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Oebel L, Mayer A, Kaufmann J, Wollschläger D, Hagemann J, Krüger M, Schmidberger H. Is bilateral radiotherapy necessary for patients with unilateral squamous cell carcinoma of unknown primary of the head and neck region? Clin Transl Radiat Oncol 2024; 45:100713. [PMID: 38192301 PMCID: PMC10772399 DOI: 10.1016/j.ctro.2023.100713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/24/2023] [Accepted: 12/06/2023] [Indexed: 01/10/2024] Open
Abstract
Background and Purpose Squamous cell carcinoma of unknown primary (SCC-CUP) of the head and neck region remains a clinical challenge, with uncertainty surrounding the necessity of contralateral irradiation of cervical lymphatic drainage in cases of unilateral involvement. Materials and Methods A retrospective study was conducted at the Department of Radiation Oncology, University Medical Center Mainz, on a cohort of 50 patients with unilateral SCC-CUP of the head and neck region treated between 2005 and 2019. 30 patients received bilateral and 20 received unilateral cervical radiotherapy. The majority (n = 38, 76 %) were treated with modern IMRT/ VMAT (Intensity-modulated Radiation Therapy/ Volumetric Modulated Arc Therapy) techniques. Results After a median follow-up of 64.5 months, locoregional recurrences occurred in 26 % of cases (n = 13/50), all of which were ipsilateral and predominantly within the volume of the previous irradiated CTV (clinical target volume) (85 %, n = 11/13). No patient treated unilaterally developed a contralateral recurrence in the neck. After 3 years, we observed 7 locoregional recurrences in the bilateral irradiated group (n = 7/30, 23 %), and 5 locoregional recurrences in the unilateral irradiated group (n = 5/20, 25 %). After 3 years, 12 patients had died in the bilateral irradiated group (n = 12/30, 40 %), and 7 in the unilateral irradiated group (n = 7/20, 35 %). 7 Patients showed distant metastases after 3 years in the bilateral irradiated group (n = 7/30, 23 %), and 2 in the unilateral irradiated group (n = 2/20, 10 %). Locoregional control (LRC) at 5 years was 66.2 % in the bilaterally irradiated group, and 70.0 % in the unilaterally irradiated group. Overall survival (OS) was 52.6 % (bilateral) and 64.0 % (unilateral). Distant metastasis-free survival (DMFS) was 74.7 % (bilateral) and 84.4 % (unilateral). No significant differences were observed in OS (p = 0.37), LRC (p = 0.91), and DMFS (p = 0.91) between the groups.Acute toxicity ≥ °2 accordingly CTCAE (Common Terminology Criteria of Adverse Events) was high with 97% while late toxicity ≥ °2 was moderate with 31%. There was no statistically significant difference between the group of unilateral and bilateral irradiated patients. Conclusion These data suggest that contralateral cervical irradiation may be of limited benefit in patients with SCC-CUP, as recurrences occured ipsilaterally, and predominantly within the area of prior irradiation. Unilateral irradiation seems to be adequate for carefully selected patients.
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Affiliation(s)
- Laura Oebel
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Arnulf Mayer
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Justus Kaufmann
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Daniel Wollschläger
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Jan Hagemann
- Department of Head and Neck Surgery, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Maximilian Krüger
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Heinz Schmidberger
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
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Chen AM. Management of unknown primary head and neck cancer with radiation therapy in the era of human papillomavirus (HPV): No longer cutting down the tree to get an apple. Radiother Oncol 2023; 189:109952. [PMID: 37844736 DOI: 10.1016/j.radonc.2023.109952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE Given the central role that radiation has in the management of head and neck squamous cell carcinoma of unknown primary origin, it is imperative to review how treatment paradigms have been refined and continue to evolve in the modern era. METHODS AND MATERIALS This study was designed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement. A literature search of peer-reviewed publications was undertaken to identify works pertaining to the use of radiation for squamous cell carcinoma of unknown primary origin presenting as cervical lymph node metastases. Articles published from January 2002 to January 2023 with full text available on PubMed and restricted to the English language and human subjects were included. The full bibliographies of identified articles were reviewed and irrelevant studies were removed. RESULTS While such breakthroughs as intensity-modulated radiotherapy, positron emission tomography, biomarker testing with immune-histochemistry, and minimally invasive surgical techniques such as transoral robotic surgery have fundamentally changed the approach to this disease in recent decades, controversies still exist with respect to the manner in which radiation is delivered. Although the incidence of head and neck unknown primary cancer is relatively low, questions regarding the necessity of comprehensive radiation using the age-old standard method of targeting the bilateral necks and entire pharyngeal axis to encompass all putative sites of mucosal disease persist. CONCLUSIONS Prospective evidence is lacking, and the available studies have been complicated by such factors as the relatively limited sample sizes, as well as the variability in work-up, treatment, inclusion criteria, and follow-up. Regardless, advances in science and technology have ushered in more precise approaches with a high degree of customization, particularly given the increased proportion of patients presenting with human papillomavirus-related disease.
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Affiliation(s)
- Allen M Chen
- Department of Radiation Oncology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, USA.
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3
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Pala M, Novakova P, Pechacova Z, Vesela L, Vrana A, Sukova J, Holeckova P, Drbohlavova T, Podlesak T, Petruzelka L. Long-term results of radio(chemo)therapy in metastatic carcinoma to cervical lymph nodes from an unknown primary. Adult Comorbidity Evaluation 27 score as a predictor of survival. Strahlenther Onkol 2023; 199:149-159. [PMID: 35943554 DOI: 10.1007/s00066-022-01983-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 07/10/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate the effectiveness and toxicity of curative (chemo)radiotherapy in patients with metastatic carcinoma to cervical lymph nodes from an unknown primary. METHODS Retrospective study of 90 consecutive patients, treated with curative radiotherapy from 2003 to 2018 (median age 59 years; current/former smokers 76%) was conducted. The distribution of nodal staging was as follows: N1: 12%, N2a: 21%, N2b: 43%, N2c: 10%, N3: 13%. In 62% of patients, neck dissection was performed before radiotherapy. Concomitant chemotherapy was given to 64% of patients. RESULTS The median follow-up of surviving patients was 86 months. The median total radiotherapy dose achieved was 70 Gy. The 5‑ and 10-year locoregional control were 84% in both cases, while 5‑ and 10-year distant control were 90% and 89%, respectively. A primary tumor in the head and neck area was detected in only 2 patients. No patient had an initial failure in the pharyngeal axis or contralateral cervical nodes. The 5‑ and 10-year overall survival were 55% and 42%, respectively. Severe early toxicity occurred in 71%; severe late toxicity in 33% of patients. Multivariate analysis demonstrated N‑status (hazard ratio [HR] 2.424; 95% confidence interval [CI] 1.121-5.241; p = 0.024) and comorbidity scores assessed by ACE-27 (Adult Comorbidity Evaluation; HR 3.058; 95% CI 1.489-6.281; p = 0.002) as two independent prognostic factors for overall survival. CONCLUSION The results of our work study demonstrate the high effectiveness of curative (chemo)radiotherapy on the pharyngeal axis and bilateral cervical nodes with long-term locoregional and distant control in 3/4 of the treated patients. N‑status and comorbidity scores were shown as strong prognostic factors influencing overall survival.
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Affiliation(s)
- Miloslav Pala
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic.
| | - Pavla Novakova
- Radiophysics Department, Bulovka University Hospital, Prague, Czech Republic
| | - Zdena Pechacova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Lucie Vesela
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Antonin Vrana
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Jarmila Sukova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Petra Holeckova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Tereza Drbohlavova
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
| | - Tomas Podlesak
- Department of Otorhinolaryngology, Bulovka University Hospital, Prague, Czech Republic
| | - Lubos Petruzelka
- Institute of Radiation Oncology of the 1st Faculty of Medicine Charles University, Bulovka University Hospital, Budínova 2, 18001 Praha 8, Prague, Czech Republic
- Department of Oncology of the 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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4
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Sherry AD, Pasalic D, Gunn GB, Fuller CD, Phan J, Rosenthal DI, Morrison WH, Sturgis EM, Gross ND, Gillison ML, Ferrarotto R, El-Naggar AK, Garden AS, Frank SJ. Proton Beam Therapy for Head and Neck Carcinoma of Unknown Primary: Toxicity and Quality of Life. Int J Part Ther 2021; 8:234-247. [PMID: 34285950 PMCID: PMC8270080 DOI: 10.14338/ijpt-20-00034.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/21/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose Proton radiation therapy (PRT) may offer dosimetric and clinical benefit in the treatment of head and neck carcinoma of unknown primary (HNCUP). We sought to describe toxicity and quality of life (QOL) in patients with HNCUP treated with PRT. Patients and Methods Toxicity and QOL were prospectively tracked in patients with HNCUP from 2011 to 2019 after institutional review board approval. Patients received PRT to the mucosa of the nasopharynx, oropharynx, and bilateral cervical lymph nodes with sparing of the larynx and hypopharynx. Patient-reported outcomes were tracked with the MD Anderson Symptom Inventory–Head and Neck Module, the Functional Assessment of Cancer Therapy–Head and Neck, the MD Anderson Dysphagia Inventory, and the Xerostomia-Related QOL Scale. Primary study endpoints were the incidence of grade ≥ 3 (G3) toxicity and QOL patterns. Results Fourteen patients (median follow-up, 2 years) were evaluated. Most patients presented with human papillomavirus–positive disease (n = 12, 86%). Rates of G3 oral mucositis, xerostomia, and dermatitis were 7% (n = 1), 21% (n = 3), and 36% (n = 5), respectively. None required a gastrostomy. During PRT, QOL was reduced relative to baseline and recovered shortly after PRT. At 2 years after PRT, the local regional control, disease-free survival, and overall survival were 100% (among 7 patients at risk), 79% (among 6 patients at risk), and 90% (among 7 patients at risk), respectively. Conclusion Therefore, PRT for HNCUP was associated with highly favorable dosimetric and clinical outcomes, including minimal oral mucositis, xerostomia, and dysphagia. Toxicity and QOL may be superior with PRT compared with conventional radiation therapy and PRT maintains equivalent oncologic control. Further prospective studies are needed to evaluate late effects and cost-effectiveness.
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Affiliation(s)
| | - Dario Pasalic
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maura L Gillison
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata Ferrarotto
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adel K El-Naggar
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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5
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Dhouib F, Bertaut A, Maingon P, Siala W, Daoud J, Aubignac L, Lestrade L, Crehange G, Vulquin N. Patterns of Failure in Patients With Head and Neck Squamous Cell Carcinomas of Unknown Primary Treated With Chemoradiotherapy. Technol Cancer Res Treat 2020; 19:1533033820905826. [PMID: 32484037 PMCID: PMC7268107 DOI: 10.1177/1533033820905826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: To evaluate the patterns of failure in patients treated for head and neck carcinoma of unknown primary and to discuss treatment practices concerning radiotherapy target volumes definition and dose prescription. Methods: Eleven patients presenting a locoregional recurrence after head and neck carcinoma of unknown primary treatment with curative-intent radiochemotherapy performed between 2007 and 2017 in the departments of radiation oncology of 2 French cancer institutes. Images of the computed tomography scan or the magnetic resonance imaging performed at the time of the recurrence were fused with those of the simulation computed tomography scan to delimit a volume corresponding to the recurrence and to define the area of relapse compared to the volumes treated. Results: Irradiation was unilateral in 6 cases and bilateral in 5 cases. The median time to onset of recurrence was 7.24 months (extreme 3-67.7 months). Six patients had only a neck node recurrence, 3 had a neck node and subsequent primary recurrence, and 1 had only a median subsequent primary recurrence. Only 1 patient had synchronous distance progression to local recurrence. All neck node recurrences were solitary and ipsilateral. The subsequent primary recurrences were in the oropharynx in 3 cases and in the contralateral oral cavity in one case. All neck node recurrences were into the irradiated volume. The subsequent primary recurrences were either within or in border of the irradiated volumes. The median of the mean dose, received by neck node recurrences, was 69.9 Gy and that of the mean dose, minimum dose, maximum dose, and dose received by 95% of the volume of recurrence was 66.7 Gy. For the primary relapses, the median of the mean dose was 52.1 Gy and that of the mean dose, minimum dose, maximum dose, and dose received by 95% of the volume of recurrence was 39.9 Gy. Conclusions: All local nodal recurrences occurred at sites that received high radiotherapy doses and doses received by sites of eventual failure did not vary significantly from sites that remain in control.
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Affiliation(s)
- Fatma Dhouib
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France.,Department of Oncology Radiotherapy, Habib Bourguiba Central University Hospital, Sfax, Tunisia
| | - Aurélie Bertaut
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France
| | - Philippe Maingon
- Department of Oncology Radiotherapy, Central University Hospital La Pitié Salpêtrière, Paris, France
| | - Wicem Siala
- Department of Oncology Radiotherapy, Habib Bourguiba Central University Hospital, Sfax, Tunisia
| | - Jamel Daoud
- Department of Oncology Radiotherapy, Habib Bourguiba Central University Hospital, Sfax, Tunisia
| | - Léone Aubignac
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France
| | - Laetitia Lestrade
- Department of Oncology Radiotherapy, Central University Hospital, Besançon, France
| | - Gilles Crehange
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France
| | - Noemie Vulquin
- Department of Oncology Radiotherapy, Centre Georges-François-Leclerc, Dijon, France
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6
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Kim DY, Heo DS, Keam B, Ock CY, Ahn SH, Kim JH, Jung KC, Kim JH, Wu HG. Failure patterns of cervical lymph nodes in metastases of unknown origin according to target volume. Radiat Oncol J 2020; 38:18-25. [PMID: 32229805 PMCID: PMC7113154 DOI: 10.3857/roj.2020.00108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 03/26/2020] [Indexed: 12/12/2022] Open
Abstract
Purpose This study was aim to evaluate the patterns of failure according to radiotherapy (RT) target volume for cervical lymph nodes in metastases of unknown primary origin in head and neck region (HNMUO). Materials and Methods Sixty-two patients with HNMUO between 1998 and 2016 were retrospectively reviewed. We analyzed the clinical outcomes and primary site failure depending on the radiation target volume. The target volume was classified according to whether the potential head and neck mucosal sites were included and whether the neck node was treated involved side only or bilaterally. Results Potential mucosal site RT (mucosal RT) was done to 23 patients and 39 patients did not receive mucosal RT. Mucosal RT showed no significant effect on overall survival (OS) and locoregional recurrence (LRR). The location of primary site failure encountered during follow-up period was found to be unpredictable and 75% of patients with recurrence received successful salvage therapies. No significant differences in OS and LRR were found between patients treated to unilateral (n = 35) and bilateral neck irradiation (n = 21). Treatment of both necks resulted in significantly higher mucositis. conclusions We found no advantages in OS and LRR of patients with HNMUO when mucosal sites and bilateral neck node were included in the radiation target volume.
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Affiliation(s)
- Dong-Yun Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Dae Seog Heo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Bhumsuk Keam
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chan Young Ock
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Soon Hyun Ahn
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Hoon Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyeong Cheon Jung
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institution, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Korea
| | - Hong-Gyun Wu
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institution, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Korea
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Grewal AS, Rajasekaran K, Cannady SB, Chalian AA, Ghiam AF, Lin A, LiVolsi V, Lukens JN, Mitra N, Montone KT, Newman JG, O'Malley BW, Rassekh CH, Weinstein GS, Swisher-McClure S. Pharyngeal-sparing radiation for head and neck carcinoma of unknown primary following TORS assisted work-up. Laryngoscope 2019; 130:691-697. [PMID: 31411747 DOI: 10.1002/lary.28200] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/11/2019] [Accepted: 07/08/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE In patients with head and neck carcinoma of unknown primary (HNCUP;pT0) following TORS-assisted workup, we have adopted a pharyngeal-sparing radiation therapy (PSRT) approach targeting only the at-risk neck and omitting treatment of the pharynx. We report outcomes following PSRT, and compare to institutional historical control subjects who received pharyngeal-targeted RT (PRT). METHODS Between 2009 and 2018, 172 patients underwent TORS-assisted endoscopy as part of their workup for HNCUP. Following TORS, 54 patients had pT0 disease, of which 45 received RT. Forty-nine percent received PSRT and 51% received PRT. RESULTS No statistically significant differences existed between the PSRT and PRT groups with respect to overall nodal distribution, p16 positivity (55% vs. 43%, P = .12), neck dissection rates (77% vs. 65%, P = .51), and administration of chemotherapy (55% vs. 65%, P = .55). Median follow-up for PSRT and PRT groups were 24 and 28 months, respectively (P = .04). Two-year RFS was 86% and 74% for PSRT and PRT patients, respectively (log-rank P = .30). Three and six patients recurred after PSRT and PRT, respectively. Two-year OS for PSRT and PRT patients was 91% and 74%, respectively (log-rank P = .31). Compared to PRT, PSRT was associated with statistically significantly less: grade 2+ mucositis (18% vs. 91%, P < .01), new opioid requirement (27% vs. 91%, P < .01), mean weight loss during RT (6.2 lbs vs. 17.4 lbs, P < .01), feeding tube placement during RT (5% vs. 43%, P < .01), and treatment-related unplanned hospitalizations (9% vs. 39%, P = .04). CONCLUSION Following TORS-assisted management of patients with pT0 HNCUP, we observed reduced toxicity following PSRT compared to PRT without apparent compromise of disease cure. LEVEL OF EVIDENCE Level 3 evidence, retrospective review comparing cases and controls Laryngoscope, 130:691-697, 2020.
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Affiliation(s)
| | | | - Steven B Cannady
- the Department of Otorhinolaryngology, Philadelphia, Pennsylvania, U.S.A
| | - Ara A Chalian
- the Department of Otorhinolaryngology, Philadelphia, Pennsylvania, U.S.A
| | - Alireza F Ghiam
- Department of Radiation Oncology, Philadelphia, Pennsylvania, U.S.A
| | - Alexander Lin
- Department of Radiation Oncology, Philadelphia, Pennsylvania, U.S.A
| | - Virginia LiVolsi
- the Department of Pathology and Laboratory Medicine, Philadelphia, Pennsylvania, U.S.A
| | - John N Lukens
- Department of Radiation Oncology, Philadelphia, Pennsylvania, U.S.A
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Kathleen T Montone
- the Department of Pathology and Laboratory Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Jason G Newman
- the Department of Otorhinolaryngology, Philadelphia, Pennsylvania, U.S.A
| | - Bert W O'Malley
- the Department of Otorhinolaryngology, Philadelphia, Pennsylvania, U.S.A
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8
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Maebayashi T, Ishibashi N, Aizawa T, Sakaguchi M, Saito T, Kawamori J, Tanaka Y, Hirotani Y, Homma T. Roles of Ki-67 and p16 as biomarkers for unknown primary head and neck squamous cell carcinoma. Eur Arch Otorhinolaryngol 2019; 276:1221-1229. [PMID: 30756227 DOI: 10.1007/s00405-019-05338-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 02/05/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE Treatment guidelines have not been established for unknown primary head and neck squamous cell carcinoma (SCC). For these patients, chemoradiotherapy (CRT) can provide a better prognosis than that for patients with other head and neck cancers. The presence of HPV in the tumor is associated with a better outcome. However, not all patients with HPV-positive unknown primary head and neck SCC experience good treatment outcomes in actual clinical settings. METHODS We thus retrospectively determined the Ki-67 proliferation index and p16 expression status to assess the associations of these parameters with treatment outcomes of patients with unknown primary head and neck SCC. RESULTS The subjects were 13 patients who underwent CRT after surgery or excision biopsy between 1999 and 2016. The 2- and 5-year overall survival (OS) rate was 76.9% and 68.4%, respectively. The prognostic factor was age. There was no significant difference in survival between patients with a high Ki-67 vs. low Ki-67 or between patients with p16-positive vs. p16-negative metastases OS. However, all p16-positive patients with low Ki-67 showed good locoregional control. CONCLUSIONS The combination of ki67 expression and p16 expression status may allow prediction of local control more accurately than p16 expression status alone.
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Affiliation(s)
- Toshiya Maebayashi
- Department of Radiology, Nihon University School of Medicine, 30-1 Oyaguchi Kami-cho, Itabashi-ku, 173-8610, Tokyo, Japan.
| | - Naoya Ishibashi
- Department of Radiology, Nihon University School of Medicine, 30-1 Oyaguchi Kami-cho, Itabashi-ku, 173-8610, Tokyo, Japan
| | - Takuya Aizawa
- Department of Radiology, Nihon University School of Medicine, 30-1 Oyaguchi Kami-cho, Itabashi-ku, 173-8610, Tokyo, Japan
| | - Masakuni Sakaguchi
- Department of Radiology, Nihon University School of Medicine, 30-1 Oyaguchi Kami-cho, Itabashi-ku, 173-8610, Tokyo, Japan
| | - Tsutomu Saito
- Radiology Clinic, Sonoda Medical Hospital, Adachi-ku, 121-0064, Tokyo, Japan
| | - Jiro Kawamori
- Department of Radiation Oncology, St. Luke's International Hospital, Chuo-ku, 104-8560, Tokyo, Japan
| | - Yoshiaki Tanaka
- Department of Radiation Oncology, Kawasaki Saiwai Hospital, 212-0041, Kawasaki, Kanagawa, Japan
| | - Yukari Hirotani
- Department of Human Pathology, Division of Pathology and Microbiology, Nihon University School of Medicine, Itabashi-ku, 173-8610, Tokyo, Japan
| | - Taku Homma
- Department of Human Pathology, Division of Pathology and Microbiology, Nihon University School of Medicine, Itabashi-ku, 173-8610, Tokyo, Japan
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9
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LaVigne AW, Margalit DN, Rawal B, Puzanov M, Annino DJ, Goguen LA, Sher DJ, Schoenfeld JD, Chau NG, Lorch JH, Rabinowits G, Haddad RI, Tishler RB. IMRT‐based treatment of unknown primary malignancy of the head and neck: Outcomes and improved toxicity with decreased mucosal dose and larynx sparing. Head Neck 2019; 41:959-966. [DOI: 10.1002/hed.25531] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 07/26/2018] [Accepted: 09/28/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Anna W. LaVigne
- Johns Hopkins University School of Medicine Baltimore Maryland
| | - Danielle N. Margalit
- Department of Radiation OncologyDana‐Farber Cancer Institute/Brigham and Women's Hospital Boston Massachusetts
| | - Bhupendra Rawal
- Department of Biostatistics and Computational BiologyDana‐Farber Cancer Institute Boston Massachusetts
| | | | - Donald J. Annino
- Division of Otolaryngology, Department of SurgeryDana‐Farber Cancer Institute/Brigham and Women's Hospital Boston Massachusetts
| | - Laura A. Goguen
- Division of Otolaryngology, Department of SurgeryDana‐Farber Cancer Institute/Brigham and Women's Hospital Boston Massachusetts
| | - David J. Sher
- Department of Radiation OncologyUT Southwestern Medical Center Dallas Texas
| | - Jonathan D. Schoenfeld
- Department of Radiation OncologyDana‐Farber Cancer Institute/Brigham and Women's Hospital Boston Massachusetts
| | - Nicole G. Chau
- Department of Medical OncologyDana‐Farber Cancer Institute Boston Massachusetts
| | - Jochen H. Lorch
- Department of Medical OncologyDana‐Farber Cancer Institute Boston Massachusetts
| | | | - Robert I. Haddad
- Department of Medical OncologyDana‐Farber Cancer Institute Boston Massachusetts
| | - Roy B. Tishler
- Department of Radiation OncologyDana‐Farber Cancer Institute/Brigham and Women's Hospital Boston Massachusetts
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10
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Aro K, Bäck L, Mäkitie A, Tapiovaara L. An evaluation of the diagnostic methods in head and neck cancer of unknown primary site. Acta Otolaryngol 2018; 138:930-936. [PMID: 30016889 DOI: 10.1080/00016489.2018.1484567] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Various detection methods to identify the primary in head and neck cancer of unknown primary (HN-CUP) require evaluation to improve and standardize management. OBJECTIVES To evaluate the use of different diagnostic methods, which aim at decreasing the incidence of HN-CUP. MATERIAL AND METHODS We conducted a retrospective analysis of patients with HN-CUP at the Helsinki University Hospital during 1995-2011. We evaluated clinical assessment, definitive treatment, histopathology, and follow up. We analyzed the success in identifying the primary site to show any changes in diagnostic methods over time. RESULTS Frequency of HN-CUP and success in identifying the primary site have remained constant despite the addition of PET-CT and determination of human papilloma virus (HPV) status in diagnostics. Among 133 patients, the diagnostic work up identified the primary site in 53% and the oropharynx predominated (69%). This left 85 patients with HN-CUP and 5-year overall and disease-free survival rates were 71 and 69%, respectively. CONCLUSIONS Panendoscopy including tonsillectomy should not be omitted in the work up. SIGNIFICANCE We demonstrate a steady frequency of HN-CUP and constant success in identifying the primary site. Detection of a primary later in the follow up did not impact the survival.
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Affiliation(s)
- Katri Aro
- Department of Otorhinolaryngology – Head and Neck Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Leif Bäck
- Department of Otorhinolaryngology – Head and Neck Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Antti Mäkitie
- Department of Otorhinolaryngology – Head and Neck Surgery, Helsinki University Central Hospital, Helsinki, Finland
- Division of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Laura Tapiovaara
- Department of Otorhinolaryngology – Head and Neck Surgery, Helsinki University Central Hospital, Helsinki, Finland
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11
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Cabrera Rodríguez J, Cacicedo J, Giralt J, García Miragall E, Lloret M, Arias F, González Ruiz MA, Contreras J. GEORCC recommendations on target volumes in radiotherapy for Head Neck Cancer of Unkown Primary. Crit Rev Oncol Hematol 2018; 130:51-59. [PMID: 30196912 DOI: 10.1016/j.critrevonc.2018.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/16/2018] [Accepted: 07/17/2018] [Indexed: 12/22/2022] Open
Abstract
Head Neck Cancer of Unknown Primary (HNCUP) is a rare condition, representing approximately 5-10% of all head neck cancers. Radiotherapy, adjuvant or radical, is usually employed in the treatment of those patients. To date, no specific guidelines for the optimal definition of the target volume to be irradiated have been published. In recent years, there have been advances in the knowledge of the molecular biology of HNCUP, its diagnostic imaging and the implementation of sophisticated radiotherapy techniques with enhanced precision in target localization and treatment delivery. These progresses have provided valuable information about the natural history of HNCUP that will allow for establishment of the best treatment for each patient, including standardized, consistent and reproducible target volumes definitions. Several recommendations regarding how to choose volumes when contouring HNCUP in clinical practice are reported, in order to achieve a high rate of loco-regional control while avoiding unnecessary toxicity.
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Affiliation(s)
- Joaquín Cabrera Rodríguez
- Radiation Oncology Department, Hospital Universitario Infanta Cristina, Avenida de Elvas, s/n, 06080 Badajoz, Spain.
| | - Jon Cacicedo
- Radiation Oncology Department, Hospital Universitario de Cruces, Plaza de Cruces, s/n, 48903 Baracaldo, Spain
| | - Jordi Giralt
- Radiation Oncololgy Deparment, Hospital General Vall D'Hebron, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Enrique García Miragall
- Radiation Oncology Department, Hospital General Universitario Valencia- ERESA, Avenida Blasco Ibáñez, 17, 46010 Valencia, Spain
| | - Marta Lloret
- Radiation Oncology Department, Hospital Universitario Doctor Negrín, c/ Barranco de la ballena, s/n, 35010, Las Palmas de Gran Ganaria, Spain
| | - Fernando Arias
- Radiation Oncology Department, Complejo Hospitalario de Navarra, C/ Irunlarrea, 4, 31008 Pamplona, Spain
| | - María Angeles González Ruiz
- Radiation Oncology Department, Hospital Universitario Infanta Cristina, Avenida de Elvas, s/n, 06080 Badajoz, Spain
| | - Jorge Contreras
- Radiation Oncology Department, Complejo Hospitalario Carlos Haya, Avenida de Carlos Haya, s/n, 29010 Málaga, Spain
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12
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Troussier I, Klausner G, Blais E, Giraud P, Lahmi L, Pflumio C, Faivre JC, Geoffrois L, Babin E, Morinière S, Maingon P, Thariat J. [Advances in the management of cervical lymphadenopathies of unknown primary with intensity modulated radiotherapy: Doses and target volumes]. Cancer Radiother 2018; 22:438-446. [PMID: 29731331 DOI: 10.1016/j.canrad.2017.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 10/24/2017] [Indexed: 11/16/2022]
Abstract
The definition of nodal and/or mucosal target volumes for radiation therapy for lymphadenopathies of unknown primary is controversial. Target volumes may include all nodal areas bilaterraly and be pan-mucosal or unilateral, selective, including the sole oropharyngeal mucosa. This review presents current recommendations in light of changes in the TNM classification, Human papillomavirus status and therapeutic advances. We conducted a systematic review of the literature with the following keywords: lymphadenopathy; head and neck; unknown primary and radiation therapy. There are no direct comparative studies between unilateral or bilateral nodal irradiation or pan-mucosal and selective mucosal irradiation. Contralateral lymph node failure rates range from 0 to 6% after unilateral nodal irradiation and 0 and 31% after bilateral irradiation. Occurrence of a mucosal primary varies between 0 and 19.2%. Initial clinical presentation and Human papillomavirus status are critical to define mucosal target volumes. Intensity-modulated radiotherapy is recommended (rather than three-dimensional irradiation) to avoid toxicities. Systemic treatments have similar indications as for identified primary head and neck cancers. Failures do not appear superior in case of unilateral nodal irradiation but comparative studies are warranted due to major biases hampering direct comparisons. Human papillomavirus status should be incorporated into the therapeutic strategy and practice-changing TNM staging changes will need to be evaluated.
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Affiliation(s)
- I Troussier
- Radio-oncologie, hôpitaux universitaires de Genève, Avenue de la Roseraie 53 CH-1205 Genève
| | - G Klausner
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - E Blais
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - P Giraud
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - L Lahmi
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - C Pflumio
- Oncologie médicale, centre Alexis-Vautrin, 6, avenue de Bourgogne, 54511 Vandoeuvre-lès-Nancy cedex, France
| | - J-C Faivre
- Radiothérapie, centre Alexis-Vautrin, 6, avenue de Bourgogne, 54511 Vandoeuvre-lès-Nancy cedex, France
| | - L Geoffrois
- Oncologie médicale, centre Alexis-Vautrin, 6, avenue de Bourgogne, 54511 Vandoeuvre-lès-Nancy cedex, France
| | - E Babin
- Carcinologie cervicofaciale, CHRU de Caen, avenue de la Côte-de-Nacre, 14033 Caen, France
| | - S Morinière
- Carcinologie cervicofaciale, CHRU de Tours, 2, boulevard Tonnellé, 37000 Tours, France
| | - P Maingon
- Radiothérapie, groupe hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - J Thariat
- Département de radiothérapie/Archade, centre François-Baclesse, 3, avenue General-Harris, 14000 Caen, France; Université Unicaen, 14000 Caen, France.
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13
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Ross RB, Koyfman SA, Reddy CA, Houston N, Geiger JL, Woody NM, Joshi NP, Greskovich JF, Burkey BB, Scharpf J, Lamarre ED, Prendes B, Lorenz RR, Adelstein DJ, Ward MC. A matched comparison of human papillomavirus-induced squamous cancer of unknown primary with early oropharynx cancer. Laryngoscope 2017; 128:1379-1385. [PMID: 29086413 DOI: 10.1002/lary.26965] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 09/01/2017] [Accepted: 09/19/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVES/HYPOTHESIS Patients with human papillomavirus (HPV)-induced cancer of unknown primary (CUP) are generally excluded from clinical trials, despite surgical series reporting detection rates of occult oropharynx primaries of >80%. We performed a matched-pair analysis to compare outcomes between T0N1-3M0 HPV+ CUP and T1-2N1-3M0 HPV+ oropharynx known primary (OPX). STUDY DESIGN Retrospective cohort study at a single institution. METHODS Patients with early T stage, node positive HPV+ OPX or CUP treated with curative intent between 1998 and 2016 were identified. For a subgroup of CUP patients with an unknown HPV status, we imputed HPV status and included patients with a >80% probability of being HPV+. Cohorts were matched based on patient demographics using a nearest neighbor propensity technique. After matching, patients were grouped according to either a favorable or unfavorable risk stratification designations per current NRG Oncology clinical trial enrollment criteria. Disease-free survival (DFS) and overall survival (OS) were calculated using Kaplan-Meier analysis. RESULTS Of 298 patients with T1-2N1-3 OPX, 48 were matched to 48 HPV+ CUP patients (32 with confirmed and 16 imputed HPV status). Median follow-up for CUP (34.1 months) and OPX (27.8 months) patients were similar (P = .23).There were no significant differences between the CUP and OPX groups for 3-year DFS (89% vs. 85%, P = .44), and 3-year OS (91% vs. 91%, P = .11), respectively. CONCLUSIONS Patients with T0N+M0 HPV-induced CUP have similar survival outcomes to matched patients with T1-2N+M0 HPV+ OPX. These patients can reasonably be included in clinical trials investigating the role of treatment deintensification and risk stratified similar to patients with early-stage known primary OPX cancer. LEVEL OF EVIDENCE 4. Laryngoscope, 128:1379-1385, 2018.
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Affiliation(s)
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Narcissa Houston
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jessica L Geiger
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Neil M Woody
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nikhil P Joshi
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - John F Greskovich
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian B Burkey
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Joseph Scharpf
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Eric D Lamarre
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Brandon Prendes
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Robert R Lorenz
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - David J Adelstein
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Matthew C Ward
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
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14
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de Ridder M, Klop M, Hamming-Vrieze O, de Boer J, Jasperse B, Smit L, Vogel W, van den Brekel M, Al-Mamgani A. Unknown primary head and neck squamous cell carcinoma in the era of fluorodeoxyglucose-positron emission tomography/CT and intensity-modulated radiotherapy. Head Neck 2017; 39:1382-1391. [PMID: 28370570 DOI: 10.1002/hed.24762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The diagnosis and treatment of head and neck carcinoma of unknown primary (CUP) have changed with the introduction of fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT and intensity-modulated radiotherapy (IMRT), with potential implications for outcome. METHODS We conducted a retrospective analysis of 80 patients with head and neck CUP who were PET-staged and treated with curative intention using IMRT between 2006 and 2016 in the Netherlands Cancer Institute. Patient, tumor, and treatment demographics were recorded and oncologic outcomes were analyzed. RESULTS Local control was 100% in mucosal irradiated patients. Regional control was 90%. Ten patients developed distant metastases, which were associated with N3, extracapsular extension (ECE) and lower neck positive lymph nodes. Overall survival (OS) at 5 years was 62% and disease-specific survival was 78%. ECE, N3 neck, multiple levels of positive lymph nodes, and positive lymph nodes in the lower neck were associated with worse prognosis. CONCLUSION Locoregional outcome of head and neck CUP managed with modern techniques is good. Future research needs to focus on reducing toxicity and patients prone for distant metastasis.
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Affiliation(s)
- Mischa de Ridder
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Martin Klop
- Department of Head and Neck Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Olga Hamming-Vrieze
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - JanPaul de Boer
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Bas Jasperse
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Laura Smit
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wouter Vogel
- Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michiel van den Brekel
- Department of Head and Neck Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Abrahim Al-Mamgani
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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15
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Abstract
CONCLUSION The management of Head and Neck Cancer of Unknown Primary (HNCUP) patients varies both between centres within and also between the Nordic countries. This study contributes to a continuing discussion of how to improve the accuracy of diagnosis and quality of treatment of HNCUP patients. OBJECTIVES The initiative for this study was based on the lack of common guidelines for diagnostic procedures and for treatment of HNCUP patients in the Nordic countries constituting a region having a rather homogeneous population. METHOD A structured questionnaire was sent to all university hospitals in the five Nordic countries. RESULTS Four of the five Nordic countries use either national guidelines or specific protocols when handling HNCUP. The main diagnostic tools are PET-CT, fine needle aspiration, endoscopic evaluation with biopsies, and most often bilateral tonsillectomy. At 21 of 22 university hospitals the treatment decision is made at a multidisciplinary conference. Three of seven Swedish centres use only radiotherapy or chemoradiotherapy to treat N+ HNCUP patients. Robotic surgery for biopsy of the tongue base is beginning to become an alternative to targeted biopsies in Sweden and Finland. Narrow Band Imaging is used only in Finland.
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