Organ preservation with radiotherapy for T1-T2 carcinoma of the pyriform sinus

Therapeutic Modalities in Head-Neck Neoplasia and Prognostication: A Review

Neoplasia of the head and the neck necessitates intervention, surgical or otherwise, as the site and stage of the pathology may dictate. The various therapeutic modalities employed and prognosis has been reviewed.

Efficacy of endoscopic ultrasonography in evaluating tumor thickness in patients with superficial pharyngeal carcinoma: A pilot study

OBJECTIVES

A histopathological tumor thickness of ≥1000 μm has been reported as one of many risk factors for recurrent lymph node metastasis in superficial pharyngeal cancer (SPC). However, methods for assessing this risk factor preoperatively have not yet been established. Hence, the current study aimed to evaluate the efficacy of endoscopic ultrasonography (EUS) in measuring tumor thickness preoperatively in patients with SPC.

METHODS

This single-center retrospective study included 44 consecutive patients with 47 lesions who underwent endoscopic submucosal dissection (ESD). Prior to surgery, EUS examination was performed while under general anesthesia. Further, microvascular irregularity in the target lesion was evaluated using the Japan Esophageal Society (JES) magnification endoscopic classification system.

RESULTS

A significant correlation was noted between histopathological and EUS tumor thickness (Spearman's correlation r == 0.879, p < 0.001). In tumors ≥1000 µm thick on histopathology, the cutoff value for EUS tumor thickness was 2.6 mm, and the following values were obtained: sensitivity, 100%; specificity, 81.8%; positive predictive value (PPV), 70%; negative predictive value (NPV), 100%; and accuracy, 87.2%. In B2 lesions ≥1000-μm thick, the following values were obtained: sensitivity, 85.7%; specificity, 90.9%; PPV, 80%; NPV, 93.8%; and accuracy, 89.4%. The diagnostic accuracy rate of combined EUS and the JES magnifying endoscopic classification system was 95.7%.

CONCLUSIONS

Tumor thickness assessed using EUS was effective in diagnosing histopathological tumor thickness of ≥1000 μm. The combined use of EUS and the JES magnifying endoscopic classification system may be useful for assessing preoperative risk factors for lymph node metastasis in SPC.

Early hypopharyngeal cancer treated with different therapeutic approaches: a single-institution cohort analysis

Purpose

Early hypopharyngeal squamous cell carcinoma (HPSCC) is a rarely diagnosed disease, for which the optimal treatment has not been defined yet. We assessed patterns of failure and outcomes in early HPSCC treated with various therapeutic approaches to identify its optimal treatment.

Materials and Methods

Thirty-six patients with stage I (n = 10) and II (n = 26) treated between January 1992 and March 2014 were reviewed. Patients received definitive radiotherapy (RT) (R group, n = 10), surgery only (S group, n = 19), or postoperative RT (PORT group, n = 7). All patients in both the R and PORT groups received elective bilateral neck irradiation. In the S group, 7 patients had ipsilateral and 8 had bilateral dissection, while 4 patients had no elective dissection.

Results

At a median follow-up of 48 months, the 5-year locoregional control (LRC) rate was 65%. Six patients had local failure, 1 regional failure (RF), 3 combined locoregional failures, and 2 distant failures. There was no difference in 5-year LRC among the R, S, and PORT groups (p = 0.17). The presence with a pyriform sinus apex extension was a prognosticator related to LRC (p = 0.01) in the multivariate analysis. Patients with a bilaterally treated neck showed a trend toward a lower RF rate (p = 0.08).

Conclusion

This study shows that patients with early stage HPSCC involving the pyriform sinus apex might need a tailored approach to improve LRC. Additionally, our study confirms elective neck treatment might have an efficacious role in regional control.

Supracricoid Hemilaryngopharyngectomy in Patients with Invasive Squamous Cell Carcinoma of the Pyriform Sinus

On the basis of a retrospective review of an inception cohort of 135 patients, with an isolated, previously untreated, moderately differentiated to well-differentiated invasive squamous cell carcinoma of the pyriform sinus and a minimum of 3 years of follow-up, consecutively managed with a supracricoid hemilaryngopharyngectomy (SCHLP) at a single tertiary referral care center and locally controlled, the authors review in detail the surgical technique, highlight the potential technical pitfalls, and document the complications and long-term functional outcome. The overall postoperative mortality rate was 3.7%. The overall mortality rate directly related to the SCHLP was 1.5%. A significant surgical complication directly related to SCHLP completion was noted in 9.6% of cases. The mean lengths of time to removal of the tracheotomy and feeding tubes were 9 and 19 days, respectively. The mean duration of hospitalization was 25 days. Normal swallowing without aspiration by the first postoperative month was noted in 64.6% of patients. Temporary grade 1–2 aspiration and grade 3 aspiration were noted in 26.9% and 8.5% of patients, respectively. Overall, in our series, successful oral alimentation without gastrostomy or completion total laryngectomy was achieved in 91.9% of patients by the first postoperative year, and the incidences of permanent gastrostomy, completion total laryngectomy, and aspiration-related death were 0.7%, 1.5%, and 0.7%, respectively. A significant late complication related to the use of postoperative radiotherapy was noted in 26.5% of cases. From a functional point of view, such results suggest that SCHLP should be integrated among the various conservation treatment options available to patients with selected invasive squamous cell carcinoma of the pyriform sinus.

Supracricoid Hemilaryngopharyngectomy in Patients with Invasive Squamous Cell Carcinoma of the Pyriform Sinus

Supracricoid hemilaryngopharyngectomy (SCHLP) was performed in 147 patients over a 19-year period for previously untreated invasive squamous cell carcinoma of the pyriform sinus. With a minimum of 3 years' follow-up, the current retrospective series was designed to document the incidence, risk factors, and consequences of local recurrence following SCHLP. Before operation, 97.4% of patients had an induction chemotherapy regimen. A complete clinical response and a complete histologic regression were noted in 21.7% and 16.8% of patients, respectively. A significant statistical relationship (p = .0001) was noted between complete clinical response and complete histologic regression. Postoperative radiotherapy was used in 49.8% of patients. The overall local recurrence rate was 8.2%. The 5-year actuarial (Kaplan-Meier life-table method) local control estimate was 90.4%. As a function of T stage, the 5-year actuarial local control estimates were 96.2%, 91.1%, 92.9%, and 62.6% in patients with tumors classified as T1, T2, T3, and T4a, respectively. On univariate analysis, the overall local recurrence rate varied significantly, from 5.3% to 55.6% if the apex of the pyriform sinus was invaded (p = .02), 6.9% to 18.7% if the posterior pharyngeal wall was invaded (p = .03), and 6.3% to 60% if the margins of resection were positive (p = .02). In a stepwise regression model, positive margins of resection (odds ratio, 8.4; 95% confidence interval, 2.2 to 32.2; p = .002) and invasion of the apex of the pyriform sinus (odds ratio, 6.1; 95% confidence interval, 1.1 to 33.3; p = .04) were the variables statistically associated with an increased risk of local recurrence. Local recurrence resulted in a statistically significant increased risk of nodal recurrence (p = .005) and death (p < .004). The overall laryngeal preservation rate was 91.2%. From an oncological perspective, these results suggest that SCHLP should become a major tool in the armamentarium of the head and neck surgeon and should be integrated into future trials aimed at organ preservation in patients with invasive squamous cell carcinoma of the pyriform sinus.

Feasibility of salvage endoscopic resection for patients with locoregional failure after definitive radiotherapy for pharyngeal cancer

BACKGROUND AND STUDY AIMS

Local failure after radiation therapy for pharyngeal squamous cell carcinoma (PSCC) is problematic. The safety of endoscopic resection for lesions within the radiation therapy (RT) field has not been assessed. We evaluated salvage endoscopic resection in patients with locoregional failure after definitive radiotherapy for PSCC.

PATIENTS AND METHODS

We retrospectively evaluated the clinical outcomes and long-term survival of 16 patients initially treated with more than 60 Gy of radiation for PSCC. These patients later presented with 19 superficial metachronous or recurrent PSCC lesions within the radiation field and were treated with salvage endoscopic resection.

RESULTS

Local recurrence developed at the primary site in 3 patients after a complete response to RT. The other 13 had multiple metachronous squamous cell carcinomas within the original RT field. Major complications associated with salvage endoscopic resection included aspiration pneumonia in 1 patient and a requirement for temporary tracheostomy in 3 patients. During a median follow-up period of 37 months (range, 2 - 72 months), 13 patients had no recurrence, 2 patients developed local recurrence, and 1 patient developed lymph node metastases. At present, 5 of the 16 patients have died: 2 of PSCC progression, 1 of esophageal squamous cell carcinoma, and the remaining 2 of unknown causes. The 3-year survival rate was 68.6 %.

CONCLUSIONS

Endoscopic resection is a potentially curative salvage treatment option for patients with superficial locoregional failure after definitive radiotherapy for PSCC.

Function and organ preservation in adult cancers of the head and neck

Treatment for primary head and neck cancer has evolved from the use of radical approaches to therapies preserving important functions. Essential to this concept is the maintenance of therapeutic efficacy. The advances of organ-sparing surgery, improved radiation techniques and fractionation, and the addition of chemotherapy and targeted systemic agents, have added to the number of patients who undergo organ-preservation therapy. Crucial functions that can be spared include speech, swallowing, vision, salivation and cosmesis. This paper examines advances in therapy that allow the preservation of these important functions, scenarios where organ and function preservation is indicated, given current technology and agents, and where there might be future improvements.

Partial laryngopharyngectomy in the treatment of squamous cell carcinoma of hypopharynx: analysis of the oncologic results and laryngeal preservation rate

CONCLUSION

Partial laryngopharyngectomy (PLP) provides acceptable oncologic results and laryngeal preservation rate in selected patients with squamous cell carcinoma of the hypopharynx. Even when local recurrence develops, the chance of successful salvage is still high.

OBJECTIVES

To evaluate the oncologic results and laryngeal preservation rate in patients with squamous cell carcinoma of the hypopharynx who underwent PLP.

METHODS

The results of 39 patients who underwent PLP were compared with those of 91 patients who underwent total laryngectomy (TL).

RESULTS

The distribution of the primary T stages were 23 (59%) pT2, 9 (23%) pT3, and 7 (18%) pT4; the pathologic stages were 8 patients (21%) stage II, 9 (23%) stage III, and 22 (56%) stage IV. All of the patients also had ipsilateral or bilateral neck dissections. Eighteen patients (46%) received postoperative adjuvant therapy. After a median follow-up of 39 months, 17 patients (44%) had recurrence, including 12 local, 2 regional, and 3 distant lesions. The 5-year overall and disease-specific survival were 44% and 56%, respectively; functional preservation was 62%. The recurrence rate was similar in patients treated with PLP and TL (44% vs 36%, p = 0.431); the local recurrence rate was higher after PLP than after TL (31% vs 8%, p = 0.001). The salvage surgery was successful in four of the six patients (67%). After salvage treatment, the 5-year overall survival (44% vs 47%) and disease-specific survival (56% vs 62%) were similar in the two groups.

Radiotherapy for stage I or II hypopharyngeal carcinoma

Hypopharyngeal squamous cell carcinoma (HPSCC) is usually diagnosed at an advanced stage, and early-stage HPSCC is relatively rare. Because of the rarity of early-stage HPSCC, few reports have been published on the efficacy of radiotherapy (RT) in its treatment. We retrospectively reviewed the clinical records of 45 consecutive patients with Stage I and II HPSCC from May 1991 to June 2010. Patient characteristics were as follows: median age, 66 years (range, 44-90 years); male/female, 39/6; and T1/T2, 27/18. The irradiation dose ranged from 60 to 72 Gy (median: 70 Gy). Of the 45 patients, 21 underwent concurrent chemotherapy. With a median follow-up period of 62 months, the 5-year overall survival rate was 81%. Local failure occurred in 5 patients, and the 5-year local control rate was 83%. All local recurrences were successfully salvaged by surgery. The 5-year functional larynx preservation rate was 92%. Acute toxicity was manageable. Grade 3 laryngeal edema and Grade 3 hypothyroidism occurred in 1 patient each. No other late adverse events of Grade 3 or greater were observed. Based on these results, RT seemed to be an effective treatment modality for early HPSCC, with favorable organ preservation and acceptable adverse events. Early detection and accurate management of local recurrence and second malignancy was deemed to be critical.

Functional organ preservation in laryngeal and hypopharyngeal cancer

The principles of open versus laser microsurgical approaches for partial resections of the larynx are described, oncologic as well as functional results discussed and corresponding outcomes following primary radiotherapy are opposed. Over the last decade, the endoscopic partial resection of the larynx has developed to an accepted approach in the treatment of early glottic and supraglottic carcinomas thus leading to a remarkable decline in the use of open surgery. Comparing the various surgical approaches of laryngeal partial resections, the oncological outcome of the patients, as far as survival and organ preservation are concerned, are comparable, whereas functional results of the endoscopic procedures are superior with less morbidity. The surgical procedures put together, are all superior to radiotherapy concerning organ preservation. Transoral laser microsurgery has been used successfully for vocal cord carcinomas with impaired mobility or fixation of the vocal cord, supraglottic carcinomas with infiltration of the pre- and/or paraglottic space as well as for selected hypopharyngeal carcinomas. It has been well documented that laser microsurgery achieves good oncological as well as functional results with reasonable morbidity. However, patients with those tumours have been successfully treated by open partial resections of the larynx at medical centres with appropriate expertise. The initially enthusiastic assessment of study results concerning the efficacy of various protocols of chemoradiation with the intent of organ preservation for laryngeal and hypopharyngeal carcinomas are judged more cautious, today, due to recent reports of rather high rates of late toxicity complications.

Posterior pharyngeal wall carcinoma presenting as sudden onset bilateral upper limb radiculopathy

This report describes the case of an elderly gentleman who presented with sudden onset bilateral upper limb radiculopathy and neck stiffness. On neck radiography, erosion of the fourth cervical vertebral body was seen. Further evaluation revealed the cause to be a moderately differentiated squamous cell carcinoma of the posterior pharyngeal wall. In spite of prompt initiation of radiation therapy with concurrent steroids, the patient died of progressive disease within 3 weeks of initial presentation.

Concurrent chemoradiotherapy improves survival in patients with hypopharyngeal cancer

PURPOSE

To retrospectively review our institutional experience with hypopharyngeal carcinoma with respect to treatment modality.

METHODS AND MATERIALS

A total of 70 patients with hypopharyngeal cancer treated between 1999 and 2009 were analyzed for functional and survival outcomes. The treatments included surgery alone (n = 5), surgery followed by radiotherapy (RT) (n = 3), surgery followed by chemoradiotherapy (CRT) (n = 13), RT alone (n = 2), CRT alone (n = 22), induction chemotherapy followed by RT (n = 3), and induction chemotherapy followed by CRT (n = 22).

RESULTS

The median follow-up was 18 months. The median overall survival and disease-free survival for all patients was 28.3 and 17.6 months, respectively. The 1- and 2-year local control rate for all patients was 87.1% and 80%. CRT, given either as primary therapy or in the adjuvant setting, improved overall survival and disease-free survival compared with patients not receiving CRT. The median overall survival and disease-free survival for patients treated with CRT was 36.7 and 17.6 months vs. 14.0 and 8.0 months, respectively (p < .01). Of the patients initially treated with an organ-preserving approach, 4 (8.2%) required salvage laryngectomy for local recurrence or persistent disease; 8 (16.3%) and 12 (24.5%) patients were dependent on a percutaneous gastrostomy and tracheostomy tube, respectively. The 2-year laryngoesophageal dysfunction-free survival rate for patients treated with an organ-preserving approach was estimated at 31.7%.

CONCLUSIONS

Concurrent CRT improves survival in patients with hypopharyngeal cancer. CRT given with conventional radiation techniques yields poor functional outcomes, and future efforts should be directed at determining the feasibility of pharyngeal-sparing intensity-modulated radiotherapy in patients with hypopharyngeal tumors.

Definitive radiotherapy for T1-2 hypopharyngeal cancer: a single-institution experience

PURPOSE

To analyze the outcome in T1-2 hypopharyngeal cancer (HPC) patients treated with definitive radiotherapy (RT).

PATIENTS AND METHODS

A total of 103 patients with T1-2 hypopharyngeal squamous cell carcinoma treated with radical RT between March 2000 and June 2008 at our institution were analyzed. Pre-RT neck dissection (ND) was performed in 26 patients with advanced neck disease. Chemotherapy was used concurrently with RT in 14 patients. Sixty patients were associated with synchronous or metachronous malignancies. The median follow-up for surviving patients was 41 months.

RESULTS

The 3-year overall and cause-specific survival rates were 70% and 79%, respectively. The 3-year local control rates were 87% for T1 and 83% for T2 disease. The ultimate local control rate was 89%, including 7 patients in whom salvage was successful. The ultimate local control rate with laryngeal preservation was 82%. Tumors of the medial wall of the pyriform sinus tended to have lower control rates compared with tumors of the lateral or posterior pharyngeal wall. Among patients with N2b-3 disease, the 3-year regional control rates were 74% for patients with pre-RT ND and 40% for patients without ND. The 3-year locoregional control rates were as follows: Stage I, 100%; Stage II, 84%; Stage III, 67%; Stage IVA, 43%; Stage IVB, 67%. Forty-two patients developed disease recurrence, with 29 (70%) patients developing recurrence within the first year. Of the 103 patients, 6 developed late complications higher than or equal to Grade 3.

CONCLUSIONS

Definitive RT accomplished a satisfactory local control rate and contributed to organ preservation.

Larynx-Preserving Partial Pharyngectomy via Lateral Pharyngotomy for the Treatment of Small (T(1~2)) Hypopharyngeal Squamous Cell Carcinoma

Objectives

To evaluate the oncologic and functional results of larynx-preserving partial pharyngectomy (LPP) via lateral pharyngotomy approach as a primary treatment for small (T1 or T2) hypopharyngeal squamous cell carcinoma (HPSCC).

Methods

We performed a retrospective review of 23 patients who underwent LPP through lateral pharyngotomy approach for small HPSCC at the our department between January 1991 and June 2007. Fourteen (61%) patients had adjuvant postoperative radiotherapy.

Results

The 2-years and 5-years disease specific survival rate was 77% and 61%, respectively. Nine patients (39%) had tumor recurrence. The most common pattern of recurrence was isolated distant failure (n=4, 44%) followed by local (n=2, 22%) and loco-regional (n=3, 34%) recurrence. The ultimate cure rate of the primary tumor was 87% (20 of 23). Twenty-two of the 23 patients (95%) could be decannulated, tolerate an oral diet, and had acceptable postoperative phonatory function.

Conclusion

LPP via lateral pharyngotomy approach appears to be a feasible procedure for selected small HPSCC patients in terms of both oncologic and functional outcomes.

[T1-T2 NO hypopharyngeal cancers treated with surgery alone. A GETTEC study (French Neck Study Group)]

OBJECTIVE

Consider whether surgery alone in the treatment of early cancers of the hypopharynx can give identical or better results in terms of survival and local control than radiotherapy.

METHODS

Forty-five patients were operated on during the years 1991-2004. Surgical treatment consisted in a resection by the transoral approach in four patients and 41 patients had a partial pharyngolaryngectomy. An elective neck dissection was performed on 43 patients.

RESULTS

The 1-, 3-, and 5-year overall survival rates were 100, 95, and 75%. The 1-, 3-, and 5-year locoregional control rates were 93, 88, and 82% and were influenced by the presence of dysplasia on surgical margins (p=0.027). The oncological occurrences observed were five local recurrences, two nodal recurrences, ten second primary cancers, and two metastases. Five locoregional failures out of seven were controlled after a second treatment.

CONCLUSION

Surgery alone gives completely satisfactory results in terms of survival and locoregional control. In case of recurrence, this makes it possible to operate on patients in nonirradiated areas with lower morbidity and mortality and better results. These results must be confirmed by a randomized trial.

[Pathological changes of the hypopharynx in the focus of imaging]

The spectrum of pathological changes in anatomical sections of the hypopharynx ranges from benign pathologies to hypopharyngeal carcinoma. Beside the clinical status and the endoscopic evaluation performed by ear, nose and throat specialists, imaging techniques play an important role in pre-therapeutic and post-therapeutic diagnostics and in the follow-up of pharyngeal disease patterns, especially for malignant lesions. A conventional x-ray swallow examination, contrast-enhanced multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI), as well as positron emission tomography (PET) and positron emission tomography computed tomography (PET-CT) are applied depending on the medical question and disease. Especially in radiological oncology, it is extremely important in regions which are clinically difficult to assess to determine the exact localization and extent of hypopharyngeal pathologies to plan the optimal therapy for the patient. This article demonstrates the radiological appearance of pathological changes of the hypopharynx and discusses in particular the hypopharynx carcinoma in the focus of pre-therapeutic and post-therapeutic imaging.

Head and neck cancer: changing epidemiology, diagnosis, and treatment

Head and neck cancers account for less than 5% of all cancers and for less than 3% of all cancer deaths in the United States. The populations at risk for head and neck cancers are those who have a long-standing history of smoking and alcohol use. More recently, the incidence of oropharyngeal cancer in younger populations has been increasing and is associated with exposure to the human papillomavirus. This subset of patients appears to have a better overall prognosis and to respond better to treatment. This review is limited to head and neck cancers of squamous cell histology, which constitute more than 90% of head and neck cancers. Because treatment of head and neck cancers is complex and involves multiple modalities, a multidisciplinary approach is needed. This review focuses on the goal of organ preservation and postoperative treatment of high-risk patients with the concurrent use of chemotherapy and radiation therapy. This review also highlights recent advances in treatment using molecularly targeted therapies, specifically the role of inhibitors of the epidermal growth factor receptor in locally advanced and recurrent/metastatic squamous cell cancer of the head and neck. Studies in the English language were identified by searching the MEDLINE, EMBASE database (1980-2007) using the search terms head and neck, squamous cell, carcinoma, chemotherapy, radiation, human papillomavirus, epidermal growth factor receptor, and targeted therapy.

Radiotherapy Alone for Early-Stage Squamous Cell Carcinoma of the Larynx and Hypopharynx

PURPOSE

To describe and illustrate examples of early-stage larynx and hypopharynx cancer that can be successfully treated with radiotherapy alone.

METHODS AND MATERIALS

Review of the NCCN and ASCO practice guidelines. Representative examples are included.

RESULTS

Early-stage larynx and hypopharynx cancer is defined by tumor extent based on physical and imaging examination.

CONCLUSIONS

Radiotherapy alone is appropriate treatment for properly selected early-stage squamous cell carcinoma of the larynx and hypopharynx. The NCCN and ASCO practice guidelines can be an aid to the clinician in identifying favorable cancers that can be successfully treated with radiotherapy alone with preservation of organ function.

Hypopharyngeal cancer

Hypopharyngeal cancers are usually squamous cell carcinomas (SCCs) that has the worst prognosis among the head and neck cancers. Overall, 5-year survival rate remains poor despite recent improvements in diagnostic imaging, radiation and chemotherapy, and improved surgical techniques. Hypopharyngeal cancers tend to present with advanced primary disease, and nodal metastasis is highly likely. The most important features determining prognosis are the size and extent of local spread of the primary carcinoma and the extent of involvement of regional lymph nodes. Distant metastasis at presentation is more common in hypopharyngeal cancers than in other head and neck cancers. Poor survival rate is partly due to emergence of second primary cancers but also to development of distant metastasis. Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) remain the mainstay of initial radiological evaluation of hypopharyngeal cancer. Imaging usually results in upstaging of the tumor at presentation. Meticulous evaluation of the extent of the primary tumor with attention to spread to the subsites of the hypopharynx, larynx, and cartilage invasion are necessary for accurate staging. After surgery and radiation therapy, it is difficult with CT and MR to differentiate residual and recurrent tumor from edema and scarring. Fluorine 18-fluoro-deoxy-glucose -positron emission tomography (FDG-PET) has high sensitivity in detection of occult, residual, and recurrent tumors but has low specificity. Combined PET and CT increase specificity and are increasingly being used to image posttreatment cases. Other newer imaging modalities such as diffusion-weighted imaging (DWI), MR spectroscopy, and MRI with superparamagnetic iron oxide (SPIO) contrast agent are reported to be useful and should be used more widely in difficult cases.

Accelerated Radiotherapy and Larynx Preservation in Favorable-risk Patients with T2 or Worse Hypopharyngeal Cancer

OBJECTIVE

To evaluate the advantage of accelerated fractionation radiotherapy for patients with hypopharyngeal cancer requiring total laryngectomy.

METHODS

Seventy patients with previously untreated, technically resectable hypopharyngeal cancer who received larynx-preserving treatment with radiotherapy between April 1992 and June 2004 were analyzed. No patients had previous history of other malignancy or poor performance status that would possibly affect the outcomes. A total RT dose of > or = 60 Gy/6 weeks was determined depending on the tumor clearance during treatment before December 1998, and fixed to 70 Gy in all patients thereafter. Accelerated fractionation (70 Gy/<49 days) was completed in 35 patients during the latter period. Concomitant platinum-based chemotherapy was used in 41 patients after May 1998.

RESULTS

Local control rates at 2 years were 72 and 68% for patients with T2 and T3/T4 disease, respectively. Patients who had received 70 Gy/<49 days achieved a better local control rate than those who had received other, more conservative total dose/overall treatment time with statistical significance (91% versus 50% at 2 years, P < 0.001). Multivariate analysis involving 70 Gy/<49 days of radiotherapy, T-classification (T2 versus T3/4), and use of chemotherapy revealed that administering 70 Gy/<7 weeks was the only independent prognostic factor (P = 0.007) for better local control.

CONCLUSIONS

Our experience in radiotherapy for hypopharyngeal cancer mirrored the results of previously conducted large randomized trials for various head and neck cancers. Encouraging local control in this study warrants prospective study to test the long-term oncological and functional outcome of larynx-preserving treatment in patients with advanced but resectable volume of this disease.

Current surgical treatment of squamous cell carcinoma of the head and neck

Historically treatment of head and neck cancers involved surgical resection followed by radiation therapy for advanced tumors. Concurrent chemoradiation therapies have shown equal survival to surgical resection with better preservation of function. However, concurrent therapy does entail significant morbidity, and recent advances have been used to minimize that morbidity. Newer tumor specific medical therapies are anticipated to be less toxic while maintaining a high degree of efficacy. For resectable cancer, transoral laser microsurgery is a new trend in surgery for complete resection of tumors with preservation of function. Advanced reconstructive techniques that allow free transfer of soft tissue and bone from all over the body improve the functional and aesthetic outcomes following major ablative surgery. With successful surgical reconstruction, dental and prosthetic rehabilitation choices are enhanced. Advances in rehabilitation of speech following removal of the larynx have improved the quality of life post-laryngectomy patients. With these newer therapies and methods of reconstruction, each patient needs to be carefully evaluated to maximize the possibility of cure and level of function, and minimize the morbidity associated with treatment. Combined chemotherapy and radiation protocols are associated with increased acute and chronic toxicities that may affect the quality of life due to the impact upon oral disease and oral function. Oral care providers must be aware of advances in cancer management and implications for patient care to effectively care for these patients.

Resection of selected invasive squamous cell carcinoma of the pyriform sinus by means of the lateral pharyngotomy approach: the partial lateral pharyngectomy

BACKGROUND

Although the lateral pharyngotomy is a well-known surgical procedure, to our knowledge, no published reports have described the results achieved with a lateral pharyngectomy approach in patients with isolated and previously untreated selected invasive squamous cell carcinoma of the lateral wall of the pyriform sinus.

METHODS

The medical files and operative charts of 30 patients with an isolated, and previously untreated, squamous cell carcinoma of the pyriform sinus, treated for cure by lateral partial pharyngectomy and primary closure, as well as postoperative radiotherapy (n = 22), and preoperative chemotherapy (n = 8), were retrospectively studied. Sixteen tumors were classified as T1 and 14 as T2. All patients but one were followed until death.

RESULTS

Three patients (9%) died in the immediate postoperative period (two from medical complications and one from a surgery-related complication). Overall, 29 patients died, resulting in a 77.7%, 40%, 23.3%, and 15% 1-, 3-, 5- and 10-year Kaplan-Meier actuarial survival estimate, respectively. Only one patient had a serious postoperative complication develop. All patients were decannulated. No patients required a gastrostomy and/or completion total laryngectomy for functional reasons. Local recurrence occurred in four patients (13%). The 3-and 5-year Kaplan-Meier actuarial local control estimates were 88.5% and 79.6%, respectively. The use of a platin-based induction chemotherapy (p = .05) regimen was the only variable that was significantly statistically related to local recurrence. Overall, a 93.3% laryngeal preservation rate was achieved.

CONCLUSION

Partial pharyngectomy by means of the lateral pharyngotomy combined with postoperative radiation therapy is an efficient and function-sparing approach to control selected invasive squamous cell carcinomas of the lateral wall of the pyriform sinus.

Review of current treatment practices for carcinoma of the head and neck

The past two decades have witnessed a paradigm shift in the treatment of squamous cell carcinoma of the head and neck. Innovation in chemotherapy, radiotherapy and surgery has led to the assimilation of these modalities into our treatment algorithms. This modern multipart treatment plan has led to improved survival; however, this has come at the cost of increased toxicity. New and future therapies will be more tumour specific and, ideally, less toxic. Current research centres on these tumour-specific therapies with the anticipation of improved survival with decreased toxicity. This article will review the standard of care, recent advances and unfulfilled needs in the treatment of squamous cell carcinoma of the head and neck.

Combined modality treatment with full-dose chemotherapy and concomitant boost radiotherapy for advanced head and neck carcinoma

The purpose of this study was to evaluate the feasibility and efficacy of a treatment concept combining three cycles of full-dose chemotherapy (CT) with concomitant accelerated uninterrupted radiotherapy (RT). Twenty-three patients (median age: 54 years, range: 35-70) with locally advanced squamous cell carcinoma of the head and neck (SCCHN) were included. The primary tumor involved the hypopharynx (n=7), base of the tongue (n=10), nasopharynx (n=2) or upper esophagus (n=1) or its location was unknown (n=3). Treatment consisted of three cycles of chemotherapy (cisplatin 100 mg/m2 on day 1; 5-FU 1,000 mg/m2 per day for 5 days as a continuous infusion, preceded by amifostine 910 mg/m2), repeated every 3 weeks. Uninterrupted concomitant boost-accelerated RT (total dose of 70 Gy in 6 weeks) started together on day 1 of the second cycle. All but two patients received the full course of RT. Eighteen patients achieved complete remission (78%). At a median follow-up of 45 months the overall survival was 56% (95% c.i. 32-79%) and the loco-regional control 71% (95% c.i. 52-91%). Toxicity involved reversible renal insufficiency of > or = grade II in 9 patients (39%) and neutropenic fever in 9 patients (39%). All patients suffered from moderate to severe mucositis (grade II/III), and 19 patients presented cutaneous toxicity grade III. Concomitant boost-accelerated RT combined with concurrent full-dose cisplatin/5-FU chemotherapy and amifostine is feasible with manageable, although substantial, toxicity. The overall survival of 4 years is promising. Newer regimens causing less acute mucosal and skin toxicity are needed.

Definitive radiotherapy alone or combined with a planned neck dissection for squamous cell carcinoma of the pharyngeal wall

BACKGROUND

In the current study,the authors analyzed the results of definitive radiotherapy for squamous cell carcinoma of the pharyngeal wall.

METHODS

Between 1964 and 2000, 148 patients were treated with definitive radiotherapy. All patients had a 2-year minimum follow-up.

RESULTS

The following 5-year rates of local and ultimate local control were obtained: T1 disease, 93% and 93%; T2 disease, 82% and 87%; T3 disease, 59% and 61%; and T4 disease, 50% and 50%, respectively. Multivariate analysis revealed that twice-daily fractionation (P = 0.0009), American Joint Committee on Cancer Stage I-II disease (P = 0.0051), and oropharyngeal primary site (P = 0.0193) were associated with improved locoregional control. The following 5-year absolute and cause-specific survival rates were obtained: Stage I, 56% and 89%; Stage II, 52% and 88%; Stage III, 24% and 44%; Stage IV, 22% and 34%; and overall, 30% and 49%, respectively. Eight patients (5%) died of complications.

CONCLUSIONS

Locoregional control and survival were found to be related to site, extent of disease, and fractionation schedule. Although outcomes have improved in recent years, the morbidity of treatment was significant in the current study and a substantial proportion of patients died secondary to the malignancy.

Hypopharyngeal carcinoma

For more than 20 years, the policy at the University of Florida has been to treat patients with favorable stage T1-T2 pyriform sinus carcinoma by using radiation therapy alone, or with a planned neck dissection if advanced nodal disease is present. This approach usually leaves the patient with nearly normal swallowing and speech, and provides bilateral coverage of the regional neck and retropharyngeal lymphatics. More advanced lesions often are not controlled with radiation alone and are usually considered for partial or total laryngopharyngectomy if the patient is medically operable. Radiation is usually administered postoperatively in this setting, unless the neck disease is thought to be unresectable, in which case preoperative radiation is given. Recent data have shown that adjuvant chemotherapy administered concomitantly with radiotherapy results in improved cure rates for patients with advanced disease compared with irradiation alone. Time-honored established guidelines are still used, although the edges have become blurred. Therefore, patients with larger primary tumors now may be considered for organ preservation treatment with irradiation and chemotherapy, reserving surgery for salvage situations. The subset of patients with advanced T4 pyriform sinus cancers (in whom cure with chemoradiation would likely result in tracheostomy and/or gastrostomy dependence) may be better served with elective surgery and postoperative irradiation. The definition of this subset of patients is unclear but probably includes patients with significant cartilage destruction and those who require pretreatment tracheostomy. The policy at the University of Florida is to treat essentially all pharyngeal wall cancers with external-beam irradiation alone.