Management of cervical lymph node metastases in squamous cell carcinoma of the tonsillar fossa, base of tongue, supraglottic larynx, and hypopharynx

Unilateral versus bilateral nodal irradiation: Current evidence in the treatment of squamous cell carcinoma of the head and neck

Cancers of the head and neck region often present with nodal involvement. There is a long-standing convention within the community of head and neck radiation oncology to irradiate both sides of the neck electively in almost all cases to include both macroscopic and microscopic disease extension (so called elective nodal volume). International guidelines for the selection and delineation of the elective lymph nodes were published in the early 2000s and were updated recently. However, diagnostic imaging techniques have improved the accuracy and reliability of nodal staging and as a result, small metastases that used to remain undetected and were thus in the past included in the elective nodal volume, will now be included in high-dose volumes. Furthermore, the elective nodal areas are situated close to the parotid glands, the submandibular glands and the swallowing muscles. Therefore, irradiation of a smaller, more selected volume of the elective nodes could reduce treatment-related toxicity. Several researchers consider the current bilateral elective neck irradiation strategies an overtreatment and show growing interest in a unilateral nodal irradiation in selected patients. The aim of this article is to give an overview of the current evidence about the indications and benefits of unilateral nodal irradiation and the use of SPECT/CT-guided nodal irradiation in squamous cell carcinomas of the head and neck.

Positron Emission Tomography-Computed Tomography Surveillance after (Chemo)Radiotherapy in Advanced Head and Neck Squamous Cell Cancer: Beyond the PET-NECK Protocol

AIMS

To evaluate the implementation of 18-fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) surveillance after (chemo)radiotherapy, to compare outcomes for those who achieved a complete (CR), equivocal (EQR) and incomplete (ICR) nodal response on 12-week PET-CT according to their human papillomavirus (HPV) status, and to assess the safety of ongoing surveillance beyond 12 weeks in the HPV-positive EQR group.

MATERIALS AND METHODS

All patients with node-positive head and neck squamous cell carcinoma (HNSCC) treated with (chemo)radiotherapy between January 2013 and September 2017 were identified. PET-CT responses were classified as CR, ICR or EQR. Patient outcomes were obtained from electronic records.

RESULTS

In total, 236 patients with a minimum of 2 years of follow-up were identified. The mean age was 59 years; 79.3% had N2 disease; 77.1% of patients had oropharyngeal cancer and 10.1% had squamous cell carcinoma of unknown primary, of whom 82.0% (169) were HPV positive; 78.0% received chemoradiotherapy. The median time from the end of radiotherapy to PET-CT was 91 days. Of the HPV-related HNSCC, 60.4% achieved CR, 29.0% EQR and 10.6% ICR. With a median follow-up of 41.7 months, there was no difference in survival between patients with HPV-related HNSCC achieving CR and EQR (median overall survival not reached for both, P = 0.67) despite the omission of immediate neck dissection in 98.0% of the EQR group.

CONCLUSION

Patients with HPV-positive HNSCC who have achieved EQR have comparable survival outcomes to those who achieved a CR despite the omission of immediate neck dissections; this shows the safety of ongoing surveillance beyond 12 weeks in this group of patients.

The Efficacy of Low Postoperative Radiation Dose in Patients with Advanced Hypopharyngeal Cancer without High-Risk Factors

Objective

To evaluate the feasibility and efficacy of low postoperative radiotherapy (PORT) dose in patients with advanced hypopharyngeal squamous cell carcinoma (HPSCC) and identify prognostic factors in this group.

Patients and Methods

Between January 2013 and September 2015, 110 consecutive patients with HPSCC with no high-risk factors were treated postoperatively to 50 Gy (n=89), 56 Gy (n=12), and 60 Gy (n=9) in 2 Gy/fraction. Overall survival (OS), 3-year progression-free survival (PFS), 3-year loco-regional recurrence-free survival (LRFS), and treatment-related toxicities were analyzed.

Results

Median follow-up time was 40 months (range=6–75 months). The 3-year local-regional control (LRC) and 3-year neck control rate were 86.3% and 91.8%, respectively. The 3-year OS, PFS, and LRFS were 69.9%, 65.5%, and 80.5%, respectively. In a univariate analysis, T stage showed a significant correlation with improved OS, PFS, and LRFS (P=0.008, P=0.039, P=0.034). On multivariate analysis, T stage showed a significant correlation with improved OS and PFS. N stage showed a significant correlation with improved PFS. However, interval surgery-radiotherapy, reconstructive methods, and RT dose cannot serve as a significant prognostic factor for survival outcome.

Conclusion

This study suggests that treating no high-risk factors for locally advanced HPSCC with a dose of 50 Gy to the whole operative bed and elective lymph node levels cannot compromise disease control and survival.

The Evolving Role of Radiotherapy for Head and Neck Cancer

The length and quality of head and neck cancer survivorship continues to meaningfully improve. Radiotherapy has been central to this process through advances in treatment delivery, fractionation schemas, radiosensitizing systemic therapy, and thoughtful interplay with technical surgical improvements. The future looks brighter still, with ongoing progress in targeted biologic therapy, immuno-oncology, and molecular-genetic tumor characterization for personalized treatment. Head and neck cancer, a disease once fraught with nihilism and failure, is evolving into a major success story of modern multidisciplinary cancer care.

Head and neck cancer management and cancer stem cells implication

Head and neck squamous cell carcinomas (HNSCCs) arise in the mucosal linings of the upper aerodigestive tract and are heterogeneous in nature. Risk factors for HNSCCs are smoking, excessive alcohol consumption, and the human papilloma virus. Conventional treatments are surgery, radiotherapy, chemotherapy, or a combined modality; however, no international standard mode of therapy exists. In contrast to the conventional model of clonal evolution in tumor development, there is a newly proposed theory based on the activity of cancer stem cells (CSCs) as the model for carcinogenesis. This “CSC hypothesis” may explain the high mortality rate, low response to treatments, and tendency to develop multiple tumors for HNSCC patients. We review current knowledge on HNSCC etiology and treatment, with a focus on CSCs, including their origins, identifications, and effects on therapeutic options.

Postoperative Radiation Therapy for Metastatic Cervical Adenopathy

The management of cancers of the head and neck focuses on primary site and regional (neck) disease control. Many patients are treated with surgery as the principal mode of treatment, and surgery often includes an elective or therapeutic neck dissection. Risk factors assessed for recurrence subsequent to neck dissection include nodal size, number, levels, and the presence of extranodal spread. Adjuvant radiation therapy (with or without chemotherapy) is offered to patients deemed at sufficient risk of recurrence based on assessment of these factors. However, randomized trials have not been performed to test the need and/or benefit of adjuvant postoperative radiation. The necessity of adjuvant radiation has been based on decades of clinical observations, retrospective studies, and indirect randomized trials. The case for postoperative radiation for patients with adverse features in the neck, and recommendations are made in the accompanying article.

An Evaluation of Elective Irradiation of Neck Nodes in Patients with Cancer of the Supraglottic Larynx

Between 1964 and 1973, 152 patients with supraglottic cancer limited to the larynx with clinically negative neck were included in the controlled randomized study designed to evaluate elective irradiation of the neck. The patients were randomized to one of the 2 treatment groups: 1) « T + N »: irradiation of the larynx and all neck nodes, tumor dose 5130 rad/6-7 weeks, 2) « T »: irradiation of the laryngeal portals only, tumor dose 5130 rad/5 weeks. All patients received 250 kV orthovoltage irradiation. The biologic dose delivered to the larynx was greater in group « T » because of faster fractionation and shorter overall time of therapy. The calculated NSD value for the patients in group « T + N » varied from 1620 to 1690 ret, and in group « T » it was 1800 ret. Five-year survival rates with a preserved larynx and without cancer were 45.3 % for group « T + N » and 66.2 % for group « T ». Seven patients of group « T » developed metastatic cancer in the neck, and 4 of them were cured by neck dissection. It is concluded that patients with early supraglottic cancer can be successfully irradiated through laryngeal portals only, including the larynx, and possibly midjugular and digastric nodes. The tumor dose should be at least equivalent to the NSD of 1800 ret in the condition of megavoltage therapy.

The Role of Irradiation in the Management of Head and Neck Cancer: Analysis of Results and Causes of Failure

The records of patients with squamous cell carcinoma of the oral cavity, oropharynx, supraglottic and glottic larynx, whose primary lesion was treated with radiation therapy from 1964 through 1973, were reviewed. End points of the study are local control rate at the primary site, ultimate control with surgical salvage, and causes of failure. The local control rate at the primary site was 90 % for T1 lesions, 80 % for T2 lesions, and approximately 70 % for selected T3 lesions. The control rates for the advanced T2 and T4 lesions are unsatisfactory; therefore, preoperative or postoperative irradiation is combined with appropriate surgical procedures to improve the local control rates and in some instances survival rates. Analysis of cervical node metastases treatment shows that the incidence of local recurrence in the radically dissected neck can be significantly reduced with either pre- or postoperative irradiation. Elective irradiation of initially clinically uninvolved areas of the neck (both ipsilateral and contralateral) has almost eliminated subsequent nodal metastases.

FDG-PET/CT for treatment response assessment in head and neck squamous cell carcinoma: a systematic review and meta-analysis of diagnostic performance

PURPOSE

18-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) is increasingly used to evaluate treatment response in head and neck squamous cell carcinoma (HNSCC). This analysis assessed the diagnostic value of FDG-PET/CT in detecting nodal disease within 6 months after treatment, considering patient and disease characteristics.

METHODS

A systematic review was performed using the MEDLINE and Web of Knowledge databases. The results were pooled using a bivariate random effects model of the sensitivity and specificity.

RESULTS

Out of 22 identified studies, a meta-analysis of 20 studies (1293 patients) was performed. The pooled estimates of sensitivity, specificity and diagnostic odds ratio (with 95% CI) were 85% (76-91%), 93% (89-96%) and 76 (35-165), respectively. With the prevalence set at 10%, the positive and negative predictive values were 58% and 98%. There was significant heterogeneity between the trials (p < 0.001). HPV positive tumors were associated with lower sensitivity (75% vs 89%; p = 0.01) and specificity (87% vs 95%; p < 0.005).

CONCLUSION

FDG-PET/CT within 6 months after (chemo)radiotherapy in HNSCC patients is a reliable method for ruling out residual/recurrent nodal disease and obviates the need for therapeutic intervention. However, FDG-PET/CT may be less reliable in HPV positive tumors and the optimal surveillance strategy remains to be determined.

Utilization and Survival of Postoperative Radiation or Chemoradiation for pT1-2N1M0 Head and Neck Cancer

Objective

To analyze the patterns of care and survival for pT1-2N1M0 head and neck cancer based on receipt of surgery alone, surgery + postoperative radiotherapy (S + RT), or surgery + postoperative chemoradiotherapy (S + CRT).

Study Design

Retrospective analysis.

Setting

National Cancer Database.

Subjects and Methods

We queried the database for patients with stage pT1-2N1M0 squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx between 2004 and 2012 who were treated with surgery with negative margins and no extracapsular extension. Logistic regression was used to assess predictors of receipt of postoperative treatment. Overall survival was assessed by the Kaplan-Meier method, and Cox regression analysis identified covariates that affected it.

Results

There were 1598 patients included in this study: 566 (35.4%) received surgery alone; 726 (45.4%), S + RT; and 306 (19.1%), S + CRT. The 5-year overall survival was 68.8%, 74.0%, and 87.8%, respectively ( P = .009 comparing S + RT and surgery alone, P < .001 for all other comparisons). On multivariable logistic regression, academic centers were associated with a decreased likelihood of S + RT (odds ratio = 0.71) and S + CRT (odds ratio = 0.66). Multivariable Cox regression demonstrated no difference in survival for S + RT over surgery alone (hazard ratio = 0.88, 95% CI = 0.70-1.09, P = .24); however, there was a survival benefit associated with S + CRT (hazard ratio = 0.57, 95% CI = 0.39-0.81, P = .002).

Conclusion

Nearly 65% of patients with pT1-2N1 head and neck cancer with negative margins and no extracapsular extension received S + RT or S + CRT. Improvement in survival was noted only for patients who received S + CRT.

Efficacy of postoperative neck irradiation for regional control in patients with pN0 oral tongue cancer: Propensity analysis

BACKGROUND

The purpose of this study was to investigate whether adjuvant radiotherapy (RT) is efficacious for regional control and survival in patients with pN0 oral tongue cancer.

METHODS

Clinicopathological features of 166 patients with pN0 oral tongue cancer were compared between those who underwent adjuvant RT to the neck (neck RT-positive) and those who did not (neck RT-negative). Study endpoints were isolated regional recurrence and 3-year regional recurrence-free survival (RRFS). Propensity score matching was also performed.

RESULTS

Cox regression analysis did not reveal any significant predictor of isolated regional recurrence, including RT field. Three-year RRFS showed modest improvement in neck RT-positive group compared to neck RT-negative group before (92.2% vs 91.9%) and after propensity analysis (93.8% vs 83.3%), without statistical significance (log-rank P = .85 and .37, respectively).

CONCLUSION

Despite more frequent unfavorable factors, the neck RT-positive group had a comparable oncologic outcome to the neck RT-negative group, suggesting that a marginal benefit in regional control might be expected from extending the RT field to the neck for pN0 oral tongue cancer.

Final Report of a Prospective Randomized Trial to Evaluate the Dose-Response Relationship for Postoperative Radiation Therapy and Pathologic Risk Groups in Patients With Head and Neck Cancer

PURPOSE

To present the long-term and final report of a phase 3 trial designed to assess dose-response relationship for postoperative radiation therapy (PORT) and pathologic risk groups in head and neck cancer.

METHODS AND MATERIALS

Patients who underwent primary surgery for American Joint Committee on Cancer stage III or IV squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx and who required PORT were eligible. Patients' primary sites and involved necks were independently assigned to higher- or lower-risk categories based on a cumulative point score representing increasing risk of recurrence. The sites in the lower-risk group were randomized to receive 57.6 or 63 Gy and those in the higher-risk group were randomized to receive 63 or 68.4 Gy, all at 1.8 Gy per fraction.

RESULTS

A total of 264 patients were included. The actuarial 5-year locoregional control rate was 67%. A second primary cancer was documented in 27% of patients. The 5- and 10-year freedom-from-distant metastasis rates were 64% and 60%, respectively, whereas the 5- and 10-year overall survival rates were 32% and 20%, respectively. There was no statistically significant difference in tumor control between different dose levels in both the lower- and higher-risk groups. On multivariate analysis, nonwhite race (P=.0003), positive surgical margins (P=.009), extracapsular extension (ECE, P=.01), and treatment package time (TPT) ≥85 days (P=.002) were independent correlates of worse locoregional control, whereas age ≥57 years (P<.0001), positive surgical margins (P=.01), ECE (P=.026), and TPT ≥85 days (P=.003) were independently associated with worse overall survival.

CONCLUSIONS

This long-term report of PORT delivered at 1.8 Gy/d to total doses of 57.6 to 68.4 Gy without chemotherapy for head and neck squamous cell carcinoma demonstrated that increasing dose did not significantly improve tumor control. On multivariate analysis, the only significant treatment variable was TPT. The results confirm that positive surgical margins and/or nodal ECE remains the most significant predictive pathologic factors.

Complete pathologic response as a prognostic factor for squamous cell carcinoma of the oropharynx post-chemoradiotherapy

Introduction

Chemoradiotherapy for squamous cell carcinoma of the oropharynx (SCCO) provides good results for locoregional disease control, with high rates of complete clinical and pathologic responses, mainly in the neck.

Objective

To determine whether complete pathologic response after chemoradiotherapy is related to the prognosis of patients with SCCO.

Methods

Data were prospectively extracted from clinical records of N2 and N3 SCCO patients submitted to a planned neck dissection after chemoradiotherapy.

Results

A total of 19 patients were evaluated. Half of patients obtained complete pathologic response in the neck. Distant or locoregional recurrence occurred in approximately 42% of patients, and 26% died. Statistical analysis showed an association between complete pathologic response and lower disease recurrence rate (77.8% vs. 20.8%; p = 0.017) and greater overall survival (88.9% vs. 23.3%; p = 0.049).

Conclusion

The presence of a complete pathologic response after chemoradiotherapy positively influences the prognosis of patients with SCCO.

Regional failures after selective neck dissection in previously untreated squamous cell carcinoma of oral cavity

AIM

To share experience with regional failures after selective neck dissection in both node negative and positive previously untreated patients diagnosed with squamous cell carcinoma of the oral cavity.

PATIENTS AND METHODS

Data of 219 patients who underwent SND at Shaukat Khanum Cancer Hospital from 2003 to 2010 were retrospectively reviewed. Patient characteristics, treatment modalities, and regional failures were assessed. Expected 5-year regional control was calculated and prognostic factors were determined.

RESULTS

Median follow-up was 29 (9-109) months. Common sites were anterior tongue in 159 and buccal mucosa in 22 patients. Pathological nodal stage was N0 in 114, N1 in 32, N2b in 67, and N2c in 5 patients. Fourteen (6%) patients failed in clinically node negative neck while 8 (4%) failed in clinically node positive patients. Out of 22 total regional failures, primary tumor origin was from tongue in 16 (73%) patients. Expected 5-year regional control was 95% and 81% for N0 and N+ disease, respectively (P < 0.0001). Only 13% patients with well differentiated, T1 tumors in cN0 neck were pathologically node positive.

CONCLUSIONS

Selective neck dissection yields acceptable results for regional management of oral squamous cell carcinoma. Wait and see policy may be effective in a selected subgroup of patients.

Head and neck squamous cell carcinoma: optimizing the therapeutic index

The four recent noteworthy strategies aimed at improving therapeutic outcomes for the curative treatment of head and neck squamous cancers include the development of altered fractionation regimens, integration of chemotherapy, incorporation of intensity-modulated radiation therapy and introduction of targeted biologic therapy. Clinical investigations during the last 30 years have demonstrated the benefits of biologically sound altered fractionation and concurrent chemoradiation regimens in improving locoregional control and overall survival. These results have contributed to redefining the standard of care, with the caveat that proper patient selection for those who will benefit from potentially toxic combined modality treatment regimens remains controversial. These benefits have come at the expense of increased acute toxicity (i.e., mucositis) and sometimes at the expense of late toxicity (i.e., fibrosis and dysphagia). There are two additional developments that may help to further widen the therapeutic ratio. Intensity-modulated radiation therapy allows for the delivery of a highly conformal 3D radiation dose distribution around intended targets, thereby limiting the volumes of mucosa receiving a high dose per fraction and high total doses. The technical basis for intensity-modulated radiation therapy delivery reopens many fractionation questions that are still being addressed and challenges us to determine which of these is optimal for use with intensity-modulated radiation therapy alone or in combination with concurrent sensitizers. Finally, combined radiation therapy and biologic therapies directed at targets expressed predominately or exclusively by tumor cells have the promise to help increase tumor cell kill, while at least not substantially increasing normal tissue toxicity. These strategies are reviewed in a clinical context.

Lymph node positive head and neck carcinoma after curative radiochemotherapy: a long lasting debate on elective post-therapeutic neck dissections comes to a conclusion

There has been a long lasting debate, whether planned neck dissections after curative radio(chemo)therapy for locally advanced head and neck squamous cell carcinomas offer some benefit in tumor control or survival. We did a thorough literature research on that topic. The results of several recently published studies are described, summarized, and reviewed. Patients with residual disease in clinical or radiographic examinations (CT or MRI scans) up to 3 months after completion of radiochemotherapy profit from neck dissections. In patients with an initial or delayed clinical complete remission after completion of radiochemotherapy, a neck dissection can be safely omitted. In conclusion, there is no longer evidence for a benefit of prophylactic post-radiochemotherapy neck dissections, but strong evidence for a therapeutic post-radiochemotherapy neck dissection in this group of patients.

The role of neck dissection after radical chemoradiation for locally advanced head and neck cancer: should we move back?

Until a few decades ago neck dissection (ND) was the standard surgical approach for node-positive tumours. Nowadays patients with locally advanced head and neck cancer can be treated with definitive chemoradiation (CRT), which includes the treatment of the neck; however, results on residual viable tumour after conservative treatment are heterogeneous and depend on initial node stage and primary treatment. Many authors accept adjuvant surgery in patients with N2-3 disease. Regardless of the results of upfront CRT, even if there is no evidence of lymph node metastases, when the risk for persistent positive neck nodes exceeds 15-20%, elective ND might be indicated. However, despite the diffusion of innovative technologies and therapies, there are controversies about both response evaluation and surgical management of initially involved neck nodes after definitive CRT and organ preservation treatment. In this paper we will analyse state of art of neck evaluation after CRT and discuss the role of ND.

Regional control after concomitant chemoradiotherapy without planned neck dissection in node-positive head and neck squamous cell carcinomas

OBJECTIVES

Although three-weekly high-dose (100mg/m(2)) cisplatin (three cycles) chemoradiotherapy has been considered a standard regimen for patients with advanced head and neck squamous cell carcinomas (HNSCC), this protocol is associated with significant acute and late toxicities. Therefore, weekly cisplatin at a dose of 40mg/m(2) has been used at our institution since 2006. This retrospective study was aimed at assessing the oncologic efficacy of weekly cisplatin chemoradiotherapy for the control of nodal metastasis.

METHODS

We analyzed 28 patients with node-positive HNSCC treated with weekly cisplatin and concurrent radiotherapy. Computed tomography was performed 4-8 weeks after the completion of chemoradiotherapy to evaluate nodal response. If residual neck disease was apparent or suspected, we performed early salvage neck dissection (ND). In cases with a complete response (CR), we took a "wait and see" approach. When no viable tumor cells were observed in the surgical specimens obtained by ND, nodal metastasis was defined as controlled by weekly cisplatin chemoradiotherapy alone.

RESULTS

Nodal metastasis was evaluated as having a CR in 20 patients (71%). Eight patients (29%) underwent early salvage ND. Recurrent primary tumors were observed in the other four patients (14%). Salvage primary resection and associated ND were performed for these four patients. In 7 of 12 patients undergoing ND, no viable tumor cells were observed. In 23of 28 patients, neck diseases were controlled by chemoradiotherapy alone (not including salvage by ND). In 27 of 28 patients, neck diseases were controlled by the overall treatment (including salvage by ND). The rate of nodal control by chemoradiotherapy alone and by the overall treatment was found to be 82.0% and 96.3%, respectively, using the Kaplan-Meier method. The three-year overall and disease free survival rates were 86.8% and 80.8%, respectively.

CONCLUSION

Concomitant weekly cisplatin at a dose of 40mg/m(2) chemoradiotherapy showed a good control rate of not only primary lesions but also neck diseases.

The contribution of neck dissection for residual neck disease after chemoradiotherapy in advanced oropharyngeal and hypopharyngeal squamous cell carcinoma patients

BACKGROUND

Planned neck dissection after chemoradiotherapy (CRT) has remained controversial in advanced oro- and hypopharyngeal squamous cell carcinoma (OHSCC) patients. We evaluated the survival contribution of neck dissection (ND) in OHSCC patients with residual nodal disease following CRT.

METHODS

We retrospectively evaluated 84 OHSCC patients with N2-3 disease treated at Aichi Cancer Center Hospital between 1995 and 2006. ND after CRT was performed for residual neck disease in 36 patients, but not in 48 patients to achieve a complete response. These two groups were analyzed in terms of both overall survival (OS) and regional control (RC), and surgical complications were evaluated.

RESULTS

The 5-year OS was 76.7 % [95 % confidence interval (CI) 58.8-87.6] for the ND group and 73.9 % (58.6-84.3) for the non-ND group (P = 0.883). The 5-year RC was 91.6 % (76.1-97.2) for the ND group and 81.1 % (65.4-90.2) for the non-ND group (P = 0.252). Stratified by primary tumor site, the 5-year RC was 96.3 % (76.5-99.5) for the ND group, and 78.6 % (58.0-89.9) for the non-ND group (P = 0.072) in oropharyngeal squamous cell carcinoma patients, and 77.8 % (36.5-93.9) for the ND group and 85.9 % (54.0-96.3) for the non-ND group (P = 0.541) in hypopharyngeal squamous cell carcinoma patients. In addition, the complications after ND were tolerable.

CONCLUSIONS

We demonstrated that ND was feasible, safe, and correlated with clinical outcomes in OHSCC patients with residual nodal disease after CRT.

Incidence of nodal disease after nonsurgical therapy in head and neck squamous cell carcinoma patients with bilateral neck disease: can a bilateral neck dissection be avoided?

BACKGROUND

We evaluated whether classifying 1 side of a patients' neck as "high risk" would help in deciding the extent of neck dissection in patients with bilateral nodal disease.

METHODS

We conducted a retrospective review of 44 patients (88 heminecks) with head and neck squamous cell carcinoma who had bilateral nodal disease and received definitive chemoradiotherapy (CRT). For lateralized lesions (70%), the ipsilateral neck was designated as the "high-risk" neck. For midline lesions, pre-CRT and post-CRT computed tomography scans were used to stage each side of the neck (hemineck); the higher staged hemineck was designated as the "high-risk" neck.

RESULTS

Twenty-seven patients had died at the time of analysis. Patients had a median follow-up of 27.8 months (range, 6 to 150 mo). Two-year neck control and overall survival were 83% and 56%, respectively. Sixty-two heminecks (71%) were dissected. A total of 6/22 (27%) "low-risk" necks were positive after CRT if the "high-risk" neck was positive versus 0/22 if the "high-risk" neck was negative (P=0.02).

CONCLUSIONS

Identifying the more "high-risk" neck may be useful when deciding the extent of neck dissection after CRT. For patients with bilateral nodal disease treated with CRT, dissection of the "low-risk" hemineck may be omitted if the "high-risk" neck is pathologically negative.

Sonographic examination of the neck after definitive radiotherapy for node-positive oropharyngeal cancer

BACKGROUND AND PURPOSE

Radiographic determination of viable disease in cervical adenopathy following RT for head and neck cancer can be challenging. The purpose of this study was to evaluate the utility of US, with or without FNA, in regard to the postradiotherapy effects on documented metastatic adenopathy in patients with oropharyngeal cancer.

MATERIALS AND METHODS

This study included 133 patients with node-positive oropharyngeal cancer who were irradiated from 1998 to 2004. Sonographic evaluation was performed within 6 months of completion of radiation. Posttreatment US results were compared with pretreatment CT images and were recorded as the following: progression, suspicious, indeterminate, posttreatment change, or regression (positive) versus nonsuspicious or benign (negative). FNAC was classified as nondiagnostic, negative, indeterminate, or positive. Results of US and US-guided FNAC were correlated with findings at neck dissection and disease outcome.

RESULTS

Of 203 sonographic examinations, 90% were technically feasible and yielded a nonequivocal imaging diagnosis. Of 87 US-guided FNAs, 71% yielded a nonequivocal tissue diagnosis. The PPV and NPV of initial posttreatment US were 11% and 97%. Sensitivity and specificity were 92% and 28%. The PPV and NPV of US-guided FNA were 33% and 95%, and the sensitivity and specificity were 75% and 74%. On serial sonographic surveillance, of 33 patients with nonsuspicious findings, only 1 (3%) had neck recurrence. Of 22 patients with questionable findings on CT and negative findings on US, none had a neck recurrence.

CONCLUSIONS

In experienced hands, serial US is an inexpensive noninvasive reassuring follow-up strategy after definitive head and neck RT, even when CT findings are equivocal.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Extensive Neck Node Metastases (N3) in Head and Neck Squamous Carcinoma

Objective. Head and neck squamous cell carcinoma (HNSCC) patients with N3 neck disease at presentation are the minority. Prognosis for such patients is poor, but there is disagreement about which treatment policy is best adopted. The aim of this study was to identify which groups of patients are best offered radical treatment, examining factors of association, prognosis, and survival.

Study Design. Prospective cohort study.

Setting. Regional tertiary head and neck cancer unit.

Subjects and Methods. Data were collected prospectively from patients treated for HNSCC with N3 nodal disease between 1975 and 2005. The data collected included age, sex, tumor TNM stage, histological grade, treatment, and survival. Odds ratio was used to calculate whether each parameter was statistically significant. Tumor-specific and observed survival curves were also calculated.

Results. A total of 275 patients had N3 disease. Multivariate analysis confirmed that advanced disease at the primary site (odds ratio = 4.6, P = .0261) mitigated against curative treatment. Comparison of tumor-specific survival between curative and palliative treatment strategies suggests that aggressive treatment is associated with greatly improved survival (median survival = 1.45 years, 95% confidence interval [CI] = 1.23-1.67 years; 5-year survival = 26.6%, CI = 17.14%-36.06%) compared with those treated palliatively (median survival = 3.18 months, CI = 3.06-3.30 months; no 5-year survivors; P < .0001).

Conclusion. A major factor in determining treatment strategies for N3 disease HNSCC is the extent of disease at the primary site. These data suggest that aggressive treatment of the neck improves survival and should be considered in these patients.

Clinical outcome following radiotherapy and planned neck dissection in N+ head and neck cancer patients

CONCLUSIONS

This study confirms earlier findings that patients with viable tumour cells in the neck after external beam radiotherapy (EBRT) have a poor prognosis. The study also indicates that neck dissection (ND) does not change the prognosis for patients with a complete clinical response in the neck. At the moment our guidelines concerning this matter are being reviewed.

OBJECTIVES

The protocol at our institution stipulates a planned ND in patients with metastasis in the neck after EBRT regardless of the response in the neck. As the necessity for a planned ND has not been clarified we wanted to evaluate our results.

PATIENTS AND METHODS

Patients diagnosed from 1998 to 2002 with metastasis in the neck who received EBRT were evaluated for histopathological findings and clinical outcome.

RESULTS

A total of 156 patients were included. Overall survival was 62% and disease-specific survival was 76%. There was a complete response (CR) in the neck in 63 patients (40%); among these 15 had viable tumour cells in the neck. In patients not achieving CR, 40% (37/93) had viable tumour cells left in the neck. Patients with viable tumour cells in the neck after EBRT had disease-specific survival of 48% compared with 90% among patients without viable tumour cells.

Patterns of failure among patients with squamous cell carcinoma of the head and neck who obtain a complete response to chemoradiotherapy

BACKGROUND

The role of adjuvant neck dissection in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) who obtain complete clinical and radiologic response following definitive chemoradiation treatment is controversial.

METHODS

Patterns of failure among 120 patients with locally advanced SCCHN, all with node-positive disease, treated with concurrent chemoradiation, were analyzed.

RESULTS

Ninety-one of the patients achieved a complete response and were observed without undergoing neck dissection. Isolated failure in the neck occurred in 2 patients. The most common site of failure was metastatic disease (17 patients). Six patients had recurrence at the primary only, and 1 experienced failure in the neck and at the primary. Partial responders with resectable disease underwent neck dissection following chemoradiation. This group had worse local control and overall survival compared with complete responders.

CONCLUSIONS

We recommend observation after definitive chemoradiation for complete responders. Further research is needed to improve outcomes among partial responders.

Management of the N0 neck in oral squamous cell carcinoma

Oral squamous cell carcinoma (SCC) has an unpredictable capacity to metastasize to the neck, an event that dramatically worsens prognosis. Metastasis occurs even in earlier stages when no neck lymph node involvement is clinically detectable (N0). Management of the N0 neck, namely when and how to electively treat, has been debated extensively. This article presents the controversies surrounding management of the N0 neck, and the benefits and pitfalls of different approaches used in evaluation and treatment. As current methods of assessing the risk for occult metastasis are insufficiently accurate and prone to underestimation of actual risk, and because selective neck dissection (SND) is an effective treatment and has minimal long-term detriment to quality of life, the authors believe that all patients who have oral SCC, excluding lip SCC, should be prescribed elective treatment of the neck lymphatics. However, this opinion remains controversial. Because of the morbidity of radiation therapy and because treatment of the primary tumor is surgical, elective neck dissection is the preferred treatment. In deciding the extent of the neck dissection, several retrospective studies and one randomized clinical trial have shown SND of levels I through III to be highly efficacious.

Role and extent of neck dissection for persistent nodal disease following chemo-radiotherapy for locally advanced head and neck cancer: how much is enough?

PURPOSE

Neck dissection (ND) is routinely performed for persistent nodal disease after definitive chemo-radiotherapy (CRT) for locally advanced head and neck cancer. This study analyzes the role and extent of ND necessary after CRT based on pathologic outcome.

PATIENTS AND METHODS

The study is based on 42 patients undergoing 48 ND's for persistent nodal disease after CRT. Patients were treated to a median radiation dose of 70.4 Gy at 1.8-2 Gy per fraction concurrently with platinum based chemotherapy. Patients with documented residual disease in neck, based on clinical or radiological examination underwent ND at a median interval of 59 days after completion of CRT.

RESULTS

Of the 42 patients undergoing ND, 11 (26%) had positive findings on pathologic evaluation. The clinical and treatment characteristics were similar for node negative and positive patients. The involved nodal level(s) were always confined within the clinically documented persistent disease. The median percentage of positive nodes to total nodes removed was 10%. Almost 50% of positive nodes removed had only microscopic or minute viable cancer pathologically. The outcome was better for pathologically node negative patients in comparison to node positive patients.

CONCLUSION

The results of this study suggest that standard ND appears to be an excessive treatment for persistent nodal disease after CRT. Limited ND or even gross nodal resection confined to involved nodal level(s) as identified clinically or radiologically should be tested in a prospective randomized trial for reducing treatment related morbidity while maintaining excellent loco-regional control.

Clinical utility of 18F-FDG PET/CT in assessing the neck after concurrent chemoradiotherapy for Locoregional advanced head and neck cancer

For patients with locoregional advanced head and neck squamous cell carcinoma (HNSCC), concurrent chemoradiotherapy is a widely accepted treatment, but the need for subsequent neck dissection remains controversial. We investigated the clinical utility of 18F-FDG PET/CT in this setting.

METHODS

In this Institutional Review Board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPPA)-compliant retrospective study, we reviewed the records of patients with HNSCC who were treated by concurrent chemoradiation therapy between March 2002 and December 2004. Patients with lymph node metastases who underwent 18F-FDG PET/CT > or = 8 wk after the end of therapy were included. 18F-FDG PET/CT findings were validated by biopsy, histopathology of neck dissection specimens (n = 18), or clinical and imaging follow-up (median, 37 mo).

RESULTS

Sixty-five patients with a total of 84 heminecks could be evaluated. 18F-FDG PET/CT (visual analysis) detected residual nodal disease with a sensitivity of 71%, a specificity of 89%, a positive predictive value (PPV) of 38%, a negative predictive value (NPV) of 97%, and an accuracy of 88%. Twenty-nine heminecks contained residual enlarged lymph nodes (diameter, > or =1.0 cm), but viable tumor was found in only 5 of them. 18F-FDG PET/CT was true-positive in 4 and false-positive in 6 heminecks, but the NPV was high at 94%. Fifty-five heminecks contained no residual enlarged nodes, and PET/CT was true-negative in 50 of these, yielding a specificity of 96% and an NPV of 98%. Lack of residual lymphadenopathy on CT had an NPV of 96%. Finally, normal 18F-FDG PET/CT excluded residual disease at the primary site with a specificity of 95%, an NPV of 97%, and an accuracy of 92%.

CONCLUSION

In patients with HNSCC, normal 18F-FDG PET/CT after chemoradiotherapy has a high NPV and specificity for excluding residual locoregional disease. In patients without residual lymphadenopathy, neck dissection may be withheld safely. In patients with residual lymphadenopathy, a lack of abnormal 18F-FDG uptake in these nodes also excludes viable tumor with high certainty, but confirmation of these data in a prospective study may be necessary before negative 18F-FDG PET/CT may become the only, or at least most-decisive, criterion in the management of the neck after chemoradiotherapy.

Pathology and FDG PET correlation of residual lymph nodes in head and neck cancer after radiation treatment

BACKGROUND

This study determines if postradiotherapy [18F]fluorodeoxyglucose positron emission tomography (FDG PET) can predict the pathology status of residual cervical lymph nodes in patients undergoing definitive radiotherapy for head and neck squamous cell carcinoma (HNSCC).

METHODS

Patients with stage N2 or higher HNSCC underwent PET and CT imaging after definitive radiotherapy. Patients with radiographically persistent lymphadenopathy underwent either neck dissection or fine needle aspiration (FNA) of the lymph nodes under ultrasound guidance. PET scan results were correlated with the pathologic findings of the residual lymphadenopathy.

RESULTS

Twenty-four hemi-necks in 23 patients with residual lymphadenopathy had neck dissection or FNA. The pathology correlated strongly with the post-RT FDG PET studies. All patients with a negative post-RT FDG PET and those with a maximum standardized uptake value (SUVmax) of less than 3.0 in the post-RT FDG PET were found to be free from residual viable tumor. Using a SUVmax of less than 3.0 as the criterion for a negative FDG PET study, the sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 84.2%, 62.5%, and 100%, respectively.

CONCLUSIONS

A negative post-RT FDG PET is very predictive of negative pathology in the residual lymph node after definitive radiotherapy for advanced HNSCC. A prospective clinical trial is warranted to determine if neck dissection can be withheld in these patients.

Long-term results of the combined modality therapy for advanced cervical metastatic head and neck squamous cell carcinoma

AIM

A consensus treatment strategy for advanced cervical metastatic head and neck squamous cell carcinoma has not been established. The aim of this retrospective study was to investigate the outcome of these patients uniformely using a strategy which consists of surgery for the primary tumor and the neck metastases followed by postoperative radio(chemo)therapy.

METHODS

We included a selected series of 518 patients with previously untreated head and neck squamous cell carcinoma. The overall survival (OS), the disease specific survival (DSS), the disease free survival (DFS), the local control (LC) and regional control (RC) estimates were calculated. The statistical relationship of various clinical and histopathological variables on the above mentioned estimates were analyzed.

RESULTS

The overall survival probability was 73.2% for pN0 stage, 43% for pN>1 stages and 31% for pN2c/pN3 stages. The pN stage significantly influenced the survival probabilities in oropharyngeal (p=0.0001) and laryngeal tumors (p<0.0001) in univariate analyses. In multivariate analysis, age, pT stage, pN stage, M stage, and extranodal spreading were independent risk factors for decreased disease-specific survival.

CONCLUSIONS

We could show that pN stage is an important independent prognostic factor in head and neck cancer. The presented multimodal treatment protocol provides excellent oncological outcomes and should therefore be standard of care for patients with operable advanced cervical metastatic head and neck squamous cell carcinoma.

Is planned neck dissection necessary for head and neck cancer after intensity-modulated radiotherapy?

PURPOSE

The objective of this study was to determine regional control of local regional advanced head and neck squamous cell carcinoma (HNSCC) treated with intensity-modulated radiotherapy (IMRT), along with the role and selection criteria for neck dissection after IMRT.

METHODS AND MATERIALS

A total of 90 patients with stage N2A or greater HNSCC were treated with definitive IMRT from December 1999 to July 2005. Three clinical target volumes were defined and were treated to 70 to 74 Gy, 60 Gy, and 54 Gy, respectively. Neck dissection was performed for selected patients after IMRT. Selection criteria evolved during this period with emphasis on post-IMRT [(18)F] fluorodeoxyglucose positron emission tomography in recent years.

RESULTS

Median follow-up for all patients was 29 months (range, 0.2-74 months). All living patients were followed at least 9 months after completing treatment. Thirteen patients underwent neck dissection after IMRT because of residual lymphadenopathy. Of these, 6 contained residual viable tumor. Three patients with persistent adenopathy did not undergo neck dissection: 2 refused and 1 had lung metastasis. Among the remaining 74 patients who were observed without neck dissection, there was only 1 case of regional failure. Among all 90 patients in this study, the 3-year local and regional control was 96.3% and 95.4%, respectively.

CONCLUSIONS

Appropriately delivered IMRT has excellent dose coverage for cervical lymph nodes. A high radiation dose can be safely delivered to the abnormal lymph nodes. There is a high complete response rate. Routine planned neck dissection for patients with N2A and higher stage after IMRT is not necessary. Post-IMRT [(18)F] fluorodeoxyglucose positron emission tomography is a useful tool in selecting patients appropriate for neck dissection.

Planned neck dissection following chemoradiotherapy for advanced head and neck cancer: is it necessary for all?

In the absence of large-scale randomized trials evaluating dissection versus observation of the involved neck after neoadjuvant chemoradiotherapy, there is a need to collect data that will either support or ultimately refute a role for planned posttreatment neck dissection. A significant percentage of patients with extensive (N2 or N3) neck disease who demonstrate a complete response to chemoradiation therapy may harbor residual occult metastases, and identification of this subset of patients remains a clinical challenge. Because surgical salvage rates are greatly diminished when occult nodal disease becomes clinically manifest, planned posttreatment neck dissection is advocated but may not be necessary in all patients. The role of positron emission tomography chemoradiotherapy (PET-CT) in this scenario remains unproven but holds promise in being able to identify which patients may be harboring residual disease in the neck after chemoradiotherapy. The implementation of as yet unidentified molecular tumor markers in combination with PET-CT may ultimately prove to be effective in identifying patients who will best benefit from posttherapy neck dissection. Correlation of imaging results and pathologic node status will be important in determining the accuracy and, therefore, the value of this imaging modality for predicting the presence or absence of residual disease.

American Society of Clinical Oncology Clinical Practice Guideline for the Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer

Purpose

To develop a clinical practice guideline for treatment of laryngeal cancer with the intent of preserving the larynx (either the organ itself or its function). This guideline is intended for use by oncologists in the care of patients outside of clinical trials.

Methods

A multidisciplinary Expert Panel determined the clinical management questions to be addressed and reviewed the literature available through November 2005, with emphasis given to randomized controlled trials of site-specific disease. Survival, rate of larynx preservation, and toxicities were the principal outcomes assessed. The guideline underwent internal review and approval by the Panel, as well as external review by additional experts, members of the American Society of Clinical Oncology (ASCO) Health Services Committee, and the ASCO Board of Directors.

Results

Evidence supports the use of larynx-preservation approaches for appropriately selected patients without a compromise in survival; however, no larynx-preservation approach offers a survival advantage compared with total laryngectomy and adjuvant therapy with rehabilitation as indicated.

Recommendations

All patients with T1 or T2 laryngeal cancer, with rare exception, should be treated initially with intent to preserve the larynx. For most patients with T3 or T4 disease without tumor invasion through cartilage into soft tissues, a larynx-preservation approach is an appropriate, standard treatment option, and concurrent chemoradiotherapy therapy is the most widely applicable approach. To ensure an optimum outcome, special expertise and a multidisciplinary team are necessary, and the team should fully discuss with the patient the advantages and disadvantages of larynx-preservation options compared with treatments that include total laryngectomy.

Concurrent Chemoradiotherapy for Locally Advanced, Nonmetastatic, Squamous Carcinoma of the Head and Neck: Consensus, Controversy, and Conundrum

Radiotherapy and concurrent chemotherapy (CRT) is superior to radiotherapy alone for the treatment of locally advanced, nonmetastatic squamous carcinoma of the head and neck (HNC). Three issues affect the use of CRT as primary treatment for advanced HNC. The first issue is the definition of advanced stage and the initial therapeutic choice of surgery or CRT and the role of post-CRT neck dissection. Function preservation considerations should guide the choice between surgery and CRT for patients with resectable disease. Fluorodeoxyglucose–positron emission tomography scanning may identify patients who require adjuvant neck dissection. The second issue is optimization of radiotherapy and chemotherapy schedules. Ideally, concurrent chemotherapy should be incorporated into radiotherapy (RT) regimens that would constitute optimal therapy were RT to be administered as single-modality treatment. Modified fractionation schemes constitute optimal single-modality RT. Platinum schedules other than bolus dosing every 3 to 4 weeks are effective and may be less toxic. The third issue is integration of biologically targeted therapy into CRT treatment programs. Epidermal growth factor receptor blockade enhances the effectiveness of RT alone. Its role and that of angiogenic blockade in CRT are under investigation.

Adjuvant Therapy in Patients With Resected Poor-Risk Head and Neck Cancer

In patients with locally or regionally advanced head and neck carcinomas, postoperative radiotherapy has historically been the adjuvant therapy applied for patients with prognostically worrisome pathologic features. Any improvement in therapeutic index achieved by adding cytotoxic agents to postoperative radiotherapy remained controversial. However, two recent randomized trials, conducted in parallel in Europe and the United States, produced level I evidence regarding improved efficacy in this setting for the concurrent administration of chemotherapy and radiotherapy. High-dose cisplatin and irradiation can now be considered the standard therapeutic approach for resected poor-risk disease. The presence of positive margins and/or nodal extracapsular spread in the surgical specimens are the subgroups that appear to benefit in the most significant way from the addition of chemotherapy to radiation. Many questions regarding the optimization of adjuvant treatments still remain unanswered, especially with respect to improvement of patient compliance, integration of novel drugs targeting both locoregional and systemic control, and modulation of treatment intensity according to risk levels.