Treatment of the N0 neck during salvage surgery after radiotherapy of head and neck squamous cell carcinoma

[French national standard for the treatment of squamous cell carcinoma of upper aero-digestive tract - General principles of treatment]

OBJECTIVES

The management of upper aerodigestive tract cancers is a complex specialty. It is essential to provide an update to establish optimal care. At the initiative of the INCa and under the auspices of the SFORL, the scientific committee, led by Professor Béatrix Barry, Dr. Gilles Dolivet, and Dr. Dominique De Raucourt, decided to develop a reference framework aimed at defining, in a scientific and consensus-based manner, the general principles of treatment for upper aerodigestive tract cancers applicable to all sub-locations.

METHODOLOGY

To develop this framework, a multidisciplinary team of practitioners was formed. A systematic analysis of the literature was conducted to produce recommendations classified by grades, in accordance with the standards of the French National Authority for Health (HAS).

RESULTS

The grading of recommendations according to HAS standards has allowed the establishment of a reference for patient care based on several criteria. In this framework, patients benefit from differentiated care based on prognostic factors they present (age, comorbidities, TNM status, HPV status, etc.), conditions of implementation, and quality criteria for indicated surgery (operability, resectability, margin quality, mutilation, salvage surgery), as well as quality criteria for radiotherapy (target volume, implementation time, etc.). The role of medical and postoperative treatments was also evaluated based on specific criteria. Finally, supportive care must be organized from the beginning and throughout the patients' care journey.

CONCLUSION

All collected data have led to the development of a comprehensive framework aimed at harmonizing practices nationally, facilitating decision-making in multidisciplinary consultation meetings, promoting equality in practices, and providing a state-of-the-art and reference practices for assessing the quality of care. This new framework is intended to be updated every 5 years to best reflect the latest advances in the field.

Occult Metastases During Salvage Oral Cavity and Oropharyngeal Free Flaps: Oncologic Outcomes

OBJECTIVES

To define rates of occult metastases in salvage oral cavity and oropharyngeal cancer resection requiring free flap, to examine the location of occult metastases, and to determine associations between occult metastasis and survival.

STUDY DESIGN

Retrospective cohort study.

SETTING

Two tertiary care referral centers.

METHODS

We identified previous cases of irradiation with recurrent or second primary oral cavity or oropharyngeal squamous cell carcinoma that had no evidence of regional metastasis and required free tissue transfer reconstruction of the primary site. Patients who underwent elective neck dissection or exploration were reviewed. The main outcome measures were the presence and location of occult nodal metastasis. Disease-free survival and overall survival were measured. Odds ratios and hazard ratios were used for analysis.

RESULTS

A total of 83 patients were included: 52 with oral cavity primary tumors and 31 with oropharynx. An overall 78 (94%) underwent elective salvage neck dissection. Occult metastases were found in 9 (11.5%) patients. The most common nodal station for occult metastasis was level 2. Neither elective neck dissection nor the presence of occult metastasis was significantly associated with regional disease-free or overall survival. Oropharyngeal primary tumors were associated with higher risk of occult metastasis (odds ratio, 1.38; P < .01) and worse overall survival (hazard ratio, 2.09; P = .01).

CONCLUSION

There is a low incidence of occult metastasis in postradiated recurrent or second primary oral cavity and oropharyngeal tumors. Elective neck dissection and occult nodal metastases were not associated with regional or overall survival. This series may help surgeons make decisions regarding the extent of neck surgery after prior radiation, especially when free flap reconstruction is required.

A Technical Guide to Palliative Ablation of Recurrent Cancers in the Deep Spaces of the Suprahyoid Neck

Treatment options for patients with recurrent head and neck cancer, whether locoregional recurrence of previously treated head and neck cancer or secondary primary malignancy, are limited. Percutaneous ablation is a minimally invasive procedure that can be used with palliative intent in the head and neck to achieve symptomatic relief and local tumor control, potentially fulfilling treatment gaps of current standard of care options. Image guidance is key when navigating the deep spaces of the neck with special attention paid to critical structures within the carotid sheath. This review article provides an overview and highlights the important nuances of performing percutaneous ablations in the head and neck. It covers general principles, ablative modalities, image guidance, procedural technique, expected outcomes, and possible complications.

Occult nodal metastasis in head and neck carcinoma patients treated with chemoradiotherapy

BACKGROUND AND AIM

Neck lymph node metastasis plays an important role in the prognosis of patients with squamous cell carcinoma of the head and neck. The aim of this study was to evaluate the occult nodal metastasis in patients with head and neck squamous cell carcinoma (HNSCC) treated with chemo radiotherapy.

METHODS

In this 5-year prospective study, patients with recurrent head and neck squamous cell carcinomas (HN-SCC) after primary treatment with chemoradiotherapy or radiotherapy that candidate for surgery were enrolled. In total, 50 patients with squamous cell carcinomas of the head and neck with N0 neck were included in the study. Age, initial location of recurrent tumor, T staging in primary and recurrent tumors, neck condition (N0 or N+), and pathology report for neck metastasis, number of affected lymph nodes and duration of tumor recurrence were examined.

RESULTS

Out of 50 patients with mean age of 57.04 ± 14.4 years, 13 were female (26%) and 37 (74%) were male. In terms of primary tumor size, 52% (26 patients) were in T2 stage. The primary and recurrent tumor was located in the oral cavity in 33 patients (66%). Nine 0f 50 patients (18%) had occult metastases.

CONCLUSION

It seems that END surgery is necessary for treatment the occult lymph node neck metastasis of recurrent head and neck cancers with N0 neck. Therefore, it is possible that END surgery has reduced cervical recurrence in these patients.

Stereotactic body radiotherapy optimization to reduce the risk of carotid blowout syndrome using normal tissue complication probability objectives

Purpose

To determine the possibility of further improving clinical stereotactic body radiotherapy (SBRT) plans using normal tissue complication probability (NTCP) objectives in order to minimize the risk for carotid blowout syndrome (CBOS).

Methods

10 patients with inoperable locally recurrent head and neck cancer, who underwent SBRT using CyberKnife were analyzed. For each patient, three treatment plans were examined: (1) cone‐based without delineation of the ipsilateral internal carotid (clinical plan used to treat the patients); (2) cone‐based with the carotid retrospectively delineated and spared; and (3) Iris‐based with carotid sparing. The dose–volume histograms of the target and primary organs at risk were calculated. The three sets of plans were compared based on dosimetric and TCP/NTCP (tumor control and normal tissue complication probabilities) metrics. For the NTCP values of carotid, the relative seriality model was used with the following parameters: D₅₀ = 40 Gy, γ = 0.75, and s = 1.0.

Results

Across the 10 patient plans, the average TCP did not significantly change when the plans were re‐optimized to spare the carotid. The estimated risk of CBOS was significantly decreased in the re‐optimized plans, by 14.9% ± 7.4% for the cone‐based plans and 17.7% ± 7.1% for the iris‐based plans (p = 0.002 for both). The iris‐based plans had significant (p = 0.02) reduced CBOS risk and delivery time (20.1% ± 7.4% time reduction, p = 0.002) compared to the cone‐based plans.

Conclusion

A significant improvement in the quality of the clinical plans could be achieved through the delineation of the internal carotids and the use of more modern treatment delivery modalities. In this way, for the same target coverage, a significant reduction in the risk of CBOS could be achieved. The range of risk reduction varied depending on the proximity of carotid artery to the target.

The potential role of imaging techniques in avoiding neck dissection during salvage surgery after head and neck carcinoma treated with bioradiotherapy

OBJECTIVE

This study aimed to evaluate the effectiveness of computed tomography and positron emission tomography-computed tomography prior to salvage surgery after head and neck carcinoma treated with bioradiotherapy and to look at the role of neck dissection in this setting.

METHOD

This study was a retrospective chart review of a series of consecutive patients with locally advanced head and neck squamous cell carcinoma treated with bioradiotherapy. Radiological and pathological stages were compared to evaluate the accuracy of computed tomography and positron emission tomography-computed tomography in detecting occult neck metastasis in the context of recurrence of primary tumour. In order to assess the impact of neck dissection on survival, Kaplan-Meier survival curves after salvage surgery with and without neck dissection were derived.

RESULTS

A total of 268 patients were identified, of which 22 underwent salvage surgery. The negative predictive value of computed tomography and positron emission tomography-computed tomography was excellent. Neck dissection did not represent an improvement on overall, disease specific and regional recurrence free survival (p = 0.67, p = 0.91 and p = 0.62, respectively) amongst clinically and radiologically negative necks.

CONCLUSION

Conservative treatment of the neck should be considered when dealing with patients with primary site recurrence or persistent disease after bioradiotherapy without evidence of neck disease.

Meta-analysis of risk of occult lymph node metastasis in the irradiated, clinically N0 neck

BACKGROUND

Recurrent head and neck squamous cell carcinoma (HNSCC) after radiation is associated with poor survival, and management of the clinically negative (N0) neck during salvage surgery is controversial.

METHODS

Studies were selected according to preferred reporting items for systematic reviews and meta-analyses guidelines. Inclusion criteria were patients with HNSCC, prior radiation to the lateral neck nodal basin, undergoing salvage surgery for local recurrence, persistence or second primary, and N0 at time of salvage. Eleven studies with a total of 382 patients met inclusion criteria.

RESULTS

The rate of occult metastasis was 15.4%. The pooled rate of occult nodal metastasis was 16.2% for oral cavity, 12.9% for oropharynx, 23.7% for hypopharynx, and 27.3% for supraglottic or transglottic tumors. There was a significantly higher relative risk of occult metastasis for locally advanced tumors.

CONCLUSION

Elective neck dissection at time of salvage surgery should be considered based on subsite, T classification, and prior history of nodal metastasis.

Predictive Value of Early Post-Treatment Diffusion-Weighted MRI for Recurrence or Tumor Progression of Head and Neck Squamous Cell Carcinoma Treated with Chemo-Radiotherapy

Aims: To investigate the predictive capacity of early post-treatment diffusion-weighted magnetic resonance imaging (MRI) for recurrence or tumor progression in patients with no tumor residue after chemo-radiotherapy (CRT) for head and neck squamous cell carcinoma, and, to assess the predictive capacity of pre-treatment diffusion-weighted MRI for persistent tumor residue post-CRT. Materials and Method: A single center cohort study was performed in one French hospital. All patients with squamous cell carcinoma receiving CRT (no surgical indication) were included. Two diffusion-weighted MRI were performed: one within 8 days before CRT and one 3 months after completing CRT with determination of median tumor apparent diffusion coefficient (ADC). Main outcome: The primary endpoint was progression-free survival. Results: 59 patients were included prior to CRT and 46 (78.0%) completed CRT. A post-CRT tumor residue was found in 19/46 (41.3%) patients. In univariate analysis, initial ADC was significantly lower in patients with residue post CRT (0.56 ± 0.11 versus 0.79 ± 0.13; p < 0.001). When initial ADC was dichotomized at the median, initial ADC lower than 0.7 was significantly more frequent in patients with residue post CRT (73.7% versus 11.1%, p < 0.0001). In multivariate analysis, only initial ADC lower than 0.7 was significantly associated with tumor residue (OR = 22.6; IC [4.9–103.6], p < 0.0001). Among 26 patients without tumor residue after CRT and followed up until 12 months, 6 (23.1%) presented recurrence or progression. Only univariate analysis was performed due to a small number of events. The only factor significantly associated with disease progression or early recurrence was the delta ADC (p = 0.0009). When ADC variation was dichotomized at the median, patients with ADC variation greater than 0.7 had time of disease-free survival significantly longer than patients with ADC variation lower than 0.7 (377.5 [286–402] days versus 253 [198–370], p < 0.0001). Conclusion and relevance: Diffusion-weighted MRI could be a technique that enables differentiation of patients with high potential for early recurrence for whom intensive post-CRT monitoring is mandatory. Prospective studies with more inclusions would be necessary to validate our results.

AHNS series: Do you know your guidelines? Guideline recommendations for recurrent and persistent head and neck cancer after primary treatment

Locoregional recurrent/persistent head and neck cancer following primary treatment is a significant challenge as it is usually difficult to treat and has worse outcomes compared to the primary setting. Surgical resection of a local or regional recurrence offers the best chance of cure when feasible. Local recurrence outcomes vary by subsite with laryngeal recurrences having the best prognoses and hypopharynx having the worst. Instances of persistent neck masses following primary nonsurgical treatment can be evaluated with positron emission tomography (PET) with CT (PET-CT) when there is no definitive diagnosis of a recurrence/persistence. Reirradiation with or without chemotherapy can be considered for primary treatment when surgery is not an option, for adjuvant treatment following salvage surgery, or for palliation. Immunotherapy represents a newer class of chemotherapeutic agents. Current guidelines recommend enrollment in clinical trials especially when surgery is not an option as outcomes remain universally poor in the recurrent/persistent setting.

Elective neck dissection during salvage surgery after radiotherapy in patients with head and neck squamous cell carcinoma

SUMMARY

Elective neck dissection in patients with recurrent head and neck squamous cell carcinoma (HNSCC) without evidence of neck disease (crN0) is poorly defined. A retrospective review was carried out on 165 crN0 patients treated with salvage surgery and elective neck dissection. Multivariate Cox analysis and recursive partitioning analysis were used to evaluate prognostic factors. The frequency of occult neck node metastases in the neck dissection (rpN+) was 16.4%. The risk of occult metastases for glottic rpT1-T2 recurrences was 5.9%, for glottic rpT3-T4 recurrences 13.2%, for non-glottic rpT1-T2 recurrences 16.1% and for locally advanced (rpT3-T4) non-glottic recurrences 31.1%. Patients with occult neck node metastases (rpN+) had a 5-year adjusted survival rate of 38.1%, while patients without nodal disease (rpN0) had a 5-year adjusted survival rate of 71.1% (p = 0.0001). Elective neck dissection can be omitted in crN0 patients with rT1-T2 glottic recurrence. We consider it advisable to perform elective neck dissection in all other situations.

Percutaneous Image-Guided Cryoablation of Head and Neck Tumors for Local Control, Preservation of Functional Status, and Pain Relief

OBJECTIVE

We report nine consecutive percutaneous image-guided cryoablation procedures of head and neck tumors in seven patients (four men and three women; mean age, 68 years; age range, 50-78 years). Ablation of the entire tumor for local control or ablation of a region of tumor for pain relief or preservation of function was achieved in eight of nine procedures. One patient experienced intraprocedural bradycardia, and another developed a neopharyngeal abscess. There were no deaths, permanent neurologic or functional deficits, vascular complications, or adverse cosmetic sequelae due to the procedures.

CONCLUSION

Percutaneous image-guided cryoablation offers a potentially less morbid minimally invasive treatment option than salvage head and neck surgery. The complications that we encountered may be avoidable with increased experience. Further work is needed to continue improving the safety and efficacy of cryoablation of head and neck tumors and to continue expanding the use of cryoablation in patients with head and neck tumors that cannot be treated surgically.

Adjuvant role of radiation therapy for locally advanced laryngeal cancer without pathological lymph node metastasis

Conclusion The application of adjuvant RT to reduce recurrence should be tailored in cases of pathologically negative node metastasis. Objectives The treatment modality following surgical resection of advanced laryngeal cancer is determined by adverse factors. Aside from lymph node metastasis (LNM) or positive margins, definite risk factors supporting adjuvant radiation therapy (RT) have not been clearly suggested. The aim of this study was to analyze the risk factors for advanced laryngeal cancer without LNM and the role of RT. Materials and methods Pathologically T3 and T4-staged laryngeal squamous cell carcinoma without LNM were reviewed. The patients were classified into RT (+) (n = 22) and RT (-) (n = 38) groups. Results Five-year overall survival (OS) of the RT (+) and RT (-) groups was 84.4% and 83.8%, respectively. Five-year disease-specific survival of the RT (+) and RT (-) groups was 88.4% and 93.9%. Five-year local control rate of the RT (+) and RT (-) groups was 94.7% and 91.3%. The factors affecting OS were smoking history and recurrence history (p = 0.02). By multivariate analysis, smoking history and recurrence history were determining factors for 5-year OS (p = 0.024 and p = 0.047, respectively).

Outcomes and Prognostic Factors of Radiation-Induced and De Novo Head and Neck Squamous Cell Carcinomas

Objective

We sought to compare clinical outcomes, pathological features, treatment patterns, and survival outcomes between radiation-induced squamous cell carcinoma (RISCC) and de novo SCC (DNSCC) of the head and neck, as well as identify prognostic factors in these patients.

Study Design

Case-control study.

Setting

Tertiary medical center.

Subjects and Methods

Retrospective case-control analysis of 34 RISCCs and 136 DNSCCs matched by age at diagnosis, sex, smoking status, and primary tumor site.

Results

Median latency of RISCC development was 13 years. Radiation-induced squamous cell carcinomas were more likely to present with node-negative disease than DNSCCs (70.6% vs 42.9%; P = .024). A greater proportion of DNSCCs was treated with curative intent (92.6% vs 79.4%; P = .048) and achieved no residual disease posttreatment (82.2% vs 41.2%; P < .001) compared with RISCCs. Patients with RISCC had poorer overall survival (OS) (median, 1.67 vs 5.03 years; P = .018) and disease-specific survival (DSS) (median, 1.67 vs 8.65 years; P = .001) than those with DNSCC. Among patients who underwent curative treatment with no residual disease after treatment, there were, however, no survival differences between RISCC and DNSCC.

Conclusion

In our cohort, RISCCs have a poorer prognosis than DNSCCs. However, those able to undergo curative treatment and have no residual disease after treatment have comparable survival outcomes. Locoregional control of these tumors appears paramount in achieving the best outcomes for patients with RISCC.

Management of the N0 neck in recurrent laryngeal squamous cell carcinoma

The most effective therapeutic approach for the node-negative (N0) neck in patients with recurrent laryngeal squamous cell carcinoma (SCC) remains a subject of dispute. In the present study, the records of 163 patients with recurrent laryngeal SCC were retrospectively reviewed. All patients had a N0 neck at recurrence. At the time of recurrence, the N0 neck was managed using a wait-and-see strategy (observation group) or treatment (treatment group). A total of 125 (76.7%) patients accepted the wait-and-see strategy and 38 (23.3%) patients underwent treatments, including surgery, radiotherapy and/or chemotherapy. The Kaplan-Meier method with the computation of log-rank was used for analysis of survival. The t-test, χ2 test or Fisher's exact test was used for comparisons of non-survival data in the groups. P<0.05 was considered to indicate a statistically significant difference in the two-sided tests. The 3- and 5-year overall survival rates after recurrence were 64.5 and 54.6% for the observation group, and 49.9 and 42.5% for the treatment group, respectively (P=0.011). The present study suggests that a wait-and-see policy is a satisfactory management option for the N0 neck in recurrent laryngeal SCC.

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.

Mutational Status of CDKN2A and TP53 Genes in Laryngeal Squamous Cell Carcinoma

Laryngeal squamous cell carcinoma (LSCC) is the second most common tumour of the head and neck. It is characterized by frequent aberrations in two cell-cycle regulators--CDKN2A and TP53. However, LSCC has been often studied as a part of the group of head and neck cancers and not as an individual entity. In the current study we aimed to examine mutation status of CDKN2A and TP53 genes in 108 LSCC patients. DNA was extracted from fresh-frozen tumour tissues; exons 1-3 of CDKN2A and exons 5-8 of TP53 were screened for mutations by direct sequencing. Genetic aberrations in CDKN2A were found in 16 (14.2%) and those in TP53--in 56/108 (51.9%) tumours. Seven mutations (two insertions, three deletions, one missense and one silent) detected in CDKN2A were not described previously. Also, we found seven novel deletions and a novel indel in TP53. No significant associations with clinical features were found. However, TP53 mutations were predominantly observed in smokers with advanced stage tumours. Screening for genetic aberrations in a defined group of LSCC contributes to the knowledge about laryngeal carcinogenesis. Further investigations are required to confirm the observed trends in associations with clinical features.

Should elective neck dissection be routinely performed in patients undergoing salvage total laryngectomy?

BACKGROUND

The prevalence of occult neck metastasis in patients undergoing salvage total laryngectomy remains unclear, and there is controversy regarding whether elective neck dissection should routinely be performed.

METHOD

A retrospective case note review of 32 consecutive patients undergoing salvage total laryngectomy in a tertiary centre was performed, in order to correlate pre-operative radiological staging with histopathological staging.

RESULTS

The median patient age was 61 years (range, 43-84 years). With regard to lymph node metastasis, 28 patients were pre-operatively clinically staged (following primary radiotherapy or chemoradiotherapy) as node-negative, 1 patient was staged as N1, two patients as N2c and one patient as N3. Fifty-two elective and seven therapeutic neck dissections were performed. Pathological analysis up-staged two patients from clinically node-negative (following primary radiotherapy or chemoradiotherapy) to pathologically node-positive (post-surgery). No clinically node-positive patients were down-staged. More than half of the patients suffered a post-operative fistula.

CONCLUSION

Pre-operative neck staging had a negative predictive value of 96 per cent. Given the increased complications associated with neck dissection in the salvage setting, consideration should be given to conservative management of the neck in clinically node-negative patients (staged following primary radiotherapy or chemoradiotherapy).

Recurrent and second primary squamous cell carcinoma of the head and neck: when and how to reirradiate

BACKGROUND

Local and/or regional recurrence and metachronous primary tumor arising in a previously irradiated area are rather frequent events in patients with head and neck squamous cell carcinoma (HNSCC). Re-treatment is associated with an increased risk of serious toxicity and impaired quality of life (QOL) with an uncertain survival advantage.

METHODS

We analyzed the literature on the efficacy and toxicity of photon/electron-based external beam reirradiation for previously irradiated patients with HNSCC of non-nasopharyngeal origin. Studies were grouped according to the radiotherapy technique used for reirradiation. Patient selection criteria, target volume identification method, tumor dose, fractionation schedule, systemic therapy administration, and toxicities were reviewed.

RESULTS

In addition to disease-related factors, current comorbidities and preexisting organ dysfunction must be considered when selecting patients for reirradiation. As morbidity from re-treatment may be considerable and differ depending on which mode of re-treatment is used, it is important to give patients information on potential morbidity outcomes so that an informed choice can be made within a shared decision-making context. With improved dose distribution and adequate imaging support, including positron emission tomography-CT, modern radiotherapy techniques may improve local control and reduce toxicity of reirradiation. A reirradiation dose of ≥60 Gy and a volume encompassing the gross tumor with up to a 5-mm margin are recommended. Concomitant administration of systemic therapeutics and reirradiation is likely to be of similar benefit as observed in large randomized studies of upfront therapy.

CONCLUSION

Reirradiation, administered either with or without concurrent systemic therapy, is feasible and tolerable in properly selected patients with recurrent or a new primary tumor in a previously irradiated area of the head and neck, offering a meaningful survival (in the range of 10% to 30% at 2 years). Whenever feasible, salvage surgery is the method of choice for curative intent; patients at high-risk for local recurrence should be advised that postoperative reirradiation is expected to increase locoregional control at the expense of higher toxicity and without survival advantage compared to salvage surgery without reirradiation. © 2014 Wiley Periodicals, Inc. Head Neck 37: 134-150, 2015.

A simple strategy to decrease fatal carotid blowout syndrome after stereotactic body reirradiaton for recurrent head and neck cancers

BACKGROUND

This study aimed to compare the therapeutic outcomes and fatal carotid blow out syndrome (CBOS) incidence rates between two different stereotactic body radiotherapy (SBRT) protocols.

METHODS

The study included 75 patients with inoperable locally recurrent head and neck cancer treated with SBRT in our department between June 2007 and March 2011. The first 43 patients were treated sequentially (group I). Then our SBRT protocol was changed due to the high rate of CBOS, and the following 32 patients were treated every other day in a prospective institutional protocol (group II).

RESULTS

Median overall survival in group I and group II was 11 months and 23 months, respectively (P = 0.006). We observed 11 cases of CBOS. Only 1 of 7 patients (14%) with CBOS survived in group I, whereas 2 of 4 patients (50%) in group II remain alive. CBOS free median overall survivals were 9 months, and 23 months in group I and group II respectively (P = 0.002). The median radiation dose received by the carotid artery in patients with CBOS was 36.5 Gy (range: 34-42.8 Gy), versus 34.7 Gy (range: 0-44 Gy) in the patients that didn't have CBOS (P = 0.15). CBOS did not occur in any of the patients with a maximum carotid artery radiation dose <34 Gy.

CONCLUSIONS

Every other day SBRT protocol for re-irradiation of recurrent head and neck cancer is promising in terms of decreasing the incidence of fatal CBOS.

Elective neck dissection for second primary after previous definitive radiotherapy

PURPOSE

The aim of this study was to define the role of neck dissection during surgery for patients who have received elective nodal irradiation in the course of treatment for a prior squamous cell carcinoma of the head and neck (SCCHN) and are subsequently diagnosed with a second primary SCCHN.

MATERIALS AND METHODS

We reviewed the medical records of 13 patients who received both definitive radiotherapy and elective nodal irradiation for T1-4 N0 M0 SCCHN of the oral cavity, oropharynx, hypopharynx, or larynx who then subsequently developed a metachronous T1-4 N0 M0 SCCHN primary at a new site. All second primary tumors were treated with surgery. Ten of the 13 patients also received an elective neck dissection (END) at that time: 7 unilateral and 3 bilateral. We report the outcomes for the patients in this series.

RESULTS

One (8%) of 13 neck dissection specimens was positive in 1 (10%) of 10 patients. The 5-year outcomes were the following: local-regional control, 67%; local control, 77%; disease-free survival, 62%; overall survival, 38%; and cause-specific survival rate, 77%. Six patients experienced treatment-related complications of grade 2 or higher (per Common Terminology Criteria for Adverse Events, version 4). Complications occurred exclusively in patients who received an END.

CONCLUSIONS

The risk of occult nodal disease may be low enough to justify omitting an END for a second primary SCCHN in selected patients while maintaining treatment efficacy and reducing patient morbidity. Larger studies on this subject are needed to further address this question.

Minimizing complications in salvage head and neck oncological surgery following radiotherapy and chemo-radiotherapy

PURPOSE OF REVIEW

The term salvage surgery denotes oncological surgery after failed radiotherapy or chemoradiotherapy (CRT). Salvage surgery is a high-risk endeavour as it carries a significant risk of complications. The purpose of this review is to assess the ways in which complications from salvage surgery can be prevented and minimized. This is a complex subject and complications are often multifactorial and interrelated. There are many aspects that can be discussed; however, to address each of them individually would be impossible and beyond the scope of this article. We will, therefore, focus this review on the most relevant aspects to current practice for head and neck surgeons.

RECENT FINDINGS

Salvage surgery after failure of radiotherapy and CRT remains controversial and many aspects still lack evidence. Many patients with recurrent cancer are not suitable for salvage surgery due to severe co-morbidities or disease progression. Salvage surgery is best carried out in tertiary centres by experienced multidisciplinary teams. Preoperative assessment and evaluation is critical to success and to minimize complications. Surgical principles include single incisions, delicate tissue handling, use of frozen sections, adopting a critical approach to neck dissections and the use of flaps, secondary surgical voice restoration for laryngectomies and appropriate postoperative care.

SUMMARY

This review emphasizes the importance of a multidisciplinary approach by experienced teams, the centralization of resources and teams, a structured and thorough patient assessment, surgical planning and a systematic attention to detail when addressing patients undergoing salvage surgery.

Reirradiation in head and neck cancers

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

ACR appropriateness criteria retreatment of recurrent head and neck cancer after prior definitive radiation expert panel on radiation oncology-head and neck cancer

Recurrent and second primary head-and-neck squamous cell carcinomas arising within or in close proximity to previously irradiated fields are a common clinical challenge. Whereas surgical salvage therapy is recommended for resectable disease, randomized data support the role of postoperative reirradiation in high-risk patients. Definitive reirradiation is an established approach for patients with recurrent disease who are medically or technically inoperable or decline radical surgery. The American College of Radiology Expert Panel on Head and Neck Cancer reviewed the relevant literature addressing re-treatment after prior definitive radiation and developed appropriateness criteria for representative clinical scenarios. Examples of unresectable recurrent disease and microscopic residual disease after salvage surgery were addressed. The panel evaluated the appropriateness of reirradiation, the integration of concurrent chemotherapy, radiation technique, treatment volume, dose, and fractionation. The panel emphasized the importance of patient selection and recommended evaluation and treatment at tertiary-care centers with a head-and-neck oncology team equipped with the resources and experience to manage the complexities and toxicities of re-treatment.

Salvage reirradiaton with stereotactic body radiotherapy for locally recurrent head-and-neck tumors

PURPOSE

In this study, we present our results of reirradiation of locally recurrent head-and-neck cancer with image-guided, fractionated, frameless stereotactic body radiotherapy technique.

METHODS AND MATERIALS

From July 2007 to February 2009, 46 patients were treated using the CyberKnife (Accuray, Sunnyvale, CA) at the Department of Radiation Oncology, Hacettepe University, Ankara, Turkey. All patients had recurrent, unresectable, and previously irradiated head-and-neck cancer. The most prominent site was the nasopharynx (32.6%), and the most common histopathology was epidermoid carcinoma. The planning target volume was defined as the gross tumor volume identified on magnetic resonance imaging and computed tomography. There were 22 female and 24 male patients. Median age was 53 years (range, 19-87 years). The median tumor dose with stereotactic body radiotherapy was 30 Gy (range, 18-35 Gy) in a median of five (range, one to five) fractions.

RESULTS

Of 37 patients whose response to therapy was evaluated, 10 patients (27%) had complete tumor regression, 11 (29.8%) had partial response, and 10 (27%) had stable disease. Ultimate local disease control was achieved in 31 patients (83.8%). The overall survival was 11.93 months in median (ranged, 11.4-17.4 months), and the median progression free survival was 10.5 months. One-year progression-free survival and overall survival were 41% and 46%, respectively. Grade II or greater long-term complications were observed in 6 (13.3%) patients. On follow-up, 8 (17.3%) patients had carotid blow-out syndrome, and 7 (15.2%) patients died of bleeding from carotid arteries. We discovered that this fatal syndrome occurred only in patients with tumor surrounding carotid arteries and carotid arteries receiving all prescribed dose.

CONCLUSIONS

Stereotactic body radiotherapy is an appealing treatment option for patients with recurrent head-and-neck cancer previously treated with radiation to high doses. Good local control with considerable 1-year survival is achieved with a relatively high rate of morbidity and related mortality.

Randomized trial of postoperative reirradiation combined with chemotherapy after salvage surgery compared with salvage surgery alone in head and neck carcinoma

PURPOSE

Full-dose reirradiation combined with chemotherapy has been shown to be feasible after salvage surgery with acceptable toxicity. The Groupe d'Etude des Tumeurs de la Tête et du Cou and Groupe d'Oncologie Radiothérapie Tête Et Cou groups performed a randomized study to assess its efficacy.

PATIENTS AND METHODS

Between 1999 and 2005, 130 patients with head and neck cancer were treated with salvage surgery and randomly assigned to full-dose reirradiation combined with chemotherapy (RT arm) or to observation (a "wait and see" approach; WS arm). Eligibility criteria were recurrence or a second primary tumor in a previously irradiated area, no major sequelae resulting from the first radiotherapy, good general condition, no distant metastasis, and salvage surgery with macroscopic complete resection. Patients in the RT arm received 60 Gy over 11 weeks combined with concomitant fluorouracil and hydroxyurea.

RESULTS

Sixty-five patients were randomly assigned to each arm. There was no imbalance in the distribution of the main tumor and patients characteristics. The most serious acute toxicity in the RT arm was mucositis, attaining grade 3 or 4 in 28% of patients. At 2 years, 39% of patients in the RT arm and 10% in the WS arm experienced grade 3 or 4 late toxicity according to Radiation Therapy Oncology Group criteria (P = .06). Disease-free survival (DFS) was significantly improved in the RT arm, with a hazard ratio of 1.68 (95% CI, 1.13 to 2.50; P = .01), but overall survival (OS) was not statistically different.

CONCLUSION

Full-dose reirradiation combined with chemotherapy after salvage surgery significantly improved DFS, but had no significant impact on OS. An increase in both acute and late toxicity was observed.

Salvage Surgery for Radiation Failure in Oral, Oropharyngeal, and Hypopharyngeal Squamous Cell Carcinoma

Few reports have covered salvage surgery after radiotherapy, especially with chemotherapy for oral, oropharyngeal, and hypopharyngeal squamous cell carcinoma. The feasibility of salvage surgery is unclear. We analyzed postoperative complications and prognosis after salvage surgery for local recurrence after definitive radiotherapy. Subjects were 37 patients with oral, oropharyngeal, and hypopharyngeal squamous cell carcinoma treated from 1994 to 2003. Of these, 14 (37.8%) had postoperative complications. The complication rate was significantly high in the reconstructive operation group (p = 0.031) and the chemotherapy group (p = 0.049). The 5-year overall survival rate after salvage surgery was 70.7%. Although there was no significant improvement, the prognosis was good in early-stage groups with primary tumors. We found that salvage surgery after definitive radiotherapy was effective for recurrent oral, oropharyngeal, and hypopharyngeal squamous cell carcinoma. We stress the need to pay attention to postoperative complications in reconstructive operation and chemotherapy groups.

Locally Recurrent, Previously Irradiated Head and Neck Cancer: Concurrent Re-Irradiation and Chemotherapy, or Chemotherapy Alone?

Patients with locally recurrent head and neck cancer previously treated with radiation have a poor prognosis. Administration of a second course of radiation to tissues within a previous radiation portal, has been traditionally considered unsafe. Survival rates of highly selected patients treated with concurrent chemotherapy and re-irradiation may be as high as 25% at 2 years—exceeding the outcome of matched historical controls treated with chemotherapy alone (10%). However, many questions exist regarding the use of re-irradiation. Uncertainty exists over the criteria for selecting patients who are most appropriate for treatment with re-irradiation. Even greater concern exists regarding toxicity and functional sequelae associated with the use of re-irradiation. Whether the benefits of re-irradiation on locoregional disease control and survival outweigh its potentially severe and life-threatening adverse effects is not clear. In this review, we will discuss re-irradiation and other treatment options for squamous cell carcinoma patients with previously irradiated, locoregional recurrent or second primary tumors in the head and neck, and describe a recently initiated randomized trial comparing chemotherapy plus re-irradiation with chemotherapy.