Response-adapted surgery after neoadjuvant immunochemotherapy in oral squamous cell carcinoma.

[OBJECTIVE] The standard treatment for locally advanced oral squamous cell carcinoma (OSCC) involves radical surgery followed by adjuvant therapy, often resulting in significant functional impairment. Neoadjuvant immunochemotherapy (NICT) has emerged as a promising strategy to facilitate surgical de-escalation while preserving oncologic outcomes. This study evaluates the feasibility of response-adapted surgery (RAS) following NICT in OSCC.

[METHODS] In this retrospective analysis, 152 patients with previously untreated OSCC received NICT followed by either RAS (n = 66) or traditional surgery (TS, n = 86). RAS was tailored to post-NICT tumor regression, while TS adhered to pretreatment tumor extent. Primary endpoints were 3-year event-free survival (EFS) and overall survival (OS). Secondary endpoints included quality of life (QoL, assessed via EORTC QLQ-HN35) and perioperative complications.

[RESULTS] The RAS and TS cohorts exhibited comparable 3-year EFS (78.8 % vs. 79.1 %, p = 0.944) and OS (90.9 % vs. 91.9 %, p = 0.826). RAS significantly reduced the need for mandibulectomy (16.7 % vs. 41.9 %, p = 0.009) and free flap reconstruction (15.2 % vs. 48.8 %, p = 0.018), with fewer major complications (4.5 % vs. 11.6 %, p = 0.048). QoL metrics favored RAS, particularly in swallowing (15 ± 3.8 vs. 28 ± 5.5, p < 0.001) and speech (14 ± 3.9 vs. 25 ± 5.2, p < 0.001) at 12 months. Major pathologic response and PD-L1 CPS > 20 were associated with improved survival.

[CONCLUSIONS] RAS after NICT achieves oncologic outcomes equivalent to TS while significantly reducing treatment-related morbidity and improving functional recovery. These findings support RAS as a viable de-escalation strategy for OSCC, aligning with the goals of precision oncology. Prospective trials are needed to validate long-term efficacy and refine patient selection criteria.