar to younger patients when functional status is adequate. 5, 1

Critical Pitfalls to Avoid

• Do not delay surgery for neoadjuvant therapy—there is no evidence supporting neoadjuvant approaches for buccal carcinoma, and elderly patients experience increased postoperative complications when neoadjuvant chemotherapy is used. 1, 4, 3

• Do not use chronological age as the sole criterion for treatment decisions—functional status predicts chemotherapy toxicity and mortality better than age. 5, 1

• Avoid inadequate surgical margins—margins ≤3 mm carry a 2.16-fold increased hazard ratio for locoregional failure, making re-excision or aggressive adjuvant therapy necessary. 2

• Do not attempt surgical salvage after radiation failure—patients who underwent surgical salvage after radiation therapy failure had a 1-year survival rate of 0%. 3

Special Considerations for Elderly Patients

• Nearly half of buccal carcinoma patients are over 70 years of age, making this a disease predominantly affecting the elderly population. 4

• Perform comprehensive geriatric assessment to categorize patients as "fit" versus "frail" before finalizing treatment decisions, evaluating comorbidities, functional status, cardiac function, and renal function. 7

• For fit elderly patients: Proceed with standard surgical resection and adjuvant therapy as indicated by pathology. 5, 1

• For frail elderly patients with borderline resectability: Consider definitive radiation therapy rather than neoadjuvant chemotherapy followed by surgery, as the latter increases postoperative complications without proven survival benefit. 1, 8