The importance of correct stage grouping in oncology. Results of a nationwide study of oropharyngeal carcinoma in The Netherlands

A different entity: a population based study of characteristics and recurrence patterns in oropharyngeal squamous cell carcinomas

Background

Cases of squamous cell carcinoma (SCC) of the oropharynx were compared with other head and neck cancer (HNC) anatomic subsites in patients treated at the provincial referral centre for HNC, the Nova Scotia Cancer Centre (NSCC).

Methods

A retrospective chart review was performed on HNC patients assessed at the NSCC between 2010 and 2011. Patient demographics, disease characteristics, treatment details and outcomes, including recurrence rates and survival were collected. Data was collected on new and recurrent cases of HNC. This data was compared between the two types of HNC using chi-square tests for dichotomous categorical variables or Fishers exact test where appropriate. Wald test was used to compare categorical variables with 3 categories. Continuous variables were compared using the non-parametric Wilcoxon test.

Results

318 charts were included in the analysis. 122 (38 %) were oropharyngeal squamous cell carcinomas (OPSCCs). In terms of disease characteristics, OPSCCs were more likely to be poorly differentiated/undifferentiated (n = 267, 49(40 %) vs 42(21 %), p < 0.001), non-keratinizing (n = 169, 25(20 %) vs 17(9 %), p < 0.001), greater than 2 cm (n = 253, 72(59 %) vs 78(40 %), p = 0.0061), stage 4 (n = 313, 55(45 %) vs 64(33 %), p = 0.0315) and have had locoregional nodal spread (n = 315, 103(84 %) vs 55(28 %), p < 0.001). In the subset of 57 patients that had p16 testing, OPSCCs were more likely to be p16(+) (37(30 %) vs 1(1 %), p < .001). There were no significant differences in terms of Charlson probability of 10 year survival, smoking or alcohol consumption although OPSCC patients were significantly less likely to have COPD as a co-morbidity (n = 318, 19(16 %) vs 53(27 %), p = 0.0175). Finally, OPSCCs had less chance for relapse than non-OPSCCs in both univariate (2.119 times less, p=0.0034) and multivariate (1.899 times less, p=0.0505) analyses along with a 1.822 times less overall mortality in a multivariae analysis (p=0.0408). 

Conclusions

This analysis suggests that Nova Scotian OPSCCs should be considered distinct from other HNC lesions, most notably in terms of disease characteristics and prognosis. Specifically, despite a higher association with disease factors traditionally considered to be linked to poor prognosis, outcomes were actually superior in terms of relapse and overall mortality.

Long-term results of surgical treatment for advanced oropharyngeal squamous cell carcinoma

BACKGROUND

The purpose of this study was to review the oncologic and functional outcomes of patients with clinical stage III or IV squamous cell carcinoma (SCC) of the oropharynx submitted to tumor resection and neck dissection with or without postoperative radiotherapy (PORT).

METHODS

We conducted a retrospective review of medical charts of 256 consecutive patients.

RESULTS

Fatal postoperative complications were registered in 5 patients (1.9%). During follow-up, there were 74 local recurrences (29%), 27 neck recurrences (10.5%), and 19 distant metastases (7.4%). The 5-year overall survival (OS) was 43.0%. The Cox multivariate model identified pT3 and pT4, pN2 and pN3, and an intense lymphocytic infiltrate as independent prognostic markers for OS. The 5-year disease-free survival (DFS) rate was 54.5%.

CONCLUSION

Surgical treatment for oropharyngeal carcinoma can be performed with a low-risk of postoperative mortality but with a risk of long-term use of tracheostomy and feeding tubes.

Stage grouping in tumors of the ethmoid sinuses and the nasal cavity using the sixth edition of the UICC classification of malignant tumors

BACKGROUND

The purpose of this study was to evaluate the prognostic impact of the sixth edition of the Union Internationale Contre le Cancer (UICC) classification and different TNM-based stage groupings for malignant tumors of the ethmoid sinuses and the nasal cavity.

METHODS

We conducted a retrospective analysis of 98 patients with malignant tumors of the ethmoid sinuses and the nasal cavity between 1967 and 2003. The UICC classification of the sixth edition and the T and N Integer Score (TANIS) and Hart were tested for their prognostic significance.

RESULTS

In univariate analysis, all stage groupings revealed discriminatory power for overall survival (OS; p < .05), however, in multivariate analysis only the UICC-stage grouping (p = .033) and the TANIS-8 scheme (p = .044) predicted OS. The TANIS did not have a better prognostic quality than the sixth edition of the UICC classification.

CONCLUSION

The UICC-stage grouping of the sixth edition is a good prognostic index for malignant tumors of the ethmoid sinuses and the nasal cavity.

Selective intraarterial chemoradiation therapy for oropharyngeal carcinoma with high-dose cisplatin

PURPOSE

Cisplatin has shown a high tumor response rate among head and neck carcinomas, and the tumor response is related to the cisplatin dosage. The purpose of this study was to evaluate the efficacy and toxicity of selective intraarterial chemoradiation therapy for oropharyngeal carcinomas with high-dose cisplatin.

MATERIALS AND METHODS

This retrospective study consisted of 21 patients with oropharyngeal carcinoma, stages II-IVB, in whom intraarterial chemoradiation therapy was performed between 2000 and 2008. All patients were given two courses of selective intraarterial infusions of cisplatin (300 mg/m(2)), systemic chemotherapy with 5-fluorouracil, and simultaneous radiation therapy (58-61 Gy/30 fractions), with a 1-week rest period.

RESULTS

The 2-year overall survival rate of the 15 patients who completed the therapeutic regimen was 71.3%. The 2-year locoregional control rate and disease-free survival rate were 95.0% and 67.7%, respectively.

CONCLUSION

Selective intraarterial high-dose cisplatin chemotherapy with concomitant radiation therapy shows results similar to those of original methods in terms of survival and locoregional control with a reduction in the number of procedure times.

Future of the TNM classification and staging system in head and neck cancer

Staging systems for cancer, including the most universally used TNM classification system, have been based almost exclusively on anatomic information. However, the question arises whether staging systems should be based on this information alone. Other parameters have been identified that should be considered for inclusion in classification systems like the TNM. This is all the more important, as a shift toward nonsurgical treatments for head and neck cancer has been made over the years. For these treatment modalities tumor/biologic characteristics next to anatomic information may be particularly important for treatment choice and outcome. The shortcomings of the current TNM classification system will be discussed, along with suggestions for improvement and expansion of the TNM system based on tumor, patient, and environment-related factors. Further improvement of the TNM classification is expected to result in better treatment choices, outcome and prognostication of patients with head and neck cancer.

Prognostic impact of different TNM-based stage groupings for oral squamous cell carcinoma

BACKGROUND

The purpose of this study was to evaluate the prognostic significance of different TNM-based stage groupings proposed in the literature.

METHODS

We conducted a retrospective analysis of 300 patients with primary oral squamous cell carcinoma (T1-4, N0-2, M0). The stage grouping systems of the sixth edition of the Union Internationale Contre le Cancer (UICC), T and N Integer Score (TANIS), the Snyderman scheme, the Hart scheme, and the Berg scheme were tested for their prognostic significance. Disease free survival (DFS) was plotted by Kaplan-Meier analysis. Prognostic factors were identified through univariate and multivariate analysis.

RESULTS

On univariate analysis, all systems revealed discriminatory power for DFS; however, on multivariate analysis, only the Hart scheme predicted DFS. The TANIS did not have a better prognostic ability than the UICC stage grouping.

CONCLUSION

Unlike in previous studies, the UICC stage grouping did perform worse than other TNM-based stage groupings, which may be due to the alterations made in the sixth edition.

RADPLAT: an alternative to surgery?

Head and neck cancer frequently presents at a late stage, leading to a poor prognosis despite optimal treatment with surgery and/or radiotherapy. Chemotherapy for advanced disease has shown little benefit as a single-modality treatment, and the use of concurrent chemoradiation is limited by problems with severe toxicity at higher doses. RADPLAT is the acronym used to describe a new technique, combining intra-arterial delivery of cisplatin with systemic neutralization by i.v. sodium thiosulphate, and concurrent radiotherapy. This allows very high cisplatin dose intensities to be used while potentially minimizing adverse systemic effects. Initial results suggest that excellent locoregional control rates are achievable in patients with unresectable disease, with a favorable side-effect profile when compared with conventional chemoradiation protocols. In addition, RADPLAT may potentially be of benefit in selected patients with resectable disease, allowing for preservation of organ function and quality of life without compromising locoregional control or survival. While current phase II data are encouraging, phase III randomized controlled trials are required in order to directly compare RADPLAT with i.v. chemoradiation therapy, the current standard of care. This article reviews the evolution of the RADPLAT concept, from initial clinical trials to its current application in the treatment of patients with advanced head and neck cancer.

Comparison of the Radiation Therapy Oncology Group recursive partitioning classification and Union Internationale Contre le Cancer TNM classification for patients with head and neck carcinoma

BACKGROUND

Prognostic models need to be tested in external validation studies to assess generalizability. Recursive partitioning analysis (RPA), a prognostic system based on the creation of a classification tree, has been proposed as a classification method in patients with head and neck carcinoma. The aim of this study was to compare the RPA and Union Internationale Contre le Cancer (UICC) TNM classification systems in patients with head and neck carcinoma treated consecutively in a single center.

METHODS

A total of 2166 patients with carcinomas of the oral cavity, oropharynx, hypopharynx, and larynx was classified according to both the RPA and the TNM classification systems, and the results were compared. The endpoints considered were observed survival and survival free of locoregional tumor. The two methods of classification were evaluated objectively by use of measures of intrastage homogeneity (hazard consistency), interstage heterogeneity (hazard discrimination), predictive power (outcome prediction), and patient distribution between stages (balance).

RESULTS

When the endpoint considered was observed survival, there were no clinically relevant differences between the two classifications. However, when the endpoint was locoregional control, the RPA system was sensitive to the type of treatment used, and it was not generalizable.

CONCLUSIONS

To evaluate generalizability, new classification proposals need external validation studies that objectively measure the quality of the model. The performance of the RPA system was not reproducible in our cohort of patients when the endpoint evaluated was locoregional control.

Selective High-Dose Intra-Arterial Cisplatin as Palliative Treatment for Incurable Head and Neck Cancer

OBJECTIVE

The purpose of the present study was to evaluate the palliative effect of selective intra-arterial chemotherapy in progressive unresectable head and neck cancer previously treated with radiochemotherapy.

PATIENTS AND METHODS

8 patients with advanced residual or recurrent squamous cell carcinoma of the head and neck were evaluated. These patients were included in the present study particularly because of progredient pain and recurrent bleedings due to tumor progression. In addition 6/8 patients suffered from unpleasant tumor-related smell. All patients received simultaneous infusions of cisplatin (150 mg/m2) intra-arterially to the tumor and sodium thiosulfate intravenously (9 g/m2) for systemic neutralization of cisplatin. The patients were treated by at most 4 cycles of selective intra-arterial chemotherapy via femoral approach.

RESULTS

Tumor-associated pain, occurrence of tumor bleeding and tumor-related smell were reduced after at least 2 cycles of intra-arterial chemotherapy in all patients. Clinical and radiological assessment of the primary tumor site revealed a partial response in 4 patients while 4 patients were classified as nonresponders. Intra-arterial cisplatin treatment was well tolerated.

CONCLUSION

Selective intra-arterial cisplatin therapy can be delivered safely for palliation of tumor-related symptoms of incurable head and neck cancer.

Different prognostic indices in 310 patients with tonsillar carcinomas

BACKGROUND

Several modifications of the TNM system have been reported as better prognostic tools than the original classification in head and neck cancer, but none of these modifications has been tested in a large series of tonsillar carcinomas. These studies did not examine host and treatment factors as predictors in addition to TNM.

METHODS

Three hundred and ten consecutively untreated patients with squamous cell carcinoma of the tonsillar region admitted to the Norwegian Radium Hospital and/or the National Hospital between 1960 and 1996 were included.

RESULTS

The five reported TN-based stage modifications were all highly significant predictors of survival. Four clinical variables indicating shorter disease-specific survival were identified: age > 60, male gender, total radiation dose < 70 Gy, and duration of radiotherapy > 50 days.

CONCLUSIONS

Earlier reported TNM-based stage modifications are all very useful predictors of survival in tonsillar carcinomas. In addition, age, gender, total radiation dose, and duration of radiotherapy were important prognostic factors. We propose that both host and treatment factors should be tested carefully when building new prognostic indices in tonsillar carcinomas.

A comparison of published head and neck stage groupings in laryngeal cancer using data from two countries

The combination of T, N, and M classifications into stage groupings is meant to facilitate a number of activities including: the estimation of prognosis and the comparison of therapeutic interventions among similar groups of cases. We tested the UICC/AJCC fifth edition stage grouping and six other TNM-based groupings proposed for head and neck cancer for their ability to meet these expectations in laryngeal cancer using data from Ontario, Canada, and the area of Southern Norway surrounding Oslo. We defined four criteria to assess each grouping scheme: (1) the subgroups defined by T, N, and M comprising a given group within a grouping scheme have similar survival rates (hazard consistency); (2) the survival rates differ among the groups (hazard discrimination); (3) the prediction of cure is high (outcome prediction); and (4) the distribution of patients among the groups is balanced. We previously identified or derived a measure for each criterion, and the findings were summarized using a scoring system. The range of scores was from 0 (best) to 7 (worst). The data sets were population-based, with 861 cases from Ontario and 642 cases from Southern Norway. Clinical stage assignment was used and the outcome of interest was cause-specific survival. Summary scores across the seven schemes had similar ranges: 0.9 to 5.1 in Ontario and 1.8 to 5.7 in Southern Norway, but the ranking varied. Summing the scores across the two datasets, the TANIS-7 scheme (Head & Neck 1993;15:497-503) ranked first, and was ranked high in both datasets (first and second, respectively). The UICC/AJCC scheme ranked sixth out of seven schemes, and its ranking was fifth and seventh, respectively. UICC/AJCC stage groupings were defined without empirical investigation. When tested, this scheme did not perform best. Our results suggest that the usefulness of the TNM system could be enhanced by optimizing the design of stage groupings through empirical investigation.

A comparison of published head and neck stage groupings in carcinomas of the tonsillar region

BACKGROUND

The combination of T, N, and M classifications into stage groupings was designed to facilitate a number of activities including: the estimation of prognosis and the comparison of therapeutic interventions among similar groups of cases. The authors tested the UICC/AJCC 5th edition stage grouping and seven other TNM-based groupings proposed for head and neck cancer to determine their ability to meet these expectations in a specific site: carcinoma of the tonsillar region.

METHODS

The authors defined four criteria to assess each stage grouping scheme: 1) The subgroups defined by T and N comprising a given group within a grouping scheme have similar survival rates (hazard consistency); 2) The survival rates differ across the groups (hazard discrimination); 3) The prediction of cure is high (outcome prediction); and 4) The distribution of patients among the groups is balanced. The authors identified or derived a measure for each criterion and the findings were summarized using a scoring system. The range of scores was from 0 (best) to 7 (worst). Data were from a retrospective chart review on 642 cases of carcinoma of the tonsillar region treated with radiotherapy for cure at the Princess Margaret Hospital from 1970-1991. None of the patients had distant metastases.

RESULTS

The scheme proposed by Synderman and Wagner, which was published in Otolaryngology Head and Neck Surgery in 1995 (vol.112, pages 691-4), scored best at 1.2. The UICC/AJCC scheme scored worst at 6.1. The hazard consistency ranged from a 3.1% average survival difference to 6.7% across the 8 schemes. The hazard discrimination measure varied by 28% from the best to worst scheme. Prediction varied by up to almost twofold across the schemes assessed. The distribution of patients varied from expected by between 0.13% and 0.57%.

CONCLUSION

UICC/AJCC stage groupings were defined without empirical investigation. When tested, this scheme did not perform as well as any of seven empirically-derived schemes the authors evaluated. The results of the current study suggest that the usefulness of the TNM system can be enhanced by optimizing the design of stage groupings through empirical investigation.

A comparison of published head and neck stage groupings in carcinomas of the oral cavity

BACKGROUND

The combination of T, N, and M classifications into stage groupings is meant to facilitate a number of activities, including the estimation of prognosis and the comparison of therapeutic interventions among similar groups of cases. We tested the UICC/AJCC 5th edition stage grouping and seven other TNM-based groupings proposed for head and neck cancer for their ability to meet these expectations in a specific site: carcinomas of the oral cavity.

METHODS

We defined four criteria to assess each grouping scheme: (1) the subgroups defined by T, N, and M that make up a given group within a grouping scheme have similar survival rates (hazard consistency); (2) the survival rates differ among the groups (hazard discrimination); (3) the prediction of cure is high (outcome prediction); and (4) the distribution of patients among the groups is balanced. We identified or derived a measure for each criterion, and the findings were summarized by use of a scoring system. The range of scores was from 0 (best) to 7 (worst). The data are population based from a prospectively gathered series in Southern Norway, with 556 patients diagnosed from 1983 through 1995. Clinical stage assignment was used, and the outcome of interest was cause-specific survival.

RESULTS

Summary scores across the eight schemes ranged from 1.66 for TANIS-3 to 6.50 for UICC/AJCC-5. The TANIS-7 staging scheme performed best on the hazard consistency criterion. The Kiricuta scheme performed best on the hazard discrimination criterion. Synderman predicted outcome best overall and Berg produced the most balanced distribution of cases among its groups.

CONCLUSIONS

UICC/AJCC stage groupings were defined without empirical investigation. When tested, this scheme did not perform as well as any of seven empirically derived schemes we evaluated. Our results suggest that the usefulness of the TNM system could be enhanced by optimizing the design of stage groupings through empirical investigation.

Comparison between TANIS and UICC 1997 stage grouping in parotid gland carcinoma

To compare the correlation of T and N Integer Score (TANIS) and International Union Against Cancer (UICC) '97 stage grouping with survival rate in parotid gland carcinoma, a series of 134 patients affected by primary carcinoma of the parotid gland was considered in this retrospective study. Data set was classified according to 1997 UICC T-category and then grouped as recommended by the two systems. Data were analyzed by means of survival analyses (Kaplan-Meier and Cox algorithms). Results showed a crude survival rate of 64.9%. Univariate analysis by means of log-rank test yielded significant P values both for TANIS and UICC '97 systems (both P < 0.0001). Multivariate analysis (Cox regression adjusted for age and gender) showed a significant correlation between the two staging systems with the mortality rate. Odds ratios were 2.64 (95% CI 1.84-3.80) and 1.79 (95% CI 1.46-2.20) for UICC '97 and TANIS, respectively. In testing the superiority, UICC '97 resulted in a higher prognostic value and TANIS did not add any statistical contribution in determining survival. In conclusion, the new UICC stage grouping better defines the prognosis for cancer of the parotid gland.

Radiotherapy in head and neck cancer in the elderly: a challenge

Elderly patients represent the most rapidly growing subgroup of the patient population in France and in the majority of industrialized countries. The effect of age in terms of the prognosis and response to treatment remains unclear. The management strategy (curative versus palliative) for head and neck cancer in the elderly has given vent to divergent opinions and controversies in several respects (the type and quality of treatment, quality of life and economic consequences). This review only focuses on the radiotherapy schedule and head and neck cancers. We compare aged patients with head and neck cancer to younger patients in terms of clinical features, tumor biology, type of treatment, side effects and response. We conclude that if the patient is in a good general condition following a complete evaluation of the cancer, physicians should propose curative treatment with radiotherapy because retrospective trials demonstrate that response in older patients when treated aggressively is comparable to that of younger patients. However, specific trials concerning aged patients with head and neck cancer, quality of life and radiotherapy are warranted.

Stage grouping reliability: TNM '97 versus TANIS in laryngeal cancer

PURPOSE

To compare the correlation of TANIS and TNM '97 with the survival rate in laryngeal cancer.

METHODS AND MATERIAL

From 1970 to 1990, 599 patients at the ENT Clinic, University of Ferrara, had a complete follow-up and met the criteria of enrollment. Data were analyzed by means of survival analyses (Kaplan-Meler and Cox algorithms).

RESULTS

Both systems showed a significant correlation with the survival rate. TANIS advanced subcategories were better correlated with the mortality rate than TNM stages IVa and IVb. Again, in the final statistical model, TANIS was more highly correlated with survival rate than TNM.

Using TNM staging to predict survival in patients with squamous cell carcinoma of head & neck

BACKGROUND

There is a need for a classification system for prognosis based on the TNM system for patients with squamous cell carcinoma of the head and neck such that patient groupings are homogeneous within and heterogeneous between.

METHODS

Six hundred fifty-five consecutive patients with invasive squamous cell carcinoma of the head and neck followed prospectively are split into a training set and a test set. Using the training set, the Cox Proportional Hazards Model and the outcome of dead with disease, we created homogeneous prognostic levels (PLs) based on RR. Using the test set, we compare our model to others in the literature.

RESULTS

Using the training set, we identified five PLs, and using the test set, we demonstrated that our model is superior to others for both within-group homogeneity and between-group heterogeneity.

CONCLUSIONS

A simple classification system can be used to group patients for survival and is valid for future study in prognostication.

Extension as a prognostic factor in oropharyngeal cancer: largest mucosal dimension compared with number of (sub)sites involved

We report a retrospective study of 64 patients with primary squamous cell carcinoma of the oropharynx. The tumours were classified by the UICC (Union Internationale Contre le Cancer) system and a New Tumour Staging (NTS) system. Results showed a crude survival of 29% at 5 years. The most important prognostic factor for survival rate was the tumour (T) stage in both classifications. NTS recommendations that consider the number of sites and subsites involved yield a better correlation between survival and T stage. NTS also discriminates better between the T stages than the UICC criteria.

A comparison between TNM and TANIS stage grouping for predicting prognosis of oral and oropharyngeal cancer

PURPOSE

The 1987 TNM classification system modified some T and N definition but it did not change stage grouping. Consequently it has not improved the prognostic validity of the advanced stage groups. In 1993, a new stage grouping was purposed, TANIS, that seems to have a higher correlation with survival. In this report, the TNM classification and TANIS system were compared to evaluate this prognostic ability.

PATIENTS AND METHODS

Data from 164 patients affected by primary cancers of oropharynx or oral cavity were analyzed by means of Kaplan-Meier and Cox regression analysis.

RESULTS

The crude survival rate at 5 years was 43.9%. Both systems showed a significant correlation with the survival rate by means of Cox regression analysis. TANIS subcategories were correlated to the mortality rate in the stage IV patients. TANIS resulted a better predictor of mortality when compared with TNM.

CONCLUSION

The TANIS system was able to separate the TNM stage IV patients into prognostic groups, yielding more information with respect to TNM for such a category of patients. When a comparison between TNM and TANIS was performed, it was observed that TANIS had a higher correlation with survival rate, whereas TNM did not add any information in defining the survival function.

Disease-specific survival and locoregional control in tonsillar carcinoma

In a nationwide survey on oropharyngeal carcinoma in the Netherlands (1986-1990), 380 patients with a tonsillar carcinoma were retrospectively studied. The records of 268 (71%) men and 112 (29%) women with a median age of 59 yr (range 31-91), who had squamous cell carcinoma (272 patients, 98%) or undifferentiated carcinoma (8 patients, 2%) were reviewed with respect to treatment, disease-specific survival and locoregional control. Distribution by stage according to the UICC'92 system was: 27 patients (7%) stage I, 59 (15%) stage II, 99 (26%) stage III, 182 (48%) stage IV and 13 patients (3%) unknown stage. Using a previously reported revised staging system the following distribution was obtained: 118 patients (31%) stage I, 120 (31%) stage II, 67 (18%) stage III, 54 (14%) stage IV and 21 patients (6%) with an unknown stage. Treatment consisted of radiotherapy alone in 231 patients (61%), surgery and radiotherapy in 101 (27%), surgery alone in 30 (8%), chemotherapy in 5 (2%) and 13 patients (3%) did not receive any treatment. At 5-yr the overall survival was 32%, the disease-specific survival 42% and the locoregional control 61%. In patients treated with radiotherapy alone the disease-specific survival was 39%, for surgery and radiotherapy 53% and for surgery alone 83%. The disease-specific survival according to UICC'92 stage was 71% in stage I, 59% in II, 50% in III and 32% in stage IV (P < 0.0001). In the revised staging the survival figures were 63% in stage I, 43% in II, 31% in III and 9% in IV (P < 0.0001). The two staging systems appeared to be comparable in prognostic discrimination; the clinical relevance of the revised stage might, however, be slightly superior to the UICC'92 version. The difference in results after radiotherapy alone and surgery + radiotherapy remained significant, also after adjusting for stage (P < 0.0001).