Histologic characteristics and tumor spread of recurrent glottic carcinoma: analysis on whole-organ sections and comparison with tumor spread of primary glottic carcinomas

Imaging in head and neck squamous cell carcinoma: the potential role of PET/MRI

In head and neck oncology, the information provided by positron emission tomography (PET)/CT and MRI is often complementary because both the methods are based on different biophysical foundations. Therefore, combining diagnostic information from both modalities can provide additional diagnostic gain. Debates about integrated PET/MRI systems have become fashionable during the past few years, since the introduction and wide adoption of software-based multimodality image registration and fusion and the hardware implementation of integrated hybrid PET/MRI systems in pre-clinical and clinical settings. However, combining PET with MRI has proven to be technically and clinically more challenging than initially expected and, as such, research into the potential clinical role of PET/MRI in comparison with PET/CT, diffusion-weighted MRI (DW MRI) or the combination thereof is still ongoing. This review focuses on the clinical applications of PET/MRI in head and neck squamous cell carcinoma (HNSCC). We first discuss current evidence about the use of combined PET/CT and DW MRI, and, then, we explain the rationale and principles of PET/MR image fusion before summarizing the state-of-the-art knowledge regarding the diagnostic performance of PET/MRI in HNSCC. Feasibility and quantification issues, diagnostic pitfalls and challenges in clinical settings as well as ongoing research and potential future applications are also discussed.

Outcomes of transoral laser microsurgery for recurrent head and neck cancer

OBJECTIVE

To report our outcomes with salvage CO2 laser surgery following recurrence of laryngeal and oropharyngeal cancer after radiotherapy.

METHOD

This study entailed a prospective review of patients treated with transoral laser microsurgery for recurrent laryngeal and oropharyngeal cancer between 2002 and 2010 at the Queen Elizabeth II Health Science Centre in Canada.

RESULTS

Sixteen patients were identified, with a mean follow up of 30.6 months. Five patients died of recurrence. Complications were common in patients with oropharyngeal cancer. The overall survival and disease-free survival rates at an average of 29.8 months follow up were 50 per cent and 68.8 per cent respectively.

CONCLUSION

Salvage surgery using transoral laser microsurgery should be considered in the management of patients with recurrent laryngeal and oropharyngeal cancer. This technique offers acceptable salvage rates with less comorbidity than other treatments.

Decision making in the management of recurrent head and neck cancer

Despite substantial improvements in head and neck squamous cell carcinoma (HNSCC) treatment, the major obstacle to long-term survival remains disease recurrence. Salvage options are often limited due to prior therapy and the escalated morbidity of retreatment. The costs of treatment must be measured against the anticipated quality and quantity of life recovered, even with resectable disease. This review surveys the recurrent HNSCC literature to better guide decision making. Across multiple studies, negative prognostic factors include impaired performance status, advanced recurrent stage, brief disease-free interval, previous chemotherapy, and nonlaryngeal sites of recurrence. When possible, surgical salvage remains the principal option for durable disease control, quality of life preservation, and cure. Nonsurgical therapies have also demonstrated measurable improvements in locoregional control. Interpretation of salvage literature must be tempered by recognition of significant selection bias. The decision for salvage therapy must be individualized, with management that involves well-informed patients resulting in the best outcomes.

Transoral laser microsurgery of recurrent early glottic cancer after radiation therapy: clinical feasibility and limitations

OBJECTIVES

Transoral laser microsurgery (TLM) is an accepted alternative to open partial laryngectomy for selected glottic cancers, but its role in salvage of radiation failure is debated.

METHODS

The records of 18 patients treated by TLM for rT1 and rT2 glottic cancer after curative radiation therapy from 2002 to 2007 were retrospectively analyzed.

RESULTS

Of the 18 patients, 10 (56%) remained free of disease after the first TLM. The 5-year local control and laryngeal preservation rates showed better outcomes in rpT1 tumors than in rpT2 tumors (87.5% versus 16.6%, p = 0.02; and 87.5% versus 33.3%, p = 0.03, respectively). However, the 5-year overall survival and disease-specific survival rates showed no significant difference between rpT1 and rpT2 tumors.

CONCLUSIONS

TLM can be a relatively safe and effective salvage option for rT1 glottic cancer. However, because of its high local recurrence rate, TLM may not be generally recommended for rT2 glottic cancer.

Diagnosis and treatment of recurrent laryngeal cancer following initial nonsurgical therapy

Surgery is the preferred modality for curative treatment of recurrent laryngeal cancer after failure of nonsurgical treatments. Patients with initial early-stage cancer experiencing recurrence following radiotherapy often have more advanced-stage tumors by the time the recurrence is recognized. About one third of such recurrent cancers are suitable for conservation surgery. Endoscopic resection with the CO(2) laser or open partial laryngectomy (partial vertical, supracricoid, or supraglottic laryngectomies) have been used. The outcomes of conservation surgery appear better than those after total laryngectomy, because of selection bias. Transoral laser surgery is currently used more frequently than open partial laryngectomy for treatment of early-stage recurrence, with outcomes equivalent to open surgery but with less associated morbidity. Laser surgery has also been employed for selective cases of advanced recurrent disease, but patient selection and expertise are required for application of this modality to rT3 tumors. In general, conservation laryngeal surgery is a safe and effective treatment for localized recurrences after radiotherapy for early-stage glottic cancer. Recurrent advanced-stage cancers should generally be treated by total laryngectomy.

Reirradiation in head and neck cancers

Salvage surgery is the mainstay of treatment for recurrences or secondary primary tumors in areas that were irradiated earlier. However, locoregional recurrence remains the main cause of death after surgery. Adjuvant reirradiation dramatically reduces locoregional recurrences but the risk-benefit ratio seems to be advantageous mostly for residual microscopic disease. In contrast, the rate of distant metastasis among reirradiated patients indicates that the local treatment alone is not sufficient. Full-dose exclusive chemo-reirradiation (over 60 Gy) can cure a subset of patients when surgery is not feasible. However, reirradiation is associated with a significant rate of severe toxicity and should, therefore, be compared with chemotherapy in randomized trials. Accrual may be difficult because of selection biases such as tumor volume, small volumes (largest axis less than 3-4 cm) being more likely to be irradiated. In addition, patients in poor general condition with severe comorbidities, organ dysfunction, or incomplete healing after salvage surgery, are unlikely to benefit from reirradiation. Noteworthy volumes to be reirradiated must be established between the head and neck surgeon and the radiation oncologist: the definition of the clinical target volume should be taken into account, the natural history of recurrent tumors, especially with regard to extension modalities, and the absence of strict correlation between imaging and histological real extension. This is even more critical with the advent of new irradiation techniques. Chemotherapy associations and new radiosensitizing agents are also under investigation. Comparison between reirradiation modalities is difficult because most trials are phase 2 mono-institutional trials. As selection of patients is a key issue, only phase 3 multiinstitutional trials can provide definitive results.

Salvage surgery after concomitant chemoradiation in head and neck squamous cell carcinomas - stratification for postsalvage survival

BACKGROUND

Salvage surgery after concomitant chemoradiation therapy (CCRT) for patients with head and neck squamous cell carcinomas (HNSCC) is challenging because of its associated morbidity/mortality and the poor prognoses of these patients.

METHODS

The outcome analysis of prospectively collected data from 93 patients with HNSCC with local and/or regional shows treatment failures but without distant metastasis after CCRT.

RESULTS

Thirty-eight patients underwent salvage surgery, whereas 55 underwent palliative treatment, with 2-year overall survival rates of 43.4% and 0%, respectively. Initial stage IV tumors (p = .017) and concurrent local and regional failures (p = .003) were independent predictors for decreased survival after salvage surgery. Two-year overall survival rates for patients with 2, 1, or none of these predictive factors were 0%, 49%, and 83%, respectively (p = .0005).

CONCLUSION

Salvage surgery after CCRT has acceptable outcomes. Initial stage IV tumors and concurrent local and regional failures were independent predictors that can stratify patients into distinct prognostic groups for postsalvage survival.

Outcomes of salvage surgery with free flap reconstruction for recurrent oral and oropharyngeal cancer

OBJECTIVES/HYPOTHESIS

To evaluate outcomes of salvage surgery with free flap reconstruction for recurrent squamous cell carcinoma of the oropharynx and oral cavity with increased use of chemoradiotherapy.

STUDY DESIGN

Retrospective patient review.

METHODS

All patients undergoing salvage surgery with free flap reconstruction for oropharynx (n = 36) and oral cavity (n = 36) squamous cell carcinomas between January 2001 and January 2008 were obtained. Mean follow-up was 14 months. Previous chemoradiotherapy was used in 40% and radiotherapy alone in 60%.

RESULTS

Complications were more frequent in oropharynx than oral cavity tumors (36% and 14%, respectively; P = .05) requiring more secondary procedures (15 for oropharynx vs. six for oral cavity). Few patients returned to a normal diet (8%), and a majority retained an enterogastric feeding tube (56%). Median survival overall following salvage surgery was 44.8 months for oral cavity and 53.8 months for oropharynx head and neck squamous cell carcinoma. Overall estimated 1-, 2-, and 5-year observed survivals were 98%, 77.2%, and 43.7%, respectively. Twelve patients had a disease-free interval of <6 months, 92% of whom died of disease. Of 17 patients with disease at the primary site and involved regional lymph nodes, 94% died of disease.

CONCLUSIONS

Salvage surgery with free flap reconstruction for recurrent oral and oropharyngeal tumors after chemoradiotherapy has acceptable morbidity and similar cure rates as salvage following radiotherapy without chemotherapy. Concurrent nodal recurrence and short disease-free interval are associated with reduced cure rates. A significant proportion will require enterogastric feeding and few will tolerate a normal diet.

US-guided transcutaneous tru-cut biopsy of laryngo-hypopharyngeal lesions

OBJECTIVE

To evaluate the feasibility and performance of ultrasound-guided transcutaneous tru-cut biopsy (USGTCB) in selected patients (with stenosis of airways or difficult intubation or contraindication to general anaesthesia) with untreated or previously treated suspicious laryngo-hypopharyngeal masses.

METHODS

Biopsies were performed with a free-hand technique by a single radiologist. Thirty-six USGTCBs were scheduled in 34 patients (24 males, 10 females; age range 47-95 years). Two USGTCBs were not performed, as lesions were not detectable: therefore, 16 USGTCBs were performed for an untreated mass suspicious for malignancy and 18 were performed for a mass suspicious for recurrence after radiotherapy alone, or associated with endoscopic laser surgery or chemotherapy.

RESULTS

USGTCB diagnosed 25 squamous cell carcinomas (73.5%) and nine benign lesions (26.5%); no false positives and two false negatives were reported, both in patients previously treated with radiotherapy. The sensitivity, specificity, positive and negative predictive value of the technique was 92.5%, 100%, 100% and 77.7% respectively, with no major complications.

CONCLUSION

Although biopsy under microlaryngoscopy remains the "gold-standard" technique, USGTCB is feasible, carries the advantages of avoiding general anaesthesia, is suitable for outpatients and is cost-effective. If applied to selected patients, it could be considered for the histological diagnosis of both primary and recurrent laryngo-hypopharyngeal masses.

Laryngeal and hypopharyngeal carcinomas after (chemo)radiotherapy: a diagnostic dilemma

PURPOSE OF REVIEW

During recent years, (chemo)radiotherapy has evolved into a primary treatment modality for both early and advanced laryngeal and hypopharyngeal carcinomas. Head and neck surgeons will be concerned more frequently with patients presenting symptoms and signs suggesting recurrent tumor or complications of (chemo)radiotherapy.

RECENT FINDINGS

Analysis of histologic characteristics and tumor spread of recurrent carcinomas on whole-organ slices of salvage laryngectomy specimens showed that recurrent laryngeal carcinomas are often present with multiple tumor foci dispersed in different regions; furthermore, they may develop beneath an intact mucosa. Only a few articles analyze the reliability of laryngoscopy and biopsy in detecting recurrences after (chemo)radiotherapy: the number of false negative biopsies is relatively high. The differentiation between radionecrosis and tumor recurrence is difficult by computed tomography scan and magnetic resonance imaging in many cases. Positron emission tomography-computed tomography and diffusion-weighted magnetic resonance imaging are promising diagnostic modalities to detect or exclude persistent or recurrent disease after (chemo)radiotherapy.

SUMMARY

Endoscopy with biopsy, computed tomography scan and conventional magnetic resonance imaging present several deficiencies in diagnosing recurrent disease after (chemo)radiotherapy. New imaging modalities such as positron emission tomography-computed tomography and diffusion-weighted magnetic resonance imaging show promising results, increasing the diagnostic efficacy.

Salvage surgery after failed primary concomitant chemoradiation

PURPOSE OF REVIEW

Primary treatment of many head and neck cancers is shifting to nonsurgical modalities with concomitant chemoradiation becoming increasing prevalent. With this change, surgery is moving to a role as a salvage treatment modality. As a result of this shift, it is important to understand the issues surrounding surgical salvage after chemoradiation.

RECENT FINDINGS

Studies have consistently found that salvage surgery after chemoradiation carries a high complication rate, higher than either primary surgery or salvage surgery after radiation alone. There are very few reports on the success rate of salvage surgery after failed primary concurrent chemoradiation, but what little data we have seems to suggest success rates approximate success rates for salvage after radiation therapy. There are also reasons to believe that efficacy of salvage surgery varies by stage and site of disease. Also, fundamental differences in the nature of cancer after failed primary therapy have been elucidated by recent studies.

SUMMARY

While salvage surgery is fraught with higher morbidity and lower efficacy than primary surgery, it remains the only potentially curative option available to patients who have failed 'organ preservation' primary therapy. We review issues to consider when managing these challenging patients.