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Oebel L, Mayer A, Kaufmann J, Wollschläger D, Hagemann J, Krüger M, Schmidberger H. Is bilateral radiotherapy necessary for patients with unilateral squamous cell carcinoma of unknown primary of the head and neck region? Clin Transl Radiat Oncol 2024; 45:100713. [PMID: 38192301 PMCID: PMC10772399 DOI: 10.1016/j.ctro.2023.100713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/24/2023] [Accepted: 12/06/2023] [Indexed: 01/10/2024] Open
Abstract
Background and Purpose Squamous cell carcinoma of unknown primary (SCC-CUP) of the head and neck region remains a clinical challenge, with uncertainty surrounding the necessity of contralateral irradiation of cervical lymphatic drainage in cases of unilateral involvement. Materials and Methods A retrospective study was conducted at the Department of Radiation Oncology, University Medical Center Mainz, on a cohort of 50 patients with unilateral SCC-CUP of the head and neck region treated between 2005 and 2019. 30 patients received bilateral and 20 received unilateral cervical radiotherapy. The majority (n = 38, 76 %) were treated with modern IMRT/ VMAT (Intensity-modulated Radiation Therapy/ Volumetric Modulated Arc Therapy) techniques. Results After a median follow-up of 64.5 months, locoregional recurrences occurred in 26 % of cases (n = 13/50), all of which were ipsilateral and predominantly within the volume of the previous irradiated CTV (clinical target volume) (85 %, n = 11/13). No patient treated unilaterally developed a contralateral recurrence in the neck. After 3 years, we observed 7 locoregional recurrences in the bilateral irradiated group (n = 7/30, 23 %), and 5 locoregional recurrences in the unilateral irradiated group (n = 5/20, 25 %). After 3 years, 12 patients had died in the bilateral irradiated group (n = 12/30, 40 %), and 7 in the unilateral irradiated group (n = 7/20, 35 %). 7 Patients showed distant metastases after 3 years in the bilateral irradiated group (n = 7/30, 23 %), and 2 in the unilateral irradiated group (n = 2/20, 10 %). Locoregional control (LRC) at 5 years was 66.2 % in the bilaterally irradiated group, and 70.0 % in the unilaterally irradiated group. Overall survival (OS) was 52.6 % (bilateral) and 64.0 % (unilateral). Distant metastasis-free survival (DMFS) was 74.7 % (bilateral) and 84.4 % (unilateral). No significant differences were observed in OS (p = 0.37), LRC (p = 0.91), and DMFS (p = 0.91) between the groups.Acute toxicity ≥ °2 accordingly CTCAE (Common Terminology Criteria of Adverse Events) was high with 97% while late toxicity ≥ °2 was moderate with 31%. There was no statistically significant difference between the group of unilateral and bilateral irradiated patients. Conclusion These data suggest that contralateral cervical irradiation may be of limited benefit in patients with SCC-CUP, as recurrences occured ipsilaterally, and predominantly within the area of prior irradiation. Unilateral irradiation seems to be adequate for carefully selected patients.
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Affiliation(s)
- Laura Oebel
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Arnulf Mayer
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Justus Kaufmann
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Daniel Wollschläger
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Jan Hagemann
- Department of Head and Neck Surgery, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Maximilian Krüger
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Heinz Schmidberger
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
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Matsuoka M, Onodera T, Yokota I, Iwasaki K, Suzuki Y, Masanari H, Kondo E, Iwasaki N. Bone metastatic cancer of unknown primary at initial presentation. Clin Transl Oncol 2024; 26:461-467. [PMID: 37395989 DOI: 10.1007/s12094-023-03267-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/25/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION Cancer of unknown primary (CUP) is a challenging malignancy. The purpose of this study was to investigate the clinical characteristics and prognosis of bone metastatic CUP using the population-based Surveillance, Epidemiology, and End Results (SEER) database. METHODS From the SEER database, we identified 1908 patients with bone metastatic CUP at initial presentation between 2010 and 2018. Histology was subdivided following International Classification of Diseases for Oncology codes as Adenocarcinoma, Squamous cell, Neuroendocrine, or Carcinoma not otherwise specified (NOS). Cox proportional hazard modeling was applied using factors of age, sex, ethnicity, histological subtype, and therapeutic intervention. RESULTS Among the 1908 patients, histology was Neuroendocrine in 240 patients, Squamous cell in 201 patients, Adenocarcinoma in 810 patients and NOS in 657 patients. In each subtype, patients tended to be predominantly male and white. Chemotherapy was introduced for 28% of patients and radiation for 34% in the entire cohort. Survival in patients with bone metastatic CUP was unfavorable, with a median survival of 2 months. Among the histological subtypes, Adenocarcinoma showed shorter survival than the other groups. In addition, treatment interventions such as chemotherapy and radiation therapy prolonged survival, particularly for Squamous cell, Adenocarcinoma and NOS, but not for Neuroendocrine. DISCUSSION Bone metastatic CUP showed extremely poor prognosis, but treatment interventions such as chemotherapy and radiation generally offered survival benefits. Further randomized clinical research is needed to confirm the present results.
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Affiliation(s)
- Masatake Matsuoka
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Tomohiro Onodera
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Koji Iwasaki
- Department of Functional Reconstruction for the Knee Joint, Hokkaido University, Kita-15, Nish-7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Yuki Suzuki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Hamasaki Masanari
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital, North 14 West 5, Kita-Ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
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Chen AM. Management of unknown primary head and neck cancer with radiation therapy in the era of human papillomavirus (HPV): No longer cutting down the tree to get an apple. Radiother Oncol 2023; 189:109952. [PMID: 37844736 DOI: 10.1016/j.radonc.2023.109952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE Given the central role that radiation has in the management of head and neck squamous cell carcinoma of unknown primary origin, it is imperative to review how treatment paradigms have been refined and continue to evolve in the modern era. METHODS AND MATERIALS This study was designed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement. A literature search of peer-reviewed publications was undertaken to identify works pertaining to the use of radiation for squamous cell carcinoma of unknown primary origin presenting as cervical lymph node metastases. Articles published from January 2002 to January 2023 with full text available on PubMed and restricted to the English language and human subjects were included. The full bibliographies of identified articles were reviewed and irrelevant studies were removed. RESULTS While such breakthroughs as intensity-modulated radiotherapy, positron emission tomography, biomarker testing with immune-histochemistry, and minimally invasive surgical techniques such as transoral robotic surgery have fundamentally changed the approach to this disease in recent decades, controversies still exist with respect to the manner in which radiation is delivered. Although the incidence of head and neck unknown primary cancer is relatively low, questions regarding the necessity of comprehensive radiation using the age-old standard method of targeting the bilateral necks and entire pharyngeal axis to encompass all putative sites of mucosal disease persist. CONCLUSIONS Prospective evidence is lacking, and the available studies have been complicated by such factors as the relatively limited sample sizes, as well as the variability in work-up, treatment, inclusion criteria, and follow-up. Regardless, advances in science and technology have ushered in more precise approaches with a high degree of customization, particularly given the increased proportion of patients presenting with human papillomavirus-related disease.
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Affiliation(s)
- Allen M Chen
- Department of Radiation Oncology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, USA.
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Pala M, Novakova P, Pechacova Z, Vesela L, Vrana A, Sukova J, Holeckova P, Drbohlavova T, Podlesak T, Petruzelka L. Long-term results of radio(chemo)therapy in metastatic carcinoma to cervical lymph nodes from an unknown primary. Adult Comorbidity Evaluation 27 score as a predictor of survival. Strahlenther Onkol 2023; 199:149-159. [PMID: 35943554 DOI: 10.1007/s00066-022-01983-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 07/10/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate the effectiveness and toxicity of curative (chemo)radiotherapy in patients with metastatic carcinoma to cervical lymph nodes from an unknown primary. METHODS Retrospective study of 90 consecutive patients, treated with curative radiotherapy from 2003 to 2018 (median age 59 years; current/former smokers 76%) was conducted. The distribution of nodal staging was as follows: N1: 12%, N2a: 21%, N2b: 43%, N2c: 10%, N3: 13%. In 62% of patients, neck dissection was performed before radiotherapy. Concomitant chemotherapy was given to 64% of patients. RESULTS The median follow-up of surviving patients was 86 months. The median total radiotherapy dose achieved was 70 Gy. The 5‑ and 10-year locoregional control were 84% in both cases, while 5‑ and 10-year distant control were 90% and 89%, respectively. A primary tumor in the head and neck area was detected in only 2 patients. No patient had an initial failure in the pharyngeal axis or contralateral cervical nodes. The 5‑ and 10-year overall survival were 55% and 42%, respectively. Severe early toxicity occurred in 71%; severe late toxicity in 33% of patients. Multivariate analysis demonstrated N‑status (hazard ratio [HR] 2.424; 95% confidence interval [CI] 1.121-5.241; p = 0.024) and comorbidity scores assessed by ACE-27 (Adult Comorbidity Evaluation; HR 3.058; 95% CI 1.489-6.281; p = 0.002) as two independent prognostic factors for overall survival. CONCLUSION The results of our work study demonstrate the high effectiveness of curative (chemo)radiotherapy on the pharyngeal axis and bilateral cervical nodes with long-term locoregional and distant control in 3/4 of the treated patients. N‑status and comorbidity scores were shown as strong prognostic factors influencing overall survival.
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Affiliation(s)
- Miloslav Pala
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic.
| | - Pavla Novakova
- Radiophysics Department, Bulovka University Hospital, Prague, Czech Republic
| | - Zdena Pechacova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Lucie Vesela
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Antonin Vrana
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Jarmila Sukova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Petra Holeckova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Tereza Drbohlavova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Tomas Podlesak
- Department of Otorhinolaryngology, Bulovka University Hospital, Prague, Czech Republic
| | - Lubos Petruzelka
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
- Department of Oncology of the 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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Faisal M, Le NS, Grasl S, Janik S, Simmel H, Schratter-Sehn AU, Hamzavi JS, Franz P, Erovic BM. Carcinoma of Unknown Primary (CUP) versus CUP Turned to Primary Carcinoma of the Head and Neck—An Analysis of Diagnostic Methods and the Impact of Primary Tumor on Clinical Outcome. Diagnostics (Basel) 2022; 12:diagnostics12040894. [PMID: 35453942 PMCID: PMC9032826 DOI: 10.3390/diagnostics12040894] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/01/2022] [Accepted: 04/02/2022] [Indexed: 12/07/2022] Open
Abstract
Background. The purpose of this study was to analyze the value of different diagnostic methods in detecting the primary site and the impact of primary tumors on the clinical outcome of carcinoma of unknown primary (CUP). Methods. In this multicenter, retrospective study, 124 patients with true CUP (n = 94) and CUP turned to primary carcinoma (n = 30) were included. Patients with evidence of primary site during the clinical examination were excluded a priori. The diagnostic procedure was comprised of imaging and invasive methods (fine-needle-aspiration, tonsillectomy and panendoscopy). All patients were treated with curative intent. Results. Despite extensive diagnostic workup, the primary site remained unknown in 75.8%. Invasive diagnostic methods showed higher primary detection rates than imaging modalities (15.1% vs. 7.8%). Tonsillectomy and panendoscopy revealed the primary tumor in 14.9% and 15.2% of patients, whereas the detection rates of CT, MRI and FDG-PET-CT were 10.1%, 4.8% and 6.5%, respectively. The occurrence of primary tumors led to a significantly deteriorating 5-year overall survival (p = 0.002) and emerged as survival prognosticator (HR = 2.764, p = 0.003). Conclusion. Clinical examination in combination with tonsillectomy and panendoscopy was superior to imaging alone in detecting the primary tumor. When the CUP of patients turned to a primary tumor, clinical outcome was significantly worse than in CUP patients.
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Affiliation(s)
- Muhammad Faisal
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore 54000, Pakistan;
- Institute of Head and Neck Diseases, Evangelical Hospital, 1180 Vienna, Austria;
| | - Nguyen-Son Le
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, 1090 Vienna, Austria; (N.-S.L.); (S.G.); (S.J.)
| | - Stefan Grasl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, 1090 Vienna, Austria; (N.-S.L.); (S.G.); (S.J.)
| | - Stefan Janik
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, 1090 Vienna, Austria; (N.-S.L.); (S.G.); (S.J.)
| | - Helmut Simmel
- Institute of Radio-Oncology, Kaiser-Franz-Josef Hospital, 1100 Vienna, Austria; (H.S.); (A.U.S.-S.)
| | | | - Jafar-Sasan Hamzavi
- Institute of Head and Neck Diseases, Evangelical Hospital, 1180 Vienna, Austria;
| | - Peter Franz
- Department of Otorhinolaryngology, Head and Neck Surgery, Rudolfstiftung Teaching Hospital, 1030 Vienna, Austria;
| | - Boban M. Erovic
- Institute of Head and Neck Diseases, Evangelical Hospital, 1180 Vienna, Austria;
- Correspondence: ; Tel.: +43-1-40422-4518
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Heianna J, Makino W, Hirakawa H, Agena S, Tomita H, Ariga T, Ishikawa K, Takehara S, Maemoto H, Murayama S. Therapeutic efficacy of selective intra-arterial chemoradiotherapy with docetaxel and nedaplatin for fixed bulky nodal disease in head and neck cancer of unknown primary. Eur Arch Otorhinolaryngol 2021; 279:3105-3113. [PMID: 34628548 DOI: 10.1007/s00405-021-07121-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/01/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Fixed bulky nodal disease in patients with head and neck cancer of unknown primary (HNCUP) remains difficult to treat. This retrospective study evaluated the therapeutic efficacy of selective intra-arterial chemoradiotherapy with docetaxel and nedaplatin for fixed bulky nodal disease in HNCUP. METHODS Data from seven consecutive patients with fixed bulky nodal disease in HNCUP who had undergone selective intra-arterial chemoradiotherapy were analyzed. Whole pharyngeal mucosa and all bilateral nodal areas were irradiated (total dose 50 Gy), and bulky nodal lesions were provided an additional 20 Gy. Intra-arterial chemotherapy used a combination of nedaplatin (80 mg/m2) and docetaxel (60 mg/m2). Outcome measures were local control, disease-free survival, overall survival, and adverse events. Statistical analyses were performed using the Kaplan-Meier method. RESULTS Median follow-up period was 24 months (range 9-64). All patients had extracapsular extension (N3b) on imaging and clinical findings. Symptoms due to bulky disease were neck discomfort (100%), tumor bleeding (43%), tracheal obstruction (14%), and carotid sinus syndrome (28%). Median value for maximum diameter of cervical disease was 84 mm (range 70-107), and 3-year local control, disease-free survival, and overall survival rates were 100, 54, and 64%, respectively. Symptoms due to bulky disease disappeared in all patients after intra-arterial chemoradiotherapy. Grade 4 leukopenia occurred in two patients (28%) as an acute adverse event. No other serious acute adverse events were observed. CONCLUSION Selective intra-arterial chemoradiotherapy with docetaxel and nedaplatin can potentially achieve both favorable local control and survival in in HNCUP with fixed bulky nodal disease.
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Affiliation(s)
- Joichi Heianna
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan.
| | - Wataru Makino
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Hitoshi Hirakawa
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Shinya Agena
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Hayato Tomita
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan.,Department of Radiology, St Marianna University School of Medicine, 2-6-1, Sugao, Miyamae, Kawasaki, Kanagawa, 216-8511, Japan
| | - Takuro Ariga
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Kazuki Ishikawa
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Shota Takehara
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Hitoshi Maemoto
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Sadayuki Murayama
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207, Uehara, Nishihara, Okinawa, 903-0215, Japan
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Sherry AD, Pasalic D, Gunn GB, Fuller CD, Phan J, Rosenthal DI, Morrison WH, Sturgis EM, Gross ND, Gillison ML, Ferrarotto R, El-Naggar AK, Garden AS, Frank SJ. Proton Beam Therapy for Head and Neck Carcinoma of Unknown Primary: Toxicity and Quality of Life. Int J Part Ther 2021; 8:234-247. [PMID: 34285950 PMCID: PMC8270080 DOI: 10.14338/ijpt-20-00034.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/21/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose Proton radiation therapy (PRT) may offer dosimetric and clinical benefit in the treatment of head and neck carcinoma of unknown primary (HNCUP). We sought to describe toxicity and quality of life (QOL) in patients with HNCUP treated with PRT. Patients and Methods Toxicity and QOL were prospectively tracked in patients with HNCUP from 2011 to 2019 after institutional review board approval. Patients received PRT to the mucosa of the nasopharynx, oropharynx, and bilateral cervical lymph nodes with sparing of the larynx and hypopharynx. Patient-reported outcomes were tracked with the MD Anderson Symptom Inventory–Head and Neck Module, the Functional Assessment of Cancer Therapy–Head and Neck, the MD Anderson Dysphagia Inventory, and the Xerostomia-Related QOL Scale. Primary study endpoints were the incidence of grade ≥ 3 (G3) toxicity and QOL patterns. Results Fourteen patients (median follow-up, 2 years) were evaluated. Most patients presented with human papillomavirus–positive disease (n = 12, 86%). Rates of G3 oral mucositis, xerostomia, and dermatitis were 7% (n = 1), 21% (n = 3), and 36% (n = 5), respectively. None required a gastrostomy. During PRT, QOL was reduced relative to baseline and recovered shortly after PRT. At 2 years after PRT, the local regional control, disease-free survival, and overall survival were 100% (among 7 patients at risk), 79% (among 6 patients at risk), and 90% (among 7 patients at risk), respectively. Conclusion Therefore, PRT for HNCUP was associated with highly favorable dosimetric and clinical outcomes, including minimal oral mucositis, xerostomia, and dysphagia. Toxicity and QOL may be superior with PRT compared with conventional radiation therapy and PRT maintains equivalent oncologic control. Further prospective studies are needed to evaluate late effects and cost-effectiveness.
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Affiliation(s)
| | - Dario Pasalic
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maura L Gillison
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata Ferrarotto
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adel K El-Naggar
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Impact of Neck Dissection in Head and Neck Squamous Cell Carcinomas of Unknown Primary. Cancers (Basel) 2021; 13:cancers13102416. [PMID: 34067697 PMCID: PMC8156697 DOI: 10.3390/cancers13102416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/06/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary A retrospective multicentric study of 322 patients with head and neck cancers of unknown primary (HNCUP) was performed testing the impact of neck dissection (ND) extent on nodal relapse, progression-free survival and survival. After 5 years, the incidence of nodal relapse was 13.4%, and progression-free survival (PFS) was 59.1%. In multivariate analysis after adjusting for nodal stage, the risk of nodal relapse or progression was reduced with lymphadenectomy, selective ND or radical/modified ND but survival rates were similar. Patients undergoing lymphadenectomy or ND had significantly better PFS and a lower nodal relapse incidence in the N1 + N2a group, but the improvement was not significant for the N2b or N2 + N3c patients. Severe toxicity rates exceeded 40% with radical ND. In HNCUP, ND improves PFS regardless of nodal stage but fails to improve survival. The magnitude of the benefit of ND did not appear to depend on ND extent and decreased with a more advanced nodal stage. Abstract Purpose: Management of head and neck cancers of unknown primary (HNCUP) combines neck dissection (ND) and radiotherapy, with or without chemotherapy. The prognostic value of ND has hardly been studied in HNCUP. Methods: A retrospective multicentric study assessed the impact of ND extent (adenectomy, selective ND, radical/radical-modified ND) on nodal relapse, progression-free survival (PFS) or survival, taking into account nodal stage. Results: 53 patients (16.5%) had no ND, 33 (10.2%) had lymphadenectomy, 116 (36.0%) underwent selective ND and 120 underwent radical/radical-modified ND (37.3%), 15 of which received radical ND (4.7%). With a 34-month median follow-up, the 3-year incidence of nodal relapse was 12.5% and progression-free survival (PFS) 69.1%. In multivariate analysis after adjusting for nodal stage, the risk of nodal relapse or progression was reduced with lymphadenectomy, selective or radical/modified ND, but survival rates were similar. Patients undergoing lymphadenectomy or ND had a better PFS and lowered nodal relapse incidence in the N1 + N2a group, but the improvement was not significant for the N2b or N2 + N3c patients. Severe toxicity rates exceeded 40% with radical ND. Conclusion: In HNCUP, ND improves PFS, regardless of nodal stage. The magnitude of the benefit of ND does not appear to depend on ND extent and decreases with a more advanced nodal stage.
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Brenet E, Philouze P, Schiffler C, Pommier P, Crozes C, Benzerdjeb N, Monchet E, Boulagnon-Rombi C, Ton Van J, Podeur F, Servagi-Vernat S, Liem X, Merol JC, Ceruse P, Serre AA, Chabaud S, Julieron M, Deneuve S. Influence of postoperative radiotherapy target volumes in unilateral head and neck carcinoma of unknown primary: A multicentric study using propensity score. Radiother Oncol 2021; 160:1-8. [PMID: 33845043 DOI: 10.1016/j.radonc.2021.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/22/2021] [Accepted: 04/01/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the impact of two radiation modalities on loco-regional control, survival and tumour emergence, after node dissection for an unilateral head and neck carcinoma of unknown primary (HNCUP). MATERIALS AND METHODS This is a multicentric retrospective study of 138 patients with unilateral HNCUP treated between 2002 and 2017. The absence of primary tumour was assessed by a systematic panendoscopy and positron emission tomography. Neck dissection was initially performed for all patients. Radiation Therapy was delivered on ipsilateral lymph node areas in 62 cases (44%: UL-RT group) and on bilateral lymph node areas and the entire pharyngeal mucosa in 77 cases (56%: COMP-RT group). Impact of radiation modalities on locoregional control and overall survival was assessed using propensity score matching method in order to balance baseline characteristics between the two groups. RESULTS The population included 80.4% men, 80.4% smokers, 32.6% P16 positive tumours and 71.0% extracapsular extension. After a median follow-up of 5 years, the locoregional control rate was 80.3% in the UL-RT group and 75.3% in the COMP-RT group (p = 0.688). The corresponding rate of contralateral lymph node recurrence was 0% versus 2.6% (p = 0.503) and the rate of tumour emergence was 11.5% versus 9.1% (p = 0.778). No significant difference was observed between the UL-RT and the COMP-RT groups for overall survival (p = 0.9516), specific survival (p = 0.4837) or tumour emergence (p = 0.9034). CONCLUSION UL-RT seems to provide similar outcomes as COMP-RT in unilateral HNCUP post-operative management.
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Affiliation(s)
- Esteban Brenet
- Head and Neck Surgery Department, Centre Hospitalo Universitaire Reims, France
| | - Pierre Philouze
- Head and Neck Surgery Department, Centre Hospitalo Universitaire Lyon Sud, France
| | | | - Pascal Pommier
- Radiotherapy Department, Centre Léon Bérard, Lyon, France
| | - Carole Crozes
- Pathological Anatomy Department, Centre Léon Bérard, Lyon, France
| | - Nazim Benzerdjeb
- Pathological Anatomy Department, Centre Hospitalo Universitaire Lyon Sud, France
| | - Elodie Monchet
- Head and Neck Surgery Department, Centre Oscar Lambret, Lille, France
| | | | - Jean Ton Van
- Head and Neck Department, Centre Oscar Lambret, Lille, France
| | - Fabien Podeur
- Oncologic Surgery Department, Centre Léon Bérard, Lyon, France
| | | | - Xavier Liem
- Radiotherapy Department, Centre Oscar Lambret, Lille, France
| | - Jean-Claude Merol
- Head and Neck Department, Centre hospilato Universitaire Reims, France
| | - Philippe Ceruse
- Head and Neck Surgery Department, Centre Hospitalo Universitaire Lyon Sud, France
| | | | - Sylvie Chabaud
- Biostatistics Department, Centre Léon Bérard, Lyon, France
| | - Morbize Julieron
- Head and Neck Surgery Department, Centre Oscar Lambret, Lille, France
| | - Sophie Deneuve
- Oncologic Surgery Department, Centre Léon Bérard, Lyon, France.
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10
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Cummings MA, Ma SJ, Van Der Sloot P, Milano MT, Singh DP, Singh AK. Squamous cell carcinoma of the head and neck with unknown primary: trends and outcomes from a hospital-based registry. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:284. [PMID: 33708911 PMCID: PMC7944267 DOI: 10.21037/atm-20-4631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Squamous cell carcinoma of unknown primary of the head and neck region is a known entity described mainly by retrospective reports. We searched a hospital-based registry to better describe the changing incidence, and to assess diagnostic and treatment strategies. Methods The National Comprehensive Cancer Database was queried for head and neck cancers from oropharynx, tonsil, tongue, larynx, hypopharynx primary sites with a designation of clinical T0, representing an unknown primary. Kaplan Meier, Cox multivariate models, and propensity matched cohorts were used to assess significant factors for overall survival. Results There were 964 cases that met the criteria, and 468 cases with known treatments, staging, and survival data. The incidence increased over time, with the highest rates supported in the last 5 years. In patients who underwent HPV testing, 72% were positive. Patients with AJCC 7th clinical N2c or N3 disease had significantly worse outcomes despite the majority receiving neck dissection, radiation, and chemotherapy. Local surgery, compared to incisional or excisional biopsy, had the highest diagnostic yield of finding a primary tumor. In multivariate models, no combination of surgical approach, radiation, or systemic therapy was significantly associated with improved survival. This remained true in 1:1 propensity matched cohorts for age, comorbidities, and clinical nodal burden. In a subset of cN1 patients, combined chemoradiation therapy after excisional biopsy or local surgery was associated with (not statistically significant) improved survival compared to radiation alone (P=0.054). Conclusions The incidence of unknown primary head and neck carcinoma is increasing, and current cases have a high proportion of HPV positivity. HPV positivity predicts strongly for a tonsil primary. Local surgery was associated with the highest diagnostic yield. Clinical nodal burden strongly predicts for overall outcome, and type of treatment facility is an important driver of survival. A subset of cN1 patients may benefit from the addition of chemotherapy to radiation.
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Affiliation(s)
- Michael A Cummings
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Paul Van Der Sloot
- Department of Ear Nose and Throat Surgery, University of Rochester, Rochester, NY, USA
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Deepinder P Singh
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Anurag K Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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11
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Moy J, Li R. Approach to the Patient with Unknown Primary Squamous Cell Carcinoma of the Head and Neck. Curr Treat Options Oncol 2020; 21:93. [DOI: 10.1007/s11864-020-00791-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/18/2022]
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12
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Dhouib F, Bertaut A, Maingon P, Siala W, Daoud J, Aubignac L, Lestrade L, Crehange G, Vulquin N. Patterns of Failure in Patients With Head and Neck Squamous Cell Carcinomas of Unknown Primary Treated With Chemoradiotherapy. Technol Cancer Res Treat 2020; 19:1533033820905826. [PMID: 32484037 PMCID: PMC7268107 DOI: 10.1177/1533033820905826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: To evaluate the patterns of failure in patients treated for head and neck carcinoma of unknown primary and to discuss treatment practices concerning radiotherapy target volumes definition and dose prescription. Methods: Eleven patients presenting a locoregional recurrence after head and neck carcinoma of unknown primary treatment with curative-intent radiochemotherapy performed between 2007 and 2017 in the departments of radiation oncology of 2 French cancer institutes. Images of the computed tomography scan or the magnetic resonance imaging performed at the time of the recurrence were fused with those of the simulation computed tomography scan to delimit a volume corresponding to the recurrence and to define the area of relapse compared to the volumes treated. Results: Irradiation was unilateral in 6 cases and bilateral in 5 cases. The median time to onset of recurrence was 7.24 months (extreme 3-67.7 months). Six patients had only a neck node recurrence, 3 had a neck node and subsequent primary recurrence, and 1 had only a median subsequent primary recurrence. Only 1 patient had synchronous distance progression to local recurrence. All neck node recurrences were solitary and ipsilateral. The subsequent primary recurrences were in the oropharynx in 3 cases and in the contralateral oral cavity in one case. All neck node recurrences were into the irradiated volume. The subsequent primary recurrences were either within or in border of the irradiated volumes. The median of the mean dose, received by neck node recurrences, was 69.9 Gy and that of the mean dose, minimum dose, maximum dose, and dose received by 95% of the volume of recurrence was 66.7 Gy. For the primary relapses, the median of the mean dose was 52.1 Gy and that of the mean dose, minimum dose, maximum dose, and dose received by 95% of the volume of recurrence was 39.9 Gy. Conclusions: All local nodal recurrences occurred at sites that received high radiotherapy doses and doses received by sites of eventual failure did not vary significantly from sites that remain in control.
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Affiliation(s)
- Fatma Dhouib
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France.,Department of Oncology Radiotherapy, Habib Bourguiba Central University Hospital, Sfax, Tunisia
| | - Aurélie Bertaut
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France
| | - Philippe Maingon
- Department of Oncology Radiotherapy, Central University Hospital La Pitié Salpêtrière, Paris, France
| | - Wicem Siala
- Department of Oncology Radiotherapy, Habib Bourguiba Central University Hospital, Sfax, Tunisia
| | - Jamel Daoud
- Department of Oncology Radiotherapy, Habib Bourguiba Central University Hospital, Sfax, Tunisia
| | - Léone Aubignac
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France
| | - Laetitia Lestrade
- Department of Oncology Radiotherapy, Central University Hospital, Besançon, France
| | - Gilles Crehange
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France
| | - Noemie Vulquin
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France
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13
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Ota I, Kitahara T. Cancer of unknown primary in the head and neck: Diagnosis and treatment. Auris Nasus Larynx 2020; 48:23-31. [PMID: 32888761 DOI: 10.1016/j.anl.2020.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/04/2020] [Accepted: 08/12/2020] [Indexed: 10/23/2022]
Abstract
Cancer of unknown primary in the head and neck is defined by the presence of cancer in one or more lymph nodes within the head and neck region, not confined to the supraclavicular region, without an identifiable primary tumor. These primary sites are increasingly being identified with the help of advanced diagnostic techniques such as endoscopy, PET/CT, the HPV test, the EBV test, evaluation of biomarkers, and pathological examination. However, the remainder of these patients fall into the category of metastatic cervical cancer of unknown primary (MCCUP). MCCUP accounts for approximately 3-5% of all head and neck squamous cell carcinomas (HNSCCs). Moreover, optimal therapy for patients with MCCUP is still controversial. The treatment options range from neck dissection alone to irradiation of the bilateral neck, with or without irradiation of plausible primary sites as well. In future, precision medicine should improve the diagnosis and methods of therapy for MCCUP patients.
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Affiliation(s)
- Ichiro Ota
- Department of Otolaryngology-Head and Neck Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan.
| | - Tadashi Kitahara
- Department of Otolaryngology-Head and Neck Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
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14
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Podeur F, Pommier P, Crozes C, Monchet E, Ton Van J, Roux P, Poupart M, Zrounba P, Julieron M, Deneuve S. Management of unilateral head and neck carcinoma of unknown primary: Retrospective analysis of the impact of postoperative radiotherapy target volumes. Head Neck 2019; 42:302-311. [DOI: 10.1002/hed.26007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/20/2019] [Accepted: 10/18/2019] [Indexed: 01/27/2023] Open
Affiliation(s)
- Fabien Podeur
- Oncologic Surgery DepartmentCentre Léon Bérard Lyon France
| | | | - Carole Crozes
- Pathological Anatomy DepartmentCentre Léon Bérard Lyon France
| | - Elodie Monchet
- Head and Neck Surgery DepartmentCentre Oscar Lambret Lille France
| | - Jean Ton Van
- Head and Neck Surgery DepartmentCentre Oscar Lambret Lille France
| | | | - Marc Poupart
- Oncologic Surgery DepartmentCentre Léon Bérard Lyon France
| | | | - Morbize Julieron
- Head and Neck Surgery DepartmentCentre Oscar Lambret Lille France
| | - Sophie Deneuve
- Oncologic Surgery DepartmentCentre Léon Bérard Lyon France
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15
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Broglie MA, Dulguerov P, Henke G, Siano M, Putora PM, Simon C, Zwahlen D, Huber GF, Ballerini G, Beffa L, Giger R, Rothschild S, Negri SV, Elicin O. A Review of Controversial Issues in the Management of Head and Neck Cancer: A Swiss Multidisciplinary and Multi-Institutional Patterns of Care Study-Part 4 (Biomarkers). Front Oncol 2019; 9:1128. [PMID: 31709188 PMCID: PMC6822019 DOI: 10.3389/fonc.2019.01128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 10/09/2019] [Indexed: 11/13/2022] Open
Abstract
Background: The Head and Neck Cancer Working Group of Swiss Group for Clinical Cancer Research (SAKK) has investigated the level of consensus (LOC) and discrepancy in everyday practice of diagnosis and treatment in head and neck cancer. Materials and Methods: An online survey was iteratively generated with 10 Swiss university and teaching hospitals. LOC below 50% was defined as no agreement, while higher LOC were arbitrarily categorized as low (51-74%), moderate (75-84%), and high (≥85%). Results: Any LOC was achieved in 62% of topics (n = 60). High, moderate, and low LOC were found in 18, 20, and 23%, respectively. Regarding Head and Neck Surgery, Radiation Oncology, Medical Oncology, and biomarkers, LOC was achieved in 50, 57, 83, and 43%, respectively. Conclusions: Consensus on clinical topics is rather low for surgeons and radiation oncologists. The questions discussed might highlight discrepancies, stimulate standardization of practice, and prioritize topics for future clinical research.
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Affiliation(s)
- Martina A Broglie
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Pavel Dulguerov
- Department of Otorhinolaryngology, Head and Neck Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Guido Henke
- Department of Radiation Oncology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Marco Siano
- Department of Medical Oncology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Medical Oncology, Hôpital Riviera-Chablais, Vevey, Switzerland
| | - Paul Martin Putora
- Department of Radiation Oncology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Simon
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Daniel Zwahlen
- Department of Radiation Oncology, Cantonal Hospital Graubünden, Chur, Switzerland.,Department of Radiation Oncology, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - Gerhard F Huber
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Giorgio Ballerini
- Department of Radiation Oncology, Clinica Luganese SA, Lugano, Switzerland
| | - Lorenza Beffa
- Department of Radiation Oncology, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Roland Giger
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Sacha Rothschild
- Department of Medical Oncology, University Hospital of Basel, Basel, Switzerland
| | - Sandro V Negri
- Department of Otorhinolaryngology, Lindenhofspital, Bern, Switzerland
| | - Olgun Elicin
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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16
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Grewal AS, Rajasekaran K, Cannady SB, Chalian AA, Ghiam AF, Lin A, LiVolsi V, Lukens JN, Mitra N, Montone KT, Newman JG, O'Malley BW, Rassekh CH, Weinstein GS, Swisher-McClure S. Pharyngeal-sparing radiation for head and neck carcinoma of unknown primary following TORS assisted work-up. Laryngoscope 2019; 130:691-697. [PMID: 31411747 DOI: 10.1002/lary.28200] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/11/2019] [Accepted: 07/08/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE In patients with head and neck carcinoma of unknown primary (HNCUP;pT0) following TORS-assisted workup, we have adopted a pharyngeal-sparing radiation therapy (PSRT) approach targeting only the at-risk neck and omitting treatment of the pharynx. We report outcomes following PSRT, and compare to institutional historical control subjects who received pharyngeal-targeted RT (PRT). METHODS Between 2009 and 2018, 172 patients underwent TORS-assisted endoscopy as part of their workup for HNCUP. Following TORS, 54 patients had pT0 disease, of which 45 received RT. Forty-nine percent received PSRT and 51% received PRT. RESULTS No statistically significant differences existed between the PSRT and PRT groups with respect to overall nodal distribution, p16 positivity (55% vs. 43%, P = .12), neck dissection rates (77% vs. 65%, P = .51), and administration of chemotherapy (55% vs. 65%, P = .55). Median follow-up for PSRT and PRT groups were 24 and 28 months, respectively (P = .04). Two-year RFS was 86% and 74% for PSRT and PRT patients, respectively (log-rank P = .30). Three and six patients recurred after PSRT and PRT, respectively. Two-year OS for PSRT and PRT patients was 91% and 74%, respectively (log-rank P = .31). Compared to PRT, PSRT was associated with statistically significantly less: grade 2+ mucositis (18% vs. 91%, P < .01), new opioid requirement (27% vs. 91%, P < .01), mean weight loss during RT (6.2 lbs vs. 17.4 lbs, P < .01), feeding tube placement during RT (5% vs. 43%, P < .01), and treatment-related unplanned hospitalizations (9% vs. 39%, P = .04). CONCLUSION Following TORS-assisted management of patients with pT0 HNCUP, we observed reduced toxicity following PSRT compared to PRT without apparent compromise of disease cure. LEVEL OF EVIDENCE Level 3 evidence, retrospective review comparing cases and controls Laryngoscope, 130:691-697, 2020.
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Affiliation(s)
| | | | - Steven B Cannady
- the Department of Otorhinolaryngology, Philadelphia, Pennsylvania, U.S.A
| | - Ara A Chalian
- the Department of Otorhinolaryngology, Philadelphia, Pennsylvania, U.S.A
| | - Alireza F Ghiam
- Department of Radiation Oncology, Philadelphia, Pennsylvania, U.S.A
| | - Alexander Lin
- Department of Radiation Oncology, Philadelphia, Pennsylvania, U.S.A
| | - Virginia LiVolsi
- the Department of Pathology and Laboratory Medicine, Philadelphia, Pennsylvania, U.S.A
| | - John N Lukens
- Department of Radiation Oncology, Philadelphia, Pennsylvania, U.S.A
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Kathleen T Montone
- the Department of Pathology and Laboratory Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Jason G Newman
- the Department of Otorhinolaryngology, Philadelphia, Pennsylvania, U.S.A
| | - Bert W O'Malley
- the Department of Otorhinolaryngology, Philadelphia, Pennsylvania, U.S.A
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17
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Abstract
In adult cervicofacial pathology, carcinoma of unknown primary is defined as lymph-node metastasis the anatomic origin of which is not known at the time of initial management. It constitutes up to 5% of head and neck cancers. Presentation may suggest benign pathology, delaying and confusing oncologic treatment. Diagnostic strategy in cervical lymph node with suspicion of neoplasia requires exhaustive work-up to diagnose malignancy and, in 45% to 80% of cases, depending on the series, to identify the primary site. Histologic types comprise squamous cell carcinoma, thyroid carcinoma, adenocarcinoma, neuroendocrine carcinoma and undifferentiated carcinoma. Association is sometimes found with human papilloma virus or Epstein Barr virus, guiding treatment. The objective of the present study was to provide clinicians with the necessary diagnostic tools, based on the current state of clinical, imaging and pathologic knowledge, and to detail treatment options.
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18
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Pflumio C, Troussier I, Sun XS, Salleron J, Petit C, Caubet M, Beddok A, Calugaru V, Servagi-Vernat S, Castelli J, Miroir J, Krengli M, Giraud P, Romano E, Khalifa J, Doré M, Blanchard N, Coutte A, Dupin C, Sumodhee S, Pointreau Y, Patel S, Rehailia-Blanchard A, Catteau L, Bensadoun RJ, Tao Y, Roth V, Geoffrois L, Faivre JC, Thariat J. Unilateral or bilateral irradiation in cervical lymph node metastases of unknown primary? A retrospective cohort study. Eur J Cancer 2019; 111:69-81. [PMID: 30826659 DOI: 10.1016/j.ejca.2019.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 01/02/2019] [Accepted: 01/06/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Patients with cervical lymphadenopathy of unknown primary carcinoma (CUP) usually undergo neck dissection and irradiation. There is an ongoing controversy regarding the extent of nodal and mucosal volumes to be irradiated. We assessed outcomes after bilateral or unilateral nodal irradiation. METHODS This retrospective multicentre study included patients with CUP and squamous cellular carcinoma who underwent radiotherapy (RT) between 2000 and 2015. RESULTS Of 350 patients, 74.5% had unilateral disease and 25.5% had bilateral disease. Of 297 patients with available data on disease and irradiation sides, 61 (20.5%) patients had unilateral disease and unilateral irradiation, 155 (52.2%), unilateral disease and bilateral irradiation and 81 (27.3%), bilateral disease and bilateral irradiation. Thirty-four (9.7%) and 217 (62.0%) patients received neoadjuvant and/or concomitant chemotherapy, respectively. Median follow-up was 37 months. Three-year local, regional, locoregional failure rates and CUP-specific survival were 5.6%, 11.7%, 15.0% and 84.7%, respectively. In patients with unilateral disease, the 3-year cumulative incidence of regional/local relapse was 7.7%/4.3% after bilateral irradiation versus 16.9%/11.1% after unilateral irradiation (hazard ratio = 0.56/0.61, p = 0.17/0.32). The cumulative incidence of CUP-specific deaths was 9.2% after bilateral irradiation and 15.5% after unilateral irradiation (p = 0.92). In multivariate analysis, mucosal irradiation was associated with better local control, whereas no neck dissection, ≥N2b and interruption of RT for more than 4 days were associated with poorer regional control. Toxicity was higher after bilateral irradiation (p < 0.05). No positron-emission tomography-computed tomography, largest node diameter, ≥N2b, neoadjuvant chemotherapy and interruption of RT were associated with poorer cause-specific survival. CONCLUSION Bilateral nodal irradiation yielded non-significant better nodal and mucosal control rates but was associated with higher rates of severe toxicity.
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Affiliation(s)
- Carole Pflumio
- Department of Medical Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Idriss Troussier
- Department of Radiation Therapy, CHU Pitié Salpêtrière, Assistance Publique, Hôpitaux de Paris, Paris, France
| | - Xu Shan Sun
- Department of Radiation Therapy, Hôpital de Montbéliard, Montbéliard, France
| | - Julia Salleron
- Department of Biostatistics and Data Management, Institut de Cancérologie de Lorraine, Vandoeuvre-Lès-Nancy, France
| | - Claire Petit
- Department of Radiation Therapy, Institut Gustave Roussy, Villejuif, France
| | - Matthieu Caubet
- Department of Radiation Therapy, CHU de Besançon, Besançon, France
| | - Arnaud Beddok
- Department of Radiation Therapy, Institut Curie, Paris, France
| | | | | | - Joël Castelli
- Department of Radiation Therapy, Institut Eugène Marquis, Rennes, France
| | - Jessica Miroir
- Department of Radiation Therapy, Institut Jean Perrin, Clermont-Ferrand, France
| | - Marco Krengli
- Department of Radiation Therapy, University of Piemonte Orientale, Pavia, Italy
| | - Paul Giraud
- Department of Radiation Therapy, Hôpital Tenon, Assistance Publique, Hôpitaux de Paris, Paris, France
| | - Edouard Romano
- Department of Radiation Therapy, Hôpital Tenon, Assistance Publique, Hôpitaux de Paris, Paris, France
| | - Jonathan Khalifa
- Department of Radiation Therapy, Institut Universitaire du Cancer, Toulouse, France
| | - Mélanie Doré
- Department of Radiation Therapy, Institut de Cancérologie de l'Ouest, Nantes, France
| | - Nicolas Blanchard
- Department of Radiation Therapy, Clinique les Dentellières, Valenciennes, France
| | | | - Charles Dupin
- Department of Radiation Therapy, Centre Antoine Lacassagne, Nice, France
| | - Shakeel Sumodhee
- Department of Radiation Therapy, Centre Antoine Lacassagne, Nice, France
| | - Yoann Pointreau
- Department of Radiation Therapy, Clinique Victor Hugo, Le Mans, France
| | - Samir Patel
- Department of Radiation Therapy, Mayo Clinic, Arizona, USA
| | | | - Ludivine Catteau
- Department of Radiation Therapy, CHU de Poitiers, Poitiers, France
| | | | - Yungan Tao
- Department of Radiation Therapy, Institut Gustave Roussy, Villejuif, France
| | | | - Lionnel Geoffrois
- Department of Medical Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Jean-Christophe Faivre
- Academic Department of Radiation Therapy, Lorraine Institute of Cancerology, Vandoeuvre-lès-Nancy, France
| | - Juliette Thariat
- Department of Radiation Therapy, Centre Francois Baclesse, Advanced Resource Center for Hadrontherapy in Europe, Caen, France, Unicaen-Normandie Universite.
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19
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Le N, Janik S, Simmel H, Erovic BM. Bilateral vs ipsilateral adjuvant radiotherapy in patients with cancer of unknown primary of the head and neck: An analysis of the clinical outcome and radiation‐induced side effects. Head Neck 2019; 41:1785-1794. [DOI: 10.1002/hed.25637] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 10/14/2018] [Accepted: 12/10/2018] [Indexed: 11/11/2022] Open
Affiliation(s)
- Nguyen‐Son Le
- Department of Otorhinolaryngology and Head and Neck SurgeryMedical University of Vienna Vienna Austria
| | - Stefan Janik
- Department of Otorhinolaryngology and Head and Neck SurgeryMedical University of Vienna Vienna Austria
| | - Helmut Simmel
- Department of Radio‐Oncology, Kaiser‐Franz‐Josef Hospital Vienna Austria
| | - Boban M. Erovic
- Department of Head and Neck Diseases, Evangelical Hospital Vienna Vienna Austria
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Troussier I, Klausner G, Blais E, Giraud P, Lahmi L, Pflumio C, Faivre JC, Geoffrois L, Babin E, Morinière S, Maingon P, Thariat J. [Advances in the management of cervical lymphadenopathies of unknown primary with intensity modulated radiotherapy: Doses and target volumes]. Cancer Radiother 2018; 22:438-446. [PMID: 29731331 DOI: 10.1016/j.canrad.2017.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 10/24/2017] [Indexed: 11/16/2022]
Abstract
The definition of nodal and/or mucosal target volumes for radiation therapy for lymphadenopathies of unknown primary is controversial. Target volumes may include all nodal areas bilaterraly and be pan-mucosal or unilateral, selective, including the sole oropharyngeal mucosa. This review presents current recommendations in light of changes in the TNM classification, Human papillomavirus status and therapeutic advances. We conducted a systematic review of the literature with the following keywords: lymphadenopathy; head and neck; unknown primary and radiation therapy. There are no direct comparative studies between unilateral or bilateral nodal irradiation or pan-mucosal and selective mucosal irradiation. Contralateral lymph node failure rates range from 0 to 6% after unilateral nodal irradiation and 0 and 31% after bilateral irradiation. Occurrence of a mucosal primary varies between 0 and 19.2%. Initial clinical presentation and Human papillomavirus status are critical to define mucosal target volumes. Intensity-modulated radiotherapy is recommended (rather than three-dimensional irradiation) to avoid toxicities. Systemic treatments have similar indications as for identified primary head and neck cancers. Failures do not appear superior in case of unilateral nodal irradiation but comparative studies are warranted due to major biases hampering direct comparisons. Human papillomavirus status should be incorporated into the therapeutic strategy and practice-changing TNM staging changes will need to be evaluated.
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Affiliation(s)
- I Troussier
- Radio-oncologie, hôpitaux universitaires de Genève, Avenue de la Roseraie 53 CH-1205 Genève
| | - G Klausner
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - E Blais
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - P Giraud
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - L Lahmi
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - C Pflumio
- Oncologie médicale, centre Alexis-Vautrin, 6, avenue de Bourgogne, 54511 Vandoeuvre-lès-Nancy cedex, France
| | - J-C Faivre
- Radiothérapie, centre Alexis-Vautrin, 6, avenue de Bourgogne, 54511 Vandoeuvre-lès-Nancy cedex, France
| | - L Geoffrois
- Oncologie médicale, centre Alexis-Vautrin, 6, avenue de Bourgogne, 54511 Vandoeuvre-lès-Nancy cedex, France
| | - E Babin
- Carcinologie cervicofaciale, CHRU de Caen, avenue de la Côte-de-Nacre, 14033 Caen, France
| | - S Morinière
- Carcinologie cervicofaciale, CHRU de Tours, 2, boulevard Tonnellé, 37000 Tours, France
| | - P Maingon
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - J Thariat
- Département de radiothérapie/Archade, centre François-Baclesse, 3, avenue General-Harris, 14000 Caen, France; Université Unicaen, 14000 Caen, France.
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Kamal M, Mohamed ASR, Fuller CD, Sturgis EM, Johnson FM, Morrison WH, Gunn GB, Hutcheson KA, Phan J, Volpe S, Ng SP, Ferrarotto R, Frank SJ, Skinner HD, Rosenthal DI, Garden AS. Outcomes of patients diagnosed with carcinoma metastatic to the neck from an unknown primary source and treated with intensity-modulated radiation therapy. Cancer 2018; 124:1415-1427. [PMID: 29338089 DOI: 10.1002/cncr.31235] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 12/01/2017] [Accepted: 12/06/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND There are few published studies to guide the treatment of carcinoma metastatic to the neck from an unknown primary (CUP). In this regard, the objective of the current study was to share the authors' current experience treating patients with CUP using intensity-modulated radiation therapy (IMRT), which principally targeted both sides of the neck, the nasopharynx, and the oropharynx. METHODS This was a retrospective study in which an institutional database search was conducted to identify patients with CUP who received IMRT. Data analysis included frequency tabulation, survival analysis, and multivariable analysis. RESULTS Two-hundred sixty patients met inclusion criteria. The most common lymph node category was N2b (54%). IMRT volumes included the entire pharyngolaryngeal mucosa in 78 patients, the nasopharynx and oropharynx in 167 patients, and treatment limited to the involved neck in 11 patients. Eighty-four patients underwent neck dissections. The 5-year overall survival, regional control, and distant metastases-free survival rates were 84%, 91%, and 94%, respectively. Over 40% of patients had gastrostomy tubes during therapy, and 7% patients were diagnosed with chronic radiation-associated dysphagia. Higher lymph node burden was associated with worse disease-related outcomes, and in subgroup analysis, patients with human papillomavirus-associated disease had better outcomes. No therapeutic modality was statistically associated with either disease-related outcomes or toxicity. CONCLUSIONS Comprehensive IMRT with treatment to both sides of the neck and to the oropharyngeal and nasopharyngeal mucosa results in high rates of disease control and survival. The investigators were unable to demonstrate that treatment intensification with chemotherapy or surgery added benefit or excessive toxicity. Cancer 2018;124:1415-27. © 2018 American Cancer Society.
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Affiliation(s)
- Mona Kamal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Abdallah S R Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Clifton David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Faye M Johnson
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- The University of Texas Graduate School of Biomedical Sciences, Houston, Texas
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Katherine A Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stefania Volpe
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- University of Milan, Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
| | - Sweet Ping Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Renata Ferrarotto
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Heath D Skinner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Tiong A, Rischin D, Young RJ, Herschtal A, Solomon B, D'Costa I, Fua T, Liu C, Coleman A, Kleid S, Dixon BJ, Corry J. Unilateral radiotherapy treatment for p16/human papillomavirus-positive squamous cell carcinoma of unknown primary in the head and neck. Laryngoscope 2018; 128:2076-2083. [PMID: 29481710 DOI: 10.1002/lary.27131] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 12/01/2017] [Accepted: 01/04/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS The outcomes of unilateral radiotherapy treatment for patients with p16/HPV-positive squamous cell carcinomas of unknown primary (SCCUP) affecting cervical lymph nodes are under-reported. Compared to radiating large volumes of the pharyngeal axis (the more common approach), this is potentially a much less toxic treatment for a good prognosis group. STUDY DESIGN Retrospective cohort study. METHODS We identified patients with SCCUP who were treated radically at our center and did not have parotid or isolated level IV or V nodal involvement. Failure-free and overall survivals were calculated using Kaplan-Meier methods. RESULTS From 2004 to 2012, there were 49 radically treated patients with SCCUP. Fourteen patients had bilateral neck treatment (they had bilateral nodal disease or suspected lesions in the base of tongue, though not proven with biopsy), two had surgery alone, whereas 33 had unilateral radiotherapy (after neck dissection, excisional biopsy, or definitively with concurrent chemotherapy). Of the 33 patients, 21 tested positive to p16/HPV and had median follow-up of 57 months. In this group, no isolated contralateral neck failures or putative primaries emerged. There was 1/21 (4.3%) ipsilateral neck failure, 1/21 (4.3%) concurrent contralateral neck and distant failure, and 1/21 (4.3%) patient with distant failure. The 5-year freedom from failure was 78% (95% confidence interval [CI]: 56%-100%) and overall survival was 90% (95% CI: 79%-100%). CONCLUSIONS With no emergence of putative primaries and no isolated contralateral neck failures, this single-institution experience in p16/HPV-positive SCCUP patients suggests that unilateral radiotherapy may be an underutilized management strategy. LEVELS OF EVIDENCE 4 Laryngoscope, 128:2076-2083, 2018.
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Affiliation(s)
- Albert Tiong
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Danny Rischin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia
| | - Richard J Young
- Molecular Therapeutics and Biomarkers Laboratory, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alan Herschtal
- Department of Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Ben Solomon
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia
| | - Ieta D'Costa
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Tsien Fua
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Chen Liu
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Andrew Coleman
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Stephen Kleid
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Benjamin J Dixon
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, St. Vincent's Hospital, Fitzroy, Victoria, Australia
| | - June Corry
- University of Melbourne, Parkville, Victoria, Australia.,GenesisCare Radiation Oncology Centre, St Vincent's Hospital, Fitzroy, Victoria, Australia
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Optimization of radiotherapy for neck carcinoma metastasis from unknown primary sites: a meta-analysis. Oncotarget 2018; 7:78736-78746. [PMID: 27791201 PMCID: PMC5346673 DOI: 10.18632/oncotarget.12852] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/14/2016] [Indexed: 11/25/2022] Open
Abstract
This meta-analysis was designed to evaluate radiotherapy (RT) options preferable for neck cancer metastases from unknown primary sites (NCUP). Relevant articles published up through September 2015 were selected from EMBASE, Cochrane, PubMed and Web of Science. Thirty-three articles were identified, and relative risks (RRs) and 95% CIs for all pre-specified endpoints were calculated. Surgery plus RT showed an advantage for 5-year overall survival (OS) (RR 0.66, 95% CI 0.52-0.83, p = 0.0004) and neck recurrence (NR) (RR = 0.74, 95% CI 0.59-0.92, p = 0.008) compared to RT alone. The RRs for NR, primary tumor emergence (PTE), and 5-year disease free survival (DFS) for bilateral neck compared to ipsilateral neck irradiation were 0.61 (95% CI 0.41-0.91, p = 0.01), 0.44(95% CI 0.26-0.77, p = 0.004), and 0.81 (95% CI 0.64-1.03, p = 0.09), respectively. Irradiation of the neck plus potential primary tumor sites (PPTS) showed a benefit for 5-year DFS (RR 0.75, 95% CI 0.61-0.92, p = 0.005), NR (RR = 0.72, 95% CI 0.56-0.92, p = 0.009), and PTE (RR = 0.23, 95% CI 0.12-0.45, p < 0.0001) compared to neck-only irradiation. Adverse events occurred more frequently with bilateral neck plus PPTS irradiation. For NCUP, surgery plus RT of the bilateral neck and PPTS was associated with greater improvement of clinical outcomes.
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24
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Lu X, Hu C, Ji Q, Shen C, Feng Y. Squamous Cell Carcinoma Metastatic to Cervical Lymph Nodes from an Unknown Primary Site: The Impact of Radiotherapy. TUMORI JOURNAL 2018; 95:185-90. [DOI: 10.1177/030089160909500209] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background Cervical lymph node metastases of squamous cell carcinoma from an unknown primary site constitute about 5% of the total head and neck cancer cases. The management of these patients is still a therapeutic challenge. The aim of the present study was to analyze the prognosis in a series of patients and, in particular, the impact of different radiotherapy techniques on the prognosis. Methods and study design Data from 60 patients with cervical lymph node metastases of squamous cell carcinoma from an unknown primary site were reviewed. Nine of 60 patients (15.0%) received excisional biopsy. Radiotherapy was delivered to the bilateral neck and pharyngeal mucosa (extensive field) in 11 patients (18.3%), to the bilateral neck in 24 patients (40.0%), and to the ipsilateral neck in 25 patients (41.7%). Fourteen patients (23.3%) also received chemotherapy. Results The 5-year overall survival rate of all patients was 68.5%. The overall survival of patients with N1, N2, and N3 stage was 100%, 68.0%, and 40.9%, respectively (P = 0.026). The overall survial of patients irradiated by ipsilateral neck, bilateral neck, and extensive field was 66.5%, 74.5%, and 54.6%, respectively (P = 0.5). At multivariate analysis, only N stage significantly affected overall survival (P = 0.032). The 5-year neck control rate of all patients was 65.6%. The neck control rate of patients with N1, N2, and N3 stage was 100%, 63.2%, and 34.6%, respectively (P = 0.064). The neck control rate of patients irradiated by ipsilateral neck, bilateral neck, and extensive field was 87.6%, 51.1%, and 72.7%, respectively (P = 0.279). Emergence of the occult primary was observed in 21.2% patients, and all of these occurred within the head and neck region. The primary tumor emerged in 23.3% of patients treated with ipsilateral and bilateral neck irradiation and in 12.5% of patients irradiated by extensive field (P = 0.469). Conclusions Patients with cervical lymph node metastases of squamous cell carcinoma from an unknown primary site have clinical features and a prognosis similar to those of other head and neck malignancies. Extensive irradiation results in a lower trend of emergence of the primary tumor than when patients are treated with ipsilateral and bilateral irradiation, but there is no significant difference in overall survival.
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Affiliation(s)
- Xueguan Lu
- Department of Radiation Oncology, Second Affiliated Hospital of Soochow University, Suzhou
- Department of Radiation Oncology, Cancer Hospital of Fudan University, Shanghai, China
| | - Chaosu Hu
- Department of Radiation Oncology, Cancer Hospital of Fudan University, Shanghai, China
| | - Qinghai Ji
- Department of Head & Neck Surgery, Cancer Hospital of Fudan University, Shanghai, China
| | - Chunying Shen
- Department of Radiation Oncology, Cancer Hospital of Fudan University, Shanghai, China
| | - Yan Feng
- Department of Radiation Oncology, Cancer Hospital of Fudan University, Shanghai, China
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25
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Troussier I, Klausner G, Morinière S, Blais E, Jean-Christophe Faivre, Champion A, Geoffrois L, Pflumio C, Babin E, Maingon P, Thariat J. [Advances in the management of cervical lymphadenopathies of unknown primary: advances in diagnostic imaging and surgical modalities and new international staging system]. Bull Cancer 2017; 105:181-192. [PMID: 29275831 DOI: 10.1016/j.bulcan.2017.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/10/2017] [Accepted: 11/15/2017] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Cervical lymphadenopathies of unknown primary represent 3 % of head and neck cancers. Their diagnostic work up has largely changed in recent years. This review provides an update on diagnostic developments and their potential therapeutic impact. MATERIALS AND METHODS This is a systematic review of the literature. RESULTS In recent years, changes in epidemiology-based prognostic factors such as human papilloma virus (HPV) cancers, advances in imaging and minimally invasive surgery have been integrated in the management of cervical lymphadenopathies of unknown primary. In particular, systematic use of PET scanner and increasing practice of robotic or laser surgery have contributed to increasing detection rate of primary cancers. These allow more adapted and personalized treatments. The impact of changes in the eighth TNM staging system is discussed. CONCLUSION The management of cervical lymphadenopathies of unknown primary cancer has changed significantly in the last 10 years. On the other hand, practice changes will have to be assessed.
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Affiliation(s)
- Idriss Troussier
- CHRU Pitié-Salpêtrière, radiothérapie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Guillaume Klausner
- Institut Gustave-Roussy, radiothérapie, 114, rue Edouard-Vaillant, 94800 Villejuif, France
| | - Sylvain Morinière
- CHRU de Tours, carcinologie cervicofaciale, 2, boulevard Tonnellé, 37000 Tours, France
| | - Eivind Blais
- Centre Bergonié, radiothérapie, 229, cours de l'Argonne, 33000 Bordeaux, France
| | - Jean-Christophe Faivre
- Institut de cancérologie de Lorraine, oncologie médicale, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - Ambroise Champion
- Hôpitaux universitaires Genève, radiothérapie, rue Gabrielle-Perret-Gentil, 4, 1205 Genève, Suisse
| | - Lionnel Geoffrois
- CHRU de Tours, carcinologie cervicofaciale, 2, boulevard Tonnellé, 37000 Tours, France
| | - Carole Pflumio
- CHRU de Tours, carcinologie cervicofaciale, 2, boulevard Tonnellé, 37000 Tours, France
| | - Emmanuel Babin
- CHRU de Caen, carcinologie cervicofaciale, avenue de la Côte-de-Nacre, 14033 Caen, France
| | - Philippe Maingon
- CHRU Pitié-Salpêtrière, radiothérapie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Juliette Thariat
- ARCHADE centre François-Baclesse, radiothérapie, 3, avenue du Général-Harris, 14000 Caen, France.
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Pynnonen MA, Gillespie MB, Roman B, Rosenfeld RM, Tunkel DE, Bontempo L, Brook I, Chick DA, Colandrea M, Finestone SA, Fowler JC, Griffith CC, Henson Z, Levine C, Mehta V, Salama A, Scharpf J, Shatzkes DR, Stern WB, Youngerman JS, Corrigan MD. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults. Otolaryngol Head Neck Surg 2017; 157:S1-S30. [PMID: 28891406 DOI: 10.1177/0194599817722550] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective Neck masses are common in adults, but often the underlying etiology is not easily identifiable. While infections cause most of the neck masses in children, most persistent neck masses in adults are neoplasms. Malignant neoplasms far exceed any other etiology of adult neck mass. Importantly, an asymptomatic neck mass may be the initial or only clinically apparent manifestation of head and neck cancer, such as squamous cell carcinoma (HNSCC), lymphoma, thyroid, or salivary gland cancer. Evidence suggests that a neck mass in the adult patient should be considered malignant until proven otherwise. Timely diagnosis of a neck mass due to metastatic HNSCC is paramount because delayed diagnosis directly affects tumor stage and worsens prognosis. Unfortunately, despite substantial advances in testing modalities over the last few decades, diagnostic delays are common. Currently, there is only 1 evidence-based clinical practice guideline to assist clinicians in evaluating an adult with a neck mass. Additionally, much of the available information is fragmented, disorganized, or focused on specific etiologies. In addition, although there is literature related to the diagnostic accuracy of individual tests, there is little guidance about rational sequencing of tests in the course of clinical care. This guideline strives to bring a coherent, evidence-based, multidisciplinary perspective to the evaluation of the neck mass with the intention to facilitate prompt diagnosis and enhance patient outcomes. Purpose The primary purpose of this guideline is to promote the efficient, effective, and accurate diagnostic workup of neck masses to ensure that adults with potentially malignant disease receive prompt diagnosis and intervention to optimize outcomes. Specific goals include reducing delays in diagnosis of HNSCC; promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies; reducing inappropriate testing; and promoting appropriate physical examination when cancer is suspected. The target patient for this guideline is anyone ≥18 years old with a neck mass. The target clinician for this guideline is anyone who may be the first clinician whom a patient with a neck mass encounters. This includes clinicians in primary care, dentistry, and emergency medicine, as well as pathologists and radiologists who have a role in diagnosing neck masses. This guideline does not apply to children. This guideline addresses the initial broad differential diagnosis of a neck mass in an adult. However, the intention is only to assist the clinician with a basic understanding of the broad array of possible entities. The intention is not to direct management of a neck mass known to originate from thyroid, salivary gland, mandibular, or dental pathology as management recommendations for these etiologies already exist. This guideline also does not address the subsequent management of specific pathologic entities, as treatment recommendations for benign and malignant neck masses can be found elsewhere. Instead, this guideline is restricted to addressing the appropriate work-up of an adult patient with a neck mass that may be malignant in order to expedite diagnosis and referral to a head and neck cancer specialist. The Guideline Development Group sought to craft a set of actionable statements relevant to diagnostic decisions made by a clinician in the workup of an adult patient with a neck mass. Furthermore, where possible, the Guideline Development Group incorporated evidence to promote high-quality and cost-effective care. Action Statements The development group made a strong recommendation that clinicians should order a neck computed tomography (or magnetic resonance imaging) with contrast for patients with a neck mass deemed at increased risk for malignancy. The development group made the following recommendations: (1) Clinicians should identify patients with a neck mass who are at increased risk for malignancy because the patient lacks a history of infectious etiology and the mass has been present for ≥2 weeks without significant fluctuation or the mass is of uncertain duration. (2) Clinicians should identify patients with a neck mass who are at increased risk for malignancy based on ≥1 of these physical examination characteristics: fixation to adjacent tissues, firm consistency, size >1.5 cm, or ulceration of overlying skin. (3) Clinicians should conduct an initial history and physical examination for patients with a neck mass to identify those with other suspicious findings that represent an increased risk for malignancy. (4) For patients with a neck mass who are not at increased risk for malignancy, clinicians or their designees should advise patients of criteria that would trigger the need for additional evaluation. Clinicians or their designees should also document a plan for follow-up to assess resolution or final diagnosis. (5) For patients with a neck mass who are deemed at increased risk for malignancy, clinicians or their designees should explain to the patient the significance of being at increased risk and explain any recommended diagnostic tests. (6) Clinicians should perform, or refer the patient to a clinician who can perform, a targeted physical examination (including visualizing the mucosa of the larynx, base of tongue, and pharynx) for patients with a neck mass deemed at increased risk for malignancy. (7) Clinicians should perform fine-needle aspiration (FNA) instead of open biopsy, or refer the patient to someone who can perform FNA, for patients with a neck mass deemed at increased risk for malignancy when the diagnosis of the neck mass remains uncertain. (8) For patients with a neck mass deemed at increased risk for malignancy, clinicians should continue evaluation of patients with a cystic neck mass, as determined by FNA or imaging studies, until a diagnosis is obtained and should not assume that the mass is benign. (9) Clinicians should obtain additional ancillary tests based on the patient's history and physical examination when a patient with a neck mass is deemed at increased risk for malignancy who does not have a diagnosis after FNA and imaging. (10) Clinicians should recommend evaluation of the upper aerodigestive tract under anesthesia, before open biopsy, for patients with a neck mass deemed at increased risk for malignancy and without a diagnosis or primary site identified with FNA, imaging, and/or ancillary tests. The development group recommended against clinicians routinely prescribing antibiotic therapy for patients with a neck mass unless there are signs and symptoms of bacterial infection.
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Affiliation(s)
| | - M Boyd Gillespie
- 2 Universityy of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Benjamin Roman
- 3 Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Richard M Rosenfeld
- 4 SUNY Downstate Medical Center, Long Island College Hospital, New York, New York, USA
| | | | - Laura Bontempo
- 6 University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | | | - Maria Colandrea
- 8 Veterans Affairs Medical Center, Durham, North Carolina, USA.,9 Duke University School of Nursing, Durham, North Carolina, USA
| | - Sandra A Finestone
- 10 Consumers United for Evidence-Based Healthcare, Baltimore, Maryland, USA
| | | | | | - Zeb Henson
- 13 University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Vikas Mehta
- 15 Lousiana State University, Shreveport, Louisiana, USA
| | | | | | - Deborah R Shatzkes
- 18 Hofstra Northwell School of Medicine, Lenox Hill Hospital, New York, New York, USA
| | - Wendy B Stern
- 19 Southcoast Hospital, North Dartmouth, Massachusetts, USA
| | | | - Maureen D Corrigan
- 21 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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28
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Axelsson L, Nyman J, Haugen-Cange H, Bove M, Johansson L, De Lara S, Kovács A, Hammerlid E. Prognostic factors for head and neck cancer of unknown primary including the impact of human papilloma virus infection. J Otolaryngol Head Neck Surg 2017; 46:45. [PMID: 28601094 PMCID: PMC5466757 DOI: 10.1186/s40463-017-0223-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/26/2017] [Indexed: 01/03/2023] Open
Abstract
Background Head and neck cancer of unknown primary (HNCUP) is rare and prospective studies are lacking. The impact of different prognostic factors such as age and N stage is not completely known, the optimal treatment is not yet established, and the reported survival rates vary. In the last decade, human papilloma virus (HPV) has been identified as a common cause of and important prognostic factor in oropharyngeal cancer, and there is now growing interest in the importance of HPV for HNCUP. The aim of the present study on curatively treated HNCUP was to investigate the prognostic importance of different factors, including HPV status, treatment, and overall survival. Methods A search for HNCUP was performed in the Swedish Cancer Registry, Western health district, between the years 1992–2009. The medical records were reviewed, and only patients with squamous cell carcinoma or undifferentiated carcinoma treated with curative intent were included. The tumor specimens were retrospectively analyzed for HPV with p16 immunostaining. Results Sixty-eight patients were included. The mean age was 59 years. The majority were males, and had N2 tumors. Sixty-nine percent of the tumors were HPV positive using p16 staining. Patients who were older than 70 years, patients with N3-stage tumors, and patients with tumors that were p16 negative had a significantly worse prognosis. The overall 5-year survival rate for patients with p16-positive tumors was 88% vs 61% for p16-negative tumors. Treatment with neck dissection and postoperative radiation or (chemo) radiation had 81 and 88% 5-year survival rates, respectively. The overall and disease-free 5-year survival rates for all patients in the study were 82 and 74%. Conclusions Curatively treated HNCUP had good survival. HPV infection was common. Independent prognostic factors for survival were age over 70 years, HPV status and N3 stage. We recommend that HPV analysis should be performed routinely for HNCUP. Treatment with neck dissection and postoperative radiation or (chemo) radiation showed similar survival rates.
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Affiliation(s)
- Lars Axelsson
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden.
| | - Jan Nyman
- Department of Oncology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Hedda Haugen-Cange
- Department of Oncology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Mogens Bove
- Department of Otorhinolaryngology, Norra Älvsborgs Hospital, Trollhättan, Sweden
| | - Leif Johansson
- Department of Otorhinolaryngology, Central Hospital Skövde, Skövde, Sweden
| | - Shahin De Lara
- Department of Clinical Pathology and Genetics, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Anikó Kovács
- Department of Clinical Pathology and Genetics, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Eva Hammerlid
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
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29
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Hu KS, Mourad WF, Gamez ME, Lin W, Jacobson AS, Persky MS, Urken ML, Culliney BE, Li Z, Tran TN, Schantz SP, Chadha J, Harrison LB. Five-year outcomes of an oropharynx-directed treatment approach for unknown primary of the head and neck. Oral Oncol 2017. [PMID: 28622886 DOI: 10.1016/j.oraloncology.2017.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Squamous cell carcinoma of unknown primary (SCCHNUP) is commonly treated with comprehensive radiation to the laryngopharynx and bilateral necks. In 1998, we established a departmental policy to treat SCCHNUP with radiation directed to the oropharynx and bilateral neck. METHODS From 1998-2011, 60 patients were treated - N1: 18%, N2: 75% and N3: 7%. 82% underwent neck dissection. 55% received IMRT and 62% underwent concurrent chemoradiotherapy. RESULTS At median follow-up of 54months, 5 patients failed regionally and 4 emerged with a primary (tongue base, hypopharynx and thoracic esophagus). Five-year rates of regional control, primary emergence, distant metastasis, disease-free survival and overall survival were 90%, 10%, 20%, 72% and 79%, respectively. The 5year rate of primary emergence in a non-oropharynx site was 3%. CONCLUSION This is the first demonstration that an oropharynx-directed approach yields low rates of primary emergence in SCCHNUP with excellent oncologic outcomes.
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Affiliation(s)
- Kenneth Shung Hu
- Dept of Radiation Oncology, New York University Langone Medical Center, New York, NY, United States.
| | - Waleed Fouad Mourad
- Dept of Radiation Oncology, Georgia Regents University, Augusta, GA, United States
| | - Mauricio E Gamez
- Dept of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, United States.
| | - Wilson Lin
- Dept of Radiation Oncology, Mount Sinai at Beth Israel Medical Center, New York, NY, United States
| | - Adam Saul Jacobson
- Dept of Otolaryngology, New York University Langone Medical Center, New York, NY, United States
| | - Mark Stephen Persky
- Dept of Otolaryngology, New York University Langone Medical Center, New York, NY, United States
| | - Mark L Urken
- Dept of Otolaryngology, Mount Sinai at Beth Israel, New York, NY, United States
| | - Bruce E Culliney
- Dept of Medicine, Mount Sinai at Beth Israel, New York, NY, United States
| | - Zujun Li
- Dept of Medicine, New York University Langone Medical Center, New York, NY, United States
| | - Theresa Nguyen Tran
- Dept of Otolaryngology, New York University Langone Medical Center, New York, NY, United States
| | | | - Juskaran Chadha
- Dept of Medicine, Mount Sinai at Roosevelt Hospital, New York, NY, United States
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30
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Müller von der Grün J, Tahtali A, Ghanaati S, Rödel C, Balermpas P. Diagnostic and treatment modalities for patients with cervical lymph node metastases of unknown primary site - current status and challenges. Radiat Oncol 2017; 12:82. [PMID: 28486947 PMCID: PMC5424363 DOI: 10.1186/s13014-017-0817-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 05/03/2017] [Indexed: 11/29/2022] Open
Abstract
Background and Purpose This review aims to provide a comprehensive overview of the literature and elucidate open questions for future clinical trials concerning diagnostics and treatment modalities for cervical cancer of unknown primary (CUP). Methods A literature search for head and neck CUP was performed with focus on diagnostics and therapies as well as molecular markers. Results High level evidence on CUP is limited. However, it seems that a consensus exists regarding the optimal diagnostic procedures. The correct implementation of biomarkers for patient stratification and treatment remains unclear. An even greater dispute dominates about the ideal treatment with publications ranging from sole surgery to surgery with postoperative bilateral radiotherapy with inclusion of the mucosa and concomitant chemotherapy. Conclusions Cervical CUP represents a very heterogeneous malignant disease. On this account many aspects concerning treatment optimization remain unclear, despite a considerable number of publications in the past. Future research in form of prospective randomized trials is needed in order to better define patient stratification criteria and enable tailored treatment.
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Affiliation(s)
- Jens Müller von der Grün
- Department of Radiation Oncology, University Hospital, Johann Wolfgang Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany
| | - Aykut Tahtali
- Department of Otolaryngology and Head and Neck Surgery, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Shahram Ghanaati
- Department of Maxillofacial Surgery, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Claus Rödel
- Department of Radiation Oncology, University Hospital, Johann Wolfgang Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Frankfurt, Germany
| | - Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital, Johann Wolfgang Goethe University, Theodor Stern Kai 7, 60590, Frankfurt, Germany. .,German Cancer Research Center (DKFZ), Heidelberg, Germany. .,German Cancer Consortium (DKTK), Frankfurt, Germany.
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31
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de Ridder M, Klop M, Hamming-Vrieze O, de Boer J, Jasperse B, Smit L, Vogel W, van den Brekel M, Al-Mamgani A. Unknown primary head and neck squamous cell carcinoma in the era of fluorodeoxyglucose-positron emission tomography/CT and intensity-modulated radiotherapy. Head Neck 2017; 39:1382-1391. [PMID: 28370570 DOI: 10.1002/hed.24762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The diagnosis and treatment of head and neck carcinoma of unknown primary (CUP) have changed with the introduction of fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT and intensity-modulated radiotherapy (IMRT), with potential implications for outcome. METHODS We conducted a retrospective analysis of 80 patients with head and neck CUP who were PET-staged and treated with curative intention using IMRT between 2006 and 2016 in the Netherlands Cancer Institute. Patient, tumor, and treatment demographics were recorded and oncologic outcomes were analyzed. RESULTS Local control was 100% in mucosal irradiated patients. Regional control was 90%. Ten patients developed distant metastases, which were associated with N3, extracapsular extension (ECE) and lower neck positive lymph nodes. Overall survival (OS) at 5 years was 62% and disease-specific survival was 78%. ECE, N3 neck, multiple levels of positive lymph nodes, and positive lymph nodes in the lower neck were associated with worse prognosis. CONCLUSION Locoregional outcome of head and neck CUP managed with modern techniques is good. Future research needs to focus on reducing toxicity and patients prone for distant metastasis.
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Affiliation(s)
- Mischa de Ridder
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Martin Klop
- Department of Head and Neck Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Olga Hamming-Vrieze
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - JanPaul de Boer
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Bas Jasperse
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Laura Smit
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wouter Vogel
- Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michiel van den Brekel
- Department of Head and Neck Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Abrahim Al-Mamgani
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Extensive Regional Metastasis of High-Grade Mucoepidermoid Carcinoma of an Unknown Primary Tumor. J Oral Maxillofac Surg 2017; 75:874.e1-874.e7. [PMID: 28042980 DOI: 10.1016/j.joms.2016.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 12/02/2016] [Accepted: 12/03/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE Mucoepidermoid carcinoma (MEC) is the most common salivary carcinoma. It arises most frequently in the major salivary glands, but can also arise in minor glands or intraosseous sites. MEC of an unknown primary occurs very rarely. The present report documents only the third case reported in medical studies. METHODS A 66-year-old man with previous carcinoma in situ (CIS) of the left posterior oral tongue that had been excised in 2004 and again in 2010 presented with a hard lymph node, 3 × 2 cm at level II of the right neck in July 2015. Positron emission tomography-computed tomography (PET-CT) revealed multiple, bilateral cervical lymphadenopathy, with no primary site identified. Fine needle aspiration biopsy and cytologic examination from the right neck was positive for malignancy, suggestive of metastatic squamous cell carcinoma. Panendoscopy and biopsy revealed CIS at the tongue bases and tonsils bilaterally (p16-negative). The patient's case was presented to a tumor board, and definitive concurrent cispl.atin-based chemoradiation was recommended for TisN2cM0, stage IVA oropharyngeal CIS, which was completed in November 2015. PET-CT in January 2015 showed complex interval changes, with some areas demonstrating improvement (ie, no uptake in the left neck) and worsening in others (ie, increased metabolic activity in the right neck), suggestive of residual disease. Repeat PET-CT in March 2016 showed increased nodal involvement and increasing standardized uptake value. Bilateral modified radical neck dissection was undertaken, and histologic examination showed high-grade MEC in 51 of 61 lymph nodes with extracapsular spread and soft tissue involvement. RESULTS The patient died in May 2016 at 2 months after surgery. CONCLUSIONS Metastatic MEC of an unknown primary is a diagnostic challenge. PET-CT might not be the most reliable diagnostic investigation to identify the primary or metastatic foci, such as was demonstrated in the present case.
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33
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Arosio AD, Pignataro L, Gaini RM, Garavello W. Neck lymph node metastases from unknown primary. Cancer Treat Rev 2016; 53:1-9. [PMID: 28027480 DOI: 10.1016/j.ctrv.2016.11.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/23/2016] [Accepted: 11/29/2016] [Indexed: 11/18/2022]
Abstract
Metastatic cervical carcinoma from unknown primary is a metastatic disease in the lymph nodes of the neck without any evidence of a primary tumour after appropriate investigation. The condition is rare and definite evidence is lacking for both diagnosis and treatment. In this review of the literature, we tried to draw some clinical indications based on the few available studies. We ultimately came to the following conclusions: (1) a thorough and accurate diagnostic work-up should be systematically offered. It includes accurate inspection with fibroscopy, CT or MRI, fine needle aspiration, panendoscopy and positron emission tomography, (2) Patients with low-volume neck disease, N1 and N2a stage and without extracapsular extension on histopathological examination should receive single modality treatment. Radiotherapy and surgery may be similarly effective but, if possible, surgery (excisional biopsy, neck dissection and tonsillectomy) should be favoured because it consents a more precise staging, (3) patients with more advanced conditions require combined treatment in the form of either resection followed by adjuvant radiation (±chemotherapy) or primary chemoradiation (±post-therapy neck dissection).
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Affiliation(s)
- Alberto Daniele Arosio
- Department of Otorhinolaryngology, School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Lorenzo Pignataro
- Department of Otorhinolaryngology, Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Renato Maria Gaini
- Department of Otorhinolaryngology, School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Werner Garavello
- Department of Otorhinolaryngology, School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy.
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34
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Ooishi M, Motegi A, Kawashima M, Arahira S, Zenda S, Nakamura N, Ariji T, Tokumaru S, Sakuraba M, Tahara M, Hayashi R, Akimoto T. Patterns of failure after postoperative intensity-modulated radiotherapy for locally advanced and recurrent head and neck cancer. Jpn J Clin Oncol 2016; 46:919-927. [DOI: 10.1093/jjco/hyw095] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 06/17/2016] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mitsutoshi Ooishi
- Divisions of Radiation Oncology, National Cancer Center Hospital East, Kashiwa
- Department of Radiology, Saga University Faculty of Medicine, Saga
| | - Atsushi Motegi
- Divisions of Radiation Oncology, National Cancer Center Hospital East, Kashiwa
- Divisions of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa
| | - Mitsuhiko Kawashima
- Divisions of Radiation Oncology, National Cancer Center Hospital East, Kashiwa
- Divisions of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa
| | - Satoko Arahira
- Divisions of Radiation Oncology, National Cancer Center Hospital East, Kashiwa
- Divisions of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa
| | - Sadamoto Zenda
- Divisions of Radiation Oncology, National Cancer Center Hospital East, Kashiwa
- Divisions of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa
| | - Naoki Nakamura
- Divisions of Radiation Oncology, National Cancer Center Hospital East, Kashiwa
- Divisions of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa
| | - Takaki Ariji
- Divisions of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa
| | - Sunao Tokumaru
- Department of Radiology, Saga University Faculty of Medicine, Saga
| | - Minoru Sakuraba
- Divisions of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa
| | - Makoto Tahara
- Divisions of Head and Neck Medical Oncology, National Cancer Center Hospital East, Kashiwa
| | - Ryuichi Hayashi
- Divisions of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tetsuo Akimoto
- Divisions of Radiation Oncology, National Cancer Center Hospital East, Kashiwa
- Divisions of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa
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35
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Galloway TJ, Ridge JA. Management of Squamous Cancer Metastatic to Cervical Nodes With an Unknown Primary Site. J Clin Oncol 2015; 33:3328-37. [PMID: 26351351 DOI: 10.1200/jco.2015.61.0063] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Squamous cell carcinoma of an unknown primary (SCCUP) of the head and neck is a rare disease. As a diagnosis of exclusion, the manner in which it is assigned merits consideration. Despite the development and refinement of several techniques designed to locate an occult tumor, including cross-sectional anatomic imaging, functional imaging, and transoral surgical techniques, delineating SCCUP remains an active clinical problem. Its relative rarity has prevented prospective study of the entity. Hence, investigators must rely on retrospective analyses to understand the disease and its appropriate treatment. The current understanding of SCCUP differs substantially from when it was initially described decades ago. The most common site of a small primary tumor initially thought to represent SCCUP is the tonsil or base of the tongue, and an increasing percentage are associated with human papilloma virus. Modern treatment of SCCUP by neck dissection alone, neck dissection followed by radiation with or without concurrent chemotherapy, or primary chemoradiation according to initial nodal disease burden produces extraordinarily low recurrence rates. Whether the potential mucosal primary site and/or the contralateral neck should be electively treated is controversial. Efficacy data seem to be similar; therefore, an evaluation of the toxicity of both treatment paradigms is warranted.
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Affiliation(s)
| | - John A Ridge
- All authors: Fox Chase Cancer Center, Philadelphia, PA.
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36
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Cuaron J, Rao S, Wolden S, Zelefsky M, Schupak K, Mychalczak B, Lee N. Patterns of failure in patients with head and neck carcinoma of unknown primary treated with radiation therapy. Head Neck 2015; 38 Suppl 1:E426-31. [PMID: 25581274 DOI: 10.1002/hed.24013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The purpose of this study was to examine patterns of failure and the relationship to radiation doses in patients with head and neck carcinoma of unknown primary (HNCUP). METHODS We reviewed 85 patients with HNCUP treated with curative-intent radiation therapy (RT) during 1995 to 2012. RESULTS There have been no failures in the pharyngeal axis. Relapse at initial neck sites of disease developed in 7 patients (8.2%). The median dose to these sites was 70 Gy (range, 63-70 Gy). Failure at neck sites without initial disease occurred in 4 patients (4.7%). The median dose was 54 Gy (range, 50-58.8 Gy). There were no contralateral failures in a small cohort of patients receiving unilateral treatment (n = 6). Percutaneous endoscopic gastrostomy (PEG) tube dependence at 12 months was 7.4%, and 2.5% at 3 years. Esophageal stricture developed in 5 patients (5.9%). CONCLUSION RT for HNCUP produces excellent locoregional control rates with acceptably low levels of late toxicity. Doses prescribed to sites of eventual failure did not vary significantly from those sites that were treated and remain in control. © 2015 Wiley Periodicals, Inc. Head Neck 38: E426-E431, 2016.
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Affiliation(s)
- John Cuaron
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Shyam Rao
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Michael Zelefsky
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Karen Schupak
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Borys Mychalczak
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
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37
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Kuijpers YAM, van Elden LJR, van Dam IE, Quak JJ. Palliative neck surgery in metastatic lung cancer: a case report. J Pain Symptom Manage 2015; 49:e2-5. [PMID: 25666516 DOI: 10.1016/j.jpainsymman.2014.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 12/31/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Yvette A M Kuijpers
- Department of Otolaryngology and Head and Neck Surgery, Diakonessenhuis, Utrecht, The Netherlands.
| | | | - Iris E van Dam
- Department of Radiotherapy, University Medical Centre, Utrecht, The Netherlands
| | - Jasper J Quak
- Department of Otolaryngology and Head and Neck Surgery, Diakonessenhuis, Utrecht, The Netherlands
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38
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Martin JM, Galloway TJ. Evaluation and management of head and neck squamous cell carcinoma of unknown primary. Surg Oncol Clin N Am 2015; 24:579-91. [PMID: 25979401 DOI: 10.1016/j.soc.2015.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The diagnostic evaluation and therapeutic management of a patient with squamous cell carcinoma of an unknown primary (SCCUP) has considerably evolved over recent decades and will likely continue to change as a result of the improving ability to identify small primary tumors and better tailor the implementation of multimodality therapy. By application of the general principles of head and neck oncology, physicians and surgeons are often able to achieve satisfactory control of the disease in patients with SCCUP.
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Affiliation(s)
- Jeffrey M Martin
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA.
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39
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Zhuang SM, Wu XF, Li JJ, Zhang GH. Management of lymph node metastases from an unknown primary site to the head and neck (Review). Mol Clin Oncol 2014; 2:917-922. [PMID: 25279174 DOI: 10.3892/mco.2014.361] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 02/12/2014] [Indexed: 12/14/2022] Open
Abstract
Cancer of unknown primary site (CUP) is an intriguing clinical phenomenon found in ~3-9% of all head and neck cancers. It has not yet been determined whether CUP forms a distinct biological entity with specific genetic and phenotypic characteristics, or whether it is the clinical presentation of metastasis in patients with an undetected primary tumor and no visible clinical signs. The treatment of patients with cervical lymph node metastases from CUP remains controversial, due to the lack of randomized clinical trials comparing different treatment options. Consequently, treatment is currently based on non-randomized data and institutional policy. In the present review, the range and limitations of diagnostic procedures are summarized and an optimal diagnostic work-up is recommended. The initial preferred diagnostic procedures include fine-needle aspiration biopsy (FNAB) and imaging. Although neck dissection followed by postoperative radiotherapy is the the most generally accepted approach, other curative options may be used in certain patients, such as neck dissection alone, nodal excision followed by postoperative radiotherapy, or radiotherapy alone. There remains controversy regarding target radiation volumes, ranging from ipsilateral neck irradiation to prophylactic irradiation of all the potential mucosal sites and both sides of the neck. When no primary lesion is identified with imaging and endoscopy in patients without history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus and/or Epstein-Barr virus is required.
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Affiliation(s)
- Shi Min Zhuang
- Department of Otorhinolaryngology-Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Xi-Fu Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Jing-Jia Li
- Department of Otorhinolaryngology-Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Ge-Hua Zhang
- Department of Otorhinolaryngology-Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
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40
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Park GC, Lee M, Roh JL, Choi SH, Nam SY, Kim SY, Cho KJ. Phospho-Rb (Ser780) as a biomarker in patients with cervical lymph node metastases from an unknown primary tumour: a retrospective cohort study. Clin Otolaryngol 2014; 38:313-21. [PMID: 23731755 DOI: 10.1111/coa.12138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Cervical lymph node metastases from an unknown primary tumour are a heterogeneous disease entity with various clinical features. There are many controversies regarding treatment methods and treatment response predictions. Therefore, we examined the prognostic significance of biomarkers in patients with cervical metastasis of unknown primary tumour. DESIGN A molecular study of retrospective cohorts. SETTING University teaching hospital. MAIN OUTCOME MEASURES Metastatic cervical lymph nodes of 36 patients with cervical unknown primary metastasis of squamous cell carcinoma were assessed by in situ hybridisation for human papillomavirus and immunohistochemistry for p16, retinoblastoma protein (phospho-Ser780), hypoxia-inducible factor-1α, glucose transporter 1 and carbonic anhydrase 9 expression. Clinicopathological factors and biomarkers were analysed for their associations with disease-free survival and overall survival. RESULTS Univariate analysis showed that nodal extracapsular spread was associated with poor overall survival (P = 0.049), nodal-positive retinoblastoma protein staining were significantly associated with poor outcomes of both disease-free survival (P = 0.035) and overall survival (P = 0.019), Multivariate analysis revealed that nodal positivity of retinoblastoma protein and nodal extracapsular spread were the significant predictors of overall survival (P = 0.049, hazard ratio = 6.21, 95% confidence interval = 1.01-38.35 and P = 0.037, hazard ratio = 4.34, 95% confidence interval = 1.09-17.21, respectively). CONCLUSION The retinoblastoma protein expression of metastatic lymph nodes represents an independent prognostic indicator in patients with cervical metastasis of unknown primary tumour.
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Affiliation(s)
- G C Park
- Department of Otolaryngology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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41
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Demiroz C, Vainshtein JM, Koukourakis GV, Gutfeld O, Prince ME, Bradford CR, Wolf GT, McLean S, Worden FP, Chepeha DB, Schipper MJ, McHugh JB. Head and neck squamous cell carcinoma of unknown primary: neck dissection and radiotherapy or definitive radiotherapy. Head Neck 2013; 36:1589-1595. [PMID: 23996575 DOI: 10.1002/hed.23479] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 07/13/2013] [Accepted: 08/23/2013] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Management of head and neck carcinoma from unknown primary (HNCUP) remains controversial, with neck dissection and radiotherapy (RT) or definitive RT both commonly used. The purpose of this study was to characterize HNCUP and retrospectively compare outcomes for patients treated with neck dissection + RT versus definitive RT. METHODS From 1994 to 2009, 41 patients with HNCUP underwent either neck dissection + RT (n = 22) or definitive RT ± concurrent chemotherapy (n = 19) at our institution. Treatment outcomes were compared using Kaplan-Meier methods and log-rank test. RESULTS There were no differences between patients treated with neck dissection + RT and definitive RT in overall survival (OS), progression-free survival (PFS), locoregional relapse-free survival (LRFS), freedom from locoregional failure (FFLRG), or freedom from distant failure (FFDF). Among 17 patients who underwent neck dissection + RT for whom human papillomavirus (HPV) status could be determined, HPV(+) patients trended toward improved OS (p = .06) and PFS (p = .15). CONCLUSION Neck dissection and postoperative RT resulted in similar outcomes as definitive RT. The prognostic implications of HPV(+) nodes in HNCUP are similar to those in oropharyngeal primary cancers.
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Affiliation(s)
- Candan Demiroz
- Department of Radiation Oncology, Uludag University Faculty of Medicine, Bursa, Turkey; Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | - Georgios V Koukourakis
- Department of Radiation Oncology, Saint Savvas Anticancer Institute of Athens, Greece; Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Orit Gutfeld
- Division of Oncology, Institute of Radiation Therapy, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Mark E Prince
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI
| | - Carol R Bradford
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI
| | - Gregory T Wolf
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI
| | - Scott McLean
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI
| | - Francis P Worden
- Division of Hematology Oncology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Douglas B Chepeha
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI
| | | | - Jonathan B McHugh
- Department of Pathology, University of Michigan, Ann Arbor, MI Avraham Eisbruch, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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Troussier I, Barry B, Baglin AC, Leysalle A, Janot F, Baujat B, Fakhry N, Sun XS, Marcy PY, Dufour X, Bensadoun RJ, Thariat J. [Target volumes in cervical lympadenopathies of unknown primary: toward a selective customized approach? On behalf of REFCOR]. Cancer Radiother 2013; 17:686-94. [PMID: 24095636 DOI: 10.1016/j.canrad.2013.07.132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 06/27/2013] [Accepted: 07/03/2013] [Indexed: 11/25/2022]
Abstract
The treatment of carcinomas of unknown primary revealed by cervical lymphadenopathy is based on neck dissection and nodal and pan-mucosal irradiation to control the neck and avoid the emergence of a metachronous primary. The aim of this review was to assess diagnostic and therapeutic approaches and criteria that may be used for a customized selective approach to avoid severe toxicities of pan-mucosal irradiation. A literature search was performed with the following keywords: cervical lymphadenopathy, unknown primary, upper aerodigestive tract, cancer, radiotherapy, squamous cell carcinoma, variants. The diagnostic workup includes a head and neck scanner or MRI, ((18)F)-FDG PET CT, a panendoscopy and tonsillectomy. Squamous cell carcinoma represents over two thirds of cases. The number of metastatic cervical nodes, nodal level, and histological variant (associated with HPV/EBV status) may determine the primary site origin and might be weighted for the determination of radiation target volumes on a multidisciplinary basis. A selective customized approach is relevant to decrease radiation toxicity only if neck and mucosal control is not impaired. Although no recommendation can yet be made in the absence of sufficient level of evidence, the relevance of systematic pan-mucosal irradiation appears questionable in a number of clinical situations. Accordingly, a customized selective redefinition of target volumes may be discussed and be prospectively evaluated in relation to the therapeutic index obtained.
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Affiliation(s)
- I Troussier
- Service d'oncologie radiothérapie, PRC, CHU de la Milétrie, 2, rue de la Milétrie, BP 557, 86021 Poitiers cedex, France
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Gani C, Eckert F, Müller AC, Mauz PS, Thiericke J, Bamberg M, Weinmann M. Cervical squamous cell lymph node metastases from an unknown primary site: survival and patterns of recurrence after radiotherapy. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2013; 7:173-80. [PMID: 23943661 PMCID: PMC3738379 DOI: 10.4137/cmo.s12169] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction The purpose of the present retrospective study was to review outcome and patterns of failure of patients who were treated with radiotherapy for cervical lymph node metastases from an unknown primary site (CUP). Patients and Methods Between 2000 and 2009, 34 patients diagnosed with squamous cell CUP were admitted to radiotherapy in curative intent. In 26 of 34 patients (76%) neck dissection was performed prior to radiotherapy, extracapsular extension (ECE) was seen in 20 of 34 patients (59%). Target volumes included the bilateral neck and panpharyngeal mucosa. Concomitant chemotherapy was applied in 14 of 34 patients (41%). Results After a median follow-up of 45 months for the entire group, 2 of 34 patients (6%) presented with an isolated regional recurrence, another 2 of 34 patients (6%) developed both local and distant recurrence, and 6 of 34 patients (18%) had distant failure only. Estimated overall survival after 2- and 5 -years was 78% and 63%. All patients with N1 or N2a disease (n=6) were disease free after 5 years. ECE, concomitant chemotherapy and involvement of neck levels 4 and 5 were associated with worse overall survival on univariate analysis. Conclusion Radiotherapy of the panpharynx and bilateral neck leads to excellent local control while distant metastases are the most frequent site of failure and prognostically limiting. Therefore intensified concomitant or sequential systemic therapies should be evaluated in future trials.
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Affiliation(s)
- Cihan Gani
- Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
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Balaker AE, Abemayor E, Elashoff D, St. John MA. Cancer of unknown primary: Does treatment modality make a difference? Laryngoscope 2012; 122:1279-82. [DOI: 10.1002/lary.22424] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 08/09/2011] [Accepted: 08/11/2011] [Indexed: 11/09/2022]
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Ampil FL, Nathan CAO, Sangster G, Caldito G. Head and neck cancer with lower neck nodal metastases: management of 23 cases and review of the literature. Oral Oncol 2012; 48:325-8. [PMID: 22405883 DOI: 10.1016/j.oraloncology.2011.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 11/16/2011] [Accepted: 11/21/2011] [Indexed: 11/29/2022]
Abstract
To investigate the patient outcomes associated with the applied modes of therapy in head and neck cancer with lower neck nodal metastases. The medical records of 23 consecutive individuals who were managed by intent to treat for head and neck cancer with metastatic disease in the lower neck nodes over a 19-year period were reviewed. The mean age was 53.5 years, and the larynx was the most frequently affected primary site (57%). Overall, locoregional tumor control was achieved in the majority (75%) of the cases and the 2-year survival rate was 48%. The 2-year survival rates of people managed by surgery and postoperative radiotherapy, chemoradiation or single modality therapy were 63%, 56% and 17%, respectively, (p=0.04). Aggressive therapy resulted in five (22%) long-term (>5 years) survivors. The combination of treatment modalities proved to be effective management for head and neck cancer with lower neck nodal metastases and should be further investigated in prospective trials.
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Affiliation(s)
- Federico L Ampil
- Department of Radiology, Louisiana State University Health Sciences Center and Feist-Weiller Cancer Center, Shreveport, LA 71130, USA.
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Stella GM, Senetta R, Cassenti A, Ronco M, Cassoni P. Cancers of unknown primary origin: current perspectives and future therapeutic strategies. J Transl Med 2012; 10:12. [PMID: 22272606 PMCID: PMC3315427 DOI: 10.1186/1479-5876-10-12] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 01/24/2012] [Indexed: 12/22/2022] Open
Abstract
It is widely accepted that systemic neoplastic spread is a late event in tumour progression. However, sometimes, rapidly invasive cancers are diagnosed because of appearance of metastatic lesions in absence of a clearly detectable primary mass. This kind of disease is referred to as cancer of unknown primary (CUP) origin and accounts for 3-5% of all cancer diagnosis. There is poor consensus on the extent of diagnostic and pathologic evaluations required for these enigmatic cases which still lack effective treatment. Although technology to predict the primary tumour site of origin is improving rapidly, the key issue is concerning the biology which drives early occult metastatic spreading. This review provides the state of the art about clinical and therapeutic management of this malignant syndrome; main interest is addressed to the most recent improvements in CUP molecular biology and pathology, which will lead to successful tailored therapeutic options.
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Affiliation(s)
- Giulia Maria Stella
- Department of Oncological Sciences, Institute for Cancer Research and Treatment (IRCC), Candiolo (Turin), Italy.
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Radio(chemo)therapy in the management of squamous cell carcinoma of cervical lymph nodes from an unknown primary site. Strahlenther Onkol 2011; 188:56-61. [DOI: 10.1007/s00066-011-0017-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 07/11/2011] [Indexed: 10/14/2022]
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Strojan P, Ferlito A, Medina JE, Woolgar JA, Rinaldo A, Robbins KT, Fagan JJ, Mendenhall WM, Paleri V, Silver CE, Olsen KD, Corry J, Suárez C, Rodrigo JP, Langendijk JA, Devaney KO, Kowalski LP, Hartl DM, Haigentz M, Werner JA, Pellitteri PK, de Bree R, Wolf GT, Takes RP, Genden EM, Hinni ML, Mondin V, Shaha AR, Barnes L. Contemporary management of lymph node metastases from an unknown primary to the neck: I. A review of diagnostic approaches. Head Neck 2011; 35:123-32. [PMID: 22034046 DOI: 10.1002/hed.21898] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2011] [Indexed: 12/31/2022] Open
Abstract
In an era of advanced diagnostics, metastasis to cervical lymph nodes from an occult primary tumor is a rare clinical entity and accounts for approximately 3% of head and neck malignancies. Histologically, two thirds of cases are squamous cell carcinomas (SCCs), with other tissue types less common in the neck. With modern imaging and tissue examinations, a primary tumor initially undetected on physical examination is revealed in >50% of patients and the site of the index primary can be predicted with a high level of probability. In the present review, the range and limitations of diagnostic procedures are summarized and the optimal diagnostic workup is proposed. Initial preferred diagnostic procedures are a fine-needle aspiration biopsy (FNAB) and imaging. This allows directed surgical biopsy (such as tonsillectomy), based on the preliminary findings, and prevents misinterpretation of postsurgical images. When no primary lesion is suggested after imaging and panendoscopy, and for patients without a history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus (HPV) and/or Epstein-Barr virus (EBV) is important.
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Affiliation(s)
- Primož Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
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Strojan P, Ferlito A, Langendijk JA, Corry J, Woolgar JA, Rinaldo A, Silver CE, Paleri V, Fagan JJ, Pellitteri PK, Haigentz M, Suárez C, Robbins KT, Rodrigo JP, Olsen KD, Hinni ML, Werner JA, Mondin V, Kowalski LP, Devaney KO, de Bree R, Takes RP, Wolf GT, Shaha AR, Genden EM, Barnes L. Contemporary management of lymph node metastases from an unknown primary to the neck: II. A review of therapeutic options. Head Neck 2011; 35:286-93. [DOI: 10.1002/hed.21899] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2011] [Indexed: 11/06/2022] Open
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Head and neck squamous cell carcinoma from an unknown primary site. Am J Otolaryngol 2011; 32:286-90. [PMID: 20719404 DOI: 10.1016/j.amjoto.2010.05.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 05/10/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND The purpose of this study is to present our experience treating patients with squamous cell carcinoma (SCC) from an unknown head and neck primary site and to determine whether a policy change eliminating the larynx and hypopharynx from the radiotherapy (RT) portals has impacted outcome. METHODS One hundred seventy-nine patients received definitive RT with or without a neck dissection for SCC from an unknown head and neck primary site. RT was delivered to the ipsilateral neck alone or both sides of the neck and, usually, the potential mucosal primary sites. The median mucosal dose was 5670 cGy. The median neck dose was 6500 cGy. One hundred nine patients (61%) received a planned neck dissection. RESULTS Mucosal control at 5 years was 92%. The mucosal control rate in patients with RT limited to the nasopharynx and oropharynx was 100%. The 5-year neck-control rates were as follows: N(1), 94%; N(2a), 98%; N(2b), 86%; N(2c), 86%; N(3), 57%; and overall, 81%. The 5-year cause-specific survival rates were as follows: N(1), 94%; N(2a), 88%; N(2b), 82%; N(2c), 71%; N(3), 48%; and overall, 73%. The 5-year overall survival rates were as follows: N(1), 50%; N(2a), 70%; N(2b), 59%; N(2c), 45%; N(3), 34%; and overall, 52%. Eleven patients (7%) developed severe complications. CONCLUSION RT alone or combined with neck dissection results in a high probability of cure with a low risk of severe complications. Eliminating the larynx and hypopharynx from the RT portals did not compromise outcome and likely reduces treatment toxicity.
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