A comparison of the clinical characteristics of first and second primary head and neck cancers. A population-based study

Survival outcomes after surgical treatment of oral squamous cell carcinoma

OBJECTIVE

To identify the clinicopathological parameters that influence survival in patients with oral squamous cell carcinoma, in order to allow for the development of individualized surveillance programmes and reduce the delay in diagnosis of recurrence.

MATERIALS AND METHODS

Retrospective chart review of 553 patients with a treatment-naïve primary oral squamous cell carcinoma, who underwent primarily curative intended surgery. Exclusion criteria were neoadjuvant radio(chemo)therapy, follow-up < 1 year, perioperative death, inoperable disease, synchronous multiple malignancies and inadequate information on clinicopathological parameters.

RESULTS

The clinicopathological factors that influence overall survival, disease-free survival and locoregional control were calculated. In the multivariate survival analysis, the occurrence of recurrence, presence of extracapsular spread, T- and N-classification were shown to be independent risk factors for overall survival.

CONCLUSION

The identification of these risk factors can lead to the development of individualized follow-up programmes based on risk stratification. This allows for the earliest possible diagnosis of relapse which is essential to offer the patient a realistic second treatment chance and to improve survival rates.

An unusual case of a glottic carcinoma metastasis to the tracheal lumen

Various mechanisms such as second primary lesion, tumour seeding or lymphogenous and haematogenous metastasis could be proposed to explain the nature of dual malignant lesions. We report the case of a glottic laryngeal carcinoma combined with a secondary endotracheal tumour. Following the imaging modalities, the patient underwent total laryngectomy and wide excision of the trachea. Histopathology ultimately established that the tracheal lesion was a metastatic tumour secondary to regional lymphatic spread of the glottic tumour. To our knowledge, there is no previous report in the English literature concerning tracheal lymphogenous metastatic involvement in the context of laryngeal malignancy. Paradoxical lymphatic spread must always remain an issue of head and neck oncology.

Incidence and Outcomes of Patients With Oral Cavity Squamous Cell Carcinoma and Fourth Primary Tumors: A Long-term Follow-up Study in a Betel Quid Chewing Endemic Area

The aim of this study was to explore the incidence and outcomes of patients with oral cavity squamous cell carcinoma (OSCC) and fourth primary tumors (PTs) in a betel-chewing endemic area.We retrospectively examined the records of 1836 OSCC patients who underwent radical tumor resection between 1996 and 2014. The outcome measures included the incidence and number of multiple PTs, the main risk factors, and their associations with overall survival (OS).Of the 1836 patients, 1400 (76.3%) had a single PT, 344 (18.7%) a second PT, 67 (3.6%) a third PT, and 25 (1.4%) a fourth PT. Univariate analyses (log-rank test) identified the following factors as significantly associated with a fourth PT: simultaneous first and second PTs, betel quid chewing, buccal subsite, and pT3-4 status. After allowance for the potential confounding effect of other risk factors, all of these factors retained their independent prognostic significance in stepwise multivariate analyses, the only exception being betel chewing. The incidences of second, third, and fourth PTs at 5 and 10 years were 20.2%/34.6%, 4.0%/8.6%, and 1.0%/2.3%, respectively. The 5 and 10-year OS rates (calculated from the diagnosis of each PTs) for patients with a single, second, third, and fourth PTs were 68%/61%, 43%/37%, 45%/39%%, and 30%/30%, respectively (P < 0.0001). Among patients with a fourth PT, those who underwent radical surgery showed a significantly higher 3-year OS than those who did not (57% vs 13%; P = 0.0442).Fourth PTs are rarely observed in OSCC patients in a betel quid-chewing endemic area. Long-term survival rates of patients treated with radical surgery seems acceptable, being 4-fold higher than their counterparts.

Open questions and novel concepts in oral cancer surgery

The persistence of cancerous cells after surgery in oral squamous cell carcinoma (OSCC) represents a major challenge, as it often leads to local recurrences and secondary primary tumors, which are eventually responsible for a large proportion of deaths. This persistence is currently evaluated by histological analyses. In this review we discuss some important pitfalls of the histopathological analysis, such as margin evaluation, specimen shrinkage and T staging. In addition, we critically analyze the appropriateness of current surgical techniques in relation to the concept of field cancerization. Finally, we describe some novel imaging and molecular approaches, which might be useful in tailoring surgical resections and encourage the use of OSCC animal models to explore and provide proof of concept of the feasibility and potential clinical utility of innovative surgical protocols.

Survivorship--competing mortalities, morbidities, and second malignancies

Mortality of head and neck cancer has declined in the United States over the past 20 years. This improvement has been linked to use of multimodality treatment of advanced disease. Despite this improvement, disease-specific survival remains low. Patients who survive head and neck cancer are exposed to morbidity and mortality secondary to the same factors as the general population. Factors related to cancer and cancer treatment predispose them to increased risk of mortality. Improvements in head and neck cancer treatment have led to a scenario where an increasing proportion of patients die from causes other than the primary cancer, called competing mortalities.

A comparative study of isolated and metachronous oesophageal squamous cell carcinoma with antecedent upper aerodigestive tract cancer

OBJECTIVES

Metachronous oesophageal squamous cell carcinoma (OSCC) has been increasing in long-term survivors of upper aerodigestive tract (UADT) cancers in recent years, but the treatment of such cases is not well established. The aim of this study was to compare the prognosis between patients with metachronous OSCC who had antecedent UADT cancers and patients with isolated OSCC.

METHODS

From January 1995 to December 2009, we retrospectively compared the data from 84 patients with metachronous OSCC who had antecedent UADT cancers (metachronous group) with the data from 527 patients with isolated OSCC (isolated group) according to their treatment modalities at Kaohsiung Chang Gung Memorial Hospital.

RESULTS

Overall, the metachronous group had significantly (P = 0.03) worse overall survival than the isolated group. For patients receiving surgery or preoperative chemoradiotherapy followed by surgery, the overall survival rates and incidence of postoperative complications were not significantly different. For patients receiving definite chemoradiotherapy or radiotherapy alone, the metachronous group had significantly (P = 0.02) inferior overall survival compared with the isolated group.

CONCLUSIONS

Offering a radical approach for the treatment of patients with metachronous OSCC who had antecedent UADT cancers is justifiable, with survival rates similar to those of patients with isolated OSCC.

Second, third, and fourth head and neck tumors. A progressive decrease in survival

BACKGROUND

Patients with a first head and neck carcinoma have a high risk of successive neoplasms, many of which appear again in the head and neck. Second head and neck tumors have a poorer prognosis than first tumors, but data about the prognosis of third and fourth tumors in the head and neck are lacking.

METHODS

We carried out a retrospective study of 4298 patients with a primary head and neck carcinoma. Survival and the characteristics of the first tumor, second tumor, and any successive tumors in the head and neck were analyzed.

RESULTS

Second and successive tumors showed a tendency to appear more frequently in the oral cavity and oropharynx and had a lower stage than that of index tumors. Five-year survival rates after a first, second, third, and fourth tumors in the head and neck were 67.6%, 56.1%, 45.0%, and 32.1%, respectively.

CONCLUSION

Survival decreased progressively with every new head and neck tumor.

Comparative mortality for 621 second cancers in 29356 testicular cancer survivors and 12420 matched first cancers

BACKGROUND

Testicular cancer survivors, many of whom have undergone radiotherapy, are at substantial risk of second cancers. Treatment for testicular cancer may limit treatment options for second cancers, thereby adversely affecting survival after the second cancer. However, no data on outcomes of testicular cancer survivors with second cancers compared to patients with comparable first cancers exist.

METHODS

Among 29356 white testicular cancer patients reported to the Surveillance, Epidemiology, and End Results (SEER) program (1973-2002), 621 developed a second cancer with known stage and were matched to a random sample of 12420 white male first cancer patients in the SEER program by cancer site, stage, diagnosis year, and age at diagnosis. Mortality was ascertained through 2002. Cancer-specific and all-cause mortality following second cancers were compared with those of matched first cancers, and rate ratios (RRs) were estimated using proportional hazards analysis. Survival functions were calculated using product-limit estimates.

RESULTS

During the study period, 284 testicular cancer survivors with second cancers died, 191 from their second cancer; 5443 matched first cancer patients died, 3929 from their first cancer. Rate ratios for cancer-specific and all-cause mortality for second cancers compared with matched first cancers were 1.05 (95% confidence interval [CI] = 0.90 to 1.23) and 1.09 (95% CI = 0.96 to 1.23), respectively. However, among testicular cancer patients who were diagnosed during 1973-1979, an era in which radiation therapy was given at high doses and to the chest area, all-cause mortality following second cancers at sites below the diaphragm (79 deaths) and second lung cancers (29 deaths) was statistically significantly higher than that from matched first cancers (RR = 1.44, 95% CI = 1.13 to 1.83, and RR = 1.65, 95% CI = 1.12 to 2.42, respectively).

CONCLUSIONS

Mortality from second cancers following testicular cancer was similar to matched first cancers, except for selected tumors in the radiotherapy field among testicular cancer patients who were diagnosed during 1973-1979, a time when radiotherapy doses for treatment of testicular cancer were high and chest irradiation was an option in standard practice.

Chromosomal imbalances in oral squamous cell carcinoma: examination of 31 cell lines and review of the literature

Classical and molecular cytogenetic analysis, including fluorescence in situ hybridization (FISH) and chromosomal comparative genomic hybridization (CGH), were used to examine genetic changes involved in the development and/or progression of oral squamous cell carcinoma (OSCC). Of 31 OSCC cell lines studied, more than one-third expressed clonal structural abnormalities involving chromosomes 3, 7, 8, 9, and 11. Eleven OSCC cell lines were evaluated using CGH to identify novel genome-wide gains, losses, or amplifications. By CGH, more than half of the cell lines showed loss of 3p, gain of 3q, 8q, and 20q. Further, molecular cytogenetic analyses by FISH of primary tumors showed that the karyotypes of cell lines derived from those tumors correlated with specific gains and losses in the tumors from which they were derived. The most frequent nonrandom aberration identified by both karyotype and CGH analyses was amplification of chromosomal band 11q13 in the form of a homogeneously staining region. Our data suggest that loss of 9p and 11q13 amplification may be of prognostic benefit in the management of OSCC, which is consistent with the literature. The results of this study validate the relationship between these OSCC cell lines and the tumors from which they were derived. The results also emphasize the usefulness of these cell lines as in vitro experimental models and provide important genetic information on these OSCC cell lines that were recently reported in this journal.

Radiotherapy for oral cancer as a risk factor for second primary cancers

Radiation exposure, known to cause DNA damage, may be a potential source of field cancerization of the upper aerodigestive tract. Radiotherapy for head and neck cancers has been examined as a possible risk factor for second primary cancers, but the results have been equivocal. We evaluated the impact of therapeutic radiation for oral cancer on the risk of second primary cancers with data from the Surveillance, Epidemiology, and End Results (SEER) program for 1973-1999. Among 30,221 first primary oral squamous cell carcinoma patients, 6163 (20.4%) patients developed a second primary cancer, 5042 of which were metachronous. Patients treated with radiation only (RR=1.64, 95%CI=1.18-2.29) or radiation with surgery (RR=1.49, 95%CI=1.07, 2.06) had elevated risks of developing a second primary tumor, whereas patients treated with surgery only did not appear to be at increased risk (RR=1.28, 95%CI=0.93, 1.76). Consistent with an expected latent period between radiation exposure and tumor occurrence, radiation became a risk factor after 10 years of follow-up for solid cancers of the oral cavity (RR=2.8, 95%CI=1.5, 5.2), pharynx (RR=5.9, 95%CI=1.7, 20.7), esophagus (RR=3.9, 95%CI=1.1, 13.4) and lung (RR=1.5, 95%CI=1.0, 2.4), and after 1-5 years of follow-up for second primary leukemia (RR=2.5, 95%CI=1.0, 6.7). Radiotherapy for oral cancer appears to be a risk factor for second primary tumors. Further studies that account for chemotherapy and examine frequency and duration of radiotherapy would be of interest in confirming the observed association.

Second primary malignancies in patients with cancer of the head and neck

OBJECTIVE: Clinical study of second primary malignancies (SPM) in patients with cancer of the head and neck (HNC).

STUDY DESIGN AND SETTING: Retrospective study over 48 patients with SPMs culled from 636 with HNC seen in 122 months. The minimum follow-up was 18 months, and the setting for the study was the institutional referral center.

RESULTS: There was association between the sites of first and second tumor. The SPMs were diagnosed with a constant rate throughout the period of study. Five year-survival rate was 29%. SPM in an advanced stage either outside of the head and neck or synchronous had poor survival.

CONCLUSION: The SPMs are a growing problem with better survival after treatment of the first malignancy.

SIGNIFICANCE: Regular follow-up is necessary in HNC patients to improve their survival, giving special attention to the development of SPM.

Can cure be achieved in patients with head and neck carcinomas? The problem of second neoplasm

The improvement in locoregional control of head and neck carcinomas over the last few decades does not appear to modify the final survival of these patients, mainly due to the appearance of distant metastases and second neoplasms. This article reviews the topic of second neoplasm in patients with an index tumor in the head and neck, making a special point of the incidence and epidemiology of second neoplasms, the influence on prognosis, etiopathogenic theories and the possibility of prevention.

Six primary squamous cell carcinomas of the head and neck

The chronic irritation to mucosa of the head and neck area by carcinogen, commonly stemming from heavy usage of betel nuts, tobacco and alcohol, leads to dysplastic mucosal changes and eventually, multiple primary squamous cell carcinomas. With improvements in locoregional control, the problem of multiple primary malignancies of the head and neck is becoming apparent. We reported a unique case of six primary squamous cell carcinomas in the head and neck area. We attribute the success of controlling cancer in this patient to our alert attitude and prompt management. Surgery remains one of the best options in treating multiple head and neck malignancies, as surgery offers an effective, quick and low morbidity approach, and does not take the chance of inducing another cancer.

Quintuple cancers: report of a case with triple cancers in the head and neck

The incidence of multiple primary cancers is increasing. We report a case of quintuple cancers, two located in the genitourinary tract and three arising on the upper aerodigestive tract, two synchronous squamous cell carcinomas of the oral mucosa and another on the larynx. We also present a brief review of the literature.

Clinical characteristics of non-Hodgkin's lymphoma as a second primary tumor: a population-based survey

Data from 29,845 patients with lymphomas, 981 of whom had lymphoma as a second primary tumor, registered in the Surveillance Epidemiology and End Results (SEER) program in the U.S.A. between 1973 and 1986 were analyzed. The characteristics of the 274 patients with lymphoma as a second tumor who had received chemotherapy and/or radiotherapy for their primary tumor (SEP PT) were compared with 675 patients with second primary lymphomas who had no prior treatment (SEP NT) and with patients with single lymphomas (SIP). Patients with SEP PT disease had a significantly higher percentage of intermediate and high-grade tumors (80%) compared to those with SEP NT or SIP tumors (73% and 72%, respectively). The survival of all patients with SIP tumors did not differ from those with SEP tumors, but the median survival of those with SEP PT disease was shorter than for SEP NT disease. This was most probably due to the high percentage of intermediate and high-grade lymphomas in the SEP PT group. This was statistically significant in the group treated by combined chemotherapy and radiotherapy but not in those treated by a single modality alone. These findings relating to a worse prognosis in patients with SEP PT lymphoma are in line with our previous observations of a poor survival in patients with other multiple primary tumors.

Second primary malignancies in the head and neck cancer patient

With improvements in locoregional control, the problem of second primary malignancies is rapidly being pushed to the forefront of head and neck oncology. While the constant long-term risk for the head and neck cancer patient has been well established, efforts at prevention, early detection, and treatment have been somewhat futile. Recent advances in genetic predisposition, biomarkers, photodiagnostic imaging, and differentiation therapy may soon offer improved outcomes. The literature is reviewed and current research is presented regarding the history, epidemiology, etiology, diagnosis, and treatment of second primary malignancies.

Clinical characteristics of metachronous colorectal tumors

A cancer-registry-based study was conducted to investigate the survival patterns associated with metachronous colorectal tumors and to compare the survival of patients with single and metachronous colorectal tumors. The study included all 1,396 White patients with metachronous colorectal tumors diagnosed among 143,283 patients with primary colorectal tumors reported between 1973-1986 to the SEER program. The influence on survival of age at diagnosis, site of tumor and stage was evaluated by means of multivariate survival analysis, using Cox Proportional Hazards Models. Metachronous tumors developed more often following left-colon tumors. Stage distribution of the second tumors was better than that of single 47% of the second tumors were discovered in regionally-advanced or distant-metastatic stages. Survival from the second tumor diagnosed in the rectum was worse than that of a single tumor in the same stage and site. Only the stage of the second tumor was found to influence survival from metachronous tumors. The relatively high rate of diagnosis of advanced second colorectal tumors may reflect either improper follow-up after the diagnosis of the first tumor, or more aggressive biological characteristics of the second tumors.

High-dose reirradiation of head and neck cancer with curative intent

PURPOSE

This study evaluates the response of new or recurrent head and neck cancers and the response of associated normal tissues to high dose reirradiation with curative intent.

METHODS AND MATERIALS

From 1964 to 1991, 15 patients with in-field new second head and neck cancers and 85 patients with recurrent head and neck cancers have had high-dose reirradiation that overlapped with previously irradiated volumes. Reirradiation was given only to patients with no more than apparent minimal clinical radiation effects from the first radiation course. The reirradiation consisted of external beam only in 82 patients, external beam plus intracavitary or interstitial implant irradiation in 14 patients, and interstitial implant irradiation only in four patients. The combined overlapping dose from both the initial and subsequent irradiation (including brachytherapy) was 69-89 Gy in 14 patients, 90-99 Gy in 15 patients, 100-119 Gy in 27 patients, and 120 Gy or greater in 44 patients. Four patients had areas of overlap that received greater than 180 Gy.

RESULTS

The actuarial 5-year survival was 37% for patients with new second primary cancers and 17% for patients with recurrent cancers. Loco-regional tumor control was achieved in 60% of the patients with new tumors and in 27% of the patients with recurrent tumors. Nine of the 100 patients developed severe adverse normal tissue effects from the reirradiation.

CONCLUSION

High-dose reirradiation of head and neck cancers can be successful curative treatment in a significant proportion of patients. It is associated with substantial but acceptable risks in properly selected patients.

Photodynamic therapy of malignant and premalignant lesions in patients with 'field cancerization' of the oral cavity

The management of patients with 'field cancerization' of the oral mucosa, with multicentric foci of invasion, presents a considerable problem for the head and neck surgeon. Surgical resection of synchronous or metachronous primary squamous cell carcinomas, along with adjacent premalignant lesions, is likely to be associated with considerable mutilation. Photodynamic therapy (PDT) has been shown to be of value in the treatment of superficial tumours in the upper aerodigestive tract, with excellent healing of treated areas. This study reports the use of PDT to treat 11 patients with 'field cancerization' occurring in the oral cavity. Six patients had multiple primary cancers and five had single primary tumours. All had associated areas of leukoplakia. Each received Photofrin 2 mg/kg 48 hours prior to photoirradiation with 50-100 J/cm2 red laser light by surface illumination. Six to eight weeks later treated areas in 10 of the 11 patients showed a complete response to PDT; one patient had areas of residual leukoplakia. Two patients developed further areas of leukoplakia or erythroplakia within 12 months but no patient has had evidence of recurrent invasive carcinoma in the treated areas. Longer term follow-up will be necessary to exclude further recurrence. It is concluded that PDT offers an effective repeatable treatment option, whether on its own or as an adjunct to local excision, for patients with 'field cancerization' of the oral cavity.

Survival of first and second primary breast cancer

BACKGROUND

A second primary tumor (SPT) in the breast is the most common one seen in clinical practice. There are conflicting reports regarding the incidence and survival of patients with SPT in the breast.

METHODS

To elucidate this, data on 139,932 patients with primary breast cancer, reported to the Surveillance, Epidemiology, and End Results Program between 1973 and 1986, were analyzed. Of these, 3431 patients had a contralateral metachronous breast cancer (interval, > 6 months).

RESULTS

Survival from the date of diagnosis of the metachronous breast tumors was compared with that of patients with single breast tumors, controlling for age at diagnosis, stage, race, and treatment. In the multivariate analysis, age and stage at diagnosis of first and second tumors were the only variables that significantly influenced survival. The survival of patients with localized SPT was similar to that of patients with a localized single breast tumor. Patients with regionally advanced SPT lived for a shorter time than did corresponding patients with only one tumor.

CONCLUSIONS

Patients with single breast cancer were at increased risk of having a SPT in the breast. As a result, efforts for early detection by physical examination and mammography of survivors of single breast cancer are advocated because the survival of patients with a localized SPT in the breast is as good as that of those with a single localized tumor.

A comparison of the clinical characteristics of second primary and single primary sarcoma: a population based study

The clinical characteristics of 240 patients with sarcoma as a second metachronous primary neoplasm (SPN) were compared with those of 8,815 patients with sarcoma as a single tumor. The data were obtained from patients registered during the period 1973-1986 in the Surveillance, Epidemiology and End Results (SEER) Program in the United States. Seventy-four of the 240 SPN patients had postirradiation sarcoma (PIS) while the other 153 patients developed the sarcoma as a second tumor in an area which was not exposed to prior radiotherapy (non-PIS). The stage of disease at diagnosis was more advanced in patients with PIS than in those with single sarcomas but the difference did not reach statistical significance. Overall, in comparable clinical stage localized and regional disease there was no statistically significant difference in survival between PIS and non-PIS sarcoma patients after adjusting for age. The survival of patients with localized or regionally advanced sarcoma as a second tumor was significantly worse than of those with single sarcomas with the same stage. There was no difference in survival between first or second sarcomas with metastatic disease.